All right, well, it's 5 o'clock and I think we'll get started for our webinar this afternoon and evening, depending on where you are in the country. Welcome to our third webinar in the series, Testimony from the Trenches, Innovations in Clinical Practice. This current series is examining new ways of delivering medication for opioid use disorder. I am John Lepley, president-elect of the AOAAM and moderator for this webinar. These webinars are designed to deliver a didactic component for the first half of the webinar. That portion is recorded and will be available on the AOAAM website learning management system. Please do remember to take the survey after this webinar so that you can claim your CME certificate. Following the presentation, we will stop the recording and we will ask that attendees interact with our speaker and myself and all other attendees to inform us about your experience with the topic at hand. This collaborative discussion component will not be recorded, so feel free to speak your mind and feel free to change your mind throughout the course of the discussion. To speak, please use the raise your hand icon and I will unmute you and give you the ability to speak. Our topic today is Introduction of Medications for Opioid Use Disorder to Patients in Residential Treatment Settings. Our speaker today provides care and serves in a leadership role at the Karen Foundation, which is a highly respected and nationally recognized residential treatment facility. Michael A. McCormick, DO, is the medical director of the Healthcare Professionals Program, a role he took on in January 2020 after serving as the addiction medicine provider for the program since its inception in 2016. He also leads Karen's Healthcare Professional Assessment Program and provides daily care to the inpatient healthcare participants. As the physician in charge of the Opioid Treatment Program, he cares for patients who suffer from a particularly deadly disease, helping them with medication-assisted treatment decisions and induction of treatment. And with that introduction, I will turn it over to Dr. McCormick. We're very fortunate to have him today. Well, thank you, Dr. Lepley. I appreciate that and Judy and certainly the AOAAM for asking me to speak today. I do really appreciate the opportunity and look forward to speaking with most of you as we get through this. What a great and relevant topic, buprenorphine use in the residential treatment setting. I've been with Karen, and thank you for the very nice introduction, for about seven and a half, eight years now, and I've seen such a change and such a movement towards buprenorphine as one of the medication-assisted treatments. And we've even moved over to medication treatment and dropped the A at times in our, really our material and what we have to offer our patients. And it certainly is data-driven and results-driven. And we think that this is an ever-changing field and certainly with this patient population, we do have to consider though how severe the results may or the successes may or may not be and what that means. Everyone on this call knows that that's not, certainly not being dramatic, but this is certainly a huge problem since the pandemic hit. We all know what those numbers have done. They've continued to grow and it's certainly worrisome to all of us in this field. So kind of we'll move around a little bit. I don't really set this up as a, you know, as a typical presentation or typical talk because this really is ever-evolving and sure there certainly is data in there and there certainly are studies in there and there certainly is quite a bit of textbook stuff around these topics. However, there really isn't. It's kind of a little bit of both. And so what I thought today, which would be interesting, was just to give our philosophy, how we go about things and how we do it. And I certainly can learn from some of you, I'm sure, and hopefully I'll help some of you. So the objective is to understand the options in medication-assisted treatment, as we all know, that'll be quick, to create a framework for guiding a patient to the appropriate MAT. That's probably the most difficult decision there and one that we think a lot about and work a lot through and never easy. The detox and induction of buprenorphine, certainly important for all of us. And then really the last one that it sometimes gets overlooked, but to us at Karen is extremely important is the post-discharge referrals. And really what happens with our patients, once they're done typically with the OTP program, part of me, as Dr. Lepley said, that I'm over the opioid treatment program. It's on average about a 28 or 30-day stack. Our healthcare professionals are with us typically for a minimum of six weeks. So we have a little longer with them, but with our OTP patients, and sometimes it's less. Someone's had a relapse and has come in for a quote-unquote stabilization and maybe just 21 days that we have someone and then they're moving to the next level of care. So it's so important. So as we all know for MAT, really three major medications that we can offer people, the buprenorphine products, as we're speaking about