A clinical encounter on a mobile unit should replicate an office-based visit as closely as possible. There are, however, potential considerations that are unique to the setting.
• Access to medicine—Federal DEA regulations render storing buprenorphine on the mobile unit an impossibility, so buprenorphine can be provided by prescription only (paper or electronic) on the van. Buprenorphine and naltrexone will never be stored on the mobile unit. Strategies may include:
– Medical courier—Having staff deliver medicine from the pharmacy to the clinical site may be an option, especially for organizations that have onsite pharmacies.
– Establishing clinical sites near pharmacies—Establish clinical sites near pharmacies where outreach workers and/or clinical staff can accompany a patient to fill his/her prescription immediately in case a patient lacks required identification.
• Considering protocols that require no restroom—Requiring patients to use a restroom for certain labs/procedures (e.g. urine toxicology) could prove challenging. Consider alternative methods (e.g. buccal swabs) that do not necessitate bathroom us
Evaluation for initiation of medications for OUD (MOUD)is the same as in office-based settings. A face-to-face evaluation between the patient and a waivered clinician is required to take place. The following needs to be assessed and documented into the patient’s electronic health record:
• Patients who have moderate to severe opioid use disorder are diagnosed
• Patient’s goals of care
• Challenges to success of treatment including co-occurring disorders
• Presence or absence of contraindications
• Presence or absence of concerning activity on review of prescription monitoring program
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Consent to treatment Contraindications for initiation of buprenorphine in the mobile setting:
• Current methadone use
• Inability to understand or adhere to proposed initiation plan
• Heavy or chaotic use of sedative-hypnotic drugs such as benzodiazepines and Z-drugs
• Heavy or chaotic use of alcohol
• Suspected diversion or other inappropriate use based on prescription monitoring program report, toxicology results, or patient history
Note—Not all instances of suspected diversion shall preclude a patient from accessing
treatment. Clinicians should use their best discretion to determine if writing a prescription poses a greater risk to the patient or others than declining to write the prescription would.
Patient education:
• Patient education will be done by the provider and other
appropriate staff.
Patient referral to other OUD treatment programs
• Patients should be referred to the appropriate program
based on the patient’s level of need. Programs may
include medically supported detox, residential treatment,
methadone or buprenorphine maintenance in an opioid
treatment program (OTP) or other appropriate programs
Decision to begin MOUD
• It is the waivered clinician’s (MD/NP/PA) ultimate
responsibility to prescribe MOUD based on their
judgement and discretion
Initiation of treatment
• Initiation of buprenorphine will take place directly in
the mobile setting and is accomplished by prescribing
medication at the site where the staff are seeing
patients including the van itself, a street or park, or an
encampment. If stationed near a pharmacy, staff will
accompany the patient to the pharmacy and assist them
in filling their prescription as necessary.
– If there is no nearby pharmacy, consider establishing
a courier service to deliver the prescription to the
patient at the clinical site as quickly as possible. If the
medication cannot be promptly delivered to the patient,
it will be returned to the pharmacy or destroyed.
• Initial prescription typically will be planned for a short
prescription interval, no longer than seven days. The
patient should be given sufficient supply to last until the
next scheduled clinic at the same location.
• Providers should personalize each patient’s initiation
plan based on their clinical situation.
• If necessary, particularly in a patient with no prior
experience with buprenorphine, patients will initiate
dosing under observation by the clinician to observe
for precipitated opioid withdrawal.
Early follow-up care
• Follow up care will depend on the patient’s clinical
situation. For individuals who are initiating treatment in
the mobile unit, follow up in seven days will be typical.
• Patients should be made aware of the hours of any
available office-based addiction care provided by the
organization. Other OBAT program schedules should be
made accessible to patients.
• The team should connect on street outreach with those
who are unable to come to the mobile unit and seek to
make reasonable accommodations to connect them to
ongoing treatment
Maintenance
• Provider visits
– Management of ongoing buprenorphine treatment
will take place as part of regular primary care visits
or addiction medicine visits on the mobile unit.
• Maintenance visit frequency should be determined by the patient’s prescription, need and mobile unit schedule.
– Care will include all services available through
the mobile health unit including substance use
counseling, harm reduction services and care for
acute and chronic medical conditions.
• Counseling
– Federal regulation requires that additional behavioral
health counseling is available to patients who require it.
» Patient counseling needs will be assessed often
and be based on patient willingness, functioning and current substance use situation.
» Available counseling may include care provided, via tele-health platforms, through collaboration with a partnering agency, within the office-based practice of the clinical organization by LICSWs/ PsyD/ psychiatrists, or referral to counseling to an outside program
Clinical testing
• Therapeutic monitoring of buprenorphine is an important component to understand patient adherence and efficacy.
• It is recommended that the mobile health program considers implementing buccal swabs for toxicology given the barriers presented by urine tests, especially since many mobile units are designed without a bathroom on board.
• Regarding the administration of toxicology tests, interpretation, documentation and review of results with patients, procedures are the same as in officebased addiction treatment programs.
Steps taken to minimize diversion in the mobile setting are
exactly the same as in office-based practice.
• Understanding diversion in Massachusetts and beyond:
– The legal problems of diverted buprenorphine and risks to the program of being overly permissive around this issue, are of concern and the DEA requires any program prescribing buprenorphine to have a diversion policy. The medical problems of diverted buprenorphine are probably generally not large, but in general, prescribers should for any medicine (including antibiotics or hypertension medications, or any other) know the person they are prescribing to. Still, concerns about preventing diversion have to be balanced against implementing policies or clinician behaviors that might unnecessarily alienate patients who need the medication for their own survival but may be hesitant to get it in an overly punitive or rigid setting. One approach is to keep rules to a minimum but clearly enforce them; our OBAT program has tried to reduce this to just two clearly explainable and understandable rules. They are: 1. You have to take your suboxone to keep getting it (and we will conduct testing regularly to make sure that you’re taking it); and 2. You have to keep your suboxone supply (meaning, we will not do early fills for lost or stolen medication).