Hello, and welcome to today's presentation. I am John Renner, MD, and I am presenting on behalf of the APA. I'm very pleased that you are joining us today for Striving for Excellence Series, the Implementation of Opioid Use Disorder Treatment in Rural Communities. The funding for this initiative was made possible in part by grant number 6H79T-IO80816-02 from SAMHSA. The views expressed in written expression, conference material, or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. Today's webinar series has been designated for one AMA PRA Category 1 credit for positions. Credit for participating in today's webinar will be available for 60 days. The PDF of the slides will be available in the chat tab. Captioning for today's presentation is available. To enable captions, click Show Captions at the bottom of the screen. Click the arrow and select View Full Transcript to open captions in a slide window. Please feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the Attendee Control Panel. We'll reserve 20 to 30 minutes at the end of the presentation for Q&A. I'd like to introduce our speaker today. Dr. D.C. Park is an addiction psychiatrist and assistant professor at Boston University Medical School. He obtained a Doctor of Medicine degree in Rosalind Franklin University and went on to complete General Psychiatry Residency and Addiction Psychiatry Fellowship in our program at Boston University. He has worked on implementing and expanding substance use disorder treatment in primary care and general mental health clinics and has presented on this topic nationally and internationally. He has served as a course faculty for the Buprenorphine Course at the APA Annual Meeting and has published on trauma-informed care and substance abuse treatment settings and in behavioral settings. Welcome, Dr. Park. Thank you. Thank you, Dr. Renner. I just wanted to mention that it's an honor and privilege to be able to present in this webinar. Also, it was a privilege to complete the Addiction Psychiatry Fellowship under Dr. Renner. Today's implementation of opioid use disorder treatment in rural communities. My disclosures, I do not have any financial conflict of interest, and I will be discussing one off-label medication discussion included. The learning objectives, we're going to talk about the general evolving standards of opioid use disorder treatment and how that can help us implement opioid use disorder treatment in rural communities. We're also going to review the various measurements that have been developed that can aid in opioid use disorder treatment. I think I'm speaking to the choir about just the epidemiology about the opioid disorder. The state of Massachusetts just published the 2022 data and it's still increasing from 2021. I do want you to note that there's an increasing amount of meth-related psychostimulants overdose in the recent trend. Just to go over briefly, the 2023, as you probably have all heard that x-waver is all eliminated. X-waver is something that you need to be able to prescribe buprenorphine for opioid use disorder. It eliminated also any caps on the panel size. Now, you used to be required to do an eight-hour training to obtain x-waver. Because x-waver is gone now, the one-time training requirements will now be tied to all new or renewed DA registration after 2023. Please check your individual states about whether they have any other specific requirements. Specifically, I think that's relevant to our topic for today. When I'm thinking about the treatment of opioid use disorder in rural communities because of the logistical barrier, I think about how effective, how easily we can utilize the virtual appointments. Thanks to all the technology advanced and different platforms that we are able to utilize to see our patients, and because of the hold of the Ryan-Haid Act during the COVID pandemic, we have been able to start and maintain people on opioid use disorder treatment through the pandemic without asking them to come in person. The Ryan-Haid Act, because of the COVID health emergency, ended back in May of this year. The DA took a lot of comments from the frontline providers. What they have published at the latest is that the starting treatment, the controlled substances without in-person encounter is allowed up until November of 2023. Just to recap, Ryan-Haid Act states that to be able to treat someone with a controlled substance, including buprenorphine, you've got to see them, you've got to evaluate them in person. That was on hold through the pandemic. Ryan-Haid Act does not specify any further frequency or mandate of the in-person visits. It just states that you have to, before starting any treatment with the controlled substances, you've got to see them in person. Now, there's a grace period that's allowed. Still, the practice is allowed until November. Additionally, if you already established the treatment with the controlled substances without an in-person encounter through the pandemic, you can continue the treatment up until November of 2024. Now, just to briefly review, how did we get here? To recap, back in almost a century ago, actually more than a century ago, Harrison Narcotics Act talked about ban of opioid agonist therapy for someone struggling with the opioid use disorder. It actually specified that the opioid production, prescription, and distribution can only be done within the professional capacity of one's profession. At the time, substance use disorder was thought to be out of purview for physicians and medical providers. Therefore, being able to prescribe opioids to treat opioid use disorder was considered to be out of purview for medical providers. It reinforced the message with the Controlled Substances Act in 1970 and the Drug Abuse Treatment Act. That's the landmark, that's where the X-Waiver. The X-Waiver gives you a waiver from the federal restriction of not being able to prescribe opioids for opioid use disorder. It allowed providers with the X-Waivers to prescribe