So, good morning, and I think we're going to get started. Thanks to all who rose early and registered early and are joining us today. So, we have three presenters today. I'm Dr. Molly Finnerty from NYU Langone in New York City, but we also have Dr. Flavio Kossoy, also from New York, Assistant Clinical Professor at Columbia University, and he will be our moderator today, and Allison Ober from RAND Corporation, and they will introduce themselves in more detail as we see each of their presentations. So, with that, I'll turn you over to Dr. Kossoy. Thank you. All right, thank you, Dr. Finnerty, and thank you, everyone, for joining bright and early on a Saturday, the first part, the beginning of this year's APA. I know we're spread around the room. Just to give a fair warning, we do have a group exercise that we'll see if folks join more. We'll do it either as one big group, or we'll split off into halves of the room, so just so you know, that's coming soon. Just so we get started, who here, please raise your hand, has prescribed buprenorphine before? Okay, about half. And who here is a sort of practicing psychiatrist or an attending psychiatrist, independently practicing psychiatrist? Raise your hand. Okay. Who here is a resident? And are med students? And nurse practitioners? Any other allied health professionals? Okay, so this is a working psychiatrist type of group, welcome. So now we know how to direct our presentation. So we have no disclosures to make, and what we want to discuss today is, you know, what the role of the outpatient ambulatory mental health clinic can be in addressing the opioid crisis. I'm going to start with giving a little bit of the context, the epidemiological context, and then Dr. Ober will discuss the development and implementation of this amazing, amazing toolkit. I think you'll all be blown away. Dr. Finnerty will talk about this incredible project that has been implemented and is ongoing in New York State to get mental health clinics to improve the capacity to treat opioid use disorder, and then we'll have a small group exercise, either it will be everyone together or we'll break up depending on the numbers that we have there, and then we'll have Q&A and discussion, you know, just open time. Okay, so my name is Flavio. I'm a psychiatrist in New York. I work for the New York State Office of Mental Health. I oversee licensed services and managed care as the medical director. I'm also an assistant professor at Columbia. So what do we know about what's happening? I mean, I don't think this is a surprise for those of you who are coming at 8 a.m. on the first day of the APA to know that, you know, the rate of overdose deaths from opioids in the U.S. continues at crisis levels, and it's mostly driven by the increase in people who are using synthetic opioids, fentanyl, and this is sort of coming from all over the place, and it's much, much more deadly because it's more potent, it's more lipophilic, it stays in the body longer than heroin or some of the sort of pain pills that people were abusing before. So there is a different drug on the street, and this is driving the death rate. So the thing that we really want to impart also is that individuals who have mental illness, mild, moderate, serious mental illness, are at risk for developing opioid use disorder. And individuals who have opioid use disorder, in the majority, have co-occurring mental illness. So this is a population that we are set up to serve. In a recent review of 38 studies evaluating the relationship between mental health disorders and overdose death among individuals, 37 found an increased risk, and evidence was strongest for mood disorders and anxiety, but also for other disorders. And when we looked at our own New York State Medicaid data, we found that 7% of clients who are receiving services in our licensed mental health clinics have opioid use disorder, but only just half had that opioid use disorder identified in the claims from the mental health clinics. So we were concerned, when we first started out, that there was a very large number of individuals who we were already treating. This is from the National Survey of Drug Use and Health. If you take the 17 million adults with an STD and any mental illness, about half are getting no treatment, and then about half are getting services for mental illness, but not for STDs. So there is a huge unmet need, and yes, fentanyl is a new drug, it's very potent, it stays in the system for a long time, increases the risk of death, but also we have service issues, structural issues that can be changed, that can meaningfully change that risk of death in so many millions of people. And we have an infrastructure that already exists, and we have a system that is already exists that could be part of that process. So what are some of the barriers? I think in APA meeting, after APA meeting, we talk about the chronic structural underinvestment in mental health services. It's difficult to get in our systems. In some ways, it's even more difficult to get into the addiction treatment system. It's difficult to navigate between multiple providers, the systems of care are siloed, we have workforce shortages, the workforce that we do have might not feel comfortable treating a condition that they haven't historically treated, all sorts of barriers. So it takes work, and the goal is to get public mental health settings to improve their capacity and help address the lack of access to medications for opioid use disorder for this population that's very vulnerable, very underserved, and have a hard time accessing care that doesn't have a lot of time accessing care that they very much need for treatment that is effective and pretty easy to deliver. So what do we want to see in the mental health clinic system? Universal screening protocols with follow-up assessments to determine what's the overdose risk, right? If someone screens positive, do an assessment to see if they're at higher risk for an overdose. Dispense or prescribe Narcan, intranasal naloxone, to people who might be at risk for an overdose, and teach people about other harm reduction strategies. For example, neverusealone.com, or fentanyl test strips, which in New York we're distributing for free to anyone who wants them, so people can test their drug supply. You know, initiate and continue buprenorphine and other medications for opioid use disorder, such as long-acting injectable naltrexone, if that's appropriate for the person. And then if anyone does need to be referred to a specialized STD setting, say for methadone, that there be warm handoffs and continued follow-ups and continued coordination, that the person isn't just