Hello, my name is Derek Glenn. I'm here to talk to you today about low-threshold treatment for opioid use disorder. I have no financial relationship with any commercial interests related to the content of this presentation. I will not be discussing off-label use during this presentation. Medication Access and Training Expansion Act, enacted June 2023, requires a one-time, eight-hour training and evaluation, treatment, and management of substance use disorder for all new providers applying for a DEA license. This presentation can be applied to that content. Objectives of this presentation. Describe low-threshold treatment for opioid use disorder. Identify medications used in low-threshold treatment. Summarize social support strategies in low-threshold treatment. Nationally, the epidemic still rages from overdose deaths. In this slide, you can see that numbers among all ages by gender, from 1999 to 2021, that over 107,000 overdose deaths, there were more men than women that had overdose deaths. The opioid epidemic has raged for over two decades. As you can see, we are in our fourth wave of overdose deaths. First wave was derived from prescription opioid overdose. Second wave due to heroin. The third wave due to synthetic opioid overdose, such as fentanyl. And now in our fourth wave, we're dealing with stimulants such as cocaine and methamphetamines that are often laced with illicit fentanyl. Opioid use disorder. Medication for opiate use involves methadone, buprenorphine, naltrexone. These are the three FDA approved medication for opiate addiction, overdose, and withdrawal. The opiate receptor agonist, methadone, attaches to the opiate receptor in the brain to block withdrawal symptoms and cravings. Buprenorphine is an opioid partial agonist. The medication attaches to the receptor and actually deactivates the agonist drug, which also often leads to a precipitous withdrawal. And you have the opioid receptor antagonist, naltrexone, which completely blocks the receptor. There are also medicines that are used to prevent or mitigate the withdrawal symptoms, such as lopoxadine, a medication that attaches and activates adjunct receptors in the brain that helps alleviate withdrawal symptoms. Now, methadone is given daily by liquid or tablets. Buprenorphine is given daily by or monthly injections. Naltrexone is a monthly injection. And buprenorphine films on their tongue can be given at home. And of course, naltrexone is, naloxone is a great emergency nasal spray for emergency reversal. Medication for opiate use disorder is effective at combining the opiate epidemic. It curbs opiate cravings, it decreases opiate overdose rates, and it decreases deaths. Now, despite the benefit of MAUD, it is estimated that out of 2.7 million individuals that die and those with opiate use disorder, only 25% receive the medication nationwide. So there's a huge, tremendous treatment gap for those that are requiring the treatment and those that are actually able to get MAUD. And how we must attack that is by getting more providers able to prescribe and give this life-saving medication. The gap. Assess the access to treatment. There's a huge gap in the rigid requirements for treatment time since last use, testing, removal, the ex waivers. These are barriers to access of MAUD, the life-saving MAUD. There's treatment stigmas, you know, that people that have opiate use disorder are junkies, they're addicts, they don't deserve treatment. Now, I always relate that opiate use disorder is a chronic health condition. And somebody that had high blood pressure or had diabetes, if they, if somebody had diabetes, ate a chocolate bar, we stopped them from their taking their medication. If somebody that had high blood pressure, if they constantly continued to eat salty foods, we take them off their blood pressure medication. It is a chronic condition that is going to have shifts from compliance to non-compliance to actually good outcomes. So that that continuum needs to be embraced and accepted that at low threshold treatment allows one to access that life-saving treatment. Is the patient involved? Having the patient involved in choosing that medication that they feel is best. Having the patient involved in selection of the facility where they want to go. Is there location flexibility? You know, addressing these gaps removes the barriers and addresses the access to patients that have substance use disorder, opiate use disorder, their ability to have access to this life-saving medication of medication for opiate use disorder. Now, what is what is low threshold? What is high threshold or low barrier and high barrier models of care? And we can see low barriers are, for example, are medications first. One gets there, they go into, they have, they have a problem, they've identified what substance use disorder, they get the medication first. It's not a waiting period to wait them, watch them going to withdrawal to start dosing. Home initiation is permitted. You don't have to go in to the facility. You don't have to go into the office. You can start the medication via home. There's various medication formulas offered. You know, one patient might choose what's best for him. They might start on methadone and then they commute to buprenorphine. So they have those options. It's patient-centered, individualized mode dosage. In other words, what dose is going to be best for me? Whether it's, I'm taking buprenorphine, is it four milligrams, is it 16 milligrams, is it 24 milligrams? What dose is going to be best? Rapid re-initiation medication after short-term disruption. If one stops going and getting the medication that they can go back, they can re-entry. So it's