Silence. Silence. Good afternoon, everyone. My name is Sejal Patel. I work with American Psychiatric Association and part of the MNet team. We will wait a couple of more minutes for others to join. So far, we have around six participants joined. So let's wait for a couple of more minutes and get started. Silence. Silence. Silence. All right. Just to keep the webinar on schedule, I think we should get started. So once again, welcome, everyone, to this MNet webinar titled Adaptations During COVID-19 for Addiction Medicine Office-Based Practice. This webinar is approved for one CME credit. So by participating in this webinar, you will be able to earn one CME credit. Once the webinar is over, I'll send more information on how to claim that credit. So stay tuned for that. You should receive it in the next 48 hours. Having said that, our speaker today is Dr. Brian Hurley. And Dr. Hurley, please, the platform is yours. Go ahead. Great. Hey, everybody. It's good to be here this afternoon. I'm Brian. I'm an addiction psychiatrist. And I am on the planning committee for MNet, president-elect of the American Society of Addiction Medicine. And I'm here to talk about Adaptations During COVID-19 for Addiction Medicine Office-Based Practice. There is a Q&A part of the Zoom chat, and there is also a chat part. I will respond to either. So when you have questions or comments, put them in there, and periodically I'll be scanning the chat to see how it could be helpful. So just a little bit about me. I work as the medical director of the Division of Substance Abuse Prevention and Control, LA County Department of Public Health. I'm also the clinical director of the Treating Addiction Starts Here in the safety net program funded by the California Healthcare Foundation. I'm a co-PI on a tobacco-related disease research program, a funded integration project for tobacco treatment. And I'm the president-elect of ASAM, and I'm a member of the MNet steering committee. I don't have any financial conflicts. I don't work for any drug companies or device manufacturers. I'm not going to try to sell you anything today. But I am going to highlight ASAM, right? I am the president-elect of ASAM, and ASAM has recommendations with COVID, publishes lots of public policy statements and national practice guidelines. ASAM doesn't really make money off of those things, but I would be biased in relationship to them. And MNet is managed by the APA. I'll be speaking about MNet, and I'm on the MNet steering committee. So although I don't personally get any – I don't have any financial – what would you call it? Investments within MNet myself. I don't make a differential money with people that enroll. I do want to see MNet be successful, and that is it's a non-financial conflict of interest. Just a couple resources to highlight today. I mentioned that I'd be highlighting MNet, so I'll be covering a little bit about PsychPro and the MNet portal, which is an addiction medicine practice-based network and tool for measurement-based care for people treating – or for clinicians treating patients with substance use disorders. And I also am going to highlight some of what ASAM has already put out with clinical recommendations for COVID. These are the learning objectives for the webinar, so we'll be going over the regulatory changes that are in place during the COVID-19 public health emergency, the implications for addiction medicine office-based practice, and be talking about offering addiction medicine office-based care through telehealth, as well as how to organize a medication management strategies that balances the risks associated with patient access, treatment outcomes, and COVID-19 virus exposure risks. Why are we talking about addiction medicine practice in the context of COVID? Well, overdoses have only gone up, and if you look at the plateauing with drug overdoses – and this is not prescription drug overdoses, this is all sources of drug overdose, so prescription drugs, illicitly obtained intoxicants, it's sort of from all sources. And we see, in early 2020, a shift in the rate, right? There was sort of a plateau between 2018 and 2020, and then ever since there, a rising rate. Now, we did see some dips in January 2022. Those are reported values that are subject to ongoing reporting, but just to point out, we have been on an escalating trajectory of drug overdose deaths. More people are dying in the United States of drug overdose than ever in our history, as far as we've collected epidemiologic data, and the public health impact of overdose really can't be overstated. What are people overdosing on? Well, across the nation, if we look at the number one drug involved in overdose deaths, it's synthetic opioids, other than methadone. That is primarily fentanyl. Fentanyl has made its way into the opioid drug supply, so when people are buying heroin, there is not infrequently fentanyl that is – you could call it a contaminant or a poison, but it's in with the heroin. We're also seeing fentanyl find its way into the methamphetamine supply, cocaine supply, ecstasy supply, right? People that purchase pressed pills that are not manufactured through an FDA-approved source, but sort of illicitly obtained or manufactured pills that look like they could be. Anything from alprazolam to oxycodone to really anything else. Those Fenta pills oftentimes have fentanyl in them, and what we're seeing is a high-potency opioid, which is what fentanyl is, right? Synthetic high-potency opioid making its way into the drug supply and a whole number of overdose deaths associated with people who are taking fentanyl that are not tolerant to opioids. Fentanyl is not uniformly toxic. Fentanyl is not cyanide. It doesn't immediately kill you, but what makes it so implicated in drug overdose is very small amounts of fentanyl, very potent, and if you're not tolerant to that, that causes respiratory arrest. It's the potency of fentanyl in a very small amount that's the difference between comfortably intoxicated and in respiratory arrest is what makes fentanyl so dangerous. Again, it's not uniformly toxic. It's just dangerous to use when people are using fentanyl when they don't know that they're getting fentanyl or they're not tolerant to the amount of fentanyl they're getting. We've been talking about this on the AMNET steering committee. One can frame fentanyl contamination in drugs as a type of poisoning. If somebody really does think they're going to get a sedative, let's say they're going to buy street alprazolam, and there's fentanyl in it, and they didn't know that, that really is like an accidental overdose. They didn't go to use opioids. The person may not even use