screened out as inappropriate from the clinic because they have an opioid use disorder, but the clinic stays involved, making sure that they're the individual is getting the care that they need. And then I just want to say, last slide before I hand off the presentation to Dr. Ober, there was just an incredible change in the federal environment. How many folks here had a Data 2000x waiver? Raise your hand. Okay. And how many folks here had decided not to pursue one? Raise your hand. Okay. Okay. So as of December, the X waiver no longer exists. That has gone out the window. And the number of like a max cap number on how many patients with opioid use disorder you could treat with buprenorphine is also out the window. But by June of 2023, when people renew their DA registration, they will have to demonstrate that they've taken eight hours of training on treatment of opioid use disorder or management of people who are using opioids. And anyone who had an X waiver before is grandfathered in. And the APA has an approved sort of eight hour class that people can take. And SAMHSA has a bunch of free trainings that also count. And we put the links on the slide. And the slide is available on the app for download. We submitted the PDF in advance so folks can get that and make sure that you've done this training by the time you register for your next DA. There's a few other folks who are grandfathered in and you can look at that. So with that context, let me hand it over to Dr. Ober. And she'll tell you about this amazing toolkit that they developed. Good morning, everyone. I'm Allison Ober. I'm a senior health policy and behavioral science researcher at the RAND Corporation. For those of you not familiar, RAND is a non-profit, non-partisan research institute. And we're headquartered in Santa Monica, California. So as Dr. Kosoi said, I'm going to tell you about our amazing toolkit that we developed to help improve uptake of medications for opioid use disorder in community mental health settings. So as you've just heard, there's a dire need to improve access to medication for opioid use disorder and for people with co-occurring disorders in particular. So given the context, we set out to understand the prescribing context and assess barriers to prescribing in public mental health settings. And then we used the data from all of our work to develop this toolkit. Our work was funded by the National Institute on Drug Abuse. And we conducted this part of our study in collaboration with UCLA and worked very closely with LA County Department of Mental Health, where we worked in eight of their directly operated clinics to assess barriers and to test out the toolkit. We also had a workgroup of staff at all levels of clinics participating in monthly conference calls with us as we developed all of the sections of the toolkit. And then we also had it peer-reviewed. And I believe Dr. Kosoi was one of those peer reviewers. So I want to tell you about what we learned in our qualitative work and in our surveys. Then I should show you the toolkit. And at the end of the presentation, we'll get your thoughts and feedback on the toolkit, whether you think it's useful, what else you think might be needed, and any other ideas you have on how we can change it to make it usable for you. So to learn about context, we talked to and conducted surveys with LA County Department of Mental Health prescribing and non-prescribing providers and clients. We did focus groups. We did surveys with providers. We did surveys with clients. And then we did telephone interviews with clients as well. So first I'll tell you about what we found in our focus groups. So in general, providers generally supported prescribing medications for opioid use disorder and providing recovery support to clients with OUD. But there were a lot of barriers. And some of them are what Dr. Kosoi already mentioned. There was a perceived low prevalence of opioid use disorder among the patients within the clinics. So when we talked to providers, they really felt that people with opioid use disorder were not coming to their clinics, that there wasn't a really high need because the prevalence wasn't very high. Also workforce issues, lack of trained available staff, stigma, also low client readiness for treatment. So as many of you know, even if you can identify people with an opioid use disorder, there's offer treatment, clients might not be ready. And this was a big issue with the providers and the clients, that it might not be the right time and it might be really difficult and challenging to start. Lack of clear protocols for staff to follow. So how do you fit all of the different elements of the workflow into the existing workflow, screening and assessing for overdose risk, urgent need to prescribe, and then providing recovery support. People said they also had mixed messages from leadership about whether this was a priority for them. There were questions about the efficacy of medications for opioid use disorder. And then within the LA County Department of Mental Health, and I think in a lot of other systems, there was confusion about billing procedures for services provided for substance use disorders generally. So there needed to be a primary diagnosis of a mental health disorder and it was unclear to providers how to incorporate a substance use or opioid use disorder into the billing and diagnosis. As I mentioned, we also did provider surveys. And overall, we learned that more buy-in from the staff, more education and training, and better communication about leadership about medication for opioid use disorder is needed. It's really similar to the focus group findings. So as you can see, what the chart shows here, we asked people whether they disagreed or agreed with statements made about treating people with opioid use disorder with medications in the public mental health setting and in their own clinics. And on a scale of 1 to 7, they rated these from extremely disagreed to extremely agree. And overall, providers generally agreed that medication for opioid use disorder prescribing matches clinic priorities. Treating people with co-occurring disorders within the clinic matches clinic priorities. The non-prescribers agreed more that medication for opioid use disorder was best provided in the clinic. Interestingly, where the prescribers thought that it would be best provided someplace outside of the clinic in specialty care or maybe at a prescribing hub. Awareness of signals from management were moderate. Prescribers were more aware that this was a priority for management. And the non-prescribers agreed less that providing the medication for opioid use disorder fit their job