today, the naltrexone products, we do use quite a bit of Vivitrol, the injectable naltrexone, and the methadone. And so we at Karen, we do not have the certification for methadone. We don't use it on our campus. We do use the first two, the buprenorphine products and the naltrexone quite a bit. Our philosophy, we can't make any of our patients in the OTP program be on one or the other of this, but really that's what our philosophy and our goal has been, is that everyone will leave on one or the other. We joke at times with them in my visits with them that, you know, I'd love to blow dart a Vivitrol injection or a sublocate or whatever it may be, but you know, we certainly can't do that. And so we have to have a lot of buy-in on the patients. So that's really them trusting in us and trusting that we're going to help them make the right decision for what it can be. I think the biggest thing, the reason I put this up is that a lot of patients may fall between two of these categories. So I think pretty straightforward that most of us know that a patient that may be appropriate for naltrexone or Vivitrol or Suboxone, you know, there certainly are some that are pretty clear cut, I think, you know, would benefit and do well with the naltrexone or the injectable Vivitrol, but maybe they're on the borderline where buprenorphine would make sense for them. And then certainly there are patients that, you know, it does seem to make sense for us that they need to be on buprenorphine and that's pretty straightforward. But then there are some patients that are on the borderline, I would say, of buprenorphine and methadone. We do have a pretty good relationship locally that if we felt a patient would need methadone that we certainly can make that referral for them. I guess the point is that if we feel like, you know, the biggest disservice we can do to someone is if we, or anyone, any of us as healthcare providers, if we feel that someone, you know, really is appropriate for naltrexone and they're on methadone, it's probably not going to work out so well. And vice versa, if, you know, someone probably, you know, really, you know, could benefit from one or the other, you know, that's the last thing that you want to do. So when we go through our detox and induction, certainly the recent history of use is extremely important. So that's amounts, that's what they're using, that's, you know, how soon they use, did they use in the parking lot or did they use 36 hours ago? And I would say that number three, the physical exam, extremely important too, very straightforward for withdrawal type symptoms. And really you get very good at diagnosing and seeing all of those withdrawal symptoms that we read about in the textbooks. And you can kind of follow that process, you know, pretty, it's pretty accurate as they go through it. The personal experience is the third one. And I think that's part of the art of what we do. And that's where, you know, it sounds extremely simplistic, but I talk to these, our patients, it's an all-male unit. We certainly take care of females that have opioid use disorders as well. But the OTP unit is an all-male unit currently. And I'll talk to them because a lot have been through detox and have been through treatment before. And we'll talk about how many hours from your last use, depending on what they've used and how soon we can induce them with the buprenorphine. So we can start that induction period and that's very, very important. So they do have a lot of knowledge. They're extremely honest, I think at most points then, sure. Certainly there'll be a one-off here and there who is looking to get the medicine sooner, but really number four is what keeps them from doing that. And that's a history of precipitated withdrawal. You know, I don't know if any on the phone call have had a patient with that. Now, we, our experience at Cairn is an interesting one. Really up until about 18 months ago, I can remember for the previous five to six years, and this is not an exaggeration, maybe two or three patients that went in the precipitated withdrawal. Over the last 18 months, that's really changed. And that's, you know, as we, you know, and as all of us on this call kind of experiences the use of fentanyl and, you know, despite the short half-life, it certainly has that longer acting. So we push patients out, whether it's, you know, our standard that we used to use was about 24 hours. And now that's really not true anymore. It's 38 hours, it's 40 hours, it's 34 hours, it's 42 hours. It just depends really on the specific patient, what their Cal score is, how they're doing, because we really want to try to avoid that precipitated withdrawal. Our treatment for precipitated withdrawal, we don't typically send those patients to the ER. They're actually really just, you know, given quite a bit of buprenorphine, and most times it's usually in the 20 to 28 milligram range over, you know, a period of six hours. It ends up being eight hours in that amount of time. With regards to the comfort medications, we give them anything and everything that we can, you know, the straightforward ones, of course, the Tylenol and