buprenorphine products for opioid use disorder treatment. Comprehensive Addiction and Recovery Act, expansion of the data act in 2000, it had a very strict cap on the patient's size. CARA Act expanded the number of patients significantly. Then also the nurse practitioner and physician's assistants can also now prescribe buprenorphine with the CARA Act. Now, with the 2023 Act, it eliminated the X-Waiver. I'm going to briefly review the three effective medication treatments for opioid use disorder. I just wanted to remind you that we're kind of actually blessed in a way with the opioid use disorder treatment that there's a very, very effective medication treatment available. I can actually say the same thing for cocaine use disorder or meth use disorder or benzoyl use disorder. The first medication that was approved for opioid use disorder treatment was for methadone. It was approved back in 1970. Slow onset, long acting, mu opioid receptor, full agonist. It can only be dispensed from opioid treatment program, also known as methadone clinics. It cannot be prescribed by an individual prescriber from office setting. It can only be dispensed. Therefore, it doesn't show up on the state PDMP for individual states because it's dispensed. Even with the tecum dose, tecum dose is dispensed from the OTP, not given to them in a prescription and they can go pick up at the pharmacy. So it's still considered dispensed. That is only for methadone that's utilized for treatment of opioid use disorder. If someone's being treated for pain, methadone can be prescribed by a prescriber from office setting. In a head-to-head trial with the flexible dosing and everything, it's likely better treatment retention than buprenorphine. Otherwise, the other treatment metrics and outcomes are pretty similar and it's usually a matter of preference and the patient's logistics, whether to treat them with the methadone or buprenorphine. As I've seen better evidence over 80 milligrams, why is this important? This is because, we'll talk about this, methadone has a lot of stigma, a lot worse stigma than buprenorphine in the community and patients are usually reluctant to go above a certain dose of methadone. I'm sure you've heard of things that they said like, oh, methadone gets in the bone or I get sick, if you stop it, I get sick in the worst way, I don't want to go a certain way. It may be better for pain than buprenorphine is for pain and people think it's because of its property as a full agonist in the mu opioid receptors. Methadone can be a very effective treatment. However, the logistics can be very difficult. There's no take-home dose except on Sunday for the first three months or depending on how they do in the treatment, it can be longer. That means that you have to go to methadone clinic every day to get your methadone dispensed. In a way, it's very much binding, very much debilitating and some people describe it as worse than being on the dialysis as to how it impacts their daily schedules. And the logistics wise, to be able to travel for any family emergency or vacation or for whatever have you, whatever reason have you, arranging a guest dosing can be very, very complicated. Sometimes it takes weeks depending on which clinics that you talk to, depending on the home clinic and the guest clinic. There's also a mandated counseling piece and whether patients like it or want it or not, usually patients in a lot of methadone clinics are mandated to be a weekly group counseling. Another factor to consider is that they become frequently targets of drug dealers while they're on the waiting line for the methadone clinic and it leads to the worst stigma in our society. And I don't want to go more further about the stigma of patients on methadone clinic in our society. Second medication that I'm going to talk about is buprenorphine. It is approved for opioid disorder treatment in the United States in 2000. Slow onset, long acting, mu opioid receptor partial agonist. It's poor oral bioavailability. So there's the buprenorphine tablets and films and strips are usually prepared in a sublingual tablet, sublingual format. It can be prescribed from an office by a prescriber. And then there are, just to make sure that there are buprenorphine products that are only approved for pain. It is actually not legal to treat opioid disorder in a consistent manner with these two products that are only approved for pain. Unless patients have a pain, chronic pain diagnosis, and unless it's within the three-day window period that is provided by DEA to be an exception to treat them while you're trying to get them into treatment for opioid disorder. Buprenorphine, very much convenient, most convenient, almost equally effective as methadone. In fact, because of its convenience, it's usually used as a primary line of treatment for a lot of prescribers. To note that the partial agonist can't stay withdrawal if those too early in a patient dependent on opioids. I'm sure a lot of other webinars talked about this property, so I'm just going to skim over. And usually we have to wait for a CAO score of 8 to 12 to give the first dose. There's an availability of 16 released subcutaneous buprenorphine, trade name Sublocate, and Broxity. Broxity was approved for use back in May of 2023, but I was informed that the regular supply of Broxity is not available until September of this year, so it's something to look forward to. The last, but not least, of opioid disorder treatment medication is naltrexone. Mutated receptor antagonist is also FDA approved for alcohol use disorder. Meta-analysis that showed that the daily oral form of naltrexone is probably not going to be effective for opioid disorder treatment, especially in the era of fentanyl. So much more potent, so much more powerful than heroin. And one more thing about the oral treatment is that the not only that it's a lot of times it's not enough to provide blockade of opioid receptors being from being bound with the receptor agonist, that