23 minute read
NEW APPROACH TO OPIOID USE DISORDER
Opioid use disorder program being modeled nationwide
By Ellen Goldbaum and David Hill
Less than a decade ago, the standard of care for treating patients with opioid use disorder in emergency departments was, for the most part, ineffective. Those experiencing withdrawal were typically given non-narcotic drugs, which did little to assuage their symptoms, and, at discharge, were handed a list of phone numbers for treatment clinics. Sometimes patients later discovered that the phone numbers were incorrect.
Allison Brashear, MD, MBA, left, vice president for health sciences at UB and dean of the Jacobs School of Medicine and Biomedical Sciences, listens as U.S. Department of Health and Human Services Region 2 Director Dara Kass, MD, speaks at the roundtable with Buffalo MATTERS leadership and community health partners. Photo by Sandra Kicman
“Emergency departments are the safety net for the medical system, so they are a critical point of entry for these patients,” says Joshua J. Lynch, DO, clinical associate professor of emergency medicine in the Jacobs School of Medicine and Biomedical Sciences and a physician with UBMD Emergency Medicine. “When patients come to us in withdrawal, we need to be able to help control their symptoms and quickly transition them to community clinics. We knew we weren’t doing a great job with either step, but there weren’t many good alternatives out there.”
That concern motivated Lynch to seek a solution. In 2015, he and his colleagues read a paper by physicians at Yale University that proved pivotal to their efforts. It reported that patients going through withdrawal who were given the opioid treatment buprenorphine in the emergency department and provided with a clinic appointment were more likely to have reduced their opioid use and remained in treatment a month later.
“When we saw that, we wanted to do it here,” Lynch recalls.
It wasn’t simple. The first step required emergency medicine providers to undergo training mandated by New York State for anyone administering buprenorphine, a controlled substance.
After encouraging fellow providers to complete the training, Lynch and his colleagues developed a standardized approach for evaluating and managing patients.
A member of the Erie County Opioid Task Force, Lynch then approached regional clinic directors to see if they would agree to see a few patients each week who had started buprenorphine in the emergency department at Kaleida Health’s Buffalo General Medical Center or Millard Fillmore Suburban Hospital, teaching affiliates of the Jacobs School.
“I was doing this on a case-by-case basis,” says Lynch, who explains that he was making the phone calls himself to the clinic directors.
Soon, it became clear that a more systematic approach was needed.
A MODEL PROGRAM IS BORN
“It wasn’t sustainable,” says Brian Clemency, DO, professor of emergency medicine at the Jacobs School, who began partnering with Lynch at that time. “We needed a framework.”
That framework developed into what today is MATTERS (Medication for Addiction Treatment and Electronic Referrals), an innovative, cost-effective program that provides medicationassisted treatment to opioid use disorder patients and rapidly transitions them into long-term treatment at a community clinic, all within about 48 hours.
The program, initially named Buffalo MATTERS, eventually grew to encompass the eight counties of Western New York. During this transitional time, it received critical seed funding from local foundations, starting with a pilot project grant from the John R. Oishei Foundation in 2017. The following year, Blue Fund of BlueCross BlueShield of Western New York awarded the program a $200,000 grant that supported efforts to train emergency department providers and to recruit community clinics to treat patients discharged from the departments.
In 2019, Lynch received additional funding to expand the project statewide. This was accomplished primarily through the development of an online referral platform housed on a secure communications system that the Department of Health (DOH) operates, with Lynch serving as technical advisor.
The online system streamlines referrals to community based, medication-assisted treatment (MAT) providers and allows them to provide ongoing care for those started on MAT in the emergency department. It also supports access to resources for providers and captures valuable outcomes data to evaluate the effectiveness of the program.
Allison Brashear, MD, MBA, dean of the Jacobs School of Medicine and Biomedical Sciences
Lynch and his colleagues also developed an app for Apple and Android devices that emergency medicine providers throughout the state can use to link patients to resources and long-term care, regardless of the patients’ health history or insurance status. Their work on the app was supported by funding from the UB Clinical and Research Institute on Addictions.
Designed to remove as many barriers to care as possible, MATTERS also provides round-trip transportation vouchers for the first clinic visit and offers a medication voucher program to cover the cost of a buprenorphine prescription for up to 14 days. The vouchers are redeemable at more than 1,000 public and privately owned pharmacies statewide, including CVS, Walgreens and Wegmans.
MATTERS now partners with over 160 community-based clinics, 1,000 pharmacy locations statewide and nearly 100 hospitals. It also offers an average of 1,700 appointment slots each week to patients seeking treatment for opioid use disorder.