opioids, may not even be tolerant to opioids, but the fact that there is a high-potency opioid that's pressed in with whatever else is in an illicitly produced pill is why people die. Fentanyl is the big driver. The other spike, though, as I would say, is psychostimulants. I live in LA, where methamphetamine is still a bigger driver of overdose than fentanyl is. More people die of methamphetamine overdose than fentanyl overdose, at least on its own. A lot of our methamphetamine overdoses are also fentanyl overdoses, but there's a lot of methamphetamine-only overdoses, where people die of strokes, heart attacks, cardiovascular collapse, the common overdose rates with methamphetamine. Just to be clear, going back a slide, these overdose stats capture that. It's driven by opioids, but it's not purely an opioid effect. There are other psychostimulants, again, primarily methamphetamine. Cocaine is also a big driver. It's been a while now since prescription opioids have been the major driver of overdose. Like I said, it's been a while. If you look at the green line, benzodiazepines are an oft-forgotten source of overdose. Not necessarily people that take sedatives on their own. It's typically sedatives taken with something else. It's the synergism of a sedative with an opioid that's often associated with overdose. Why is it important for us to talk about addiction medicine practice during COVID-19? COVID-19 is one driver of increased overdose rates, and addiction medicine has the promise to help reduce those risks. It's not just opioids and illicit drugs, though. Alcohol. I pulled this from an article on COVID-19 pandemic and alcohol consumption that looks at the COVID-19 pandemic, which drove social isolation and many health departments declared lockdowns, was associated with both an increase in physical vulnerability and risky behavior that increased alcohol consumptions and patterns. There's this actually great study published in December of 2020, looking at the months of April, May, June, July, August, and September of 2020, looking at alcohol behavior. They had roughly 1,000—it's not exactly 1,000, so the number is varied each month—but roughly 1,000 respondents responding each month for a six-month period, so totaling nearly 6,000 audit respondents, looking at who had an audit score of above 8. An audit score of 8 or above is associated with risky drinking. An audit score of 15 or above is high risk, and an audit score of 20 or above is probable alcohol use disorder. There's probable alcohol use disorder at 15 or above, and then severe probable alcohol use disorder at 20 or above. 20% of the sample in April was associated with heavy drinking. By September, we saw that at 30%. For probable alcohol dependence, we started around 10%, we got into nearly 20%, and among people who are already at higher risk, we went from 4% to 12%, so like tripling of people in that high, high risk category of an audit score over 20. So, a point is, we saw drinking go up during the COVID-19 pandemic, and one of the hypotheses that this article evaluated is social isolation was a big risk factor for this. The fact that this happened in places that were locked down, more so than places that weren't locked down, seemed to be associated with a big explanation for changes in alcohol-related behavior. And then there's this other study, again, published about a year ago, looking at retail alcohol and tobacco sales, and alcohol sales went up by 30%, and tobacco product sales went up by 13% during the COVID-19 pandemic in 2020. Anxiety, hopelessness, and social isolation were, you know, were observably related to increases in use. So, yes, the COVID-19 pandemic is driving overdose, and yes, it seems to be driving less drug use, and alcohol use, and tobacco use, sort of like substance use across the board is impacted. So, for those of us that work in the addiction field, what do we do, right? Like, the COVID-19 pandemic limited access, or certainly in-person access to addiction medicine care. So, I'm going to review some of what we did, right, some of what has already been described in terms of addiction medicine adaptations for COVID. But I would be remiss in talking about, you know, what do addiction clinicians and addiction medicine do in this context, without talking about the treatment gap. 6%, or the usual number I use is 5%, because it's a rounder number, but 5% of people with addiction get treatment each year. 95% of people with a substance use disorder do not get substance use disorder treatment. If we're waiting for patients to come to a vital spiritual experience and come to us, we'll be waiting for most of their lives. Part of doing effective addiction practice is getting care to where people are, and that means typically either getting clinicians, or getting clinicians to get their expertise in the treatment out remotely, as opposed to expecting patients to always come in for care. That's not to say there shouldn't be in-person services, right? There's a role for residential treatment, there's a role for inpatient addiction treatment. But office-based practices need to be just as flexible with when patients need to come in, versus when patients can be managed remotely. This data comes from the NSDUH, the National Survey on Drug Use and Health. The report was published last year, but the results were from the 2020 survey. It's a national household survey conducted over the telephone. One of the questions they ask for people in the orange part of the circle is, for those that had a substance use disorder that didn't get treatment, why didn't you? Does anyone know, and this is not rhetorical, I'm actually curious, so you can use the chat or the Q&A to respond. When they ask people who didn't get treatment, why didn't you get treatment, what's the number one reason why people didn't get treatment? Does anyone know? Again, not rhetorical. And then since y'all, I'm going to put in a link to the slide deck here. I meant to put it in up front, but I don't think I can, I don't have the access to be able to distribute it. Ah, here we go. The Q&A. Stigma, not understand what treatment involves. Yeah, Mark, totally. Stigma is a huge reason. You know, absolutely huge reason why people don't get treatment and not understanding what treatment involves and Dodds not asking, yes. The biggest reason I think, thank you, Mark. Mark's got the answer. The biggest reason people don't get treatment is they don't think they need it. Why do you get treatment? I don't need it. Now, I agree with you, Rick. One of the reasons they don't think they need is they don't understand what treatment is, right? There's this assumption of the people start fully