not a, if I stop taking this medication, I no longer can have access. So that's what low threshold allows one to have continuous access to that medication. Well, high threshold or high barriers, two or more visits before medication. So in other words, you have to demonstrate that you are persistent just to get a medication. And the clinic initiation is required. So it's not that you have one individual has to go into the clinic, individual has to go into the doctor's office to get the treatment. There's a limited medication formula, formulation options. In other words, there's a limit on amount of medication that one can get. There's a uniform maximum dosage. The induction required to restart a medication. In other words, if one goes and stops, they have to start from the beginning. In other words, with the induction process. So that's something to understanding. Low threshold, low barrier, also called, is going to increase access, improve access to life-saving mod training, mod access, and it's going to give patients that have opiate use disorder, it's going to improve their outcomes. Again, low threshold removes barriers to access. It removes the rigid requirements. It's harm reduction strategy, such as allowing needles to change, allowing naltrexone, allowing one to continue taking their medication while you're starting mod. It's patient-centered. Patients have the option of actually choosing which medicine they want to, where they would like to go, whether they would like to go, if it's methadone, where they like to go every day, or if it's buprenorphine, they can take home or go in the office. There's location flexibility of care. Oftentimes there's mobile units that are able to distribute medication for opiate use disorder. The rigid requirements are removed. Recently, the ex-waiver prescription for prescribing has been removed. It does not require one individual to be abstinence. Abstinence is the complete elimination of any kind of illicit drugs. Again, with low threshold treatment, one can still... We know that substance use disorder really often involves what polysubstance one might smoke, one might drink. Very rarely, it's a monotherapeutic or just one substance that is involved. Oftentimes, a patient that might be on mod might still be on cannabis. They might still be drinking. It's not a barrier if one does not stay abstinent, but you still have access to this life-saving medication. Elimination of counseling. Oftentimes, with MAT, it requires you... Medication-assisted treatment. It required that medicine with the behavior therapy or therapy had to be attached in order for you to get the medication. Of course, there's benefit to that because that reinforces peer support and reinforces the changing behavior aspect. However, if one does not get counseling, it should not prohibit them from getting the medication. The no-urine toxicology. Oftentimes, goes to these centers and they have to have a urine toxicology. If one ends up having a non-clean toxicology, then they won't have access to that medication. It's a barrier. Eliminating that no-urine toxicology is a way to increase access to that medication. The ex-waiver was signed on the bus bill and it removed the requirements for practitioners to submit a notice of intent to have a waiver. This is huge because it really increases access to patients to multiple providers so they can get this life-saving medication. Now, when we think about substance use disorder, we think about a continuum. That continuum that can be seen here, whether we are abstinent, whether we experimental use, whether we use by social occasions, whether we're prescribed, whether we're probably going to use where we get that prescribed prescription and we continue to use it outside the prescription illicitly. When we become dependent and that continuum can go along the spectrum. When we're talking about our treatment, when we talk about opiates disorder, it's a chronic condition. One might find their self on the continuum at any point in time. What's important when we think about the treatment and the recovery process is that we have access to this medication and that just like with any other chronic condition, there's going to be times that there's compliance, there's non-compliance and there's the ultimate goal is that we are giving patients access to this life-saving medication so they can go on their road to recovery. Oftentimes, peer support groups such as 12-step and behavior therapy are very important to help mitigate and reinforce the positive behavior of staying off opioids. However, again, sometimes that can be a barrier to access eliminating the requirement for counseling can also increase this. Just the elimination of the urine tests, again, this creates barriers also to access. Oftentimes, patients, again, they're polysubstance abusers so they might be on cannabis, they might be using cocaine but the fact that they're trying to continue to try to be on the medication is a start. And to understanding for providers to understand the continuum, what one might be on at any point in time, is crucial to understanding the road to recovery that must be patient-centered to allow patients to be successful. Again, we must focus on outcomes that are important to the patient. You know, the patient desires to be off of opioids. They desire to be on medication so they can function. They desire to be on this medication so they can function on their daily activities, their job. And so it is a start for recovery that they are being persistent. And I think with any process, it's a start that you have to, it's a building block, it's a scaffold that we build a foundation in each level that