description. And they felt less prepared to discuss and diagnose opioid use disorder. So in the client survey, this is where we learned about the prevalence. We assessed probable prevalence using an instrument called the ASSIST. And we found that prevalence of opioid use disorder was very high, with 8% having a probable opioid use disorder related to prescription drug misuse, and 2% having a probable opioid use disorder related to heroin use. And we examined which factors predicted provider willingness to take buprenorphine in particular. And we found that clients who believed that buprenorphine could help people stop using were more likely to say that they were willing to take buprenorphine. Also pain level was associated with greater willingness, as well as younger age. So again, I misspoke. These are factors among clients that predicted their own willingness to try a medication for opioid use disorder. And also having a probable heroin use disorder compared with a disorder-related prescription drug misuse and prior treatment were associated with greater willingness to receive any OUD treatment within the mental health setting. And then we also conducted telephone interviews with clients. And we found that clients generally were very receptive to talking about their opioid use disorder with their mental health providers, and also to receiving medication for opioid use disorder within their clinics. But more discussion and education was needed. And some clients believed that medications for opioid use disorder were really only used to substitute for opioids or stave off withdrawal symptoms. And they didn't really know that it was a good treatment, an effective treatment. And as this client said, suboxone, I used it here and there when I couldn't find any opioids. That's always the first thing that people have a lot to give away. I never saw it as a way to stop. It would just hold you over until you could find something else. So really, this points to a lack of understanding about what buprenorphine is. Also, there were negative perceptions of methadone and methadone treatment and negative experience of methadone and methadone treatment and negative experiences were prevalent. And the thought is that having come from these experiences, it might affect overall perceptions of other medications like buprenorphine. This client said, methadone, it's not a good medicine because it messes up your calcium, your bones, all your body. You become an old man. And most clients also viewed readiness to quit as critical for initiating medications for opioid use disorder. And this one client just gave an idea of what it felt like to be ready, what that feeling feels like, which is, I'm tired of being dominated by opioids, by heroin, by pills. You're tired. You're mentally, physically, and emotionally tired. You want something different. And you're willing to do whatever it takes to stop using opioids. So the implications of our findings for implementation in community mental health settings and also for our toolkit really are that we learned that providers need more data on the prevalence of opioid use disorder among their clients. They need workflow protocols for prescribing, for screening and prescribing, clear messaging from leadership, clarity around billing and training, ongoing support, and also more resources. And that clients need discussion with providers about opioid use disorder. They indicated they're willing to discuss opioid use disorder and are open to more discussion, more education about the purpose and effectiveness of different medications, and also about how it can work with pain management, techniques that increase their readiness for treatment, and a lot of resources as well. So we took all of this and we created our amazing toolkit, which I'm going to show you. I'm going to attempt to toggle here back and forth between this presentation and the toolkit. So we basically divided implementation into four steps. Envision, learn and adapt, prepare, and launch. So under envision, the steps here are to develop a shared vision. And again, this is within a system or a clinic to develop a shared vision, which is a goal for the future of providing treatment for people with co-occurring disorders in clinics. And this vision can be shared collectively among the staff. And vision can clarify the direction for change within the clinic. And I should say too, we used the data that we obtained from the clinics and we also used theory from implementation science and organizational change theory. And a lot of my work is based on implementation science. And we know from implementation science that having a shared vision and having these steps where you're engaging staff and getting people very involved makes it more likely that new practices like medication for opioid use disorder will be, there'll be uptake and also they'll be sustained. So these are factors that lead to better implementation and sustainment. So the second is engaging staff, implementing and sustaining a successful vision require that staff get engaged. And we have learned in our work, not just in mental health clinics, but also in primary care, improving uptake of medications for opioid use disorder, that engagement of staff at all levels is really critical. Staff, everyone from the security guard at the front door, through the front desk staff, and all of the providers. Engagement at every level is important to make a change like this. And then building a change team. So each member of a change team who is educated on their role, members of the change team can be part of different segments of the clinic. So I'm just going to show you the website to get you oriented. So you can see here at the top, we have the four steps here across the top. And then there's different over here, toolkit resources on the right side. Oh, yeah, my pointer is showing. And I'll show you these in a minute, and resources for clients and families. So if I click on Envision, it takes us to what I just talked about. And it also provides resources. So for example, part of developing a shared vision and engaging staff involves having a kickoff meeting. And we've provided here kickoff meeting agenda. And so this really takes you through the step by step process of going through envisioning and engaging and building a change team. So the next step, learning and adapting. So we heard from providers that it was difficult to envision how these steps were going to be integrated into the workflow in the clinic. And so we developed a workflow that takes you through the steps of the whole cascade of care for providing medications for opioid use disorder. And it's not one size fits all. We