Care practices of mental health clinical pharmacist practitioners within an interdisciplinary primary care model for patients with substance use disorders

Abstract

Background.

Clinical pharmacist practitioners (CPPs) play an increasingly important role in interdisciplinary care for patients with substance use disorders (SUDs). However, CPPs’ scope of practice varies substantially across clinics and settings.

Objectives.

We sought to describe CPP practices and activities within an interdisciplinary, team-based primary care clinic dedicated to treat Veterans with histories of substance use disorders, experience of homelessness, high medical complexity, and other vulnerabilities.

Methods.

We conducted a retrospective cohort study of CPP activities using Department of Veterans Affairs (VA) administrative data in 2019.

Results.

CPPs provided care for 228 patients, including 770 in-clinic visits, 340 telephone visits, and 626 chart reviews, with an average of 2.5 hours spent per patient per year. Patients seen by CPPs frequently experience mental health conditions and SUDs, including depression (66%), post-traumatic stress disorder (52%), opioid use disorder (OUD) (45%), and alcohol use disorder (44%). CPPs managed buprenorphine medications for OUD or chronic pain in 76 patients (33%). Most CPP interventions (3,330 total) were for SUDs (33%), mental health conditions (24%), and pain management (24%), with SUD interventions including medication initiation, dose changes, discontinuations and monitoring. As part of opioid risk mitigation efforts, CPPs queried the state’s prescription drug monitoring program 769 times and ordered 59 naloxone kits and 661 lab panels for empaneled patients.

Conclusion.

CPPs managed a high volume of vulnerable patients and provided complex care within an interdisciplinary primary care team. Similar CPP roles could be implemented in other primary care settings to increase access to SUD treatment.

Introduction

Nearly one in seven primary care patients meets criteria for a substance use disorder (SUD),¹ yet most patients with SUDs do not receive evidence-based treatment.^2–5 Emergency department visits attributed to SUD-related causes increased by 45% from 2013 to 2018.⁶ With rising opioid-related overdoses and deaths,^7–9 there have been calls for primary care to assume a greater role in providing treatment for SUDs, including opioid use disorder (OUD).¹⁰ However, system and provider barriers persist.^11–14 Primary care providers (PCPs) often describe time constraints and lack of support staff as key barriers to prescribing medications for opioid use disorder (MOUD), even after receiving certified training to do so.^15–18 Expanding the role of clinical pharmacist practitioners (CPPs) within primary care could address PCP staff shortages, mitigate time and resource barriers to medication treatment for SUDs, and prevent more costly hospital-based services.^19,20

CPPs can provide comprehensive SUD medication management under an expanded scope of practice.^21,22 To date, CPPs have been integrated into some intensive outpatient SUD programs, inpatient psychiatric units, and mental health clinics^23,24 where they monitor medication adherence and help prevent return to illicit use.²² In specialty clinics, CPPs assist in OUD management by collecting patient information for the provider, who then creates a care plan.²⁵ In some states, CPPs can independently prescribe buprenorphine for OUD following passage of the 2023 Consolidated Appropriations Act.

Even in states without prescribing authority, CPPs with specialty training and board certification in mental health can improve treatment access and SUD medication management in a variety of ways.²⁴ For instance, patients receiving medication treatment may transfer their care to mental health CPPs for ongoing management, reducing workload for prescribing providers.²⁶ The Department of Veterans Affairs (VA) has integrated mental health CPPs in SUD roles across the country, typically in mental health settings with psychiatrist-led teams.²⁷ Some VA facilities have also incorporated CPPs within primary care and pain clinics to promote access to MOUD care.^16,28 However, published studies generally do not describe or quantify the scope of SUD care activities provided by mental health CPPs within primary care environments.^22,23,25,29

We sought to describe mental health CPP roles and activities performed within an interdisciplinary, team-based primary care clinic. Understanding how CPPs are utilized for mental health and SUD management can guide the development of CPP programs in both addiction (e.g., SUD clinics, outpatient mental health clinics) and non-addiction settings (e.g., primary care, pain clinics, community pharmacies) and demonstrate how pharmacists may play a role in improving access to SUD treatment.

