Based at Dell Seton Medical Center — part of Ascension Seton — a Buprenorphine Team comprised of hospital staff and Dell Medical School faculty members is getting noticed for its work to care for patients with opioid use disorder (OUD). Team lead Richard Bottner facilitated this Q&A with the Buprenorphine Team, also known as the B-Team, in response to frequent inquiries about their work.
What Is the B-Team?
The B-Team is a hospital-based consultation service that provides patients with OUD the opportunity to start medication-assisted treatment (MAT). More specifically, we help primary teams screen patients for OUD, identify which patients are eligible for MAT, initiate therapy during the hospitalization, and then facilitate outpatient follow-up by arranging appointments and providing warm handoffs to the community clinic.
What Is Medication-Assisted Treatment?
Medication-assisted treatment is an evidence-based intervention for patients with opioid use disorder. It combines a medication with other psychosocial services including cognitive behavioral therapy, counseling, and social work. MAT improves patient mortality related to OUD and increases the length of time spent actively participating in treatment. There are two primary medications used as part of a MAT program: methadone and buprenorphine. The B-Team focuses on the latter.
What Is Buprenorphine?
All opioids (and the medications used to treat addiction to opioids) act on the mu receptor in the brain. This is an important part of human physiology. If I were to get into a car accident and suffer serious injury, I might receive morphine in the hospital for pain relief. Morphine works on the mu receptor. Some patients also experience a sense of euphoria. However, the mu receptor is also responsible for the dangers associated with opioids. If I receive too much morphine, the medication might slow my breathing. If not monitored appropriately, that respiratory depression might lead to respiratory arrest. This is how patients die from opioid overdose — they stop breathing. Morphine, heroin and oxycodone all work similarly from the standpoint of basic brain chemistry.
Buprenorphine also acts on the mu receptor. However, a major distinction is that unlike other medications that seek out this part of the brain, buprenorphine only partially activates it. Patients typically have vastly improved control of their cravings for illicit opioids without experiencing euphoria. Partial activation also means that it is challenging to overdose from buprenorphine. In addition, buprenorphine has extremely strong affinity for the mu receptor; it hugs the receptor and does not want to let go. This reduces the risk of overdose in the event a patient relapses while taking buprenorphine.
Methadone works similarly except that it activates the mu receptor fully (similar to the example of morphine.) Because of methadone’s higher potential for overdose and other adverse effects, federal regulations restrict its access to clinics that specialize in this medication. The regulations supporting buprenorphine therapy are designed to increase access to opioid addiction treatment for patients who need it most.
What Expertise Is Necessary to Do Your Work?
Up until recently the United States medical education system across all disciplines did not adequately address addiction. We believe that clinicians should address OUD in the hospital setting just as they would any other chronic disease state such as diabetes or heart failure, to name a few.
We can teach our colleagues how to identify a patient with OUD in less than fifteen minutes. That’s the first step. Starting a patient on buprenorphine in the hospital requires a bit more training, but is something we have taught in under an hour. We also do “just in time training” for primary teams, nurses and pharmacists if they are not familiar with the medication. To provide buprenorphine at discharge, prescribers must complete a course that is certified by the Drug Enforcement Agency. This “x-waiver” class is eight hours for physicians and 24 hours for physician assistants and advanced practice nurses. The B-Team providers also have their x-waivers and can prescribe buprenorphine at discharge.
What Role Does Interprofessional Collaboration Play on Your Team?
Interprofessional collaboration plays an absolutely critical role. Our team includes a nurse, social worker, physician, physician trainee, chaplain, physician assistant and pharmacist. Our team members offer varied and unique perspectives that allow us to deliver optimal care. There are many examples of this: our pharmacist was vital in developing medication protocols, our nurse helped assess what processes would work at the bedside and our social worker helped build relationships with the outpatient clinic.
