Implementation of a collaborative care management program with buprenorphine in primary care: A comparison between opioid-dependent patients and patients with chronic pain using opioids nonmedically

Authors

  • Joji Suzuki, MD
  • Michele L. Matthews, PharmD
  • David Brick, BA
  • Minh-Thuy Nguyen
  • Robert N. N. Jamison, PhD
  • Andrew L. Ellner, MD, MSc
  • Lori W. Tishler, MD
  • Roger D. Weiss, MD

DOI:

https://doi.org/10.5055/jom.2014.0204

Keywords:

opioid dependence, collaborative care management, buprenorphine, nonmedical use of opioids, primary care

Abstract

Objective: To implement a collaborative care management program with buprenorphine in a primary care clinic.

Design: Prospective observational study.

Setting: A busy urban academic primary care clinic affiliated with a tertiary care hospital.

Participants: Opioid-dependent patients or patients with chronic pain using opioids nonmedically were recruited for the study. A total of 45 participants enrolled.

Interventions: Patients were treated with buprenorphine and managed by a supervising psychiatrist, pharmacist care manager, and health coaches. The care manager conducted buprenorphine inductions and all follow-up visits. Health coaches offered telephonic support. The psychiatrist supervised both the care manager and health coaches.

Main outcome measures: Primary outcomes were treatment retention at 6 months, and change in the proportion of aberrant toxicology results and opioid craving scores from baseline to 6 months. After data collection, clinical outcomes were compared between opioid-dependent patients and patients with chronic pain using opioids nonmedically. Overall, 55.0 percent of participants (25/45) remained in treatment at 6 months. Primary care physicians (PCPs)' attitudes about opioid dependence treatment were surveyed at baseline and at 18 months.

Results: Forty-three patients (95.6 percent) accepted treatment and 25 (55.0 percent) remained in treatment at 6 months. The proportion of aberrant urine toxicology results decreased significantly from baseline to 6 months (p < 0.01). Craving scores significantly decreased from baseline to 6 months (p < 0.01). Opioid-dependent patients, as opposed to patients with chronic pain using opioids nonmedically, were significantly more likely to complete 6 months of treatment (p < 0.05). PCPs' confidence in treating opioid dependence in primary care increased significantly from baseline to 18 months postimplementation (p < 0.01).

Conclusion: Collaborative care management for opioid dependence with buprenorphine may be feasible in a primary care clinic. More research is needed to understand the role of buprenorphine in managing patients with chronic pain using opioids nonmedically.

Author Biographies

Joji Suzuki, MD

Instructor in Psychiatry, Harvard Medical School, Boston, Massachusetts; Division of Addiction Psychiatry, Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts.

Michele L. Matthews, PharmD

Associate Professor of Pharmacy Practice, Massachusetts College of Pharmacy and Health Sciences University, Boston, Massachusetts; Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts.

David Brick, BA

Harvard Medical School Center for Primary Care, Boston, Massachusetts

Minh-Thuy Nguyen

Harvard Medical School Center for Primary Care, Boston, Massachusetts.

Robert N. N. Jamison, PhD

Professor of Anesthesia, Harvard Medical School, Boston, Massachusetts; Department of Psychiatry, Brigham and Women's Hospital, Boston, Massachusetts; Department of Anesthesia, Perioperative, and Pain Medicine, Brigham and Women's Hospital, Boston, Massachusetts

Andrew L. Ellner, MD, MSc

Instructor in Medicine, Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts; Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts

Lori W. Tishler, MD

Assistant Professor of Medicine, Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts

Roger D. Weiss, MD

Professor of Psychiatry, Harvard Medical School, Boston, Massachusetts; Division of Alcohol and Drug Abuse, McLean Hospital, Belmont, Massachusetts

References

Substance Abuse and Mental Health Services Administration: Results from the 2011 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-44, HHS Publication No. (SMA) 12-4713. [Internet]. Substance Abuse and Mental Health Services Administration; 2012. Available at http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011.htm. Accessed July 23, 2013.

Clark HW: Office-based practice and opioid-use disorders. N Engl J Med. 2003; 349(10): 928 - 930.

Greene P: Outpatient drug utilization trends for buprenorphine years 2002-2009 [Internet]. 2010. Available at http://buprenorphine.samhsa.gov/bwns/2010_presentations_pdf/09_greene_508.pdf. Accessed August 30, 2012.

Furlan AD, Sandoval JA, Mailis-Gagnon A, et al.: Opioids for chronic noncancer pain: A meta-analysis of effectiveness and side effects. CMAJ. 2006; 174(11): 1589 - 1594.

Højsted J, Sjøgren P: Addiction to opioids in chronic pain patients: A literature review. Eur J Pain Lond Engl. 2007; 11(5): 490 - 518.

Chou R, Fanciullo GJ, Fine PG, et al.: Opioids for chronic noncancer pain: Prediction and identification of aberrant drugrelated behaviors: A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain Off J Am Pain Soc. 2009; 10(2): 131 -146.

Malinoff HL, Barkin RL, Wilson G: Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005; 12(5): 379 - 384.

Berland DW, Malinoff HL, Weiner MA, et al.: When opioids fail in chronic pain management: The role for buprenorphine and hospitalization. Am J Ther. 2013; 20(4): 316 - 321.