people, patients treated with the oral naltrexone, they have to make a daily choice of choosing to take the medication. If they're particularly not feeling like to take the medication for the day, then that renders them vulnerable for the day. There's an extended release intramuscular monthly form of naltrexone, trade name is Vivitrol, effective once the patient gets it. That's an asterisk. So why do I say it's effective once the patient gets it? So there are studies that show that once patient gets the Vivitrol, the efficacy of them staying in treatment and staying sober from the fentanyl and opioids is comparable to patients on buprenorphine or methadone. However, about a quarter of patients are lost to follow up and they never get the injection while they're waiting for the Vivitrol. And because it's a blocker, it's an opioid antagonist, it has the least stigma in our society as far as the medications go. So to talk about how we can further help patients to get patients on methadone treatment for rural communities. So typically the conventional, the old protocol for methadone titration treatment was that you start at 30 milligrams and you titrate very slowly, increased by 10 milligram every four to five days, not faster than that. The reason being that is because it has a slow onset, long acting and the stable level is reached after about five to seven days. And you're not going to truly know how much they're able to tolerate this dose of methadone until they reach state to state level. Now that was the old school of thought because of the potency and the power of the fentanyl. At least a lot of my colleagues working in the inner city of Boston are modifying their titration protocol. They start at 40 to 50 milligram even daily and increased by 10 milligram every two to three days. Obviously this is usually done in an inpatient setting in a hospital, kind of keeping them, monitoring them for safety. And then you titrate them up, you obtained their Cal score, which is metrics of the withdrawal and also their cravings. And the goal is to titrate them up to an effective dose before you discharge them to their home clinics in rural communities. If you don't stabilize them urgently and patients, especially in the rural communities, they have logistical barriers and they're still trying to fight through their cravings and their withdrawal symptoms to get to methadone clinics every day. And in fact, like fentanyl is a lot more accessible, a lot more easily accessible, then you'd be setting up for a demo for failure. So the rapid titration is the key for patients in medicine clinic, titrate them to an effective, helpful dose as much as possible before discharging them to a home clinic. Now, when I talk about rapid titration, so there's something about this protocol, direct admission. A lot of this has been very much utilized in the last 10 years. It is very much legal for a hospital, medical hospital, or psych hospital, or detox admission, as long as they have a memorandum of understanding, not quite a contract, but in a relationship with the different local clinics, they can actually start the methadone within their institution, even though they're not OTP themselves. And the goal would be to start them and titrate them up to a stable dose before they discharge to a home clinic. Now, compare this to an older protocol where patients would be managed with a methadone or buprenorphine taper during their hospitalization, and they're discharged with no methadone, and they get referred to a medicine clinic. They have to wait certain days before they get the first dose. Again, setting them up for failure, especially more important for patients with logistical barriers. Or the idea that only limited communities are doing this, it's called methadone van. The proper name is the mobile opioid agonist treatment. I talked about how methadone clinics, because of the daily dosing, daily dispensing mandate, it can be very much challenging for patients in rural communities to travel far. If you're a doctor that you see once a month, once every three months, it's 20 miles away, that's usually not a problem. If it's 100 miles away, if it's every three months, every six months, and provided that you're maintaining your phone calls and video visits, you can make that work. If it's a methadone clinic, then you cannot do that. Even for every week, if you live 20 miles away, 100 miles, 50 miles away, you cannot do that every day. Now, what if we take the methadone to them? There's a mobile agonist that methadone van will travel to local communities. We have seen that there's a severe disparity in access to methadone treatment, despite how helpful methadone is. And we've seen that the patients who are reached by methadone van, they tend to be IV daily users with a less treatment history, and not inferior to conventional methadone clinics out of methadone clinics. And it's something that we should think about expanding further, especially for rural communities. This is, so I talked about how methadone maintenance treatment is usually daily dosing for the first three months or longer. With the beginning of the COVID pandemic, everyone actually was given two weeks of take-home dose. And the fear was that the illness was gonna lead to a lot of destabilization of a lot of patients. We found that actually the more take-home dose is generally safe and improves access for patients. There was a transient increase of overdose when everyone was given two weeks of take-home dose. I personally have one particular patient who had done well on methadone maintenance for six months. Pandemic started, given two weeks, and he relapsed and it took him, we just got him back into recovery. So it took him about three years before he can, he was able to get back into recovery. There's a, you know, there is a growing voice to argue that the methadone for opioid use or treatment should be able to be prescribed by a provider in an office setting, something to be