Motrin, Phenergan, and we will certainly add muscle relaxers if needed. You know, we can only get to a certain level, though, with that, and where we really push them through. Over the last six months, though, I do feel like we've used and I've used more phenobarbital early on with these patients, even without a benzodiazepine history. If they have a benzodiazepine history along with the opiates, I'm going to probably start them on our typical taper right away of the phenobarb, and they're still going to get the intermittent or as-needed phenobarbital doses, but we're going to really use that more liberally with them and try to push them out as far as we can before we give them the buprenorphine. We did use the buprenorphine naloxone pretty routinely for everyone, and really, as our experience has changed over this last year or year and a half, as I discussed, we have now used the monoproduct a lot more, the plain buprenorphine, at times, and then transition them depending on what they are going to do, whether it's going to be stay on maintenance or taper off of that. With regards to our dosing, so what we typically do is give a 4-milligram dose first, at times a 2-milligram dose, but we'll give a 4-milligram dose and see how that reaction is, and then over the next 30 to 45 minutes, they'll be scored again, they'll be followed pretty closely The way, which is interesting, I think the way that we're set up at Karen is that it's almost like a T formation where the detox beds are all right there, and then the medical offices are within 20 or 25 feet, so obviously, if this is going on at night, we're not there, but during the day, there's multiple physicians that are right there that are able to see a patient, make changes, check in on them as the afternoon goes on. One other thing that we've done and we've changed as the opioid, the OTP program got put into place was early discussions about taper versus maintenance, so we do talk to them about that from day one with us going forward, certainly someone's wishes on day one don't always match up with day seven as they're tapering off or day 10, but we do begin that discussion because it helps us to know from a lot of different things of concern where we're going to go with them and what we're going to give them. So the decision, that's what I refer to, and that's what so many of us, and I wish there was a straightforward playbook or game plan for this. A good history really is important, and we do spend the time with them to get that history, what does this use look like, how long has it been, typically what day, is it intravenous now or is it intranasal, which is still such a concern recently, we've had quite a bit of them smoking it, so we get into all of that. With regards to the street bupe versus a program, and that's very often, do you have an exposure to buprenorphine, have you taken Suboxone before, yeah I have, well what is that, is it buying five or $10 strips to get you through until the next day when you can get something or have you been in a program with good therapy, with 12-step recovery, with a physician watching over you, with urine drug screens, all of that, so we really get into that very much. Karen is based, it's a 12-step based facility, many of us are in recovery at that facility as well as our board, so many of us have really been helped by the 12-step of either Alcoholics Anonymous or Narcotics Anonymous, so we talk about that and what that involvement looks like with the patient. And whether there is a true block there or whether someone has, I mean, you know, someone has had experience with meetings and does have a sponsor and has gotten away from that, that factors into our decision making. You know, probably, really one of the most important things, and I wish I could say without fail what the results are, and that's, are they done, you know, that's a dimension for really where they are. Sure, certainly patients, some that come in are one end of the spectrum or the other, but it's probably the middle ones that we're, you know, have the most difficulty with knowing truly what that surrender is and are they done, and I can't answer that, right, none of us can on this, it's really an individual thing, but it's a very important part of our decision and where they are. We do, we talk about overdoses and ER visits and the use of Narcan. And, you know, has it been three times over the last 10 days and it's been recurrent? Has it been, you know, two times over the last five years and what that means and what those situations are? We go through all of that with our patients. As the time progresses, so typically our detox period, they can be with us down there anywhere from, you know, two days to five days in the detox unit. Then they're seen back at the seven to 10 day mark again with me, and that's where we're probably able to more easily dive into the dimension six. And what does it look like when we're going home? You know, what's there? What's the support there? Does this make sense? Or are we going to a sober living or are we going back with mom and dad? Or are we going back with our wife or our husband? Or are we, you know, what is that? But