Anne Zeng

In the evolving landscape of primary care, family medicine Medication-Assisted Recovery (MAR) clinics serve as critical access points for people struggling with substance use disorder (SUD). These clinics offer comprehensive, compassionate, evidence-based addiction care. At Miles Square Main (MSM), patients often present with opioid use disorder (OUD) from fentanyl use.

I had the privilege of meeting patients in different stages of their recovery journey, some of whom shared vulnerable stories of the circumstances that led them to fentanyl use. It takes a village–I also met some members of the interdisciplinary team of family medicine physicians, behavioral health experts, social workers and social worker aides, pharmacists, and nurses who serve a central role in addressing OUD in the broader context of our patients’ lives.

In my observations, the team is well-positioned to provide MAR longitudinally. Yet, challenges exist and at times undermine the impact of these essential interventions.

Good design: integrated, comprehensive care

As much as possible, MSM aims to be a “one-stop shop”. Mental health professionals are integrated into the clinical workflow; a “warm handoff” between a family medicine physician and a behavioral health provider can make the difference between a patient getting help versus delayed or missed opportunities to access behavioral health experts. Patients undergoing treatment also need frequent, routine lab work and imaging–all of which are available in the same building as the SUD clinic. Moreover, should a patient express interest in resources like housing, food access, or a variety of basic needs, social worker aides connect patients appropriately. The clinic also engages in partnerships with community organizations and case management. Providers also offer flexible scheduling to accommodate transportation barriers or unpredictable schedules. In this way, the clinic does all it can to provide contextually meaningful care.

This integrated system can be broken down using the AEIOU model:

Activity (A): Trauma-informed care and MAR for OUD

Environment (E): Centralized, interdisciplinary clinic at MSM with accessible lab and imaging services

Interactions (I): Patient-provider interactions across multiple disciplines with real-time communication and coordination among clinical staff

Objects (O): Electronic health records system (Epic), MAR medications

Users (U): Patients with SUD, family medicine physicians, nurses, pharmacists, social workers and social worker aides, behavioral health experts

Bad design: impaired ability to follow-up outside of clinic

Perhaps more a reflection of the current US healthcare system than the SUD clinic at MSM, there are many systemic barriers for patients to return to clinic and for providers to ensure patients adhere to treatment. There is also stigma around methadone clinics, which provide patients with regular doses of an OUD treatment medication. Some patients also receive medication to take at home, but it can be difficult to accurately assess patient adherence. Most notably, a patient may express interest in managing their substance use, but without stable housing, income, food, and access to appropriate mental health resources, recovery can become unsustainable.

Though complex, this system is simplified using the AEIOU model:

Activity (A): Fragmented care and follow-up due to systemic constraints

Environment (E): Patients’ external lived environments

Interactions (I): Limited or no communication between clinic and patient once they leave

Objects (O): Take-home medications, cell phones/communication tools, transportation vouchers or lack thereof

Users (U): Patients with SUD, family medicine physicians, nurses, pharmacists, social workers and social worker aides, behavioral health experts (same as above)

To truly improve patient outcomes, clinics must be built around real lives. Our goal this summer and beyond is to facilitate this process.

The treatment and management of opioid use disorder has evolved over the last few decades in response to federal and policy changes as well as the increasing prevalence of fentanyl.

Many primary care physicians do not lack the resources or technical knowledge to treat OUD. “Medication-assisted recovery for opioid use disorder: A guide” is an important peer-reviewed article in The Journal of Family Practice, which gives concise guidance on the best practices for treating OUD. One of the authors is none other than our Family Medicine CIP program director, Dr. Nicole Gastala, so it is not a surprise that the SUD clinic at MSM follows the structure and practice guidelines described in the article. Some of the most important features are summarized below:

1. Approved medications for opioid use disorder (MOUD): methadone, buprenorphine, and naltrexone are FDA-approved MOUDs for the treatment of OUD. Methadone is a controlled substance and can only be administered by opioid treatment programs (OTP). Historically, these centers have been associated with stigma against people with OUD. At MSM, the OTP is integrated into primary care settings and offers a more discrete setting for medication dispersal.
2. Low threshold MOUD prescribing models: in a clinic that offers MAR, low threshold MOUD practices can increase absolute enrollment. This includes same-day treatment, flexibility with the patient and their needs, and enhanced accessibility to MOUD with nontraditional medical settings.

MOUD focuses on medications for patients actively in the recovery process. In the case of an overdose, there are other medications that can be used. Narcan Nasal Spray is the brand formulation of intranasal naloxone. It is used in emergency settings with the user goal of an easily administered, needle-less delivery system. The medication formulation and pump system are patented (US20180360822A1) and allows for rapid, effective administration of ready-to-use naloxone.