Methods

Setting.

In 2018, the VA Salt Lake City Health Care System implemented an interdisciplinary model to engage patients with addiction, adverse social determinants of health (e.g., homelessness), and high use of health care services—in a primary care setting. This Vulnerable Veteran Innovative Patient-Aligned-Care-Team (VIP) Initiative incorporated two mental health CPPs within this interdisciplinary model.^26,30 As described elsewhere, the interdisciplinary team included four primary care providers, a mental health nurse practitioner, a social worker, two nurse care managers, and two mental health CPPs all co-located in the same clinic.²⁶ Both mental health CPPs hold Board Certified Psychiatric Pharmacy (BCPP) credentials—the highest certificate a mental health pharmacist can obtain.

VIP enrollment occurs through a CPP consultation process where CPPs determine the appropriateness for VIP versus referral to a higher level of care. Next, CPPs perform an intake chart review of all active problems and makes medication recommendations. Following intake, the provider may retain all medication management or refer to the CPP for medication management needs. Referrals may include shared medical appointments with the CPP and PCP, and/or independent CPP appointments.

CPPs perform both direct patient care duties and administrative tasks. Through a scope of practice, CPPs independently manage a panel of patients with SUDs or other mental health conditions through in-clinic, telephone, and telehealth visits. Duties include taking SUD histories, managing withdrawal, placing referrals to other disciplines if indicated, and initiating or discontinuing medications for mental health and SUDs, including buprenorphine/naloxone. Other roles include daily huddles with PCPs, monitoring prescription drug monitoring programs (PDMPs), ordering/interpreting labs, providing opioid overdose education and naloxone distribution, addressing harm reduction, and assessing suicide risk.

Design and Sample.

We conducted a retrospective cohort study of CPP activities using data abstracted from the VA’s electronic health record (EHR) between January 1 and December 31, 2019. Eligibility criteria included having 1+ in-person or telephone encounter with a VIP CPP in 2019. All patients who met study criteria were included in analyses. Study activities were approved by the VA Salt Lake City Health Care System and University of Utahs’ institutional review boards for research and quality improvement activities.

Patient Characteristics.

We examined demographic characteristics of VIP patients, including age, sex, and race/ethnicity. Clinical characteristics included mental health and substance use disorder histories, determined from International Classification of Disease (ICD) codes in the 12 months prior to clinic enrollment.

CPP Workload.

We counted the number of in-person, telephone, and chart review encounters completed by CPPs in 2019. Time spent with each patient was captured using categorical data from encounter billing codes in the EHR (e.g., telephone visit 5–10 minutes, telephone visit 11–20 minutes, telephone visit 21–30 minutes). We calculated the total time spent per patient by multiplying the number of encounters with the median of the time range per encounter type. We also counted medication interventions recorded in the “PharmD Tool.”^31,32 As described elsewhere,³¹ the PharmD Tool is a data collection instrument within the VA’s EHR that documents pharmacist clinical activity by type of intervention (e.g., medication initiation) and condition (e.g., OUD). Other patient care activity variables extracted from the EHR included number of consultation requests; and referrals, naloxone kits orders, and lab orders placed by CPPs in 2019.

Analyses.

Univariate statistics (means, standard deviations, medians, percentages) were calculated in Stata version 17 to describe the demographics of patients managed by CPPs, and to quantify annual CPP activities and workload.

Results

Patient Characteristics.

CPPs saw 228 unique patients in 2019, of whom 96% were male, 94% non-Hispanic, and 96% white (Supplemental Material Table 1). The average age was 54.6 years. The majority of VIP patients managed by a CPP had a mental health or SUD diagnosis (87% and 83%, respectively). The most common mental health diagnoses were for depression (66%), post-traumatic stress disorder (52%), and anxiety disorder (42%). SUDs included OUD (45%); alcohol use disorder (AUD, 44%); and drug use disorders specified for stimulants (21%), cannabis (15%), cocaine (6%), sedatives (6%) or unspecified substances (5%). One-third of patients (33%) received buprenorphine products managed by CPPs.