aware. So it's right now, 1227, I'm gonna, one of the things, buprenorphine, rapid induction to buprenorphine should be a high priority. Similar principle with the methadone. Get them while you have them, get them, titrate them up as fast as possible as while it's safe to do so, and then discharge them to a local provider is probably the best way. Telephone calls, you know, until stable in treatment, frequent telephone calls, even for five minutes, even for three minutes is a whole lot better and can be very effective. Induction, usually the starting of the buprenorphine can be a barrier for many patients because if you have to travel 50 miles and you, you know, to see a doctor in an office, to see a prescriber in an office, and then you're told that you're not ready for induction, you know, and you send them home, they're not gonna come back. They're not gonna come back. The alternative is that you can send them home with a prescription, with a home induction. And there is an app to guide them to kind of self-score their withdrawal scores and then determine when it's the first time to get the first dose. I'm not gonna talk about the name of the app because they don't pay me any loyalties or any consultation fees, but you can actually look up buprenorphine in the app store and something will come up. Buprenorphine extended release. So one concern about patients in rural communities who are not able to visit patients on a routine basis is about their compliance and adherence. The extended release subcutaneous of buprenorphine can mitigate some of the concerns, sub-blockade. You treat them with the buprenorphine for seven days and then you get them on the sub-blockade 300 milligrams. There's an asterisk, there's an open-label study where, you know, people, obviously it was done in the ED, in the ED, they gave them one dose of sublingual buprenorphine. If it didn't cause persistent withdrawal, they proceeded with giving them sub-blockade and most of the people, 19 out of 21 patients, you know, tolerate the sub-blockade. And, you know, the dosing, 300 milligram, 300 milligram, that's the loading dose. And, you know, you can either maintain them with 300 milligrams or versus 100 milligrams. Alternative dosing is 300 milligrams and then you maintain them with 100 milligram. That's about equivalent to eight to 12 milligrams of sublingual suboxone. I will say that the sub-blockade has been a game changer for my, you know, for my practice and my treatment and really, really improved the treatment outcomes and the quality of life for patients who were not able on the high dose of buprenorphine because they didn't have to think about it, they didn't have to make a choice to take buprenorphine every day. Very briefly, contingency management provides, you know, chance-based monetary reimburse, you know, reimbursement for patients who are getting injectable medication for opioid disorder. It does increase incentive for, it doesn't increase the adherence to the medication. Again, it's something that we use to convince people to consider sub-blockade or Vivitrol instead of a sublingual. I'm gonna study, I'm gonna skip over. So opioid disorders, so that's far, as far as the medications go, just briefly, probably a third of my patients are in the rural settings. And, you know, I also know the challenges of, you know, because you're not gonna have addiction psychiatrists being able to reach those populations, every single one of them, it's just not gonna be possible. So it's gonna be very much, you know, just a task to primary care providers or general mental health prescribers to provide, you know, medications and treatment for opioid disorder. There's the, briefly, there's a Project ECHO extension for community healthcare outcomes. Depending on your healthcare organizations or institution, you'll have, you know, regular gathering and the consultation available for the most challenging patients. And they go over as a community of providers, and you learn and you get better at managing, you know, patients with the opioid disorder. Hub-and-spoke model, very similar, very centralized, resource concentric, you know, probably gonna be located in the urban setting and the rural community, rural community providers are able to access, have that resource by putting in consultation, by requesting a tele-visit for patients that are managing in person. Nurse care manager model is something that we utilize in my practice, instead of, as opposed to prescribers checking in with the individual patients, therefore, you know, a bulk of a burden on the prescribers, you know, addiction-trained nurses are the frontline providers for patients with the opioid disorder, and they are providing brief counseling, you know, crisis counseling, and this was counseling them about the dosing changes of buprenorphine and other medications. I'm gonna go over some technology advancement for opioid disorder, especially applicable for patients, you know, for rural communities. So, for, according to SAMHSA, patients in OTP, they must undergo toxicology testing at least eight to 12 times per year. Now, that was, and there's no mandated toxicology testing for patients on buprenorphine or naltrexone or Vivitrol. However, I think most healthcare, most providers in the community kind of try to follow that guideline before the pandemic, to get at least eight to 12 times of, you know, toxicology testing. Now, with the pandemic, I think most people kind of learned to go few and far in between toxicology testing, and they learned that actually patients do find generally, if you determine that the patients are stable enough and or have a substantial rapport, that you're not really there to catch them with the use, it's not gonna be punitive, it's not gonna result in punitive, you know, consequences if they report relapse. And, you know, along with the toxicology testing, every three months, every six months. I know of some other providers who do like once a year toxicology