Good afternoon, everyone, and welcome to today's seminar. On behalf of the AMNET development team and its executive and steering committee, we would like to welcome you to the session on measurement, assessing outcomes in office-based addiction treatment. Before we get started, I'm going to turn it over to Dr. Youssef, who is just going to run us through some housekeeping stuff. Youssef? Hello, and welcome, everyone. Thank you so much, Dr. Clark. A few housekeeping goals. I don't know why this isn't working. So if you can, please mute your microphone. Clicking on the microphone icon here. And if you're using both the computer and telephone, it might cause some feedback noise, so if you can use only one of them. To raise your hand, please use the raise hand button. And please type in any questions that you have in the chat box, and we'll be monitoring the chat box and answering any questions in the Q&A session. Thank you so much. Dr. Clark. Okay, great. Thank you so much. So next slide. Today's speaker is Dr. Karen Drexler, and I want to welcome you, Dr. Drexler. So Dr. Drexler is the medical director of the American Academy of Addiction Psychiatry, where she serves as a member of the board of directors and a subject matter expert on addiction treatments and policies for the organization's leadership team. In addition, Dr. Drexler is an associate professor in the Department of Psychiatry at Emory University School of Medicine, where she has served in various roles since joining the group in 1994. Dr. Drexler served as the National Mental Health Program Director for Substance Use Disorders at the Veterans Affairs Central Office for many years. Her research interests include neurobiology of addiction, clinical trials, health services, and quality of care research in addictive disorders. It is this wealth of knowledge and expertise that Dr. Drexler brings to her role as a member of the steering committee for AMNET and to her presentation today. Dr. Drexler, thank you for agreeing to lead this webinar on such an important topic for the field. Welcome. Thank you, Dr. Clark, and thank you for this kind invitation. I want to welcome everyone and thank you for joining today. Next slide, please. Today, we have an ambitious agenda. I'd like to describe the rationale for measurement and assessing outcomes of addiction treatment and make a distinction, although there is some overlap, between quality measures and measurement-based care. We'll talk more about that. At the end, I have several slides that I hope you'll be able to use to become aware of government-sponsored resources that you can help to implement changes in your practice. I hope at the end you'll select at least one metric to measure success in implementing addiction treatment in your practice. Next slide. Why measure? Yogi Berra is one of the wisest people I know. If you don't know where you're going, you might wind up someplace else. There's really two reasons to understand the effectiveness of an intervention with individual patients, which is the measurement-based care that we'll spend the most time on this afternoon, or implementation of a new treatment in a clinic or for a population. Next slide, please. Quality improvement is measuring change at the practice level or, as Dr. Clark mentioned, in my role in VA Central Office, we were trying to improve quality for a population of 9 million veterans that were engaged with the VHA. Next slide. Think about what are your goals for your practice. Do you want to... I think about prevention at many levels. I remember learning this back in medical school, primary prevention of addiction in patients Maybe through education of your whole patient population about the USDA dietary guidelines for alcohol use, for example. Or the risks of tobacco or opioids or cannabis or other drug use. Or secondary prevention of addiction in patients who are at risk. Maybe they're at risk in your practice of general psychiatry because they're on benzodiazepines or Z-drugs for insomnia. Maybe they use medical marijuana or even recreational marijuana. The fact that our patients in psychiatry have a mental illness puts them at increased risk for many substance use disorders. And maybe you just want to focus on the folks whose alcohol intake exceeds the USDA dietary guidelines. On the other hand, perhaps you are interested in tertiary prevention of the medical and psychiatric complications of substance use disorder by starting medications for opioid use disorder or alcohol use disorder in your practice. Or maybe prescribing naloxone to those at risk and educating loved ones about how to reverse an overdose. Next slide, please. I love this way of thinking about the big picture from Robin Williams and colleagues. This idea of a cascade of opioid use disorder care. This was really adapted from a public health framework for addressing the HIV epidemic. And Robin took this same idea and adapted it to OUD care. So this is just another graphic way of looking at primary prevention for opioid use disorder is through education of the public at large or perhaps using opioid sparing pain care among providers. Secondary prevention would be targeting those Americans who are at risk due to opioid analgesic exposure and doing secondary prevention through opioid safety measures and education. Or you could focus down on an even smaller population, which is still huge, 10 million Americans with opioid misuse. 97% of that misuse in the United States in 2019 was misuse of prescription opioids. So this is a really important population. But you might do secondary prevention through identification of opioid use disorder. And once you've identified it, hopefully in your practice you would also be ready to start medication for opioid use disorder. Next slide, please. So let's focus in just for a moment on initiation of medications for opioid use disorder or MOUD for short. In your clinic, you might think of who's your target population. Unless you're a specialist like me, it's probably not all of your patients. And even if you're a specialist, it's probably not all of your patients that have opioid use disorder. You might target just those who have been clinically diagnosed. If that number is changing, then consider creating your metric as a ratio so that you have the denominator being the population that you want to target and then the numerator of that ratio is the actual patients that, say, initiate medication for opioid use disorder. And then think about how can you identify these patients. It may be that you decide to do what we did in the VA. Every time I treat a patient, I check out the encounter in my electronic health care record. And that means I record a diagnosis and I record a procedure, which could be evaluation and management of the