ready with absolute goals of care, which, again, is not true. Right. Most patients don't start with absolute goals of care. So, so oftentimes there's this assumption that people with addiction will have no goals of care. And so they start with absolute goals of care, which, again, is not, is more the exception than the rule. Right. Most patients don't start with absolute goals of care. So, so oftentimes there's this assumption that people with addiction will have insight into the fact that what they're experiencing is a substance use disorder and immediate latch on to treatment. And actually the opposite is true. The reason the biggest, what you call bottleneck or barrier to entry into addiction treatment is patient readiness. Right. Most patients don't seek treatment because they're not ready to go to treatment. And so part of that means getting addiction treatment into primary care, into specialty mental health care, into street medicine care, into hospital care, into, you know, other types of specialty care. Right. Like it's, it's addiction treatment is not this thing that happens over in a silo. And there is, there is a role for specialty addiction care. There is a role for residential IOPs. Right. OTPs. Right. The whole specialty network. But that specialty network is, is, you know, very inappropriately low in its access and penetrance into the community that needs it most. So it means getting addiction treatment out. And so what were some of the principles, and are, because COVID hasn't gone away, what are some of the principles of addiction medicine practice in the context of COVID? So in the context of COVID, you want to try to minimize in-person interactions to the extent possible. Now, that doesn't mean that, you know, it really depends on individual clinicians' risk profiles. We now have a vaccine. It looks like we're about to come out with a second, you know, a second wave of vaccines. So individual clinicians have sort of different risk profiles around their ability to see patients in person. But I think the idea is, particularly early on in the pandemic, when we knew less around risk factors and spread, continue to engage patients while minimizing in-person interactions. That we use telemedicine, or which telemedicine is defined as audio-visual. It's what I'm doing here, audio and visual, right? So there's a picture and then there's the audio. As opposed to telephone visits, which is if I turn my video off and I was just on the phone, that would be like a telephone-based visit. And then assess on a literally patient-by-patient and actually case-by-case, right? Like a basis of whether it makes sense, whether conducting an in-person exam is worth the benefit. What would that exam likely change in the treatment plan? So this is a slide that essentially goes through, what are the considerations for addiction medicine practice during COVID-19? Thank you, Sajal, for putting out the handout to everybody. All right, cool. So telehealth, how to use telehealth. And I know, I'll just speak to my own practice. Clinically, I would only see patients in person prior to COVID. I mean, truly, like in an exception, I might make a phone call to help try to coordinate the patient getting into the office. But it was, to get a prescription, you need to come to the office and give a urine, right? That was my standard. And did I get a urine every time? No, it really depended, right? But that was the kind of default. And so it required me to shift, like, okay, when do I need to come into the office? Like, when is that important enough for the risks of participating in the COVID spread? It changed the duration of my prescriptions, right? I would usually start everyone off with a week or less, and I started going to two weeks, right? I have patients who, I have colleagues that start patients off at two weeks, lower threshold sort of medications for opioid use to sort of programs that would go to a month, right? Like minimizing the amount of time somebody would need to go back to the pharmacy or a delivery person would need to come over. Oftentimes, I've worked with patients to arrange for counseling and other types of psychosocial treatment, like self-help groups happening virtually. You can still do pill counts as long as you've got an audio-visual platform, you can see patients as long as they get the bottle. I will say the abilities for patients to, I'll call it this, the fidelity of those pill accounts sometimes goes down when you don't have the bottle with the pills in the office. The camera is helpful, but it doesn't replace in-person. But just making sure that patients have an adequate medication supply. I think I was much less rigid on making sure patients had 28 days and then on the 28th day is when the refill gets processed, right? So that there's no overlap. But really making sure that if a patient has enough excess supply that they're not gonna run out. In the context of the COVID-19 pandemic, anyone that uses any illicit intoxicants gets a prescription for naloxone. Opioids, stimulants, sedatives, right? They can all have fentanyl in it, right? And naloxone rescues you from opioid poisoning or opioid overdose. And that's what fentanyl essentially is. It drives opioid overdose for which naloxone can rescue people. So there's a big push to make sure that naloxone is prescribed to every patient at risk for overdose. And that's not just patients with opioid use disorder. I'm not defaulting to naloxone prescriptions. I mean, any patient that wants to have naloxone on hand, I'm not a naloxone prescriber to them. But I don't default naloxone prescriptions for my patients whose only use disorder is alcohol. We're not seeing a lot of fentanyl in alcohol. I'm not seeing a lot for patients that use cannabis products. Although some may be out there. There's not a lot of these literature that I've seen on fentanyl and cannabis. It's typically in pathogenics like NDMA, stimulants like cocaine or methamphetamine or other campions or stimulant analogs. Certainly in any of this, we produce sedatives, whether they are purported prescription sedatives or some of the designer sedatives and in most of the opioid supply. For high risk patients, I do see patients in person, right? Like I never actually stopped seeing patients in person, but it was always sort of a calculated risk. And particularly for systems, right? I now work for a health plan, the Medi-Cal health plan in Southern Cal, or for LA County in Southern California. There was an entire like a schematic for how to make sure providers get their, rendering providers or contracted agencies could get reimbursed in the coding that was necessary for that. Particularly