References:

Posen A, Keller E, Elmes AT, Messmer S, Gastala N, Neeb C, Jarrett JB. Medication-assisted recovery for opioid use disorder: A guide. J Fam Pract. 2023 May;72(4):164-171. doi: 10.12788/jfp.0591. PMID: 37224548.

This week, I explored unmet needs related to patients with SUD. One in particular stood out for its urgency: housing instability. For patients struggling with SUD without access to stable housing, it becomes more difficult to maintain and adhere to MOUD treatment, avoid stressful or triggering environments, and consistently attend appointments.

This issue is especially important because it involves a critical factor that makes recovery sustainable: safety and consistency.

Still, of the three unmet needs I focused on this week, I consider this to be the weakest of the three needs statements because the ability to truly impact the population (patients with SUD with housing instability) is limited and less actionable without massive policy and structural changes. The timelines to impact are long which is underscored by the lack of IP and commercial solutions.

Shadowing the SUD clinic in the last few weeks shines a light on this very important issue, but truly addressing this unmet need remains a challenge.

References:

• Gaeta Gazzola M, Carmichael ID, Christian NJ, Zheng X, Madden LM, Barry DT. A National Study of Homelessness, Social Determinants of Health, and Treatment Engagement Among Outpatient Medication for Opioid Use Disorder-Seeking Individuals in the United States. Subst Abus. 2023 Jan-Apr;44(1):62-72. doi: 10.1177/08897077231167291. Epub 2023 May 3. Erratum in: Subst Abus. 2023 Jul 18:8897077231185670. doi: 10.1177/08897077231185670. PMID: 37226909.
• Han BH, Doran KM, Krawczyk N. National trends in substance use treatment admissions for opioid use disorder among adults experiencing homelessness. J Subst Abuse Treat. 2022 Jan;132:108504. doi: 10.1016/j.jsat.2021.108504. Epub 2021 May 29. PMID: 34102461.
• McLaughlin MF, Li R, Carrero ND, Bain PA, Chatterjee A. Opioid use disorder treatment for people experiencing homelessness: A scoping review. Drug Alcohol Depend. 2021 Jul 1;224:108717. doi: 10.1016/j.drugalcdep.2021.108717. Epub 2021 Apr 20. PMID: 33985863; PMCID: PMC9758007.
• Shearer RD, Howell BA, Khatri UG, Winkelman TNA. Treatment setting among individuals with opioid use and criminal legal involvement, housing instability, or Medicaid insurance, 2015-2021. Drug Alcohol Depend Rep. 2023 Jul 12;8:100179. doi: 10.1016/j.dadr.2023.100179. PMID: 37502021; PMCID: PMC10368753.

This week, we continued shadowing providers in the SUD clinic. Consistent with previous observations, a high percentage of patients identified as People Experiencing Homelessness (PEH). Accordingly, I conducted more literature review and updated last week’s card with more secondary literature and a more refined focus.

Solving homelessness is not within the scope of this program, however, bridging access to sleep, hygiene, and/or other barriers caused by homelessness may partially alleviate stress and increase safety for PEH. This may include more temporary solutions inspired by camping equipment or emergency services equipment.

Some terms found in the card are defined below:

QALY (Quality-Adjusted Life Years): standard measure in health economics that combines life expectancy with quality of life. One QALY = one year in perfect health.

ICER (Incremental Cost-Effectiveness Ratio): compares cost of intervention to health benefit. Under $90,000 considered acceptable/cost-effective in US health policy.

For San Jose, CA, the estimated annual cost to house city’s 6340 PEH would be $113.8million with estimated $72.6million in health care savings. The cost of living in Chicago, Illinois is lower than San Jose, CA so it is likely that the cost-benefit analysis is even more favorable.

This week, our team focused on creating a storyboard to visualize and map out the process and user interactions with the MOUD system.

MOUD regimens and tapers can become complex and cumbersome, especially for OUD patients who have other preexisting barriers to treatment or access. This storyboard outlines the common pitfalls OUD patients face when transitioning from methadone to buprenorphine or tapering their buprenorphine scheduling.

Written instructions may confuse patients, especially those with low literacy or limited familiarity with medical terms. Errors in tapering and medication management can trigger unpleasant and sometimes health-threatening withdrawal symptoms, overdose, or increased risk of relapse into substance use.

This storyboard serves as a anchoring point for future directions. It is of substantial benefit to OUD patients and OTP clinics to improve the way patients manage their MOUD medications outside of clinic.