testing, and their report have been very much positive. Patients, and they maintain them, they still see them on a tele-visit, but the maintenance, but the frequency of in-person visit along with the toxicology testing was very much not needed for a bulk of patients. So when I think about the in-person visits, because of the need for the, you know, a lot of our providers who are treating patients with an opioid disorder, they have this, you know, I can still see them remotely, but what about the toxicology testing? And I can tell you that the toxicology testing, the evolving standard of care is that the patient can be very much not as frequent as we thought before. Urine specimen still remains the gold standard for the toxicology testing. It's considered non-invasive, non-invasive in a way that is, well, you know, it's especially if it can be invasive invasion of privacy if you're employing some sort of a direct observation protocol, but it's not invasive. It's not intrusive. It's not, you're not taking needles. You're not, you know, walking out a hair follicle. It still remains the gold standard because of convenience and also because of the sensitivity and specificity when you're testing a urine specimen and because also detection window. Hair follicle test, obviously very, very accurate. However, it is very much expensive, up to 1500 or $2,000 per testing. And it also catches any single time use within the three months prior, depending on the substances. And clinically, that is not very useful to me. I'm more interested in, you know, patients, if they're, you know, struggling more recently than any single time use in the last three months. So it still remains the gold standard, but obviously you cannot do urine testing if you are, you don't have them in your office. Oral fluid testing, it can be actually, you know, depending on your lab standards and everything, it can be done as a point of care over-the-counter testing. And it can be observed. The result can be observed remotely over the video cam. It can be a viable option. Other concern about keeping patients remotely and not in-person is adherence with the patient's medications. As I said, a big thing about sublingual buprenorphine or oral naltrexone is whether they're adhering to their treatment, because they have to choose every day to take the medication. Or, you know, especially for buprenorphine, you're worried about their diverting buprenorphine. Electronic pill dispenser, you know, this was recently, you know, came out in market in the last, you know, three years. It comes very sophisticated. It's only a lot during the program time. And it provides a certain daily dispense dose is unlocked from like 8 a.m. to 10 a.m. or, you know, or however you want it to be programmed. And, you know, it's a very, you know, or however you want it to be programmed. And whether they took the medication or not is automatically reported to the prescriber office. Now, it's not going to report to the prescriber office if the patient takes the medication and doesn't put that in their mouth and then just discards it or sells it. There's one caveat. But I think the bigger concern is that patients are missing the dose either, you know, consciously, or they're just, you know, you're just worried about whether they're adhering to the medications or not. And that can be sent to prescriber office automatically. There's also a protocol for video directly observed therapy. I think we've seen that and with the tuberculosis treatment that is actually cheaper and more effective just to have them be observed to take their medications. And especially if you're concerned about patients adherence, you know, obviously you're not going to have time for, you know, for doing this for every single day, for every single patient. But if you had any support from nurse care manager model or other staff, what you can set up is that to have directly observed them taking the medication via video. Now, with the Suboxone tablets and with the buprenorphine tablets, you're going to be, it's going to take a lot longer to dissolve and it's not going to be practical for you to directly observe them, wait for 10 minutes to 15 minutes to fully dissolve the tablets. But the strips will dissolve a lot quicker within a minute or two. Virtual group therapy. So I think a lot of people are experienced with the individual group therapy virtually or remotely over telemedicine. There have been more and more evidences. I think a lot of AA meetings went virtual via Zoom with the beginning of the pandemic. It really, pandemic really, COVID pandemic really jumpstarted the impetus for, you know, virtually available appointments. There's more need for randomized trial, but it is not, as far as the current evidence, it is not inferior to in-person group therapy in at least in one study in terms of treatment retention, patient satisfaction and their recovery status. Just to kind of, you know, personally, you know, share my anecdote. We built a virtual intensive outpatient program that provides group therapy up to eight hours a week for four weeks. It was received very positively by patients. We do ask them to come in person in the beginning. So we will collect the urine test, urine toxicology testing, and we will make sure that they're not going to be withdrawing acutely from alcohol, benzos or opioids. We're going to make sure that the, you know, their vitals are stable and their labs are stable before we start any medications. But other than that, a lot better actually attendance than in our partial hospital. Part of the reason why I built up this virtual IOP was that our partial in-person partial program was running from 9 a.m. to 3 p.m., Monday through Friday. A lot of patients who coming from rural communities couldn't get here or didn't want to get here every day. They also had other obligations with their work, with their family, with their school during that time of the day. So what we set out to do specifically was to build