did this using LA County DMH as a prototype. But every clinic could take this workflow and adapt it to their own setting. And this slide gives you an idea of what the workflow map looks like. I'm not going to switch back to the website yet. But in the website, you can scroll down. And there's about 12 tasks that take you through every step, every procedure that would be needed, including how you screen for opioid use disorder, what are the tools that you could use to conducting OUD diagnosis. And we also developed a medication management for opioid use disorder prescription in the mental health setting. And that's also available on the toolkit. In step three, prepare. This is about preparing clinic resources and preparing clinic staff. And in this step, we also provide several worksheets for assessing exactly who will be doing what, what the roles will be, and what kind of training and other resources they need to do this. And then in the last step, launch and monitor. So for any program to be successful, you want to have quality metrics that you're examining and returning to these from time to time, and then adapting your program to fit, to adjust, and to improve. And so we show here quality metrics that we developed with LA County Department of Mental Health. Percentage of clients screened for opioid misuse and percent taking medication, which at the time in LA County, Department of Mental Health was very low. And so the idea is by developing a monitoring plan as part of a program, you could set up these quality metrics in advance and be ready to launch your toolkit and your program. So I'm just going to go back. I think I have like one or two more minutes and show you these different parts of the toolkit here. I actually have exactly two more minutes. So again, under Learn and Adapt, you would click on opioid use disorder. We also have a track for learning how to integrate treatment pharmacotherapy for alcohol use disorder. And here you would click on the opioid use disorder care track. And you have all of the elements of the workflow. And as I mentioned, then all of the tasks down the left side. And these dots indicate which clinicians could do each role. But again, because it can be adapted to your clinic, these could also be interchangeable. And then when you click on each of the tasks, there's resources, as I mentioned, for each task. And then there is here a listing of resources in the entire toolkit. You could download all of the resources that you would need for implementation of treating co-occurring disorders for opioid use disorder. We also have an About page, which has some facts about co-occurring disorders, some of what we heard from clients. And we talk about our methodology for creating the toolkit. And then last, we have resources for clients and families. So this is actually designed to be user-friendly, client-friendly, and family-friendly. Let me return here. You mentioned that the link is on the PowerPoint. Yes, the link is on the PowerPoint, on the page where I introduced the toolkit. And just to acknowledge, we had a lot of people helping us with this at RAND, at UCLA, and at LA County Department of Mental Health and Department of Public Health. And with that, I'm going to turn it over to Dr. Cunningham. OK. So we were introduced to really the need by Dr. Kossoyer. And he talked about the opportunity for mental health and psychiatry to make an impact in this epidemic. And I know it's tough times to be thinking about that. We've had too many epidemics all at the same time. And unfortunately, the opioid epidemic was not one that decreased during COVID. And Dr. Obert started to talk about, well, why aren't we doing that already? Why aren't opioid use disorders routinely identified and addressed in our mental health settings, given that the majority of individuals with opioid use disorder have a co-occurring mental health condition? Likely, they're coming to us for help. And for their other conditions. And why isn't it already the case that a person with opioid use disorder could count on being able to get support and treatment? And what are some of the tools that might help? And what I'm going to talk about is a project that was designed to try and move the needle on that, trying to help build capacity within mental health settings to identify and deliver treatment for opioid use disorder in those treatment settings. So this was a New York State initiative. And our context is just, this is a little bit what I'm going to talk about, the New York State context, a little bit about the initiative itself, and then some follow-up surveys we did to really understand, to appreciate the progress we've made to date, but try to understand better where the challenges still lie and some of the implications for future work. So just starting with the New York State context, New York is one of those states where we have several health-related agencies. So some states are all together. And in ours, they're very distinct. The Department of Health, the Office of Mental Health, and the Office of Addiction Services supports each separately licensed programs in those specialty areas. So your primary clinics are licensed by Department of Health. Mental health clinics, licensed by the Office of Mental Health. And substance use specializing clinics, like all the methadone clinics, are licensed solely by the OASAS. So there's some structural issues there, you can see already. Even the same service gets a different billing rate code within those. So those are things for us as a state to think about how to bridge some of those gaps. And a lot of work is being done in that area. This project will focus on the Medicaid mental health program, largely because that's where we have the best data, and some oversight responsibility and authority that we share with the Department of Health for ensuring the quality of care delivered to the Medicaid population. And then lastly, just another piece of context is that there are a lot of challenges right now in mental health clinic settings. So in a survey, we found that 43% of mental health clinics have vacancies for their prescribers. And if you look at all the lines together, we have 12%. And in some regions, up to 17% of the lines needed for psychiatrists and nurse practitioners are vacant. So that does create challenges for a practice like treatment of opioid use disorder that requires prescriptions. So this is taking a look, again, at the Medicaid population and saying, who is at increased risk? So among those who already have a mental health diagnosis and are receiving some mental health service, who is at increased risk in our population? So it's starting