Literature Collection

BACKGROUND: As the death toll continues to rise in the opioid overdose epidemic, increasing access to medications for opioid use disorder (OUD), such as buprenorphine, is vital. Psychiatric clinical pharmacist practitioners (CPPs) can help bridge the gap in care but are limited in their ability to prescribe buprenorphine given federal restrictions. OBJECTIVE: This study aimed to describe a pharmacist-psychiatrist collaborative practice designed to increase access to buprenorphine for OUD in rural communities by maximizing the CPP role. PRACTICE DESCRIPTION: A CPP operating under a scope of practice with prescriptive authority to manage substance use disorders (SUDs) and comorbid mental health conditions was hired in June of 2020 at a rural Veterans Affairs (VA) hospital in Tomah, Wisconsin. PRACTICE INNOVATION: A collaborative agreement with X-waivered psychiatrists was established to manage buprenorphine for patients with OUD. EVALUATION METHODS: A retrospective chart review was conducted on all patients with an OUD diagnosis from July 1, 2020, to October 31, 2021, to assess the use of medications for OUD, comorbid psychiatric, and SUD diagnoses; active naloxone prescription; and CPP involvement in care. For patients prescribed buprenorphine, their average wait time to initiation appointment was calculated in days and compared before and after CPP implementation. RESULTS: As of October 31, 2021, there were 60 patients with OUD cared for by the Tomah VA, of whom 28 received buprenorphine comanaged with the CPP. On average, those requesting urgent access appointment for buprenorphine assessment from the CPP were seen for same-day induction appointments compared with historically an average of a 6.1 day wait for outpatient appointments and 5.8 days for scheduled inpatient inductions. CONCLUSION: Collaborative approaches to buprenorphine management with a CPP improve access to care. Although collaboration decreases time burden for X-waivered psychiatrists, care could be more efficient and timely if a CPP could independently induct, stabilize, and manage patients on buprenorphine.

BACKGROUND: The specific aims of this project were to create a fully integrated, nurse-led model of a psychiatric nurse practitioner and behavioral health care team within primary care to facilitate (1) patients receiving an appropriate level of care and (2) care team members performing at the top of their scope of practice. METHOD: The guiding model for process implementation was Rapid Cycle Quality Improvement. Three task forces were established to develop interventions in the areas of Roles and Responsibilities, Training and Implementation, and the electronic health record. INTERVENTION: The four interventions that emerged from these task forces were (1) the establishment of patient tiers based on diagnosis, medications, and risk assessment; (2) the creation of process maps to engage care team members; (3) just-in-time education regarding psychiatric medication management for primary care providers; and (4) use of a registry to track patients. RESULTS: The process measures of referrals to the psychiatric care team and psychiatric assessment intakes performed as expected. Both measures were higher at the onset of the project and lower 1 year later. The outcome indicator, number of case reviews, increased dramatically over time. CONCLUSIONS: For psychiatric nurse practitioners, this quality improvement effort provides evidence that a consultative role can be effective in supporting primary care providers. Through providing education, establishing patient tiers, and establishing an effective workflow, more patients may have access to psychiatric services.

Importance: Prescription opioid misuse is a national crisis. Few interventions have improved adherence to opioid-prescribing guidelines. Objective: To determine whether a multicomponent intervention, Transforming Opioid Prescribing in Primary Care (TOPCARE; http://mytopcare.org/), improves guideline adherence while decreasing opioid misuse risk. Design, Setting, and Participants: Cluster-randomized clinical trial among 53 primary care clinicians (PCCs) and their 985 patients receiving long-term opioid therapy for pain. The study was conducted from January 2014 to March 2016 in 4 safety-net primary care practices. Interventions: Intervention PCCs received nurse care management, an electronic registry, 1-on-1 academic detailing, and electronic decision tools for safe opioid prescribing. Control PCCs received electronic decision tools only. Main Outcomes and Measures: Primary outcomes included documentation of guideline-concordant care (both a patient-PCC agreement in the electronic health record and at least 1 urine drug test [UDT]) over 12 months and 2 or more early opioid refills. Secondary outcomes included opioid dose reduction (ie, 10% decrease in morphine-equivalent daily dose [MEDD] at trial end) and opioid treatment discontinuation. Adjusted outcomes controlled for differing baseline patient characteristics: substance use diagnosis, mental health diagnoses, and language. Results: Of the 985 participating patients, 519 were men, and 466 were women (mean [SD] patient age, 54.7 [11.5] years). Patients received a mean (SD) MEDD of 57.8 (78.5) mg. At 1 year, intervention patients were more likely than controls to receive guideline-concordant care (65.9% vs 37.8%; P < .001; adjusted odds ratio [AOR], 6.0; 95% CI, 3.6-10.2), to have a patient-PCC agreement (of the 376 without an agreement at baseline, 53.8% vs 6.0%; P < .001; AOR, 11.9; 95% CI, 4.4-32.2), and to undergo at least 1 UDT (74.6% vs 57.9%; P < .001; AOR, 3.0; 95% CI, 1.8-5.0). There was no difference in odds of early refill receipt between groups (20.7% vs 20.1%; AOR, 1.1; 95% CI, 0.7-1.8). Intervention patients were more likely than controls to have either a 10% dose reduction or opioid treatment discontinuation (AOR, 1.6; 95% CI, 1.3-2.1; P < .001). In adjusted analyses, intervention patients had a mean (SE) MEDD 6.8 (1.6) mg lower than controls (P < .001). Conclusions and Relevance: A multicomponent intervention improved guideline-concordant care but did not decrease early opioid refills. Trial Registration: clinicaltrials.gov Identifier: NCT01909076.

PURPOSE: The development of an outpatient psychiatry clinical practice learning experience for PGY2 ambulatory care pharmacy residents in preparation for the treatment of psychiatric disorders in the primary care setting is described. SUMMARY: With the increased prevalence of psychiatric disorders, significant mortality, and limited access to care, integration of mental health treatment into the primary care setting is necessary to improve patient outcomes. Given the majority of mental health treatment occurs in the primary care setting, pharmacists in patient-centered medical homes (PCMHs) are in a unique position with direct access to patients to effectively manage these illnesses. However, the increased need for pharmacist education and training in psychiatry has prompted a large, Midwestern academic health system to develop an outpatient psychiatry learning experience for PGY2 (Postgraduate Year 2) ambulatory care pharmacy residents in 2015. The goal of this learning experience is to introduce the PGY2 ambulatory care residents to the role and impact of psychiatric clinical pharmacists and to orient the residents to the basics of psychiatric pharmacotherapy to be applied to their future practice in the primary care setting. CONCLUSION: The development of an outpatient psychiatry learning experience for PGY2 ambulatory care pharmacy residents will allow for more integrated and comprehensive care for patients with psychiatric conditions, many of whom are treated and managed in the PCMH setting.