a program to accommodate those patients. And it runs from 4 p.m. to 6 p.m., Monday through Thursday. And that lets patients to do whatever they want to do or need to do during the daytime and they can get on the, uh, they can get on the, uh, virtual groups, um, about four hours are, you know, Of the eight hours a week as devoted to CBT SUD and DBT, uh, principled groups, uh, the other four groups, uh, psychoeducation, uh, you know, crisis, uh, distress tolerance, um, and, uh, specific one topic, uh, one group hour specifically designated to, to PTSD and how it's related to, to substance use disorder. It is the biggest comorbidity that we see in our clinic. Um, to summarize, uh, so Ryan hate act, uh, is, uh, it was, it's because of the, with the end of the public health emergency, uh, back in 2023, uh, the DA took a lot of comments from the frontline providers is on hold. Uh, so you can still start, uh, treatment with the control substances, specifically, uh, with the buprenorphine is, uh, comes in mind, uh, up until November of 2023. If you happen to start, uh, someone on a control substance without an in-person visit, uh, during that up until November of 2023, you have until November of 2024 to get that, to see them in person. Uh, but otherwise you can still continue the treatment. Um, especially with the methadone, uh, and buprenorphine, uh, the hope is that the, uh, to work with the, uh, the, uh, more suburban or urban, uh, control, uh, hospitals to focus on a convenient initiation and rapid penetration to, to a stable dose. Um, and, uh, before they're discharged to their roles, you know, home communities, uh, because otherwise, uh, for, for them to come to the, uh, you know, come see their doctor, come see their prescriber once every three months, uh, you know, 70 miles away, a hundred miles away and to wait for the titration, uh, you know, you're, you'll be setting them up for failure. So my hope is that the, the message is not only for providers in the rural communities, but for, for communities, for providers in the, uh, in the more urban setting to focus on rapid initiation, convenient initiation and rapid titration. Utilize, uh, you know, virtual individual and group therapy options. Um, it's, uh, I can tell you personally that the, you know, development of a program for virtual IOP has been very much rewarding. Uh, we are accessing, we are reach, uh, we are, we are able to reach a lot of, uh, a lot of patients that we were not able to reach before. Um, it, it does take us some, uh, you know, a learning curve, uh, to be able to moderate, um, you know, in, you know, group therapy, uh, you know, it takes a, it takes a practice. Uh, you also want to make sure that the, uh, your internet and their internet, uh, your equipments, headset matters. Uh, it really improves the audio quality of the virtual group therapy, uh, for, for, for the facilitators as well as the, for the patients, um, and utilize them as much as possible technology. Uh, we talked about, uh, because of the, I think almost everyone has, uh, has, uh, smartphones, uh, that are capable of, uh, you know, webcams, uh, video directly observate, you know, observe the treatment, uh, therapy protocol, electronic pill dispenser that's connected remotely, uh, wirelessly, and they can submit the report to the prescribers automatically and, or, or fluid testing observed over the video can, uh, can aid you in monitoring for adherence and relapses on patients on treatment for, for, for opioid disorder. So that is, uh, what I have. Uh, and I put a lot of references here. Uh, and I'm going to stop talking and I'll, uh, leave time for questions. Thank you very much, Dr. Park. That was a fascinating, uh, presentation. And I, I had a number of questions, uh, that came up during the course of the presentation that in the, in the early part, when you talked about methadone, you were describing how people would be started rapidly on methadone in the hospital setting. And then outpatient, I was curious about how high a dose of methadone you aim for, or what was the dose when you transferred them from the hospital to outpatient? How long did you keep them in the hospital in terms of what dose did you try to get to? So even the, uh, you know, so right. The, the, I think, I think I talked about how 80 milligrams of methadone is usually the first, uh, you know, the barometer is aim for, for, for patients. A lot of patients, a lot of patients don't want to take more than 60 milligrams or 80 milligrams. I think you've seen that. Um, it also depends on if they're in a medical hospital, medical hospital is not going to wait for, for us to touch it at the methadone to 80 milligrams or 60 milligrams. Uh, if, as long as they're done with the acute withdrawal and there's no medical symptoms, the hospital is going to tell the prescribers, the treatment teams to, to discharge them to a local mesclun clinic. Similar thing can play it out in, in the, in the inpatient detox for, or, uh, or, or, you know, like a psychiatric unit. Um, if you can get patients to, to agree to take 60 milligrams, uh, 80 milligrams, I think that's a good goal. Uh, I feel a lot better with the patients on 80 milligrams of methadone or higher. Uh, and that's what I'm going to, uh, you know, aim for it. Usually it doesn't happen that way. And it's not just because of systematic barriers, it has to do with the, uh, patients don't want to wait, uh, that long, uh, because they got, you know, they got business to take care of, you know, family business or other obligations. A lot of them have stigma against the methadone and there have this, uh, you know, idea of I'm going to get off methadone within like next two weeks within a month. I don't want to be, I don't want to go up any higher than 60 milligrams. So there's a lot of, uh, factors. Um, but yeah, you want to aim for 80 milligrams or higher. Okay. Well, uh, my question is though, if you have rapidly increased people to 80 milligrams and then discharge