patient. That's my most common procedure. So am I going to base it on encounter diagnoses or am I going to formally screen folks using a screening tool? How will we measure success? It was very handy in the VA because our electronic medical record recorded the prescriptions. When I wrote the order for a prescription, it was recorded. And when the pharmacy filled that prescription, it was recorded. And if you don't have that built into your medical record, then do you have staff who can manage a spreadsheet or a database for you? Next slide, please. So I'm going to do a little bit of a deep dive into one example from the Department of Veterans Affairs. And I want to tell you the story of how we got to this one particular initiative and then the success that we saw with that initiative. I hope it will be inspiring. So what this graph shows is the number and percentage of veterans with an opioid use disorder diagnosis who received that acronym CPG, clinical practice guideline consistent medications. So the VA and Department of Defense have clinical practice guidelines for management of substance use disorders. There are three medications recommended by those guidelines. Methadone administered through an opioid treatment program. Buprenorphine in any of its various formulations. Or injectable naltrexone. The VA DOD clinical practice guideline does not recommend oral naltrexone because of challenges with adherence. But the injectable form has been shown to be effective. So starting back in 2004, we started tracking the administration of these medications through the electronic medical record system at our corporate data warehouse. This is encounter-based data. So of those encounters where a patient was checked out with a diagnosis of opioid use disorder or ICD-10 diagnosis of opioid dependence, what percentage of them or how many of them received one of those indicated medications? And the number was about 7,500 back in 2004. The percentage at that time was less than 10%. By 2019, that number was over 26,000, and it was more than 40% of the veterans clinically diagnosed in any clinic, not necessarily a substance use disorder treatment clinic, but primary care or inpatient, not inpatient hospitalization because these were all outpatients, but it could be an encounter in the emergency department. So we had made tremendous progress, but we still have a long way to go. About 80 to 90% of patients who are clinically diagnosed with hypertension or diabetes receive indicated medications. So even though 40% seems like tremendous progress, we still had a way to go. One of the things we knew from the way we tracked data in the VA is that most of this treatment had been provided in SUD specialty care clinics. So we were providing that treatment for the majority of patients who were seeking treatment for their opioid use disorder, but for those who had been diagnosed in primary care or a pain clinic or a general mental health clinic, most of those patients were not receiving indicated medication. So next slide. So we started thinking, if the patients who come to us in specialty care are getting the treatment they need, then we need to think about how can we bring the medication to where the patients are. So we know that there is a stigma associated with substance use disorder treatment, and that may impact a veteran's willingness to come to the specialists. We also know that there's just a matter of convenience and trust. If you trust your general psychiatrist or your pain specialist or your primary care provider, you are much more likely to engage in treatment with that provider. So the idea with stepped care was to provide the treatment where the veterans were, meet them where they're at, and then step up the care with a warm handoff, not a long wait, if the patients needed more support than could be provided in those general settings. Next slide, please. So we started this initiative back in May of 2018. The VA, as you may or may not know, is organized into integrated service networks. And each of these has a lead for mental health, for substance use disorder treatment, for primary care and for pain. So we engaged the leadership for those networks. And then we also asked those leaders to recruit a champion, a physician in SUD specialty care and another one in one of those general clinics, which we called level one clinics, primary care, general mental health or pain management. Then have those champions recruit their teams to implement this. Next slide, please. So this shows you it's sort of a complex idea, but we really wanted providers within the same medical center to work together. So one champion from SUD, one champion from primary care, mental health or pain. And then they were not alone. We want the one champion to do all of the prescribing so they each had a backup. And then an RN to help facilitate because a lot of the tasks can be done by the nurse on the team. And a therapist or case manager. And then in VA, we have something called clinical pharmacists who are kind of the glue who hold the whole thing together. So level one consisted of 13 individuals, four leaders, and nine workers. Next slide, please. So the teams, we asked the leaders to start forming their teams in May. We had a couple of webinars to educate the leadership as well as the team members about what they were getting into. And then in August of 2018, we had a kickoff face-to-face conference. And we had senior VA leadership who also came and supported the initiative. That helped a lot. We had 246 participants with teams from all 18 of our integrated service networks. And then we were able to recruit national leaders in the field. So Dr. David Filleen from Yale, who's a primary care physician who developed medical management for opioid use disorder in primary care. And Colleen LaBelle, who was a nurse care manager, who implemented a version of that medical management in a primary care practice in which the nurse, RN, not an advanced practice nurse, did a lot of the tasks that Dr. Filleen had originally taken on himself. We had them provide the classes. We had facilitated discussions to help each of those 18 teams develop their action plan. And then we had another team of experts in implementation to help facilitate the implementation of those plans. Next slide. So this is just a slide explaining what the facilitation looked like. There were email check-ins with the champions. There were phone check-ins with the champions. And then with the entire pilot team. And then at least quarterly with the VISN leadership, too. So many of the barriers to implementation had to do with systems issues. And it was really helpful to have some leaders in the system who could move mountains, if that's what it took, to help implement these changes that