Last fall, the New York State Department of Health provided funding to hire an additional nine regional care coordinators for MATTERS. The coordinators are working to facilitate the expansion of the program beyond hospitals to nontraditional care settings—including law enforcement agencies, correctional facilities and pre-hospital settings—in specific regions in the state.
INTEREST AT THE FEDERAL LEVEL
The program’s success has not gone unnoticed. This spring, U.S. Department of Health and Human Services (HHS) Region 2 Director Dara Kass, MD, visited the Jacobs School to meet with Lynch and his colleagues, as well as Jacobs School administrators.
Kass—an emergency medicine physician by training whom President Joe Biden appointed as HHS Region 2 director in November 2021—oversees HHS operations in New York, New Jersey, Puerto Rico and the U.S. Virgin Islands. She was in Buffalo for a few days to convene stakeholder meetings with partners aligned with HHS health priorities, which include treatment for opioid use disorders.
Kass was impressed by the level of integrated care MATTERS provides patients and said that President Biden fully endorses such efforts. “This administration is committed to supporting programs that get medication into the hands of patients who need it,” Kass said.
“I am grateful to be here with you. I am grateful to everyone working together and providing an incubator and a pilot for what I hope to help communicate to the rest of the country,” she added.
Allison Brashear, MD, MBA, vice president for health sciences at UB and dean of the Jacobs School, who attended the meeting, praised the work Lynch and his colleagues have done in expanding MATTERS across New York State. “We are so proud of what has been created here,” she said, adding that UB’s breadth of health sciences schools and their associated educational and research opportunities uniquely position UB among other schools nationally, especially when it comes to treating conditions such as opioid use disorder.
“We are committed to training the next generation of physicians to be patient-centered,” Brashear said. “This means understanding what patients and families need in terms of comprehensive teambased care—and MATTERS is a great example of this.”
The roundtable discussion included several Jacobs School faculty members affiliated with MATTERS, as well as key community health partners, such as Evergreen Health Services, Horizon Health Services and BestSelf Behavioral Health. Additional partners present included Cheektowaga Police Chief Brian Gould and representatives from Albany Medical Center’s Department of Emergency Medicine.
Also in attendance were representatives from three New Jersey organizations with which MATTERS is forging a partnership as the program continues its expansion: Cooper Health, the New Jersey Department of Human Services and the New Jersey Department of Health.
Lynch and his colleagues are also working to make the program available to people who are incarcerated, and through obstetrics and gynecology offices to treat pregnant women who are opioid users. They have been contacted by cities throughout New York State and beyond that are interested in starting programs similar to MATTERS and have presented on the subject to international audiences.
At the roundtable with HHS, Clemency described how UB physicians created a standardized dose of buprenorphine that emergency room doctors can administer to patients who are in withdrawal. If patients aren’t experiencing withdrawal, then they are given instructions on how to administer buprenorphine at home once they begin having severe withdrawal symptoms.
Before being discharged from the emergency departments, patients are provided an iPad that shows them the options they have for a community clinic to attend.
Brian Clemency, DO, professor of emergency medicine
“One of the most unbelievably empowering things for a patient who’s used to being told what to do, is handing them an iPad and saying, ‘Here are all the places that you can go tomorrow to be seen; you tell us where you want to go,’” Clemency said.
Joshua J. Lynch, DO, clinical associate professor of emergency medicine
TELEMEDICINE INTRODUCED
In 2020, COVID-19 presented yet another barrier to treatment for patients with opioid use disorder, as emergency departments were swamped with people severely ill with the virus. In another demonstration of its commitment to removing barriers to care, MATTERS developed virtual emergency departments staffed by UBMD emergency medicine physicians in Kaleida Health hospitals and at Erie County Medical Center.
As a result, patients can be prescribed buprenorphine and receive a MATTERS referral without ever presenting in person to the emergency department. Patients referred through this telemedicine partnership are offered the same harm- and barrierreduction resources as individuals presenting to an emergency department in person.
Many clinic partners also offer virtual appointments, as well as other harm-reduction services, such as syringe-exchange programs and treatment for HIV/AIDS and hepatitis C.
Lynch emphasizes that the MATTERS program serves as an integral resource to connect patients to outpatient programs that will best meet their needs while not overwhelming already challenged emergency departments.
ENSURING CONTINUITY OF CARE
Policymakers are interested. Both houses of the New York State Legislature are considering passing legislation that would require the kind of medication-assisted treatment that has been initiated by MATTERS.
“MATTERS is already helping substance use disorder patients in 20% of the hospitals in New York State,” says Robert McCormack, MD, chair of the Department of Emergency Medicine in the Jacobs School and president of UBMD Emergency Medicine, who testified at the New York State Assembly last year. “The ‘warm handoff bill’ will mandate this expediting of treatment for hospitals across the state.”