that plays a big part. And that's where we have our team meetings in the mornings with our clinical staff. And they're able to really help us with that because that plays a factor as well, as we all know. With regards to the mental health status, another big issue, right? We, when I started at Karen, you know, these statistics, we were around 63 or 64% with co-occurring disorders. And now we're in the high 80s. I mean, that's just a huge number. And all of you that are taking care of patients on this call know that. You're seeing this on a daily basis. So what I mean by that is, where are we with that? You know, we have a very active psychology department and a great psychiatry department. And with them, we're able to really, you know, as best as we can in that amount of time, get a good diagnosis, figure out where we are with them, and then begin a treatment plan or continue one, really, if they're already on medications. You know, you all know this slide, right? So obviously the sublingual tabs and films are, you know, extremely universal. We use both at our facility, both the tabs and the films, the monoproduct we have as well. But we do work with our patients, and maybe some of you don't have the difficulty with prescribing that and finding pharmacies and everything on the outside. We really try, unless there's a true allergy, which, you know, we've seen some, you know, but a lot it's, they tell you that it's the taste or it's that, and then we talk about the, you know, proper way to take the medication and that you're not swallowing that. And, you know, is it ideal, or can our patients sit out there for 15 minutes leaning forward in the chair, wash out their mouth before, spit it out, wash out their mouth again? No, that's not realistic when, you know, you have 30 to 40 patients coming over for tapers. And so that's all I'm not gonna try to play, we do it and give the medicine and they take the medicine exactly as it's supposed to be done. That's just not really true. The injectable buprenorphine has become a lot more, I wanna say popular, or the patients know more about it. We right now are not set up at Caring to do that. And that's just, you know, just an institutional thing. However, we do have a good relationship with one of the larger groups locally, and we've been able to. So we have patients that will come in who have received the sublocate injection, have had trouble in their recovery and have fallen off and have used again. But we're able to get them a shot a few times on a few occasions, actually, while they're with us, we're able to take them over by car, get that injection a day or two before discharge if they're going to a sober living or they're going somewhere not back home, which is pretty great. But we're able to talk to them about that. You know, a lot of them are asking about, hey, can I get this? It's an easier withdrawal and everything. So we talk through all of that with them and different ways that it's handled as an outpatient. But right now we're not set up to give the injectable. I know there are studies and papers recently about it used as a withdrawal management. We don't have it currently at Caring, but it's certainly a great program. So where do we land? As I said, we start with, and I apologize, I'll go back to it. We start with a four milligram dose and then give another four milligram at about a half hour, 45 minutes after that first one. We do wait several hours, usually four to six hours to give that third four milligram on that first day. If it's earlier in the day, they may get another four milligram that evening. So you're at 16 for that day. It just depends. We have some patients who get eight and it seems to settle them and they seem to be in a good spot. But I would say on average, it's 12 that first day, 12 milligrams that we give. So where is the sweet spot with our patients? And this is one that I think is a good one to discuss in the fact that we have some patients that wanna be on two milligrams or four milligrams or six milligrams, but we talk about the second part, which is the scientific discussion. We talk about the coverage of bathing those receptors and decreasing the cravings and getting them what they need. Many patients come to us and say four milligrams is what I need, that's the dose I need. And we kind of talk about the science with them. It's not that we're looking to increase their dose, but at the same time, if they're gonna be on the medication, we really wanna deliver the appropriate dose of medication. We use buprenorphine a lot as well, just as a side for chronic pain. And that typically is two milligram doses, anywhere from four to six times a day. I would say we average around three or four times a day. That's because we do get some post-op patients and we have a large chronic pain program. So we get a lot of those patients and transition them over to that. But when I talk about the scientific discussion, maybe we're just lucky, I don't think so, because these patients are extremely well-educated and they're able to really understand what it means and coverage of the receptors. And they get all of that, pretty unbelievable, truthfully. So