we're building upon. And so being patient-focused is key to improving outcomes for people that have opioid use disorder. Now, states that limit take-home medication, it reduces patient flexibility. When there's a limit on the flexibility of taking the medication home, you can see here that oftentimes these states limits take-home medication in the first 39 days of treatment. This decreases the flexibility, which is so crucial to improving outcomes, remaining persistent on medication, and recovering from opioid use disorder. So the flexibility is a low-threshold component that must be addressed. And this flexibility really allows patients to have just increased access to this medication. Now, what does location flexibility involve? That means taking the medicine home. Telehealth. When one gets initiated with buprenorphine, they can do telehealth initiation. So they can be at one part of the state and be initiating, or another part of another state, they can do this telehealth initiation. And that really creates increased access and mobility and access to patients. Mobile units. Oftentimes mobile units, they're even in, um, they can move to different areas that are high concentration of opioid use disorder or substance use disorder patients. So they're able to be mobile and transport to get this medicine to the patient. So really meet the patient's needs by getting them access to this life-saving medication. Embracing non-traditional settings. You know, instead of mainly being at opioid treatment facilities, primary care. Primary care, having access and understanding without the X-waivers and the ability and just getting this eight-hour training will allow them to prescribe and give this medicine to patients. It doesn't always have to be an office-based setting. There's emergency rooms. Now that oftentimes patients come through the emergency room that one can start them on buprenorphine and then follow them up at a facility or just communicate to get that going. There's also new programs such as EMS, Emergency Medical Assistance, where they're actually specially trained EMTs that are trained in opioid use disorder or withdrawals. And they will basically, if they get a call for withdrawal, they will come out to the house of those individuals and they will stay and do an induction at the home. And so this increases access, this decreases overdose deaths, and there's also sometimes they go into the homeless shelters. This really meets patients at their needs. So homeless healthcare treatment sites is a new up-and-coming, non-traditional setting. Again, buprenorphine, they can be taken at home. They often, once a patient gets the medication from the pharmacy, they can take the medicine at home prescribing by the doctor. Telehealth. Telehealth has really transformed since the pandemic. It has really transformed healthcare. Not only can you do telehealth via counseling, but you can also do telehealth with inductions. So there's often ways that one can use telehealth to really increase access to the patient to get the help that they need. These mobile units, again, they're mobile, they're accessible and they really allow providers and healthcare workers to really access the patient in a way that it eliminates the four walls of medical facilities. It eliminates the stigma of, oh, I'm going to this opioid treatment facility. This eliminates that by going to them, going to where they're at, where they need to get the help and allows them to get access to treatment. Now, what do medication use in low threshold treatment? Well, it's usually two methods that are typically used and that's methadone and buprenorphine. Now, we talked about methadone. Methadone is a pure agonist and buprenorphine is a partial antagonist. Of course, methadone has a huge abuse potential and buprenorphine does not have as much abuse potential. It can be abused. It's often attached with naltrexone so the abuse will be limited. But with methadone, it's a complete agonist. However, with buprenorphine, they're partial agonists but it has a huge affinity for the mu receptor and oftentimes when one starts on buprenorphine, the patient, if they recently took an opioid, the opioid will be cleaved off because buprenorphine has such high affinity for the mu receptor and what happens is the patient goes into a precipitous withdrawal. That precipitous withdrawal, of course, patients do not like to be on precipitous withdrawal so oftentimes, many patients will choose methadone over buprenorphine but buprenorphine, of course, methadone has a huge respiratory depression so it has linked to more morbidity and mortality but buprenorphine has a safer profile, less abuse and it has a higher, it has a ceiling effect where no matter how much medicine you give, it's not gonna cause a respiratory depression. Again, methadone, it's only provided by specialty credentialed opioid treatment programs, OTPs. Patient must show up in person every day to receive the medication. The take home doses are strictly limited and again, it has a high abuse for potential. Again, this is an example of how one, usually opioid treatment facilities, they open up early, early in the morning, like four or five o'clock in the morning and patients get their methadone dose via the windowsill and that's how they have to get it, early in the morning and they have to show up every day to get it. Oftentimes, they are required to give a urine sample. Again, with low threshold treatment, that urine sample would not be required because they're seeking to get the needed help and medicine they need. We don't wanna create a barrier for that. Methadone take home flexibility. States can request a blanket