The team at Boston Medical Center’s Opioid Treatment Center includes (left to right) Karen Hannon, R.N.; Katie Chen, Clinician; Lexie Bergeron, Program Manager; Colleen LaBelle, Program Director; and Daniel Alford, Medical Director.
Buprenorphine Treatment: A Nurse’s Story
By Meredith Hogan Pond
“The greatest day of my life was when we were able to get rid of our waiting list,” said Colleen LaBelle, R.N., CARN, Program Director for the Boston Medical Center’s Office-Based Opioid Treatment (OBOT) program in Boston, MA, and State Director for the Department of Public Health’s OBOT sites.
“People shouldn’t be waiting for buprenorphine treatment. If patients are ready to start their recovery from addiction to heroin or other opiates, we want to be ready to help,” Ms. LaBelle said.
Currently, at the Boston Medical Center, a total of 375 patients are managed through their varying levels of opioid addiction treatment with the medication buprenorphine. The nurse care management model is an important part of this expanded availability of treatment services at the center.
How does this model help?
“This model has allowed us to provide buprenorphine treatment to a large number of patients without adding more work for the physicians. The nurse does the majority of the upfront assessment, education management, and paperwork to get a patient into care,” said Ms. LaBelle. That frees up physicians—who have received waivers from SAMHSA to prescribe buprenorphine—to manage a larger group of patients. (See box.)
Approved by the Food and Drug Administration (FDA) in 2002 and available in pharmacies in 2003, buprenorphine allows opioid-dependent patients to bypass specialized methadone clinics and seek treatment in the privacy of their own doctor’s office or local clinic. The medication alleviates drug cravings and eases the withdrawal of patients addicted to heroin, prescription narcotics, and other opioid drugs.
Each specially trained physician received a waiver and was allowed to serve no more than 30 patients at a time. (See SAMHSA News online, “SAMHSA Helps Bring Buprenorphine to the Field, March/April 2004.)
“This was a very big deal,” said Ms. LaBelle. “We were getting calls for treatment information from across the state, from politicians, from nurses, from lawyers, from CEOs, from people from all walks of life, she said. The Boston pilot program was funded by the Massachusetts Bureau of Substance Abuse Services to see if using this model in an academic-medical setting would allow for the expansion of treatment for patients with opioid dependence.
The goal of the pilot program was to get more patients into care for their opioid addiction by using the nurse care management model with waivered physicians ready to see patients, to identify the patients appropriate for this treatment protocol, and to be their prescriber of record.
“Even with that program, we had a waiting list of more than 300 people. People were literally dying on our waiting list because there wasn’t enough treatment,” said Ms. LaBelle. “Imagine asking for someone who has come up on your waiting list and hearing from her mother on the other end of the phone that she recently died from a heroin overdose.”
In December 2006, the situation improved. At that time, the FDA approved certain physicians who met the criteria to serve 100 patients at a time.
“In August 2007, we had two full-time nurses, and I oversaw that project, along with another grant award from the state to provide training and technical support for 19 health centers modeled after our pilot program,” said Ms. LaBelle. The goal of the 19 sites was again to expand treatment, provide training and support, and build a network for nurses across the state who were doing addiction work.
“I provided daylong buprenorphine trainings, specific to nurses, modeled after the American Society of Addiction Medicine’s waiver trainings.” In addition, Ms. LaBelle provided quarterly training on topics of interest related to addiction, along with conference calls, site visits, networking, and more.
“Ms. LaBelle is a pioneer in the nurse care management model for buprenorphine treatment,” said LTJG Sara Azimi-Bolourian, M.S.N., M.H.A., M.B.A., a public health advisor in SAMHSA’s Division of Pharmacologic Therapies, Center for Substance Abuse Treatment.
“Her knowledge made her a key person to provide expert nurse review for SAMHSA’s Technical Assistance Publication (TAP) 30,” said LTJG Azimi-Bolourian, SAMHSA’s project officer for TAP 30. (See related article.) “My co-author, Katherine Fornili, R.N., M.P.H., CARN, and Kathleen Gargano, an expert nurse reviewer, also deserve recognition for their efforts making TAP 30 such a valuable tool for nurses.”