they get it, it's funny. They know the difference between 12 milligrams and 16 milligrams. And some of them will say to me, I know 24 doesn't make any sense. Like that blows my mind that they're, I don't even have to talk to them about that. And they say, I used to get three strips a day, but I was selling the one and I'm like, yeah, that's pretty much unfortunately what can happen. Some patients do need 20 milligrams a day though, please don't get me wrong. Everyone's individualized and different. We don't put them all in a box. The duration of treatment is a great, really a great discussion. So we like, our recommendation is for a minimum, a minimum, we don't put a set time of one year of either the Vivitrol or the buprenorphine once they leave our facility. As many on this call know, it could be two years, three years, it could be anything like that. But when we talk to them about it, the weaning process, if they're on maintenance, we will discuss that to get off of a dose of buprenorphine will take typically at least a nine to 12 month period if done correctly and done the right way as an outpatient. So they do have all that information going in before they make their decision about the maintenance versus the taper. Our taper is a little quicker. It's a six or seven day taper. We're able to do that because we have the support right there for them. I mean, literally there's a lot of support on that backend as you can imagine, that goes into that. Many, you know, very frequently, I'll see them several times. And as we taper down from 12 milligrams, which is our starting dose down to off, we may extend the two milligram doses a few days. We may give one milligram dose for several days. We kind of, or we may stop at the fours, the two and twos and extend that out longer then extend, you know, three or four days, then extend the two milligrams out three or four days, then a milligram out three or four days. It just depends. And that's why, you know, there's not a textbook. There's not a set way of doing this. It's just what we do. And it seems to be working quite well, but you know, it's a lot of communication with not only the staff, how they're doing, the clinical staff, the psychologists, but also in the nurses, but with the patients. So there's a lot of frequent visits with them. You know, with regards to the neurocognitive discussion, where we see that, that's when I put my other hat on with dealing with the healthcare professionals. So dealing with nurses and physicians and dentists and where is it in the safety sensitive profession and what we do. And so we do more, I'll speak for the state of Pennsylvania. You know, if the safety sensitive professional is on the medication, it does, you know, require good neurocognitive testing, which we do before they're discharged. And, you know, I can think of three over the last year and all have done quite well on the testing. Their doses were in the eight to 10 milligram range a day. It's not as, you know, we're seeing a whole heck of a lot more of that. You know, we have 20 patients up there at a time. So, you know, we're seeing hundreds of patients a year. So it's not a large percentage. I think that the biggest thing that we see with our OTP program though is the third question is, you know, what happens if I'm drug tested by my employer? What will that show up? We talk about five panels and 10 panels and 17 panels. You know, we go through all of those specifics with them and try to give them as much information as they can. And the reason they're asking is what do I have to or not disclose to my employer? And that's how we kind of walk through that with them. So good, yeah, big one is the public perception, right? So very frequently I speak to families, I speak to spouses, speak to parents because the most common thing, which, you know, many of you may hear is, you know, I sent my son there to get off of, you know, the opiates and now he's trading one for the other. So it's a very, very big job or a big deal for the educational portion of this. And so we do, we really try to work with families. Our family program is, you know, extensive. It's changed, of course, with COVID. It used to be in person, it's now virtual, but we really work with the education with that. And we look at long-term. So we've had some difficult discussions with family. You know, let's look at the last three years. What does this look like at home? You know, let's talk about the two overdoses, the Narcan ones in the basement, you know, what's going on and what's the best decision to allow your son, your husband, your father, you know, to get better from this disease without those things occurring. It's very difficult. The family input is tough. It's a, you know, you know, we've even had patients who've come in who are on buprenorphine maintenance and are using around that, of course, and with their opiates. And so, you know, a family member, a wife, a parent will say like, I don't understand, I sent them to you to get off this. And they're angry at first, but with a lot of patients and a lot of talking to them, we're able to help them kind of through that. The 12-step biases is