It’s important to note that our work is also multidisciplinary. There are over two million patients in the United States who have OUD. Our belief is that all clinicians have a role in identifying and treating these vulnerable patients — not solely the disciplines of psychiatry and addiction medicine.
Let’s use heart failure as an example. There are several medical disciplines that treat patients with heart failure including internal medicine, family medicine, emergency medicine, and of course, cardiology. However, not every patient with heart failure sees a cardiologist on a frequent basis. Quite the contrary. Our other disciplines manage these patients and refer to the cardiologist as needed for complex cases and periodic review.
This is the model we are developing with the B-Team; we are advocating for our colleagues to identify and treat OUD, and care for them in concert with our behavioral health colleagues based on complexity, need and local availability.
The interprofessional and multidisciplinary B-Team (left to right): Evan Solice, chaplain; Kirsten Roberts, pharmacist; Ken Giorgi, nurse; Clarissa Johnston, palliative care and hospital medicine physician; Rachel Holliman, social worker; Elise Carper, palliative care advanced practice nurse; Blair Walker, psychiatrist; Amber Dunbar, medical student; Chris Moriates, hospital medicine physician; Rich Bottner, physician assistant; Nick Christian, internal medicine resident.
How Do Community Organizations Support Your Work & Your Patients Upon Discharge?
The program has been received warmly by the medical community in Travis County. There are too many partners to name here but we continue to work closely with the Dove Springs Clinic, which is operated by CommUnityCare and Integral Care. Throughout the United States, thousands of community organizations and policy-oriented groups are seeking novel ways to curb the opioid crisis. Despite taking positive steps towards prevention (i.e. improved prescribing practices, etc.) we still have more than 100 patients dying every day nationally from opioid overdose.
What Inspires the Team’s Work?
A great part of our work has been around stigma reduction. Opioid use disorder should be treated just like any other chronic lapsing-remitting medical condition. I have been involved in health care for 15 years and it wasn’t until 18 months ago when I began to appreciate that I was feeding into the stigma of addiction and not appropriately treating patients with addiction. I used poor language that was not patient-centered and I focused only on the medical problem before me instead of the underlying issue. The more I learned, the more I changed my practice. This is the most rewarding work I have had the privilege of doing, a sentiment that is strongly echoed by everyone on our team. Now it’s our job to raise awareness and inspire others to do the same.
Why Is It Important to Offer Medication-Assisted Treatment During Hospitalization?
Beyond stigma reduction, we recognize that hospitals are an ideal time to offer patients therapy for OUD. These patients are often hospitalized for weeks at a time with medical issues related directly to their intravenous drug use such as infections of the heart or spine. Hospitalized patients are a captive audience and are outside their triggering environment. We also know that 80 percent of patients with opioid addiction who are not provided a service like ours during hospitalization will return to opioid misuse after discharge. That’s a staggering number and a massive opportunity. The hospital is an ideal place to do this work, yet there are no programs like this in Texas and only a handful elsewhere in the United States.
Do You Have Plans for Growth in the Future to Expand Your Impact?
Absolutely, this is just the beginning. For inpatient medicine, we are actively seeking clinicians who want to join our team. There are several practitioners who are obtaining their certification currently. As we perfect the inpatient model, our next step will be to expand services to the emergency department and obstetric unit. As the programs grows, we have a thorough process in place for collecting, analyzing, and sharing important outcomes data.
In parallel to the B-Team work happening at Dell Seton Medical Center, Dell Med is launching Support Hospital Opioid Use Treatment (SHOUT) Texas. The goal is to create a center of excellence and thought-leaders for Texas’ 600-plus hospitals seeking strategies for treating patients with opioid use disorder. The SHOUT Texas program is highly informed by the B-Team work and colleagues engaged in this work around the country. This model of expanding hospital-based opioid treatment work was pioneered by the original SHOUT program at the University of California San Francisco in 2015. Dell Med is proud and excited to be the first official satellite partner of the SHOUT program.