Number of Encounters.

CPPs completed 1,107 visits in 2019 (mean per patient=4.9, sd=5.9; Table 1). Of these, 766 visits were in-person (mean per patient=3.4, sd=5.1) and 341 were by telephone (mean per patient=1.5, sd=2.1). Patients (n=228) often had both types of visits (43% had in-person only, 15% phone only, 41% phone and in-person), however any visit where a controlled substance was started required the patient be seen in-person. Visits ranged 5–120 minutes in length, with most telephone visits lasting 5–10 minutes (58%) and in-clinic visits lasting 15–30 minutes (66%). Most chart review encounters (n=626) were less than 15 minutes (63%). In total, CPPs spent 566 hours providing direct patient care through in-person (285 hours), telephone (81 hours), or chart review (215 hours) activities, for an average of 2.5 hours per patient per year.

Table 1.

Visits with VIP Mental Health Clinical Pharmacist Practitioners in 2019, by Type of Visit

Type of visit	Total	Mean (SD) per patient	Range per patient	Median (IQR) per patient
In-person	766	3.4 (5.1)	0–33	1 (1–3)
Telephone	341	1.5 (2.1)	0–14	1 (0–2)
All	1,107	4.9 (5.9)		2 (1–6)

Abbreviations: IQR, interquartile range; SD, standard deviation; VIP, Vulnerable Veteran Innovative Patient-Aligned Care Team

Medication Interventions.

CPPs performed 3,330 medication interventions in 2019 (Supplemental Material Table 2). The three most common medication interventions were for SUDs (n=1,112), mental health conditions (n=814), or pain management (n=809). Of the SUD interventions performed (n=1,112), 45% were for OUD, 24% for AUD or alcohol withdrawal, 24% for tobacco use disorder, and 7% for other SUDs.

The type of intervention varied by SUD (Table 2). For most SUDs, CPP interventions typically involved monitoring medication without changes. However, CPPs initiated medication treatment in 5% of OUD interventions and 10% of AUD interventions. The most common interventions for tobacco use disorder involved non-pharmacologic treatment (64%).

Table 2.

Substance Use Disorder (SUD) Interventions Performed by VIP Mental Health Clinical Pharmacist Practitioners in 2019, by Type of SUD

	Type of Substance Use Disorder
Interventions	Opioid use disorder	Alcohol use disorder / withdrawal	Tobacco use disorder	Other	Total
Initiate medication	25 (5%)	26 (10%)	54 (20%)	N/A	105 (9%)
Adjust dose frequency meds	62 (12%)	8 (3%)	22 (8%)	N/A	92 (8%)
Changed or discontinued	6 (1%)	24 (9%)	21 (8%)	N/A	51 (5%)
Monitor medication, no changes	381 (77%)	184 (70%)	N/A	79 (95%)	644 (58%)
Non-pharmacologic treatment	24 (5%)	22 (8%)	170 (64%)	4 (5%)	220 (20%)
Total	498	264	267	83	1112

Abbreviation: VIP, Vulnerable Veteran Innovative Patient-Aligned Care Team

Patient Care Activities.

The CPPs triaged 320 outpatient consults in 2019 and completed 74% of these outpatient consults (Supplemental Material Table 3). They also triaged 45 e-consults and completed 87% after triage. They placed 26 referrals to higher levels of care (17 to addiction treatment services and 9 to opioid treatment programs). CPPs queried the PDMP 769 times, ordered 59 naloxone kits, and ordered 661 lab panels that were completed by patients.