them, aren't you at risk for intoxication over the next couple of days or overdoses if people are, you know, have not had adequate time to sort of get tolerant to that dose? Definitely. So, you know, I think, uh, you know, before the, uh, the fentanyl era, I think, uh, what we've, uh, you know, seen and heard was that the patients given 30 milligrams, 40 milligrams, they're doing fine. And they're still complaining of their cravings. They're still telling you they're having withdrawal and they're fine, fine. And you're, you're arguing with them and you're trying to slow down the titration process as long as possible. And then five days or six days later, he's found down, you know, I think that's the, that's the typical, like in a horror story that we hear and that we hear from our colleagues and from colleagues, colleagues. Now with the, with the fentanyl, uh, these days and the potency, the, the, the standards that I, the standards that I hear in the community, uh, providers from Boston Medical Center, uh, from other Brigham and other that patients are doing fine with the 50 milligram and they're keeping them on, um, on the regular cows, uh, holding, you know, they're adding the holding parameter for, for methadone dose and they're, um, uh, they're still scoring high on the individual scale. Uh, and there's no sign of over sedation. Now, the beauty of the direct admission is that after they're discharged from the hospital, you're not distracting them with the, with the prescription of methadone, uh, with a direct admission along as soon as you're starting the methadone in your, in your unit, in your hospital, you already communicate that to, to the local methadone clinic that the patients will be going to. And the, the, the methadone clinic will be seeing them the day after their discharge. And they're going to continue to get monitoring of the, the methadone, uh, making sure that they're not over sedated and they're not overdosing on methadone. Okay. I want to remind our audience that if you have questions, please submit them to the Q and A's area, uh, you know, on the, on your screen, and then we will try to get to them. Uh, but to go back to your response, then most of these patients are probably from what you said, they're probably up to 50 milligrams methadone and transferred to the clinic on the outside. Yes. You know, so it's going to be up to that clinic to determine how rapidly they go higher. I would assume the 50 milligrams were most of these patients with a fair amount of tolerance is probably safe. Yes, very much. So I will say that the, uh, from the, so inpatient hospitals and, you know, it has to do with the staffing and the monitoring too, they're, they're more cavalier, uh, with their, in terms of initiating methadone and then patching up the methadone or because, you know, they got, they got nurses, they got medical provider, they can make a staff, uh, are, you know, checking in with them. Methadone clinics, uh, they only see them for their dosing window and they're sending them home. So they've been, uh, a lot more careful with the titration. I've heard from the local medicine clinics, like, you know, like, uh, you know, if, uh, you get patients on 80 milligrams within the last, uh, you know, 10 days, like, you know, they'll be, they'll be nervous about it. No. So I've seen between their attitudes. Yeah. And I would assume that, and then they probably would going back to the more traditional patterns of, you know, maybe five milligrams every week or something. Yeah. Yeah. Well, I had, I had some more questions about patients on buprenorphine with the model that you're describing, you're able to sort of initiate the buprenorphine fairly rapidly with these patients. And are you doing that with home inductions for most of the patients? Are you doing that with in-hospital inductions and then, then following them remotely, they return to a rural area? Yeah. So I think most of the inductions for buprenorphine happen as a, as an home induction these days, for me, um, a lot of patients actually have experience with the illicit buprenorphine or, or, or, you know, legitimate prescription in the past. And they can tell us, uh, they can tell me when they're ready for, for buprenorphine. Um, if they're particularly nervous about it, uh, if they're particularly unstable and we're still determining whether they need to, you know, we're going to recommend them to go into inpatient detox right now, we'll invite them to come into inpatient, but otherwise, uh, you know, I can talk to them over telephone or, you know, have a, have a virtual visit with them, um, and send them, uh, prescriptions of buprenorphine to be started at home. Now the sub-blockade cannot be injected by the patients themselves. Uh, it can only be dispensed to a, to a medical staff. The, the big worry is that obviously, you know, the patients, uh, you know, they're not, you know, it's not cutaneous injection, it's not a rocket science, but the big worry was that the, uh, you know, when, when the sub-blockade was developed was that the patients are going to try to abuse the sub-blockade by injecting that through IV. Um, so our pharmacy, I think a lot of, uh, you know, so to be able to inject sub-blockade, you gotta be registered Rams with the, with the pharmaceutical company. Um, and it's only, you can only dispense to a medical staff who are gonna, who are gonna take the, uh, the injection and, you know, take the injection and inject it to the patients. And that, you know, you have to come in, you do have to come in. Um, yeah. I think we can safely assume that in the U S no one, no one is getting supplicate other, other than by injection, not have access to it. Yeah. When you've got a brand new patient who is, let's say has gotten onto buprenorphine or, uh, or a sub-blockade within the first say week or so they're now back in their community, try to work with them remotely. Uh, and the first couple of weeks, how often do you see the patient