from the folks we serve. And what you can see is that there's a couple characteristics that make people about twice as likely, twice the risk. So male, male sex. There is also a number of psychiatric conditions that put you at increased risk compared to others. So PTSD, bipolar disorder, anxiety, people struggling with sleep, sleep-wake disorders, ADHD, and personality disorders all put you at approximately twice or more the risk. There's some things that incur a little bit of risk. So for example, there's some race and ethnicity disparities. So in our state, American Indian individuals or people identifying as Hispanic or Latinx are at significant but some increased risk there. The largest increase in risks come from people that have other co-occurring substance use disorder, which we know is incredibly common in our mental health populations. So for alcohol, you're three to four times more likely to also have an opioid use disorder. And for cocaine users, over 10 times increased risk of having a co-occurring opioid use disorder as well. Interestingly, individuals who have a suicide attempt are nearly four times as likely to have an opioid use disorder as well. So you might not think, oh, that's a group for increased risk, but that's what we found. So in this initiative that was designed to try and identify and address some of these gaps, we identified five best practices for individuals with mental health conditions and co-occurring opioid use disorder. And a very low intensity intervention, because again, a lot of this was during COVID. People had other quality initiatives they were engaged in, and as we know, the system is incredibly stressed. We know what has happened to workforce during the COVID epidemic. So every six months, a clinic was only required to have one of their representatives attend one informational webinar. They were required every six months to self-assess on these five best practices. How are you doing now? And to identify one that they would try to improve over the next six months. This is a list of the best practices, one that you should screen. And not just screen for opioid use disorder, but using a instrument that is validated for identification of opioid use disorders, like the RODS or even the NIDA, followed by the ASSIST, that they would provide naloxone prescriptions to individuals with identified opioid use disorder. That if they felt that they were unable to serve or it was a client preference, that they would provide timely referrals out. So our mental health clinics are not allowed to prescribe methadone. If that was a preferred treatment for the individual, that we would give a timely supported referral, not say a list of names. It would make the appointment, follow up to make sure it got kept. These are really people's lives are at risk here, and really giving it greater support to ensure that the care was connection was made. But to have wavered prescribers available in the clinic, and to prescribe both offer induction and maintenance services for buprenorphine and naltrexone. So this is where we ended up over the past three years and change. You can see for each of the best practices where people reported being at baseline, and then where they were 39 months later. And you can see that all of those differences were tested and are significantly better. And if you look at Matt, where only 10% of our clinics were offering those services at the beginning, where now we doubled it, right? So hooray, doubled it. And at the same time, it's pretty sobering to say, OK, 20%, you've got a one in five chance of walking into a clinic that's going to help you with this issue. So lots to be proud of here, I think, for the clinics really stepping up and putting these practices in place. And at the same time, I think it makes it clear that we still have a long way to go. Those are data self-reported, and we also looked at Medicaid, which is independent. And you can see a slow and steady increase. And again, these are significant increases. The first one, I think Dr. Kassoy had highlighted, that when people are served in mental health clinics and have an opioid use disorder that we can see in Medicaid because they showed up in an emergency room, or they had an overdose, and we can see that from a different provider, that the clinic was rarely noting it. And so that was actually increased from below 40% at start to eking over 50% here a couple of years later. So these are slow and steady improvements that we see here. The number of individuals with a naloxone prescription in the past year, the number who received any MAT during the past year. So in conclusion, this sort of low and slow and steady intervention, and it's really the largest of its kind in the country with 484 participating mental health clinics, was impactful. And at the same time, we still have a long way to go. So we need to better understand what the barriers are and how to deliver interventions that can help with uptake of these practices. So we did a survey in the interest of better understanding, and we hope that in the breakout groups, we would really like to hear your opinions from your work experience and your settings of what you see as the challenges and what might be the tools and supports that would help overcome. So in this survey in our clinics, we had about half MDs and half nurse practitioners prescribing and responding, and about two-thirds saying they would be willing to do this, and about a little over a third saying, no, they would not be willing. And when we tried to understand what was happening here, is it that you think it won't help? But no, 83% are saying, no, I think these medications do help, and overdose risk will be decreased. And then they were also pretty confident that they could identify people with OUD, 75% saying, yeah, I'm pretty confident in my skills there. But if we look down towards the bottom, what's getting the lower or under half or about half saying, do I have the skills to provide buprenorphine maintenance? Do I have the skills to initiate buprenorphine lower? So less than half feeling confident, right? This isn't necessarily things that people were trained on, and so they're new skills they need to develop. When asking a couple knowledge questions, we see that the ones that people did do well on, but there's gaps in all of these. So these are percent correct. But understanding what are the current regulations, as Dr. Ksoi said, they're changing a lot. It's not clear to most of us maybe what the current regulations are or things like that. So some knowledge gaps here. And then lastly, factors that would impact your willingness to prescribe. And I think there's a lot of