as waves of the pandemic come through locally, I've seen many of our provider organizations experience staffing challenges and need to institute waiting room precautions. For a while, many of our residentials were doing mandatory quarantines until people's testing came back. So those were all considerations to addiction medicine practice during COVID-19. I'm gonna dive in on the bolded piece, telehealth here for a minute. So telehealth again is an audio visual visit, right? And it requires synchronous, like it's literally in the statute, right? It's synchronous audio visual visit between a patient and their clinician. So synchronous telehealth platforms like that's it. Now there are e-visits, which is an online exchange, right? They typically don't involve the video part. Think of if you have any providers that use an EHR that has a patient portal, it's messages that could get sent. And then there's consultation visits. So synchronous, it's possible for providers and consultants to do a synchronous visit, particularly if the patient's in the room. One of the things that I helped set up locally with our local health department is a medications for addiction treatment. And that includes medications for opioid use disorder, but also medications for tobacco use disorder and alcohol use disorder consultation service. Because we recognized that patients were vulnerable to increasing their substance use. And any ability we had to be able to consult in to any exam room across our system and help providers link patients to effective care we wanted to take full advantage of. And then e-consult is just that, but not synchronously. Like it happens through an e-consult platform. And these are separate from telephone care, which is audio only, can be synchronous, which is you're on the phone with somebody or asynchronous, which is a voicemail exchange without a visual component. And that does not meet the federal definition of telehealth. And that's relevant for how we provide or how we prescribe, how we're allowed to prescribe controlled substances to patients. There's a lot of really good guides on the APA psychiatry website, on the AMA website. There's a bunch of really helpful resources. But I'll pull just what I look at as the cliff notes, which is for telehealth session best practices, factor in the patient's ability and familiarity with the technology platform. I sometimes get asked, what's the best platform? And it's the one that patient knows how to use, right? So something that the patient is understanding of, user-friendly, compatible with their available technology, that's really important because our exam is only as good as the patient can be seen and heard. And that is oftentimes patient-specific factors shape that. But once you've evaluated the patient's ability and familiarity with the technology platform, confirm the patient's identity and location, that's kind of step one. Have a backup. So it's the patient's phone number if the technology fails. Explicitly document the patient's consent to participate in telehealth and then arrange for any medically necessary monitoring and follow-up. Is kind of the, look at that as the standard. And when talking about standards, the standard of care is the same whether treatment is rendered in person or via telemedicine. You might say, wait a minute, there's a lot of things I can't do in person, or I can't do over telehealth that I can do in person. That's true. So the standard of care isn't that you do all the same steps. The standard of care is that you've considered all the same steps, right? You've evaluated the risk and benefit in context for the medications you prescribe, the diagnostics you run, the types of exam, the sort of exams you do. It's not the expectation that it's the same. The expectation is the medical decision-making factors in the factors that shape that you've taken appropriate care of the patient given the circumstances, right? So the standard of care is the same, even if all the way you would organize the services would need to be adapted because if you're seeing a patient remotely. If you go to the ASAM website, there's a link to supporting access to telehealth services that links to the APA, AMA, and the other resources I mentioned. And the federal government was very quick to authorize an 1135 waiver. So now I'm talking about regulations to authorize providers to offer telehealth services in any healthcare facility, right? It doesn't matter if you're doing hospital care, outpatient care, specialty care, like telehealth is allowed. And you're allowed to now issue a controlled substance prescription for patients we've not previously conducted an in-person medical evaluation. The Ryan Hate Act, which I have a whole slide on, was suspended during the COVID-19 pandemic, still suspended, but is not permanently suspended, right? Just to be clear, the authority to prescribe controlled substances to patients without an in-person exam or, and there was an exception to the in-person exam rule for patients that were physically in the presence of another DEA registered practitioner or clinician. That exception has not been made permanent. Just, you know, cause it was kind of, it was interesting to me in March of 2020 to have the federal government essentially say, we're not enforcing HIPAA or we're forcing HIPAA, but more likely. So there was this relaxation of HIPAA rules in 2020. And so any technology that didn't sort of broadcast the encounter. So you couldn't do like a Facebook Live or an Instagram Live, or, you know, you couldn't use a broadcast technology, but anything that was secure one-to-one was permissible outside of the typical HIPAA rules. And those flexibilities ended in June. So June of 2022, I would refer you to the Healthy Human Services HIPAA guidance, which they do want to protect access to remote delivery of care, but we don't have nearly the range of available platforms to do telehealth as we did before. There is the expectation of encryption and privacy in our HIPAA platforms in a way that is different than early on in the pandemic, where we wanted to really protect access, potentially with the trade-off of being less rigid or less absolutely secure information platforms. So I mentioned RiotHate earlier. So just as background, and I'm sorry for the text. When you give a talk on regs, I don't know how to talk about regs without text. So appreciate your understanding. In April, 2019, the DEA published a rule called Implementation of the RiotHate Online Pharmacy Consumer Protection Act of 2008. So that was a law passed in 2008, but the rule was published in April, 2009. And it amended the DEA regs to add several new