“We actually counted the number of patients across those 19 health centers before we started, and there were 324 patients total. A year later, we had 1,600 patients enrolled,” Ms. LaBelle explained.
At each site, nurses enroll an average of 2 to 3 new patients a week until they reach 100 active patients, which is considered “a manageable caseload” for a full time nurse. “In addiction treatment, people come on and come off all the time,” said Ms. LaBelle. “It’s not uncommon for patients to come and go many times in the course of their treatment as they work through their disease.”
Buprenorphine is a life-changing medication for individuals who can’t move forward in their disease of addiction because of how it affects their brain. People can take this medication at home when they get up in the morning. They take their medication and get on with their lives.
Find out more about buprenorphine or search the physician locator at SAMHSA’s Web site. You can also call SAMHSA’s Center for Substance Abuse Treatment (CSAT) for information at 1-866-287-2728 (1-866-BUP-CSAT) or email firstname.lastname@example.org.
Technical Assistance Publication (TAP) 30, Buprenorphine: A Guide for Nurses is currently available from SAMHSA’s Health Information Network at 1-877-SAMHSA-7. Ask for publication number SMA09-4376.
Nurse care-managers typically handle the initial screening — either by telephone or onsite — for a patient who is seeking medication-assisted treatment with buprenorphine.
Initial screening includes medical, psychiatric, social, and substance abuse histories. “We ask where they’re at in their treatment process, whether they’re safe, and whether they’re on any medications that may be contraindicated, and what their treatment goals are,” said Ms. LaBelle.
If patients are found to be appropriate candidates for outpatient treatment, they come in to meet with the nurse for an intake assessment. The initial screener intake is reviewed to make sure the information is accurate and to add details as needed.
“If a patient is already in the medical system, we review the medical history, medications, and current treatment, along with education about buprenorphine,” said Ms. LaBelle. That means letting a patient know what the medication is, how it works, how it’s administered, and what the program entails. “We want to be sure that the patient can meet the program requirements.” Questions include the following: Are they going to be able to come in and see the nurse weekly? Will they be able to go to counseling? Do they live nearby? Have transportation? Do they work? Have any legal issues?
In addition, nurses do an “education,” on the disease of addiction, the medication, the induction process, and potential complications (e.g., injuries, hospitalizations, emergencies, pregnancy). After that, the patient signs a treatment agreement and a consent of treatment.
“Every buprenorphine program has a consent of treatment, letting the patient know that this is an opioid, that individuals can become dependent, and there’s the potential for withdrawal symptoms if the person comes off the medication,” said Ms. LaBelle.
In a meeting with the treatment team, patients agree to program requirements in a treatment agreement, so patients know what to expect up front. “When patients are going through the intake process, they will promise you the moon because they want the medication,” said Ms. LaBelle. “It’s understandable. People are desperate for treatment. As we move forward and patients stabilize, we always review the treatment plans and agreements so that patients remember what they committed to. We work through the treatment process step by step with everyone on the same page.”
Treatment agreements are standard program requirements and the treatment plans are specific to a patient’s treatment needs. “We try to meet folks where they are at in their disease and make modifications and changes to assist them in the recovery process,” added Ms. LaBelle.
After the various screenings, the patient is scheduled to see a doctor who has a waiver and is permitted to prescribe buprenorphine. When that patient meets the doctor, all of this up-front work is done. The doctor sees the patient after the initial assessment, history, education on the treatment and program, lab work, urine tox, treatment agreement, consents, and the education. “The doctor does a physical exam for the patient, reviews all the information, confirms an opioid dependence diagnosis, and quickly moves the patient to start buprenorphine with the support of the nurse who facilitates this process,” said Ms. LaBelle.
“Typically, when a patient gets through the screener, through the nurse, and makes it in to see the doctor, that patient is appropriate for treatment. The doctors make the final decision, and work with the team to move this patient to induction. They are key to the success of this process.”
For more on buprenorphine, visit SAMHSA’s Center for Substance Abuse Treatment.