The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Sadie Roestenburg, PharmD, BCPS
Mental Health Clinical Pharmacy Specialist
George E. Wahlen Department of Veterans Affairs Medical Center
Salt Lake City, Utah
Dr. Roestenburg, PharmD, BCPS, is a mental health clinical pharmacist at the Salt Lake City Veterans Affairs Medical Center. She works with the addiction medicine teams on both the inpatient Substance Abuse Residential Rehabilitation Program unit (SARRTP), as well as offers support for outpatient addiction services. She graduated from the University of Montana Skaggs School of Pharmacy in Missoula, Montana, and then went on to complete a PGY1 pharmacy residency with Intermountain Healthcare at Utah Valley Regional Medical Center in Provo. Her PGY2 mental health pharmacy residency was completed in 2015 at the George E. Wahlen Department of Veterans Affairs Medical Center. She currently works within the Addiction Treatment Services department which includes the Substance Abuse Residential Rehabilitation Treatment Program (SARRTP) as well as outpatient addiction services. She is actively involved in the Overdose Education and Naloxone Distribution (OEND) initiative for the Salt Lake City Veterans Affairs and has been an active leader in the development of a Mental Health Pharmacy Transition of Care service.
1. What is the most common myth/misconception about managing MAT inpatient?
MAT definition: Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.
- A common misconception from providers in various inpatient settings is that patients taking opioid replacement therapy (such as buprenorphine/naloxone (Suboxone®) or methadone) must first withdraw from these opioid medications prior to receiving treatment for other medical conditions, or that the patient is adequately covered for pain control with the Suboxone® or methadone. The patient may go through unnecessary discomfort and may be undertreated for pain due to these misconceptions. Generally, it is appropriate to continue the MAT during inpatient admissions and to consult with the mental health or addiction team or other resources to help to appropriately manage the specific medical conditions, pain management, and addiction.
- Another common misconception is that using buprenorphine/naloxone (Suboxone®) for opioid use disorder is replacing one addiction for another. By utilizing opioid replacement therapy, it can help reduce opioid cravings and withdrawal, which can help free the patient from the preoccupation of obtaining illicit substances and can enable the patient to effectively work on the psychosocial aspects of addiction. Some patients stay on these medications for short term, but some stay on them long term depending on what the individualized goals are for each patient (staying out of jail, obtaining a job, etc.).
2. What strategy do you recommend for aiding in continuity of care?
- An essential strategy as a pharmacist in aiding in continuity of care for patients with MAT is to identify and network with addiction treatment contacts within your facility and your community (i.e. know the Suboxone® and methadone clinics around your area, get to know your local addiction medicine providers, find out if there is a mental health consult service in your facility). Keeping strong professional connections with addiction medicine providers and contacts in all areas of care (outpatient, inpatient consult, treatment programs) can significantly help to facilitate smooth transitions of care for these patients.
- Another aspect to keep in mind as a pharmacist is to verify state prescription drug databases, as well as the medication doses and last fill dates for all medications. Within these databases, it is important to monitor for the prescribing and use of benzodiazepines and opioids with patients who are on MAT due to the dangerous drug interactions and addiction potential of these medications.
3. What are some ways to communicate with inpatient providers to ensure appropriate patient care?
- Oftentimes inpatient providers are unfamiliar or uncomfortable with MAT medications and want to understand more about the evidence behind using these medications. Taking an academic detailing/educational approach can often times be an effective strategy when discussing MAT with inpatient providers. Providers who may not have expertise in addiction medicine may not be familiar with the regulations regarding appropriate continuation of MAT during inpatient admissions. If recommendations are being made either verbally or written to inpatient providers regarding MAT, you may consider addition of reference citations relating to MAT use and outcomes. Communication about outcomes and evidence-based treatment can be provided in many forms such as in-services, individual face-to-face, email, etc.
- Also, keep in mind your resources and referrals that are available for mental health and addiction. For example, a great way to communicate with the inpatient providers and team is to recommend that the mental health/addiction consult service team (or another addiction medicine point person) discuss with the inpatient medical teams regarding MAT management and help to provide education. A few resources that I utilize include the Substance Abuse and Mental Health Services Administration (SAMHSA) website, the American Society of Addiction Medicine (ASAM) Principles of Addiction Medicine textbook, and the Veterans Affairs Management of Substance Use Disorder 2015 Clinical Practice Guideline
- I provide group education to both the inpatient Veterans in our residential program, as well as Veterans participating in our intensive outpatient program for Veterans working through our outpatient addiction services. I use these educational groups to provide education about MAT and to allow patients to ask questions regarding the medications and concepts related to MAT. Group education provides an excellent way for patients to share their stories with each other, identify and resolve misconceptions, and understand more about their care and the various options available to them.