Review

We sought to describe and quantify CPP activities within an interdisciplinary primary care clinic in order to demonstrate how mental health CPPs can help address barriers to primary care management of SUDs, including provider shortages and needs for clinical support. CPPs performed a wide breadth of services for a large panel of patients, many of whom had co-occurring mental health conditions and SUDs and required frequent patient visits. The CPPs initiated and discontinued SUD medication treatment, adjusted dose frequencies, and monitored medication treatment in collaboration with PCPs. Overall, this study demonstrates the vital role of mental health CPPs within an interdisciplinary primary care team setting which may serve as a model to address unmet SUD treatment needs in other primary care settings within and outside the VA.

Our study adds to the literature in several important ways. First, while other primary care-based studies that have utilized CPPs have shown effectiveness of CPPs for treating a single condition such as OUD alone,²³ we found that mental health CPPs can successfully manage patients in a primary care setting when illness severity and medical complexity are high. Second, while previous studies have shown promise for CPPs in limited ways (e.g., through small patient panels or restricted autonomy such as only following patients already stabilized on medications for SUDs^23,33), this study depicts successful CPP care management for a large patient panel where CPPs had autonomy to initiate medication treatment (i.e., 5% of OUD interventions and 10% of AUD interventions performed by CPPs). The VA allows for CPPs to be co-located within primary care clinics and, in the present interdisciplinary clinic, the two CPPs collaborated closely with PCPs under their scope of practice. Thus, our results offer an example of how adding mental health CPPs to primary care settings can support PCPs in providing SUD care.

Our interdisciplinary clinic model differs from typical VA primary care³⁴ in important ways. Nationally, VA primary care-mental health integration (PCMHI) clinicians (e.g., psychologist, social worker, mental health care manager) screen and provide brief interventions for AUD but often lack specialized training and prescribing authority to provide comprehensive SUD treatment within primary care.¹³ In contrast, the VIP clinic has 1) dedicated mental health CPPs not shared with other primary care clinics; 2) prioritized enrollment for patients with medical, mental health, and social morbidities; and 3) greater staffing-to-patient ratios. Our finding that only a few patients managed by CPPs required referrals to higher levels of care, such as specialty SUD clinics, suggest that the specialized mental health CPP training and skills were sufficient to meet the clinical needs of most patients. In an era where optimizing care within a resource-constrained environment is paramount, this interdisciplinary primary care model involving mental health CPPs appears promising. It may be worthwhile to expand mental health CPP roles as part of national PCMHI initiatives. However, additional research comparing interdisciplinary primary care involving CPPs to usual VA primary care is needed.

This study has limitations. First, the cross-sectional design precludes causal inferences. Second, we relied on electronic health records to quantify CPP workload, which undercounted activities such as time spent collaborating with PCPs. Third, this study was conducted in an interdisciplinary VA primary care clinic offering comprehensive SUD care. Findings may not generalize to non-VA primary care settings that have limited CPP scope of practice. Finally, this study was conducted prior to legislative changes lifting restrictions on buprenorphine prescribing. Beginning in 2023, CPP activities in our clinic include independent buprenorphine prescribing.

Conclusion

Our results offer an example of how mental health CPPs may be utilized to increase primary care capacity to treat SUDs, including OUD, within their scope of practice. CPPs can play an integral role in bolstering interdisciplinary primary care models that simultaneously address medical needs, SUDs and social determinants of health.

Highlights.

• Clinical pharmacists can be utilized as practitioners in primary care settings to provide care for patients with substance use disorders, including medication management.

• Expanding the scope of practice for clinical pharmacists in the primary care setting could mitigate some barriers to medication treatment for substance use disorders and better address complex patient needs.

• The VIP clinic may serve as a model to improve primary care capacity for treating substance use disorders.

Abbreviations and acronyms

ASHP

American Society of Health-System Pharmacists

AUD

alcohol use disorder

BCPP

Board Certified Psychiatric Pharmacy

CPP

Clinical Pharmacist Practitioner

EHR

Electronic Health Record

MOUD

mediation for opioid use disorder

OUD

opioid use disorder

PCPs

primary care providers

PDMP

prescription drug monitoring program

SUDs

substance use disorders

VA

Department of Veterans Affairs

VIP

Vulnerable Veteran Innovative Patient Aligned Care Team