Physicians team up to treat addiction in rural areas

Troy Parks
Staff Writer
AMA Wire
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Physicians in New Mexico have developed a distance learning model to address inadequate access to medical care in rural and traditionally underserved areas. Through a special focus on substance use and behavioral health disorders, the project has bolstered primary care physicians’ ability to care for patients with substance use disorders in the midst of the opioid overdose epidemic.

Led by Professor of Medicine Sanjeev Arora, MD, Project ECHO (Extension for Community Healthcare Outcomes) was created at the University of New Mexico Health Sciences Center in 2003. The project is a free-of-charge distance education model that connects primary care professionals with specialists through simultaneous video conferencing to help them develop and share knowledge in the care of a variety of complex health conditions they may not have felt prepared to treat.

How Project ECHO works

The ECHO model connects local clinicians, or “spokes,” with specialist teams at academic medical centers, or “hubs,” in weekly teleconference clinics called teleECHO™ clinics. During these weekly two-hour sessions, participants present patient cases that raise challenging medical and other treatment issues to collect the input of their colleagues and the specialists on the call.

TeleECHO clinic sessions typically begin with a brief didactic discussion on an aspect of substance use disorder or behavioral health. Then a participant gives an oral case presentation—cases are submitted by participants in advance of the session. Questions are solicited from other participants, including the specialists at the hub, and then the group has a discussion around the teaching points raised by the case. These recommendations are summarized and sent to participants as a reference.

In light of the opioid overdose epidemic, Project ECHO has been ahead of the curve with two focus areas: effective treatment of substance use disorders and supporting medication-assisted treatment (MAT) with buprenorphine. Since 2005, specialists in treatment of substance use and behavioral health disorders at Project ECHO have offered the weekly Integrated Addictions and Psychiatry (IAP) teleECHO Clinic.

Miriam Komaromy, MD, associate director of Project ECHO and an internal medicine specialist and addiction consultant, leads the IAP teleECHO Clinic sessions which have been used to recruit physicians to participate in buprenorphine waiver trainings. In 2006, only 36 physicians in New Mexico were buprenorphine-waivered. Since that time, 375 physicians in New Mexico have participated in buprenorphine waiver trainings offered by Project ECHO’s IAP teleECHO Clinic. New Mexico now has more buprenorphine-waivered physicians per capita than all but three other states.

National expansion of the ECHO model

Several states, including Connecticut, Montana, Hawaii and upstate New York, have jumped on board and started their own substance use teleECHO clinic sessions in the last year. The ECHO Institute offers a rolling, monthly training that lasts up to three days and shows leaders how to establish the model in their state or region.

In addition to individuals trying to connect and wanting to start programs in their own areas, Dr. Komaromy is involved in a national effort in collaboration with the American Society of Addiction Medicine (ASAM), with funding from the Center for Substance Abuse Treatment. “We’re doing a 16-week pilot we’re calling Fundamentals of Addiction Medicine teleECHO Clinic (FAME),” she said. “We recruited participants who had attended a one-day pre-course called “Fundamentals of addiction medicine” at the annual ASAM meeting.”

“Every week people are coming into the clinic from all different corners and presenting cases,” she said. “A unique feature is that we’ve recruited a bench of addiction specialists from around the United States and Canada.” Dr. Komaromy facilitates the live conversation, but the guest specialists give didactic presentations and participate in the patient case discussion each week.

“It’s been a rich opportunity for people at different levels of knowledge to interact and for the primary care physicians to develop mentorship relationships with the specialists,” she said.

Participants ask questions and talk about patient cases to “promote the kind of dialogue that doesn’t happen enough between specialists and primary care physicians,” Dr. Komaromy said. “The specialists also learn from the primary care physicians, so it’s a really collaborative learning environment.”

As a result of Project ECHO’s success, Sens. Brian Schatz, D-Hawaii, and Orrin Hatch, R-Utah, recently introduced the Expanding Capacity for Health Outcomes (ECHO) Act in an effort to expand the model to rural health networks throughout the country.

How participants are responding

Dr. Komaromy has heard a lot of positive responses from physicians. One physician said he has started to see the Thursday morning clinic session as an anchor to his week. He saves up questions, and when he runs into a challenging case, he wants to bring it to the group for discussion.

A nurse practitioner in Alaska said that she just doesn’t have many resources in her area for substance use treatment, and it’s helpful to have a network of people whom she can run cases by and gather advice.

Another benefit of the ECHO sessions has been helping participants better understand the patient’s perspective as well as the power of language when talking about substance use and addiction.

“We see people change over time,” Dr. Komaromy said. “Stigma is a big issue. It’s huge in the medical profession because it’s huge in society. Sometimes we’ll role play discussions … [and] model bringing compassion to the interaction—trying to understand this patient’s point of view, particularly focusing on trauma, which can help turn the conversation around.”

“As physicians our tendency is to think the most helpful thing is to talk about the medication or the biology of the situation,” Dr. Komaromy said. But understanding the relationship component and how to talk with these patients is critical.

“I think one of the most important components that we have is an excellent addiction counselor who is part of our faculty,” Dr. Komaromy said. To see medical professionals collaborating with the counselor and learning some very practical techniques for framing the issue with their patients “is very powerful to experience,” she said. “The multidisciplinary nature of the clinic is very helpful.”

Reducing the stigma of substance use disorders and enhancing access to treatment for those who have a disorder is one of the five things physicians can do to prevent opioid abuse, recommended by the AMA Task Force to Reduce Opioid Abuse, which physicians convened to help the nation move closer to the goal of ending the opioid epidemic.

Learn more about what physicians are doing to end the opioid epidemic

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Mar 19, 2017
The Human Diagnosis Project has recruited thousands of specialists from dozens of countries to provide online curbside consults to front-line physicians.