Lynch adds: “The bill requires warm connections to treatment providers, which is what the MATTERS program does. MATTERS is what the warm handoff looks like.”
MATTERS was designed to work in any size hospital, Lynch points out. “We designed it to work just as well in a 500-bed hospital as in a critical access community hospital staffed by a physician assistant and two nurses.
“Patients in withdrawal who drive to the emergency room because they know they need help are looking for a way to get better,” he continues. “Thanks to MATTERS, these patients can now leave the emergency department, not only with buprenorphine in hand for their symptoms, but also a treatment plan and a convenient follow-up clinic appointment within 48 hours—usually in their own neighborhood. There’s probably nothing that more powerfully says to them, ‘your community is here for you and we want to help you.’”
An early enrollee in MATTERS succinctly summed up how the program affected him: “They were in my corner before I was in my own corner.”
Buffalo MATTERS founder and medical director Joshua Lynch, MD, clinical associate professor of emergency medicine and a physician with UBMD Emergency Medicine speaking to the roundtable. Photo by Sandra Kicman
MATTERS is currently funded by private foundations and government agencies, including the New York State Department of Health, the New York State Office of Addiction Services and Supports, the federal Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration and others.
For more information, visit https://mattersnetwork.org/
Surgical
Resident Receives Citizen Honors One of the highest civilian awards in the U.S. Award
By Bill Bruton
When Aaron Epstein, MD, a trainee in UB’s general surgery residency program, received a call earlier this year informing him that he was being awarded the prestigious 2022 Citizen Honors Award for Service, he thought it was a spam call.
“I was in Ukraine at the time and saw a number come up from the U.S. I usually don’t answer phone calls from numbers I don’t recognize, but this time I did and figured ‘I’ll see what the telemarketer has to say.’ I picked it up and heard, ‘Congratulations you’ve won this award.’”
To Epstein, it sounded more like a Publishers Clearing House commercial, so he ignored it.
“Then they called again, and I thought OK maybe it’s something real,” Epstein says. “I remember talking to the representative over the phone and saying ‘sure, right, whatever,’ and it didn’t really register. So it took a while to come across as something legit.”
CARE AROUND THE WORLD
The national award, which is overseen by the Congressional Medal of Honor Society that represents living recipients of the Congressional Medal of Honor, is one of the highest civilian awards in the U.S. It recognizes those who distinguish themselves by their service or an act of heroism.
Epstein founded the Global Surgical and Medical Support Group (GSMSG) in 2015 while a medical student at Georgetown University and serves as president of the organization.
The GSMSG started out sending U.S.-trained physicians to conflict zones to treat patients in places like Iraq and Syria and provide medical care and training when local health care systems were overwhelmed.
During the COVID-19 pandemic, the organization also operated stateside, erecting mobile clinics to aid in the fight against the coronavirus and staffing field hospitals that went up in New York City during the initial wave of the pandemic.
Earlier this year, Epstein and a team of doctors from GSMSG spent time training Ukrainian fighters and civilians in combat care.
The Congressional Medal of Honor Society cited “Epstein’s commitment to providing medical relief to communities in conflict zones, austere environments and disaster areas around the world.”
NIMBLE AND EFFICIENT
“At the time, I had recently been in the Middle East. It seemed groups would come and go and they would dump some supplies and take their photo op and leave,” recalls Epstein, who earned a master’s degree in intelligence and security studies at Georgetown in 2012 and worked in national security for a few years before entering medical school.
“I remember thinking if we could get a couple of real doctors here, that would be great. All I anticipated from the beginning was finding a way to bring a couple of doctors into conflict areas. I was really just looking for four to 10 people to go with me to these areas,” he adds.
From that modest start, the organization has grown to 1,500 volunteer surgeons and special operations veterans ready to deploy at a moment’s notice.
“We’re very nimble and efficient as a group. We’re more of a cloud organization than a brick-and-mortar group that has offices all over and has to maintain a massive administrative budget,” Epstein explains. “If there’s an emergency somewhere in the world, or there’s a trip coming up somewhere, I send a message to the team and say, ‘If you’re available, let’s meet at this date and time at this airport, and I’ll take it from there.’”
Epstein, 37, isn’t one for hoopla, but he’s grateful for anything that helps the organization.
“I’m not one for awards. My ultimate goal is to do as much work on the ground in these countries as possible,” he says. “The award doesn’t mean much unless it helps the organization. If it gives more visibility to our program and it helps us in some way with our work, that’s great.”