provisions that prevent distributing or dispensing controlled substances to the internet and requiring an in-person medical evaluation before prescribing controlled substances. As you can imagine, for patients in rural areas where they don't have a lot of doctors there in-person or other clinicians there in-person, prescribing clinicians in-person. There was a question, well, if I've got a patient who's off somewhere and I'm the only ex-waivered doc or ex-waivered clinician, say, in my area, I can't physically be everywhere. So the DEA clarified, well, you can use telemedicine to prescribe medications for opioid use disorder. And let's be clear, methadone is regulated under a separate set of statutes under a federally licensed opioid treatment programs. And most other medications for addiction treatment are not controlled substances. So the one controlled substance we're really talking about here is buprenorphine. Just to be clear around, we're talking about medications for opioid use disorder. The big implication here is buprenorphine treatment for opioid use disorder. It says, okay, well, the physician or other prescribing clinician providing telemedicine must be, and it's telemedicine, again, audio-visual, right? Not audio only. Must be licensed in the state where the patient's seen. Must have all appropriate state licenses, including the state DEA license. So I'm licensed in Massachusetts. I maintain my Massachusetts-controlled substance certificate, right? So that would be a state DEA or DEA-equivalent certification. Should have a practice agreement with the clinic or practice in which the patient is seen. And the patient has to physically go and be in the presence of a DEA-registered clinician or DEA-registered clinic, right? So the patient's allowed to go, physically be seen by someone, but that somebody would be somebody that I could have a CPA with, a collaborative practice agreement with, and then I could telehealth in and see the patient, right? That was pre-COVID-19. So again, if all of these are met, right? I'm licensed where the patient is. I have a CPA, and I have all the appropriate state licensures, including any required controlled substance certificates. The patient physically goes to a DEA-registered clinician or clinic that could do telehealth visit and start the patient on buprenorphine for their opioid use disorder. If all of the above are met, then the clinician prescribing through telemedicine does not have to do the initial assessment in person. The prescribing clinician should ensure that whoever's doing the in-person evaluation is also qualified to make their own assessment and determine whether buprenorphine was indicated for opioid use disorder. And you can pull up, this is a rule that was published in 2018. What happened during COVID? This rule was relaxed. The 1115 waiver, again, authorized clinicians, Dr. Tell Health and Indian Health Care Facility. Ryan Haidt is effectively suspended. During COVID-19, we can issue controlled substance prescriptions for patients we've not previously conducted an in-person medical evaluation. And, and this is a big one, the SAMHSA and the DEA issued a letter essentially saying buprenorphine for opioid use disorder can be initiated by a telephone evaluation. So if I want to prescribe somebody a schedule three drug that's not buprenorphine, a sedative, whatever, clonazepam or something, or a schedule two medication, alphenedate, dexamethamine, amphetamine, you know, other medications, I do have to see that person through telehealth, through an audio-visual component in order to be able to prescribe it. But for buprenorphine, I'm allowed to do it through telehealth or telephone. And if you're like, wait a minute, that's confusing. Actually, the DEA has published guidance for controlled substance prescribing during COVID-19. You know, has the prescriber previously examined the patient in person? If so, you can proceed as usual, right? The establishment of care is the key point. It does not have to be a telehealth visit for every follow-up visit, but it's the initial kind of the establishment of care. So the clinician must first evaluate the patient in the steps described in the following. If it's for buprenorphine and the clinician is data-2000 or X-wavered, then telephone is permissible. If it's for non-buprenorphine, or actually not just buprenorphine, buprenorphine for the indication of OUD, right? So buprenorphine for pain follows the every control, every other controlled substances pathway, which is establishing care via telemedicine real-time to a audio-visual communication device. And just as a reminder, as of this month, these flexibilities have not been made permanent. And if the COVID, whenever the COVID-19 public health emergency is declared to be over, they will lapse and Ryan-hate will be resumed, and we will be back to arranging for patients to go establish care in person, and either from wherever they are in person, tele-healthing to a wavered DAC, or prescribing clinician, or having to come in in person, you know, on their own. I mentioned opioid treatment programs. SAMHSA did publish some additional flexibilities for opioid treatment programs. There was a blanket exception for states that can request for OTPs to be, so the state had to request this, right? So the SAMHSA guidance was for states, not for individual OTPs, but states can say, I want our OTPs to be able to dispense up to a 28-day supply at a time for patients determined to be stable. And states can request up to 14 days of a take-home supply for patients that are less stable, but whom the OTPs can safely handle this level of OTP medication. And those determinations, although there was some guidance over what counts as stable or not stable, were ultimately deferred to local, like the local medical director had some fair amount of clinical leeway in determining stability over non-stability. And this exemption does expire when you're following the end of the public health emergency in which case it's back to six-month daily pickup for at least six out of seven days of the week for the first six months of treatment, which is the standard OTP reg. And this is for OTPs that can dispense methadone for the indication of opioid use disorder or buprenorphine for the indication of opioid use disorder. But there was an actual permanent rule instituted a little over a year ago in June of 2021 that authorized opioid treatment programs to add a mobile component to their existing registration. So rather than OTPs needing to go do an entirely new application for each site, they can add a mobile component or satellite site on their existing registration and it eliminates the