exemption for stable patients in an opioid treatment facility to receive up to 28 days of take home doses of methadone. So this is increased since the pandemic. This is a way that we can increase patients to go ahead and take their medication on a consistent basis at a take home. Again, because mainly with methadone, one has to go to the opioid treatment facility to take the medication. But if one has been stable, they can request a blanket statement and patients can be given this medication for 28 days. There's also a legislation that started in June 1st, 2021, where there's guest dosing allowed OTP patients to travel. So oftentimes, if one had or is on methadone, they were really limited in their travel. They really couldn't go to different states. So it limited one's travel. Now, there's different countries. I mean, different states that you can see that allow guest dosing, especially permitted. So right now it's still limited to the states, but it creates more portability of patients to get access to medication once they communicate with other opioid treatment facilities. Now, buprenorphine is safe. It's effective. It's flexibility, much more than methadone. It supports entry into treatment and removes barriers. You can do telehealth. It has take-home doses, such as buccal patches, some lingual doses. With buprenorphine, with low threshold, it allows one to have same-day treatment options. There's no waiting. You don't have to wait till you're in full withdrawal. There's no waiting to access with this. So really low threshold, really embraces getting access to the patients that need it. So that same-day treatment option. Social support. Family and peers having that social support is so crucial to the success of a patient that has an opioid use disorder. Having that network of people around them will help their recovery. Now, the social contextual factors, such as where they live, where they work, whether they have a job, whether they have a car, are they able to even get to the site if they're trying to get the medication? And understanding the social contextual factors are a bigger part of social determinants of health and understanding that if one does not have a job, if one does not have a facility, then a place to live, and they don't have any food, then their needs, their social contextual needs are gonna be impacted, and it's gonna impact whether they're gonna be successful in the treatment program they're in. So low threshold addresses that. It eliminates some of these barriers, and it also addresses the social contextual component of a patient so that they can get this needed treatment. Now, this is a slide of barriers to prescribing buprenorphine by prescribing and non-prescribing physicians. Again, one of the major things is eliminating the X waiver, but oftentimes still, even though we have removed this, there's still a lack of psychosocial support. There is a time constraint. There's a lack of confidence. That's why education is so important. These eight hours, understanding support, understanding with the medication is key. Resistance from practice partners. Oftentimes, the partners don't wanna get involved with that with primary care. Lack of institutional support. There's concern about reimbursement. Oftentimes, with the lack of Medicaid expansion, there's a concern of reimbursement. Lack of patient's needs. So, understand that patients are crucial in this whole process in adoption of medication for opiate use disorder. It must be patient-centered. That low threshold must be embraced, and it's gonna improve outcomes. Now, in that continuing, engage with organizations and regions. Coordinate warm handoffs upon release. Once one comes out of opiate treatment facilities, or they come out of the ER, that that communication continues on to the next provider. Screening tools. Support during transition period. Again, it's a continuous process. So, having that social contextual support, having that support, having that support system around them is gonna lead them to improve outcomes. It's gonna improve the access to low threshold, and it's gonna increase outcomes of patients that have opiate use disorder. Primary care includes maintenance, mod, social determinants of health. Again, that whole process in low threshold is gonna really help improve the outcomes of those patients. Understanding that primary care is a way that patients can access. With the elimination of X waivers, removing restrictions can allow primary care providers to prescribe this medication. Maintenance of mod. In other words, removing the requirement that one has to be abstinence, that you can have entry in and out of treatment. Understanding the social determinants of health factors, such as where they live, whether they have a home, whether they have transportation. These factors will help or assist one in their recovery. So, that low threshold to take home is gonna remove barriers, it's gonna increase access to life-saving treatment, and it's gonna give the patient that has opiate use disorder, in that continuum, that chronic health condition, ways to continue to access the treatment. And right here are resources that are very important that one might be abuse provider clinical support system, the Substance Abuse and Mental Health, SAMHSA, American Academy of Addiction, American Society of Addiction Medicine, and American Osteopathic Academy of Addiction Medicine. So these are resources that one might use to get more resources for understanding low threshold in ways that we are using to increase access. Thank you.

opioid use disorder

low-threshold treatment

methadone

buprenorphine

naltrexone

social support

primary care