similarities here to what Dr. Uber had shared from the California study of prescribers. But what rose to the top here is the red bar this is a strong contributor to why I would be willing or not willing to prescribe versus towards the bottom, the less impactful ones. And at the top is this idea that in these mental health clinics, the feeling, the first two really relate to support, right? That if I get in trouble, if I'm over my head, I have no ability to send a complex patient to substance use treatment. Like I don't have the backup, right? That's sort of what they're saying there. Or no immediate access to an addiction expert to consult. So it's sort of a feeling of like I'm all alone here. I don't really have enough backup support. Then in the middle, right under that is things, well, maybe the patients will misuse or maybe I don't understand this, how to do this treatment well enough, are some of the next set of answers. And then in the middle there too is this idea about whether can I initiate, things like that, and whether I have leadership support. So there's some similar themes emerging from these two surveys about the barriers that are in front of us. And again, in the break, I really hope that we can dig into this a little bit and get your perspectives. Practitioners do believe that buprenorphine can save lives. And at the same time, they feel that they have some lack of clinical support and training. But support even more than training. Someone to help if I'm in over my head or I need a quick referral or consult. Lack of clarity about training requirements, stigma, and then lack of clarity about leadership prioritization. So we need to sort of better understand how to move at scale, right? Because this epidemic has decreased our country's life expectancy for the first time in a long time. And how it's really something that could be in our court and something we have an opportunity to do something about. So this is a tremendous collaborative effort with the New York State Office of Mental Health, the Office of Addiction Services and Supports, and the Department of Health really working together on this, as well as Columbia's Center for Practice Innovations and the Clinical Educational Initiative. So, thank you. All right. Okay. Thank you for those great presentations. So now we really do want your help in this next step. And what we are thinking is to sort of break up the room. I think we have enough for three groups of about eight. So if you, you know, in a minute or so, if you could sort of arrange yourselves to be able to get close enough to have this conversation. And I guess the questions really are, you know, what are the barriers to implementing treatment of opioid use disorder in your practice setting? And, you know, we have presented some barriers. Do these sort of resonate with you? I see some folks leaving as we're about to go into the breakouts. Don't be scared. And are there other barriers that you know of that we haven't identified? You know, if you have identified barriers in the past that you've overcome, how have you done that? You know, we're really curious to hear about that. And what tools do you need? You know, we sort of showed you this particular toolkit. You know, how does that look to you? Do you want something else? You know, what would be useful to bring up? So I think there's about an equal number of people on each side of the room, but everyone is like really spread out. So if we could try to come up with about three groups of maybe like eight to 10-ish, that would be amazing. And the three of us will go and sort of join each group and listen into the conversation. And let's reconvene at about 9.08. Okay, folks, let's reconvene. I see that there's intense discussions happening. I feel bad about interrupting. You know, I didn't announce this in the beginning of the breakout group, but I think, you know, we want to do a report back. So would someone from each group be comfortable going up to one of the aisle mics and giving like a quick summary thought? I'll volunteer Dr. Iyer to go first and go to the aisle mic and give a quick summary. It wasn't fair that we didn't tell them. A small group discussion. Dr. Kosoi and I work together, so he volunteered me knowing I'm on four hours of sleep. So our group, I think, was talking a lot about, you know, the barriers more so than anything else. And it was kind of an interesting discussion because we had a lot of people from very varied backgrounds and varied practice settings. Amongst the barriers that we talked about, number one, and perhaps foremost, is the lack of knowledge. And people feeling uncertain, insecure about being able to prescribe buprenorphine because they don't really know how it works. It feels like it's something separate. For those of us in more resource settings, there might be a substance use team or substance use clinic connections where there's someone else that could do that. So why should I need to have to worry about that in my setting because there's always another person that can do it for me. It was an interesting extra wrinkle, which I thought that if you end up being the person who is educated, learns how to prescribe buprenorphine, now you're suddenly the one person who can prescribe buprenorphine. And all of your colleagues start pointing their fingers at you and sending you all their patients. And suddenly you're overwhelmed with a bunch of buprenorphine prescribing rather than being able to have the very practice you might have started with. It's very overwhelming and a disincentive to educate yourself about buprenorphine. And some of it is just that we're all in very varied settings. It was great that we had someone who was international in our group as well where opioid use disorder, thankfully, is not as pronounced as it is here. And it's tricky then to know how to come up with a universal mechanism to be able to approach buprenorphine prescribing in a very varied set of settings that psychiatrists prescribe. Thank you. Does someone want to volunteer from one of the other groups? Dr. Hong is also my husband. Yes. You've recruited people into each group to speak to you. I think we identified very similar factors as Dr. Iyer's group. I think a lot of us practice in very different settings but same kind of theme of hesitancy amongst providers, siloing. Even in like a more well-resourced hospital, there's this separate substance abuse treatment team that had the X waivers and so everyone just kind of went to them even though they were well-resourced and there were many, many more hospitalists who could be prescribing but just weren't and many more psychiatrists who could help. So I