separate registration requirement, which actually takes a fair amount of time. And you might also be asking, well, okay, but if I'm doing all of this care remotely, how do I check urines, right? How do I do urine toxicology testing? So toxicology testing has historically been conceptualized as a routine component of treatment, right? We get a urine on the first visit and my rule historically was, oh, if I'm issuing a prescription, I'll do a urine. If I'm issuing a prescription, I'll do a urine because whatever's in the urine might shape something on the duration or the dose or something about the prescription. But during COVID-19, there are apps and other technologies to permit remote testing. So remote breathalyzers using an app remote saliva testing, using an app or sending a patient to a lab, which again, you know in the context of COVID did increase the risk of in-person interactions, but only a subset of patients really did have access to this remote testing technology. And there's this great article by Bytel published in the Journal of Substance Use Treatment 18 months ago that says, you know, you're in toxicology testing. And if you think about it, you know like I'm going to test you. And then on the basis of that shift your prescription has roots in a punitive approach. Now I'm not of the opinion that you're in drug toxicology you know, you're in toxicology testing is by definition punitive. It is not by definition punitive. You can do so quite collaboratively. But it has roots in that. And I know like working with some of the clinicians I work with locally, you know there are many communities that just the minute you talk about you're in toxicology testing, it invokes probation or parole, it invokes reincarceration. There's a strong carceral system response to toxicology testing. The basis for toxicology testing really is based on clinical habit, right? Like I think Dan Alford describes it as like universal precautions. Not that they're super evidence-based but it just sort of like, this is just what we do. But there's really limited evidence that you're in drug testing actually has a huge impact on patient's outcomes and safety. I know when I first got wavered there was this idea that any patients that take buprenorphine, that take a benzodiazepine buprenorphine is solidly contraindicated because there's, you know, 27 French case reports of synergistic overdose with buprenorphine and sedatives ignoring that the French case reports were from buprenorphine monotherapy and not buprenorphine with naloxone, ignoring that a lot of that buprenorphine was injected not taken as prescribed. And yeah, you inject buprenorphine with injecting another sedative. You can very well be, it's a very rapid way of administering buprenorphine into your body. You can get a synergism that can drive you to respiratory arrest. Buprenorphine, when taken sublingually on its own, even if you have a benzo on board, there is some safety risk with like accidental injuries, right? Benzos are not benign. They are associated with, you know, motor and other cognitive deficits, but you don't get huge drops in like safety, right? Like, or you could call it other safety risks. You don't get overdoses. You don't get drops in treatment retention. And the FDA in 2017 actually said don't withhold buprenorphine from patients taking sedatives. Although it's true that there is risk to doing buprenorphine for opioid use disorder along with a sedative, the harm caused by withholding buprenorphine or even methadone for OUD from patients who are taking sedatives outweighs the risks of that combination treatment. I'd much rather have a patient be on hypothetically buprenorphine with alprazolam and I'm working on their alprazolam compared to, you know, and getting them up, compared to fentanyl and alprazolam, right? Where they're not even engaged in treatment at all, right? And much better off engaging the patient in treatment. And ACM's appropriate use of drug testing and clinical addiction medicine says, you know, what are the questions we seek to answer with toxicology testing? And again, this Pytel article basically says, you know, we should be basing our prescribing decisions on the basis of the exam, on the basis of the reported history and not defaulting to urine toxicology testing unless there's a question that I need to answer. And so sometimes the question I need to answer is, are you taking my buprenorphine? Right? If I'm prescribing to you, are you taking it? That's one of the big reasons to do urine toxicology testing is just adherence. But is that the only thing that can tell me whether they're adherent? For example, are they showing up? What is their clinical exam? Are they looking better? Are they reporting doing better? Like there are other measures. They're not like objective lab measures, right? But there's other clinical measures that I can use in interacting with somebody to see, are they looking better? That can oftentimes trump whether or not any particular urine result. I'm going to pivot to talking about AMNET measures, but I feel compelled to pull up a Q and A. All right, cool. Shortshard Gray says, more of a comment than a question. What I see in Northern Minnesota is concomitant use of gabapentin in those with opioid use disorder. Most often a gabapentin is prescribed by another practitioner with a complaint of anxiety or back pain. And it's very difficult to get people to wean from gabapentin. And it takes about a year for them to buy in if they ever do. Don't misunderstand there's a role for gabapentin. Of course, gabapentin, pregabalin and Z-drugs gabapentin, pregabalin and Z-drugs share some GABAergic effect. You've been successful with very few in weaning from zolpidem who've been on it for over 20 years. Yeah, so what you're describing, which is the physiologic tolerance that comes with being on a GABAergic agent or a Z-drug or even a benzo, right? Oftentimes patients need slow weanings. I think that's true. There is actually some literature that gabapentinoids increase the risk of overdose. So just gabapentin is not uniformly benign. And I think you're making that point quite well is that gabapentin is associated with, what do you call it? Sort of a physiologic dependency where people really have a hard time getting off of it. It's not identical to benzodiazepine dependency, right? It's not, you don't get the full characteristic withdrawal syndrome, but I think you're also hearing, but that doesn't mean that patients, it's easy for them to stop taking it. So appreciate your comment. Besides fentanyl and its analogs, some type substitutes such as carfentanil, which are more potent than fentanyl. I