His organization is making a positive difference in so many ways.
For example, with Muslim patients it is preferrable for a
Aaron Epstein, MD
healthcare professional conducting a physical exam to be the same sex as the patient.
“What we started doing is bringing over female military veteran medical professionals and we started training Iraqi and Kurdish women and girls on how to be medical providers. Every couple of months we would come back to Iraq and we’d see women come to our courses and when we came back they’d say ‘my family knows I can take care of them and watch out for their well-being,’” Epstein says. “Then they’d take another one of our courses and we’d come back the next year and now the community feels like they are real health care providers and can provide care to the community around them. We saw the place of women in these societies change from just being in the home to becoming trusted medical providers. It’s very empowering.”
He sees a difference in some of the ex-military members who have joined the group as well.
“You get these guys who are elite special forces and leave the military and they come back to the U.S. and suddenly they’re no longer a special forces elite medic. They’re doing a job where they feel they aren’t making a difference, and that can exacerbate PTSD,” Epstein says. “Then they come with our team and they’re with a whole bunch of special forces men and women again, and they get to go overseas and deploy with a team. You can almost see a 180 degree change in these people’s mindsets. They’re a whole new person. We see a lot of that. It’s very rewarding in terms of our work.”
Epstein, who is in his fourth year as a resident in the Department of Surgery, doesn’t know if he’d be able to do what he’s doing in any other surgical residency program in the country, and gives a lot of credit to Steven D. Schwaitzberg, MD, SUNY Distinguished Service Professor and chair of the department.
“Dr. Schwaitzberg has been incredibly supportive. Everyone I talk to, whether it’s attendings or residents of other programs, they’re all like, ‘How are you able to do this?’” Epstein says. “Dr. Schwaitzberg has been uniquely supportive of all of these global surgery efforts. That’s why I chose to come to UB. I’ve been very fortunate.”
DEDICATED TO HUMANITARIAN CARE
“Aaron Epstein is one of those unique individuals whose supreme dedication to the cause of humanitarian care serves as an exemplar to us all,” said Schwaitzberg, himself a veteran of the Gulf War. “He is unselfish and willing to go to some of the most difficult places on earth to help those who need medical and surgical care. There is no doubt he will continue to have a remarkable career.”
Epstein has put a positive spotlight on the entire Jacobs School of Medicine and Biomedical Sciences.
“Dr. Epstein’s passion for delivering critical care to communities in crisis around the world, and leading others to do the same, is an inspiration to everyone at the Jacobs School and the entire UB community,” says Allison Brashear, MD, MBA, UB’s vice president for health sciences and dean of the Jacobs School.
Epstein’s residency is taking longer than normal—he hopes to complete it after the next academic year—but that’s OK with him.
He’s doing what he loves—and making a difference.
Remote Monitoring for advanced Diabetes Care
By Ellen Goldbaum and Megan Veirs
$1 million grant from Helmsley Charitable Fund expands care for children
When Ryan Morlock’s seven-year-old daughter, Charlotte (“Charlie”), was diagnosed with Type 1 diabetes a year ago, she said she was “dumbfounded.”
“I knew nothing about it before Charlie was diagnosed; I mean, I knew some people who had it, but I had never asked questions.”
Today Morlock and her husband, Michael, have lots of questions, but they also have certified diabetes care and education specialists available to answer them via text, email, phone or telehealth visits. The South Buffalo family has access to these resources through a new program at UB that provides “virtual” support to children with Type 1 diabetes and their parents in an effort to help achieve better control of blood sugar levels.
The program confronts the fact that a majority of children living with Type 1 diabetes in the United States are not meeting their hemoglobin A1c (HbA1c) goals, a measure of average blood sugars, and a leading indicator of both short- and long-term disease state complications. Current research indicates that this trend is particularly prevalent in underserved communities.
In an effort to address this problem, pediatric endocrinologists at UBMD Pediatrics and the Jacobs School of Medicine and Biomedical Sciences have launched a collaboration to provide remote care management and physiological monitoring for children living with Type 1 diabetes. The team is evaluating the financial viability of providing these services as well as their impact on diabetesrelated outcomes.
A $1.43 million grant awarded to UBMD Pediatrics from The Leona M. and Harry B. Helmsley Charitable Trust is making this program possible.
Despite recognition of the benefits of remote care programs that deliver support in between physician visits, most primary care and specialty providers lack the financial resources to deploy them effectively. Moreover, the COVID-19 pandemic has exacerbated gaps among underserved communities primarily due to limited access to remote care services and community-based resources.