think that's pretty much what our team talked about, mostly on barriers. But as I was thinking about this, this came to my end separately from our group but I'm wondering if it would be helpful to have like an order set for starting buprenorphine because we have order sets for like sliding scale insulin. We have order sets for alcohol withdrawal, all of which are actually pretty complicated things. And yes, these protocol, these like sliding scale or order sets don't cover every single patient in every single scenario but they cover the vast majority of folks. And I think if a hospitalist can just type all, I'll type in this protocol and it becomes an order set. That includes like naloxone at discharge. It's like the whole thing, like a whole package. It might be less scary because our alcohol withdrawal protocol is very complicated. It follows CWOA and there's like if it's CWOA this, give this. Maybe we can do something similar with cows and have people monitor vitals regularly. It just becomes like a thing you do. Thank you. Someone want to volunteer from the third group? There's intense pressure. We're not going to judge. We talked about we don't have the final clarity on the telehealth prescribing. It's a barrier. Let's see. Helplines are to set up in more rural areas. The one thing about telehealth is that the cost to go to a clinic, you know, in a major city or even in a rural area can be prohibitive for certain patients. That was some. I think the silo the gentleman just spoke, that's mental health, that's substance abuse, that's mental health treatment. Even though the X waiver is done away with, by the way, you've got to get eight hours of training. Hurry up. It sends a message that it's still very specialized and you're not ready. I think it was one of the things. The supply of providers I think is a barrier in psychiatry and with nurse practitioners. I'm not sure about the other disciplines, although I can tell you for psychiatry and for nurse practitioners and the system I'm in, it's a challenge. And I hear from the community so that we're not alone. Any other barriers that I've left out? Yeah, the physical delivery. So for telehealth, you know, if the medicine has to be mailed, that can be a challenge because, you know, FedEx, UPS, they're not requiring signatures anymore. They just drop it as it gets stolen. You know, can it be sent to a PO box? Those type things. Although in Philadelphia, I think she mentioned that Philadelphia has done a real good job within their e-prescribing with their pharmacies. That's less of an issue. But I would, in rural areas, and I've seen it in the system I'm in. Anything else? Okay. All right. Thank you. Your name is? David Walker. Dr. Walker, thank you. I think I meant to have said this in the beginning and I forgot. I appreciate the reminder. But hot off the press news is that anyone who has a telehealth established relationship with a patient can continue to prescribe controlled medications by telehealth without that in-person visit through November of 2024. After November of 2023, if you are establishing a relationship with a new patient, you have to see the individual in person at least once before prescribing any controlled medication, including benzodiazepine, stimulants, testosterone. And that might change. Because this is like a temporary rule from the DEA. So the flexibility might just expand altogether. But for now, you're good if you have a prescribing relationship with a patient to prescribe via tele through November of 2024. Then we don't know what's going to happen after. Go to the mic, please, because we are doing the APA on demand. That is the continued barrier in pregnancy. Say that on the mic again. Pregnancy. So in other words, the barrier of women not wanting to seek treatment because of fear of legal concerns, child taken away at birth, those type things. And then even a helpline. I think you mentioned, you know, if you're in a state and you have a pregnant female, you know, how can you get help if you have questions? And that could be a barrier to treating opioid use disorder. I think there was one strategy the group came up with about having support, either helplines or consultation for clinics. And I don't know if someone from the group wanted to talk about that. Like we're doing a better job on barriers than we are on strategies. But I know you guys did think of some. So I want to make sure you have a chance to share those. Hi. I'll speak to that. So I'm Diana Robinson from Dallas, Texas. And so we were talking about I put the question out to the group of is there something or can we use the infrastructure like child and adolescent psychiatry and perinatal psychiatry have used with many states with great access to care in terms of having Monday through Friday eight to five experts in those fields that either psychiatrists or pediatricians, OB-GYNs can contact with their questions since we know that many of those people will never get to a psychiatrist or psychologist. So where can they get expert advice for prescribing as well as resources and referrals for those high quality referrals. So addressing those two points that people feel are major barriers to prescribing as so using that for substance. And so I just did a quick Google search. It looks like California is doing that. So it looks like states are using those same patterns. So kind of expanding that to other states could be ways to have expert level advice lower cost multiple people in communities rural areas so they don't have that fear of what happens if I get over my head. Who do I ask. What if I'm that person getting started but you know doesn't feel comfortable for some of the complex situations. So how do we have that. And so one of the other things that our system is doing is if a major barrier is the induction that having someone else induce and then transfer the care when they stabilize. So like we do with many things in terms of integrated care systems of stabilizing then referring to a lower level of care in terms of task sharing. Thank you sir. I'm Keith Logan. I am here from North Carolina and I work in both a VA setting and a private practice setting. And a couple of things that I wanted to talk about. I'm glad you brought up the national state guidelines and how they change. That's one of the barriers in my settings with prescribing any controlled substance is getting a clear idea of what the guidelines are. We've all gone through the recent terrible situation with stimulant medications and no one can give a clear answer on why there are limitations in prescribing and you know who's deciding it. Is it the FDA. No one's giving clear guidelines. So if you