certainly one that we talk to them about. You know, I had a patient a year and a half ago who was doing quite well in NA and was sponsoring guys and had been on buprenorphine for three years. And somehow he hadn't shared it with his sponsor, which was probably his mistake, nor his network. And when he shared it in a meeting, it was almost like he was ostracized and unfortunately led him back to using overdose and got back to us. So we talk upfront a lot about that, about, you know, your small network, whether it's your sponsor and those of you that are close with you in recovery, let's really talk about how to address it with them and how to discuss with them, hey, I'm on this product or I'm not. We do even get some people that talk about Vivitrol or naltrexone and how that's looked down upon. So, you know, to me, that's something that's real and it's something that we have to address with them and help them, you know, right or wrong. I talk to them, you know, I'm a guy in recovery myself. And so we talk about that recovery is all about honesty, right? It's all about honesty and self-disclosure and vulnerability and all of that. But at times, and I say to them, guys, I don't know if I'm right or wrong here, but I don't know that everyone needs to know that you're on buprenorphine if you're doing well and you're doing everything you can. You know, we talk about, you know, if you're getting your tablets and you're crushing them and snorting them or you're melting down your strips and you're shooting them, you're probably not in recovery and you're not taking the medication the right way. That's a different story. But if you're taking that medication as prescribed and you're doing all of the next right things and you're working the steps and you're doing well, you know, I really think that that's what's most important and that you continue on. Things have changed, you know, it's very different. The way that I may have gone through this process, I can't put that on these, you know, these patients now. It's just not the right thing to do. And that's kind of the open-mindedness. This is far from an advertisement for Karen, but that's the open-mindedness and the ability for us to evolve and change as an institution and go from a purely abstinence 12-step-based program to what we're seeing today. So I think that's a really good one. The post-discharge plan, very important too. You know, they do all this work. You get them through the time with us. And what do we do then? Well, for us, when I put that to good like-minded doc, we did a lot of work over, you know, probably two years ago, two and a half years ago, when we opened this community or program there to find docs all over. And we have a lot of, you know, we get our patients from all over the place, but we've got certain physicians in certain areas that we feel very comfortable with handing them off to. The warm handoff is an easy one. I mean, we do make a lot of calls and say, hey, you know, Joe Blow is coming to you. Here's what he did. Here's how he did during it. And really that two or three minute or five minute call goes a long way. And we feel very comfortable with that. You know, for us, it's very important that they do get plugged into a group or individual therapy, whether they need it, you know, or what they need particular, I guess is what I should say, excuse me. A lot of our patients go to Sober Living. So, you know, many of you may run into that trouble. We have a list of Sober Living facilities that take the tabs and films and that don't. And then we have a list that takes Sublicate but doesn't. And so that always plays in. The IOP, obviously, if it's important, the family involvement and buy-in, extremely important as well. And that's part of the educational. And so we have those hard discussions with the family while they're with us. And that's usually around day 14 to 21 because we don't want them, we don't want to have any family involvement. You discharge them home and they're like, hey, I've got to go to the pharmacy and fill my prescription. And then they're having a conversation in the car that, you know, could just get completely out of control. They get frustrated. And then we just lost 30 days and who knows what. 12-step involvement, very important to us. You know, a 12-step recovery program with a sponsor, a sponsor who has a sponsor, step work. You know, we really, it's very important to us for continued treatment because as we all know, you know, time and treatment is directly proportional to success and recovery. And so that's really where we like that to kind of continue on. So, sorry, really ran through that, but I didn't want to spend too much time because I look forward to the discussion because I know this is a very good topic and relates to so many of us. So thank you all again for allowing me to speak. Really appreciate it. Thank you. That was a great presentation. And I think we can go ahead and stop the recording and then transition to our collaborative discussion.

medications for opioid use disorder

buprenorphine

naltrexone

methadone

personalized approach

post-discharge referrals

medication-assisted treatment