By working with Cecelia Health, a “virtual-first health care provider,” UBMD Pediatrics is supplementing the in-person patient care it provides with care from an experienced remote diabetes and chronic care management team. Cecelia Health provides patients with a spectrum of support in managing their diabetes to ease the daily burden, help improve health outcomes and free up care resources for providers.
A key goal of the program is to explore how improving access to remote support and the internet to manage chronic conditions will improve outcomes. In particular, the program is examining whether access to fully supported cellular-enabled tablets and remote counseling enables patients to take full advantage of their existing diabetes technologies, such as continuous glucose monitors and insulin pumps. In return, this should improve A1c levels and reduce hospital admissions for diabetic ketoacidosis, a life-threatening condition that develops when the body doesn’t have enough insulin to allow blood sugar into cells for use as energy.
“Using telehealth to improve care of youth with Type 1 diabetes is at the forefront of clinical care,” says Lucy Mastrandrea, MD, PhD, professor and chief of the Division of Pediatric Endocrinology/ Diabetes at the Jacobs School and UBMD Pediatrics. “We expect to show that utilizing diabetes care specialists to deliver virtual support and education to our patients and families is financially sustainable. We are also taking this further by studying the clinical outcomes of patients with limited internet access who are provided tablets with cellular service and full technical support.”
“Our Division of Pediatric Endocrinology/Diabetes cares for about 1,000 patients with diabetes,” says Kathleen Bethin, MD, PhD, principal investigator of the study and clinical professor of pediatrics at the Jacobs School. “We have many years of experience with both basic and clinical research to improve the lives of our patients.”
Cecelia Health has worked with several university and hospital diabetes specialty clinics during the COVID-19 pandemic.
“During the first year of the COVID-19 pandemic, thanks to the support of the Helmsley Charitable Trust, we were fortunate to leverage the expertise of Cecelia Health and its team of specialists
The Morlock family, from left: Charlotte (“Charlie”) in the foreground; Ryan holding son, Austin; Michael holding son, Landon; and Kaleb, right.
to provide telehealth support services to our diabetes patients who were unable to be seen in-person at regular intervals,” says Bethin, also a member of UBMD Pediatrics’ Division of Endocrinology/Diabetes.
Additionally, the researchers are interested to see how video care support along with improved ability to share data from pumps and blood glucose devices compares to phone-only support.
For the Morlock family, the impact of the program has been immediate and positive. Charlie visits Mastrandrea, her UBMD endocrinologist, every three months, and in between visits, she and her family have the team at Cecelia Health to look to for guidance and support in addition to monthly telehealth appointments.
“It’s very helpful,” Morlock says. “It’s nice to have extra hands. We have four children and Charlie is our only girl, so she’s taking it all in and loving the attention when it comes to having extra resources. When I don’t know the answer, it’s amazing to be able to reach out for help because it definitely takes a village these days.”
Morlock explains that working with their Cecelia Health contact, they have “come up with a game plan to essentially make Charlie’s numbers steady because she’s had a lot of ups and downs with everything. She’s very, very active. She’s in dance and soccer and she’s outside all the time with her brothers, but there are times, like yesterday, when her numbers were high for the majority of the day and it took a lot to bring them down.”
For the telehealth visits, Morlock says “Charlie is there, present and speaking.” In addition, the team at Cecelia Health has secure access to data on Charlie’s insulin pump and can further monitor
her glucose levels. “So, it’s like she’s standing right there in front of them,” Morlock notes. The Helmsley Charitable Trust, the funder of this project, is one of the largest private foundation funders of Type 1 diabetes research in the nation. “Telehealth has the unparalleled ability to meet patients where they are, but for these services to be used, they must be reimbursed properly” says Sean Sullivan, PhD, program officer for the Helmsley Charitable Trust’s Type 1 Diabetes (TD1) Program. “This innovative work aligns with our goal at Helmsley to better understand the impact and viability of programs that can expand access to quality care for all people with Type 1 diabetes, regardless of their zip code.” “When I don’t know the answer, it’s amazing to be able to reach The grant will support this collaboration for three years. The Leona M. and Harry B. out for help because it definitely Helmsley Charitable Trust aspires to improve lives by supporting takes a village these days.” exceptional efforts in the U.S. and Ryan Morlock around the world in health and select place-based initiatives. Its Type 1 Diabetes Program is focused on understanding the disease, developing better treatments and improving care and access in the U.S and low- and middle-income countries. For more information on Helmsley and its programs, visit helmsleytrust.org. To learn more about how to support children with Type 1 diabetes through medical discovery and advances at the Jacobs School, contact Kathy M. Swenson, senior director of advancement, at kswenson@buffalo.edu or by calling 716-829-5052. S.A. Unger contributed to this article.