could give a suggestion on sort of where to go to stay up with the most current guidelines that would be very helpful. And then the second thought that I had was I'm old enough to remember when we were doing trainings and we were being encouraged to prescribe opiates like as you know taking pain is the vital sign as a vital sign. And we were encouraged to prescribe. So one of the things that was mentioned was the stigma attached to prescribing these medications. And you know I think some people are gun shy with having anything to do with opiates because of all the liability issues that came from that. So it's a part of a historic perspective. So Dr. Logan you're not you're not so old. This happened just this was not that far back. I think it's hard to know what's happening because there is you know it's it there's the FDA sort of regulates approval of medications but then the D.A. controls control you know controlled medications right. So these are not always necessarily aligned. I think the first place to start is the D.A. website. But then the states have their own separate guidance. So and you know in New York it took us the entire pandemic to get our Bureau of Narcotic Enforcement to be aligned with the federal D.A. And that was three years right. And but now we are. The it it's that. So the question was this federal override state law. No both apply. So you know if the state is more strict you follow the more strict in your practice setting. Now the V.A. is federal is like you're practicing the federal setting. Right. So you know I don't know how much state regs apply to the V.A. but for generally for the public mental health system you follow whichever is most strict. I'm a regional director of V.A. health care. I'm business seven director. And so the federal supremacy that the V.A. has does not override what the states require for narcotics for controlled substances. So you still need to it's the whatever North Carolina is requiring where federal supremacy in the V.A. does is with for instance certain telehealth things about telehealth we can do but for controlled substances the federal supremacy does not override it. So this is tricky. You know but but I think I think what we're seeing is a growing recognition among regulators that we have to do something different to stem the tide of opiate overdose deaths. So I think we're seeing you know in this hodgepodge way different federal agencies the different state agencies move in that direction. So which the trend is for it to get easier to prescribe. And this is you know not a tricky medication. I think Dr. Logan asked where can you sort of get sort of coaching. You know the SAMHSA the Substance Abuse Mental Health Service Administration as a service through a Web site called PCSS and I forget what it stands for that you can get someone to call you back and answer questions about how to prescribe. So it's very useful tool. I mean it's not in real time when you have a patient in your office but you can get an answer back from someone who knows how to how to do this and and they will answer your particular questions. PCSS we were just chatting about it. There we go. Do you know because one of the other things that the group I was sort of listening in with they they identified so one was like wouldn't it be great if there was a helpline kind of like set up for caps for individual cases. But the other is can you get consultation at a at a program level like let's say hey we want to get ourselves up and starting. And so I know you know Dr. Uber presented on the toolkit but is if you called PCSS would they give you a consultation for your program. Because I know like in New York there's hubs you can call for that kind of But do you know nationally. I don't think PCSS does that because mostly the people who answer the calls are just regular working clinicians. They're not necessarily system administrators. You asked about tools. I mean I think one thing that would be a little bit helpful is sort of risk stratification in terms of follow up like how you might want to handle different kinds of patients. We talked a lot in our group about needing to have 24 7 availability day and night you know to drop Suboxone into anybody's lap in order to get people started. But then there's lots of concerns about liability and things that go along with that. And if there were some sort of protocols for assessing risk and then different kinds of ways that patients could follow up that might work better for some kinds of patients and others that might be helpful. That's interesting. You know our New York addiction agency is moving towards low barrier people enough in prescribing so like the regs in New York are going to go even easier to prescribe it. And we have two minutes left. You know this is this is a great conversation. You know we'd love to continue it but let me see if Dr. Finnerty or Dr. Ober have any last thoughts. No I just thank you people for your interest and also like some great suggestions and ideas and things for us all to take back. Would this work. Yeah I agree. I appreciate your engagement and you're coming here first thing on a Saturday morning. And also I appreciate the comments about how you know you know we're talking about low barrier prescribing and we provide all these tools but what I heard in our group is that really it's so complex and like you're just saying it's complex in different ways for different people. And so we need to really pay attention to the nuances and the details. So I think we'll you know obviously take that back with us and think about you know producing new tools and what we can offer. But but that that really came through for me is that it's you know it still is complex and there still is a lot of support needed. So thank you for sharing that. Appreciate it. I think I think Dr. I will have the last word. Yeah I just wanted to sneak this into the APA on demand so that everyone has it at home. It's the provider clinical support system. And that's the Web site is P C S S now dot o r g p c s s now dot o r g. All training on there is free. And I think it's actually better than a lot of the other paid stuff that's out there. And those links are also provided on the resource pages of the toolkit. If you go into resources there's a lot of resources and links for providers it probably needs to be refreshed. But piece the PCS us that now link is on there too. OK. Thank you all.

opioid crisis

outpatient mental health clinics

opioid use disorder

synthetic opioids

mental health disorders

medications for opioid use disorder

barriers in mental health settings

structural barriers

provider education

integrating OUD treatment