couldn't agree more. Carfentanil, sufentanil, alfafentanil. I mean, you know, I think there's like numbers now. I mean, like it's not just fentanyl, right? It's fentanyl and its analogs. I, yes, I agree. Is FaceTime on the iPhone considered to help? And if the patient agrees, can the visit be recorded and kept on part of the chart? Actually, I don't have an iPhone, so I don't know. I would have to look on the, I would refer you to the Health and Human Services guidance on HIPAA. For initially in March, 2022, FaceTime absolutely counted as like a platform that was allowable, but I don't use FaceTime in my practice. And so I would need to refer you to the HHS HIPAA guidance to see whether FaceTime continues to be permissible or not. Cause I just, I don't know enough about it's like encryption to know whether it does. And tell us before giving a form of buprenorphine, don't you have to determine that the patient is not on a long, on an opioid or long-acting opioid drugs before prescribing to precipitate withdrawal? No, I do not need to determine that the patient is not on an opioid. In fact, oftentimes when I'm evaluating the patient, I'm expecting, I mean, if they have opioid use disorder, I'm expect active untreated opioid, you know, soon to be, but not yet treated opioid use disorder. I expect that they're using opioids. I expect that they're using opioids. So what I do is I write a prescription for the patient to pick up at the pharmacy. And I tell them, stop taking what you're taking, stop taking your opioid, whatever it is. And when you get to very long acting opioids, like methadone, it's a little trickier cause you should really taper down the methadone first before you start a medication like buprenorphine. But for short acting opioids, it's pretty straightforward, which is you have the patient stop taking their oxycodone, hydrocodone, heroin, whatever it is, wait until they're in withdrawal. You could give them a cow scale. Most patients don't know how to self-administer it. You can give them a sow's scale, which is a subjective opioid withdrawal syndrome scale, which I'm going to mention here and patients can fill it out. Or the rule of thumb is three objective features. Pupils are big, pile erection, tachycardia, sweating, yawning. Those are all like objective features of withdrawal. And three or more, you're usually in enough withdrawal that when you take buprenorphine, you're going to kind of get precipitated withdrawal. So you do this as an instruction. And actually with most of my patients, I'm like, hey, have you ever gotten, because a lot of patients with opioid use sort of have tried stopping and then they get sick. And so I say, hey, you know what I'm talking about? When you stop opioids and get sick, they're like, oh yeah, yeah. Just stop taking it, wait till you feel sick and then start taking buprenorphine, you'll feel better. Most patients do fine with that. You don't need to, there's no protocol where you have to show urine evidence of opioid abstinence to get them started because urine is going to show typically days, if not longer, depending on the duration of the opioid of opioid use. So I would expect a urine to be positive for opioids while I'm starting buprenorphine. And it's again, dose-based on withdrawal symptom. There are more cases of precipitated withdrawal with fentanyl. Fentanyl is super lipophilic. And so it's elimination. It tends to be a little bit more wonky. Like it is a short acting opioid actually, but when people take high amounts, for a long time, it sort of saturates into adipose tissue and begins to look kind of like a longer acting opioid. And sometimes in cases of fentanyl, you have two strategies. One is do you wait the patient is in more than moderate, you know, like more than mild withdrawal, like you into the moderate, you know, to the higher calc scores before they take their first dose of buprenorphine. Or those protocols where you microdose, use low doses of buprenorphine while the patient continues to take their illicit fentanyl and kind of titrate up their buprenorphine for more comfortable initiation. I work in a community that has a hard time with that low dose initiation. So I'm mostly defaulting to the former, you know, wait until you're feeling really sick and then taking buprenorphine. But there are public protocols of this sort of low dose buprenorphine initiation. Okay. I never prescribe on a telehealth visit. I tell the patient stop at 5 p.m. the day before, see the patient next morning via telehealth. Yeah, so it sounds like you're doing an observed, an observed initiation. And if you have a family member who you've met holding the buprenorphine, yeah, it does sound, so Rick, I appreciate your comment. It does sound like you're doing an observed initiation of buprenorphine. And you said many patients tried and got sick. So I'll take sort of both of these together. You can always do an observed initiation, right? If you've got the scheduling flexibility to do it. My experience with patients are like, yes, I took buprenorphine, it made me sick, is to say, well, did anyone tell you to wait until you were in withdrawal? And oftentimes patients are like, well, no. I'm like, well, okay, that's why you felt sick. You got precipitated withdrawal. If you wait until the right time to take it, then you'll feel better. And that's usually how I handle that. I'll say, you know, three fourths, maybe like, you know, 75 to 80% of my patients do fine with what's called a home initiation or where you essentially prescribe buprenorphine, walk them through how to do it. Rick, you're talking about people with substance use disorders. You're right, a lot of people sometimes don't always proceed with full information. So part of what I see as my job is to do is to make sure people get the information they need to use the treatments we have effectively. All right, so where does Amnet fit into this? So Amnet is a portal-based tool. Has a number of measures that are relevant to treating opioid use disorder in a remote link, right? Where you don't need the patient to come in to get meaningful clinical information. So patients can fill out the TAPS tool. The TAPS tool can be either patient administered or clinician administered depending, but either way, this is a standard screening tool. We can use it for all of our patients to determine who do we need to do more diagnostic workups on to assess whether or not they have a substance use disorder. So you can look more around, you can sort of see the TAPS score and there's TAPS scores for different substances. Again, over a period of time that can give you an idea of like if I'm remembering TAPS as past month