Roux P, Sullivan MA, Cohen J, et al.: Buprenorphine/naloxone as a promising therapeutic option for opioid abusing patients with chronic pain: Reduction of pain, opioid withdrawal symptoms, and abuse liability of oral oxycodone. Pain. 2013; 154(8): 1442 - 1448.

Rosenblum A, Cruciani RA, Strain EC, et al.: Sublingual buprenorphine/naloxone for chronic pain in at-risk patients: Development and pilot test of a clinical protocol. J Opioid Manag. 2012; 8(6): 369 - 382.

Walley AY, Alperen JK, Cheng DM, et al.: Office-based management of opioid dependence with buprenorphine: Clinical practices and barriers. J Gen Intern Med. 2008; 23(9): 1393 - 1398.

Gilbody S, Bower P, Fletcher J, et al.: Collaborative care for depression: A cumulative meta-analysis and review of longerterm outcomes. Arch Intern Med. 2006; 166(22): 2314 - 2321.

Von Korff M, Gruman J, Schaefer J, et al.: Collaborative management of chronic illness. Ann Intern Med. 1997; 127 (12): 1097 - 1102.

Katon W, Von Korff M, Lin E, et al.: Collaborative management to achieve depression treatment guidelines. J Clin Psychiatry. 1997; 58 (Suppl 1): 20 - 23.

Unützer J, Katon W, Callahan CM, et al.: Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. JAMA. 2002; 288(22): 2836 - 2845.

Roy-Byrne PP, Katon W, Cowley DS, et al.: A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Arch Gen Psychiatry. 2001; 58(9): 869 - 876.

Dobscha SK, Corson K, Perrin NA, et al.: Collaborative care for chronic pain in primary care: A cluster randomized trial. JAMA. 2009; 301(12): 1242 - 1252.

Alford DP, LaBelle CT, Kretsch N, et al.: Collaborative care of opioid-addicted patients in primary care using buprenorphine: Five-year experience. Arch Intern Med. 2011; 171(5): 425 - 431.

Miller W, Rollnick SR: Motivational Interviewing: Helping People Change. 3rd ed. New York, NY: Guilford Press, 2013.

Hettema J, Steele J, Miller WR: Motivational interviewing. Annu Rev Clin Psychol. 2005; 1: 91 - 111.

Britt E, Hudson SM, Blampied NM: Motivational interviewing in health settings: A review. Patient Educ Couns. 2004; 53(2): 147 - 155.

Center for Substance Abuse Treatment: Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2004.

Cleeland CS, Ryan KM: Pain assessment: Global use of the Brief Pain Inventory. Ann Acad Med Singapore. 1994; 23(2): 129 - 138.

Chien C-W, Bagraith KS, Khan A, et al.: Comparative responsiveness of verbal and numerical rating scales to measure pain intensity in patients with chronic pain. J Pain Off J Am Pain Soc. 2013; 14(12): 1653 - 1662.

Jensen MP, Turner LR, Turner JA, et al.: The use of multiple-item scales for pain intensity measurement in chronic pain patients. Pain. 1996; 67(1): 35 - 40.

Weiss RD, Griffin ML, Mazurick C, et al.: The relationship between cocaine craving, psychosocial treatment, and subsequent cocaine use. Am J Psychiatry. 2003; 160(7): 1320 - 1325.

Fiellin DA, Pantalon MV, Chawarski MC, et al.: Counseling plus buprenorphine-naloxone maintenance therapy for opioid dependence. N Engl J Med. 2006; 355 (4): 365 - 374.

Mintzer IL, Eisenberg M, Terra M, et al.: Treating opioid addiction with buprenorphine-naloxone in community-based primary care settings. Ann Fam Med. 2007; 5 (2): 146 - 150.

Jamison RN, Ross EL, Michna E, et al.: Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial. Pain. 2010; 150 (3): 390 - 400.

Dreifuss JA, Griffin ML, Frost K, et al.: Patient characteristics associated with buprenorphine/naloxone treatment outcome for prescription opioid dependence: Results from a multisite study. Drug Alcohol Depend. 2013; 131 (1-2): 112 - 118.

Pergolizzi J, Aloisi AM, Dahan A, et al.: Current knowledge of buprenorphine and its unique pharmacological profile. Pain Pract Off J World Inst Pain. 2010; 10 (5): 428 - 450.

Weiss RD, Potter JS, Fiellin DA, et al.: Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: A 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011; 68 (12): 1238 - 1246.

Fiellin DA, Barry DT, Sullivan LE, et al.: A randomized trial of cognitive behavioral therapy in primary care-based buprenorphine. Am J Med. 2013; 126 (1): 74.e11 - 74.e17.

Ling W, Hillhouse M, Ang A, et al.: C omparison of behavioral treatment conditions in buprenorphine maintenance. Addiction. 2013; 108 (10): 1788 - 1798.

Published

05/01/2014

How to Cite

Suzuki, MD, J., M. L. Matthews, PharmD, D. Brick, BA, M.-T. Nguyen, R. N. N. Jamison, PhD, A. L. Ellner, MD, MSc, L. W. Tishler, MD, and R. D. Weiss, MD. “Implementation of a Collaborative Care Management Program With Buprenorphine in Primary Care: A Comparison Between Opioid-Dependent Patients and Patients With Chronic Pain Using Opioids Nonmedically”. Journal of Opioid Management, vol. 10, no. 3, May 2014, pp. 159-68, doi:10.5055/jom.2014.0204.

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