yourself? How often do you have a nurse contact the patient? What, what would, what would you do with a brand new patient during that first week? So I think I'll, you know, so I've been, I've been putting a lot of effort into training our nurses to, to kind of, so I think, uh, nurse, especially at the beginning of the treatment, we'll probably call them every day or every other day, at least for the first week to make sure that they are, their, their buprenorphine doses titrate up depending on their response. I'll call them weekly. Uh, I'm not gonna, I'm, I'm, I'm still billing for it, but I'm not going to spend 30 minutes to, to talk to the patient. Um, and because it's better, you know, I think, uh, you know, once, uh, it's just, uh, it is the, the, the best care often is there is a barrier of, uh, of, uh, providing good enough treatment. And, um, you know, I do, I would like to see them in person for 30 minutes to kind of talk about various aspects. If I cannot do it, if they cannot do it, I'd rather call five more patients using five-minute telephone phone calls, check in on, on their, on their, you know, stability. Just regular phone calls with these patients, or are you doing them with video phone calls? Regular phone calls, regular phone calls, uh, you know, and, uh, I will see them on video, uh, in about a month, uh, if they're, they're going to it. Um, you know, I think a COVID pandemic really changed, uh, my practice and a lot of, uh, you know, other, you know, practices as well before the COVID, like I, I would insist on, you know, having them come in, come back in person the next week, or, you know, see them for, for full follow-up visit over video next week. Uh, with the COVID pandemic, we were kind of forced to, to, just to do whatever we could do to, to reach the patients. And, uh, the, what we've seen at least anecdotally is that the patients do okay. Uh, patients do okay. So, um, I'll do it, you know, telephone, uh, they'll tell me, you know, they can pick up, you know, they don't have to be in front of, uh, they don't have to secure private space, uh, or time. They can just pick up the phone. Um, and, um, and if I'm concerned, uh, you know, if they're not doing well, then we'll ask them to either come in or see me on video, or otherwise, uh, we'll, uh, you know, get them, we'll send them the next supply of, uh, you know, buprenorphine medication without seeing them in person or on the video. How many patients do you see with, you described as sort of a virtual intensive outpatient program where you use patients for maybe eight weeks a week. Uh, I'm curious how many patients are seen with that frequency versus, you know, someone who may be just be getting a phone call once a week, uh, in their first couple of weeks. Can you, can you repeat the question again? Well, you, you, you described a program where you had intense outpatient visits, something like eight contacts a week. Yes. Yes. Participated in. And I was just curious how many patients got that high level of intensity of virtual contact patients who just got a phone call from the nurse or got a phone call from you once a week, something like that. So, um, right now we have, uh, I think, uh, seven, eight patients right now in the program. Uh, it's going very well. Uh, one thing though, is that the, uh, we've tried hard. I mean, so there, you know, just to, for, for the audiences, there's definitely a better evidence for people who do well, if they do better in the first three months of treatment, uh, their overall prognosis with opioid disorder is a lot better, um, in terms of overdose and treatment retention, uh, and vice versa. So I think, uh, we should ask, you know, we, we make an every effort of trying to attract patients to attend either partial or our virtual IOP, especially in the beginning of our treatment. I, we don't have a lot of, uh, takers on, on, on that. Uh, many patients, uh, tell me that the, uh, you know, they think, uh, just getting on the medication is going to solve all their problems. Um, and, uh, while we, we try to encourage them to consider more intensive options, um, if, uh, they, they're not wanting to do that, then, then by no means, uh, we're, we're forcing them to, and, and when we don't force them to, we don't have a lot of takers of virtual IOP, uh, of, uh, you know, of, of, uh, patients who are starting their journey of the opioid disorder recovery. A lot of our patients, uh, in our, in, in our virtual IOP tend to be, um, patients with the alcohol use disorder, uh, or if they have opioid disorder, they tend to be, uh, uh, kind of like a seasoned veteran. Uh, they have seen, they have already experienced the values of a group therapy before, and, and they're telling, they're telling us like, look, I, I'm struggling right now and I need a refresher. I think this is a perfect way. I'm not at the, I'm, I'm not there yet, uh, to like, you know, just to put everything behind and just to go into residential program. I think I can still work. I can, you know, I can still do this, but I just need more group structure. So, so they are coming to us asking for, for virtual IOP. Okay. Well, it sounds like a very exciting program. I think we are out of our time today. So I want to thank you very much for fascinating presentation. I want to thank our audience for participating. Uh, thank you all for joining in the webinar today. We will be having an MSM webinar on Wednesday, August 2nd, from 3 to 4 PM Eastern time. This webinar will be on adolescents and substance use disorders, prevention, treatment, and recovery. We hope that you will be able to join us for that webinar. Thank you again. Uh, and, uh, appreciate, uh, the audience today and our next presentation will be, uh, with Dr. Hector Colon-Rivera. Thank you. Thank you.

opioid use disorder treatment

rural communities

medications

virtual appointments

telemedicine

extended-release medications

technology advancements

remote treatment options

evolving standards of care