substance use. Then there's the SALs, right? So there's a CALs, clinician administered, or the SALs, which are a patient's operating scale that they can use to register how much withdrawal they're in. So if I've got a patient that's really tentative, giving them the kind of lay instructions on how to start buprenorphine and they wanna use a scale and that has those scales, both the SALs scale for the patient to complete on their own and I can then look at the results or the CALs scale that I can administer with the patient, say virtually. The brief addiction monitor or the BAM is the kind of standard monitor to see how somebody is doing over time. And again, you can look at the BAM to measure treatment effectiveness over time. And the treatment effectiveness assessment, which can give some information around the patient's functional response treatment. Literally this rate, like treatment's going well or not well. So it's a useful subjective measure. And then I mentioned depression and anxiety and isolation are huge risk factors in the context of the pandemic for alcohol and other substance use. The PHQ-2 plus one is a screening tool for depressive symptoms that can be used to assess for that. And the PHQ-9 being the longer tool that that reflexes to for patients that report any one of those measures anyway, the score of two or more is considered positive for the PHQ-2 plus one or any positive response on the suicide measure. And then for patients that really are severely hopeless the Columbia Suicide Severity Rating Scalar, CSSRS. So there are these measures that I think can help guide effective treatment even when the patients can't come into the office. And it doesn't necessarily require us as clinicians to go through them with every patient. Patients can log into the portal and complete these and it can give us useful information to help us take care of patients remotely. So this is the psychiatry.org.mnet with information around signing up. And on behalf of the American Society of Addiction Medicine which is an organization I will be president-elect or I am president-elect, I will be president shortly and MNET and the APA. I appreciate everyone's time and attention. We have a few minutes left. What questions do you have? Rick, I appreciate your comments. That is a question from Dr. Arun Gupta. He raised his hand, so you are unmuted. Go for it. Given the circumstances with the fentanyl, should not fentanyl be a class one drug and a weapon of mass destruction to solve this crisis that is getting progressively worse by the day? Fentanyl is a class one drug. It's also class two. It can be prescribed, but it's also listed under schedule one, which is illegal. I think that we are likely not to be able to prosecute or interdict our way out of the opioid crisis. Fentanyl is very small, right? Very small amounts go a long way. So it's much easier to smuggle, much easier to sell. That's one of the reasons, I mean, with the amount of, the more pressure we put on the drug cartels, the more we're gonna be pushed towards higher potency drugs, just like fentanyl because they're just, they're easier and you get less of a loss ratio the drug cartels when they're doing this to the supply. So I think the most promising interventions that I can think of are, I mean, yes, securing the drug supply, I see the rationale with that, but I also see a role for aggressive naloxone distribution, aggressive treatment of opioid use disorder when it's unidentified, universal screening for opioid use disorder to link patients to treatment whenever patients are found to have trouble. And then overdose prevention resources, right? To give people an opportunity, if they're going to use, right? A maximum chance of survival are things that I think are also demonstrated to decrease the overdose rate. We've not really seen prosecution of drug sales actually have a meaningful difference on drug overdose rates, which is dispirited. You think it would, but generally speaking, the people that sell drugs are very, very efficient around getting it and getting it into the drug supply in ways that our law enforcement and other systems of interrupting that just haven't been able to mitigate. Thank you. I'm sure I'm pronouncing this. Shirazizard, sorry if I got that wrong. And then psychedelics for trauma or PTSD, that sounds like a good topic. Depression, you seem some pretty remarkable studies through, you mentioned Hopkins, Davis, and I think there's others. Lisa, I appreciate your being here. Any other question? Yeah, any other? Rick, you've taken care of many patients' IOPs and outpatient programs. Many people who come, who were readmitted, and many people refuse treatment with buprenorphine for opioid use disorder. Some IOPs use buprenorphine inappropriately and buprenorphine is tapered off. Many admissions from across the nation are readmitted because you see it as a way of preventing homelessness. Yeah, I live in a city that has got the most number of unsheltered individuals compared to any other city in the country. And yeah, I think I am aware that there are patients that for whom residential, or we even offer recovered bridge housing for patients that are in non-residential services, it becomes just as much about housing as it does about recovery. And seeing there being more recovery-focused housing I think would be a huge boon where people are not necessarily trying to use treatment as a replacement for housing. I also think that addiction is a chronic relapsing condition, right? I do expect that patients need to learn their way out of addiction and that means trial and error, right? And so while I want every patient... Sorry, we got a request for the slides. I have a link, but I can, well, actually, let me see if I can type it in. There we go. Yeah, I just sent the link in the response. Hopefully you can get it through the Q&A. And anyone else wants to, there was a question for the link and I tried to send it out, but I couldn't message all participants. Anyway, so Rick, to expect that addiction is a chronically relapsing condition. So I do expect patients to need to go and be readmitted. That said, are the types of readmissions always medically necessary? Are the way that patients utilize buprenorphine, is that always effective? Buprenorphine should treat withdrawal, helps with withdrawal, but makes no difference on long-term recovery unless it's used as a maintenance medication. I think it'd be time. I really appreciate everyone's time and attention and look forward to the next time. Thank you, Ana. Good to see you. Take care, everybody. Bye-bye. Thank you. Thank you, everyone.

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