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Boston: Implementing SUD Treatment in Pediatric Primary Care

Background

The thrust towards primary care integration has created a mandate to integrate substance use disorder (SUD) treatment for adolescents into health care settings. Despite this emphasis, SUD treatment is not effectively managed in pediatric primary care. Fewer than 10% of adolescents with a SUD ever get recommended treatment, and the vast majority of referrals originate in the justice system. A recent report found that less than 2% of adolescents that were receiving treatment for opioid use disorder were prescribed medications, despite clear recommendations from the American Academy of Pediatrics. The goal of primary care integration is falling short for adolescents.

Description

The Adolescent Substance Use and Addiction Program (ASAP) and the Pediatric Physicians Organization of Children’s Hospital (PPOC) have partnered to re-envision primary care integration. In this new multi-disciplinary model, a subspecialty “hub” supports an entire staff – primary care providers, nurses, SUD and behavioral health (BH) counselors and administrators - to offer a range of fully integrated SUD services. The program is comprised of three components: 1) intensive training, provided by ASAP, including buprenorphine waiver training, SUD screening, drug testing, opioid prescribing and management, and confidentiality and ongoing, quarterly in person site visits and quality assurance rounds with ASAP faculty; 2) a dedicated support phone line to answer questions about SUD management, 3) an embedded, fully integrated, ASAP-trained and supervised licensed social worker delivering direct services in pediatric offices and participating in team rounds and multi-disciplinary care. In this model, PCP’s and other staff members participate in SUD care through screens and initial assessments, warm hand-offs, reinforcement to patients, parent guidance and medication prescribing. PCP’s learn to manage adolescent substance use as they do other chronic medical conditions such as asthma to diabetes.

Sites

The PPOC is a network comprised of 90 pediatric primary care practices that together provide care to nearly 25% of children state-wide. This project leverages the PPOC BH integration program that has brought an integrated BH clinician as well as new skills and competence in the provision of care for screening, psychopharmacology and management of mental health diagnoses. ASAP is comprised of clinical, training, research and advocacy arms. The clinical program provides SUD services to adolescents and young adults up to age 24. ASAP has extensive experience in education and training and is home to the first accredited Pediatric Addiction Medicine Fellowship in the US.

Pilot Work

With support from the BCBS Foundation, the PPOC and ASAP have begun piloting this work. We launched intensive provider education and a consultation line in 9/16/17. A half time integrated ASAP social worker has been deployed to Wareham Pediatrics since 3/17/17. Data as of April 2018 is below.

Patients referred by PCP60
SUD appointments scheduled40
Age range12-21

Our second site, Bridgewater Pediatrics, opened in April 2018. We have subsequently secured funding for two additional sites: Child Health Associates in Auburn and Village Pediatrics in Brockton are both scheduled to open in early 2019. To date, 6 practices have agreed to participate and 17 pediatricians have or are in the process of waiver training. The project has already garnered national attention, including from Senator Elizabeth Warren at a recent Senate committee meeting (which can be seen here https://bch.wistia.com/medias/anpxwg79rk).

Future directions

Our goal over the next 5 years is to establish 25 integrated SUD programs. To address the dire lack of outpatient SUD treatment services for youth, we are directing services to the areas most impacted by the opioid epidemic: the private physician office. To achieve this, we are seeking funding to help with 1) support for the training and start up periods for each embedded social worker and 2) ASAP clinicians and staff serve who serve as the resource center for this expansion, providing logistical support, quality assurance and training for primary care staff and embedded social workers.

Media Coverage

Today Show: https://www.today.com/health/how-help-teenager-kick-heroin-t117276
AMA Wire: https://wire.ama-assn.org/delivering-care/pediatric-primary-care-could-be-key-solving-teen-opioid-crisis
Boston Globe: https://www.bostonglobe.com/metro/2017/06/12/office-close-home-wareham-youths-get-addiction-treatment/Zb22nJjrfy2GjlWnD5js7M/story.html
Boston 25 news: http://www.fox25boston.com/news/pilot-program-helps-get-south-coast-teens-into-opioid-recovery-programs-1/555681737

Publication

Levy S, Mountain-Ray S, Reynolds J, Mendes SJ, Bromberg J. A Novel Approach to Treating Adolescents with Opioid Use Disorder in Pediatric Primary Care. Substance Abuse. 2018; 1-9. doi:1080/08897077.2018.1455165.