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PCSS-MAT CHAT Webinar: Forensic Issues with Buprenorphine

Friday, May 22, 2015

Laurence Westreich, MD | Associate Clinical Professor of Psychiatry Division of Alcoholism and Drug Abuse, Department of Psychiatry, New York University School

of Medicine

Michael Gendel, MD | Associate Clinical Professor of Psychiatry, University of Colorado, Denver Medical Director Emeritus, Colorado Physician Health Program

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Laurence Westreich, MD and

Michael Gendel, MD Disclosures • Laurence Westreich, MD has no financial relationships

to disclose.

• Michael Gendel, MD has no financial relationships to disclose.

The contents of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.

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Planning Committee, Disclosures

AAAP aims to provide educational information that is balanced, independent, objective and free of bias and based on evidence. In order to resolve any identified Conflicts of Interest, disclosure information from all planners, faculty and anyone in the position to control content is provided during the planning process to ensure resolution of any identified conflicts. This disclosure information is listed below:

The following developers and planning committee members have reported that they have no commercial relationships relevant to the content of this module to disclose: PCSSMAT lead contributors Frances Levin, MD and Adam Bisaga, MD; AAAP CME/CPD Committee Members Dean Krahn, MD, Kevin Sevarino, MD, PhD, Tim Fong, MD, Tom Kosten, MD, Joji Suzuki, MD; and AAAP Staff Kathryn Cates-Wessel, Miriam Giles and Blair-Victoria Dutra.

All faculty have been advised that any recommendations involving clinical medicine must be based on evidence that is accepted within the profession of medicine as adequate justification for their indications and contraindications in the care of patients. All scientific research referred to, reported, or used in the presentation must conform to the generally accepted standards of experimental design, data collection, and analysis. Speakers must inform the learners if their presentation will include discussion of unlabeled/investigational use of commercial products.

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Target Audience

• The overarching goal of PCSS-MAT is to make available the most effective medication-assisted treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings.

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Educational Objectives

• At the conclusion of this activity participants should be able to: Recognize buprenorphine-specific Informed

Consent themes Construct a coherent office policy for prescribing

buprenorphine Collaborate with psychiatrists, therapists, and

pain specialists Manage unusual buprenorphine regimens Minimize the risk of inappropriate prescribing and

diversion

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Introduction

• What is the value of Buprenorphine? • What has been my experience with buprenorphine? • We will be “skimming the surface” on the below

questions, but leave time at the end for more in-depth discussion.

• Legal disclaimer – we are not giving legal advice, only relating our experience

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Informed Consent for Buprenorphine

• Usual informed consent • Buprenorphine- specific points

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DATA-2000 Waiver

• Genesis of the DATA-2000 Act • Absolute necessity for having the waiver in place

before prescribing • Where to obtain training

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Record-keeping requirements

• Usual record-keeping • Preparing for an office visit • Enhanced scrutiny of opioid record-keeping

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Office rules for prescribing buprenorphine

• Early prescriptions, lost prescriptions, dosage changes, etc.

• Having a coherent and structured policy

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DEA rules for prescribing opiates

• Exceptions (3-day waiver) • Political issues with opiates • Prescribing opiates for pain

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Collaboration with colleagues

• Pain-management physicians, therapists, other prescribers

• Challenges in finding and working with knowledgeable colleagues

• Assessing a colleagues’ skill set • Need to document collaboration, or attempts to

collaborate • Documentation

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State Pharmacy Management Programs

• Affirmative obligation to check • Making this a part of the office visit

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Urine Drug Screens for Buprenorphine patients

• Lab screens: clinical v forensic • POS screens • Evading UDS • Mechanics of POS screens • Office collection v lab collection

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How to manage unusual treatment regimens

• High dosages, uncommon indications, combinations with other medications)

• Consultation w/colleagues

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DEA office visits for Buprenorphine prescribers

• Emotional responses to inspection • Role of the DEA

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Confidentiality issues in contacting family members

• HIPAA, 42 CFR

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Discharging a Patient

• General Principles: Clear rationale, Offer help in finding treatment elsewhere, time frame, consider patient’s needs

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Diversion of buprenorphine

• UDS • Keeping track of prescriptions • Problematic usage/diversion of buprenorphine or

other opiates: who to help while still protecting oneself

• Health care workers who divert to themselves • Reporting obligations are state-specific – know

yours!

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Using buprenorphine in the management of opioid-addicted doctors

• Liaison with Physician’s Health Programs

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Comments on off-label uses, advantages and risks

• Caution!

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Questions

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References

• Boothby L , Paul L. Doering P :Buprenorphine for the treatment of opioid dependence.doi: 10.2146/ajhp060403 American Journal of Health-System Pharmacy February 1, 2007 vol. 64 no. 3 266-272

• Clinical Guidelines for the Use of Buprenorphine in the Treatment of Opioid Addiction TIP 40 http://buprenorphine.samhsa.gov/Bup_Guidelines.pdf

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PCSS-MAT Mentoring Program

• PCSS-MAT Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid addiction.

• PCSS-MAT Mentors comprise a national network of trained providers with expertise in medication-assisted treatment, addictions and clinical education.

• Our 3-tiered mentoring approach allows every mentor/mentee relationship to be unique and catered to the specific needs of both parties.

• The mentoring program is available, at no cost to providers.

For more information on requesting or becoming a mentor visit:

pcssmat.org/mentoring

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Funding for this initiative was made possible (in part) by Providers’ Clinical Support System for Medication Assisted Treatment (5U79TI024697) from SAMHSA. The views expressed in written

conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names,

commercial practices, or organizations imply endorsement by the U.S. Government.

PCSSMAT is a collaborative effort led by American Academy of Addiction Psychiatry (AAAP) in partnership with: American

Osteopathic Academy of Addiction Medicine (AOAAM), American Psychiatric Association (APA), American Society of

Addiction Medicine (ASAM) and Association for Medical Education and Research in Substance Abuse (AMERSA).

For More Information: www.pcssmat.org

Twitter: @PCSSProjects