were needed in the clinic. Next slide, please. So here were our outcomes. We had three main outcomes. We wanted to look at the number of patients with an opioid use disorder who were prescribed buprenorphine or injectable naltrexone in these level 1 clinics. By definition, the level 1 clinics can't dispense methadone because they're not specialty clinics. And then we also wanted to look at the percentage of patients who initiated treatment and received buprenorphine, which was the most common medication, for greater than 90 days. So we were interested in initiation as well as retention. Then we wanted to make this we didn't want the scout initiative to set up just little satellite specialty clinics within the level 1 clinic. We really wanted this to spread so that each provider was caring for the handful of patients that they had in their own panel who had an opioid use disorder. So we wanted to not only increase the number of patients, but also the number of providers who were prescribing buprenorphine or injectable naltrexone. And then we also looked at barriers and facilitators. We had an amazing team of experts, Hilde Hagedorn, Adam Gordon, and Eric Hawkins. Each took on this role of facilitation or of evaluation. And part of Eric Hawkins' contribution was these great qualitative surveys, as well as the quantitative data about outcome, identifying the key findings from each data source and triangulating the data. So I'll show you, this is like next slide, some amazing outcomes. So this is the simple for me to understand outcome. You can see the timeline, that first set of bars, the number of patients in these level one clinics receiving the indicated medication. And then the red bar, the lower bar is the number of prescribers. And as you can see in the lead up when we were recruiting folks and starting to educate them, they were already seeing some increases in both patients and providers. Part of this was due to other national efforts to try to increase access to this lifesaving medication. But then in that pre-implementation phase, before the full implementation, you can see there's like a change in the slope of this line connecting the bar graphs. And then at full implementation, it seems to go up even faster from there. So we were really pleased with these results in the first 12 months. Next slide. And this is the even cooler, more sophisticated stuff that I don't quite understand, but Eric Hawkins does. So here he had a very sophisticated model for noting the change in prescribing of these medications prior to the launch and after the launch. So you can see the blue line is the actual prescribing. It was gradually going up. And then the green dotted line is the predicted trend without this stepped care for opioid use disorder. And then the overall increase that we actually saw with this initiative that we referred to with the acronym SCOUT, Stepped Care for Opioid Use Disorder, Train the Trainer Initiative. And this difference, you can see it passes the eyeball test. It was, we did see an increasing trend over and above what you might expect without this intervention, but it also met statistical significance. And this is in process. Hopefully will be published soon. Next slide. Okay, so getting the medication started is a huge hurdle and we're excited that we were able to start the medication, but retention is even a bigger challenge. In VHA, we had been looking, we had had a metric for quality outcomes in SUD treatment that we'd been following for several years and our three-month retention in SUD specialty care treatment, which we measured by having at least two visits a month for three months after you initiate treatment, was somewhere in the mid-20s. And with a lot of effort, we got it up into the mid-40s for overall retention in SUD specialty care. So we wanted to look at retention in these level one clinics which potentially have less resources to track folks down if they drop out. So that was an important outcome for us. So we were interested in, and I'd like you to think about, do you wanna follow this as a retention measure? Think about how are you gonna identify folks, those who got one of these prescriptions to begin with, buprenorphine, oral naltrexone, injectable naltrexone, or those receiving methadone through an OTP. And then can you measure continuous retention? How are you gonna measure it? Prescription fills in the medical record? Do you have access to pharmacy data? Are you gonna create your own patient registry or spreadsheet? Next slide, please. So what we did in BHA is we had, we defined the proportion of patients receiving 90 or more days supply, and then we had to make a definition for what that meant. So the time on buprenorphine was calculated from the date of the first medication fill in a prescribed scout clinic, and then subsequent prescriptions anywhere in the system would count because we had this idea that if patients were struggling in the level one clinic, they could step up to specialty care and that would still be providing quality care. So Eric and his team were able to track those prescriptions wherever they were received. And we even in this outcome gave credit for patients that switched over from one of those other medications to a methadone clinic. So any patient episode during the implementation year was used to generate the metric. Next slide. And here's what we saw. It was eye-popping. I was so amazed. Overall retention in all of the level one clinics was almost 77%. It was best in mental health and next in pain and primary care, but there's really not a significant difference between these three. Overall, it was amazing and almost twice as good as retaining patients in SUD specialty care. I especially wanted to highlight this to inspire those of you who I assume most of you are not specialists and you may have felt a little intimidated about providing good quality SUD care in your more general practice. The good news is it's possible to do and it's possible to have even better retention than in specialty care just because of that trusted relationship and alliance you already have with your patients. I think that's key. And the second thing is making it convenient for patients. They don't have to go to someplace else and all of the hassles, whether that's just struggling through traffic to get there or other barriers. Next slide, please. Okay, so now we're switching gears from thinking about quality improvement at the macro level to now improving the quality of care for each individual patient. And I'm gonna refer to that using a term measurement-based care. This is really something that we do every day in managing chronic illnesses, collecting information for patients that inform individualized adaptive treatment planning and shared decision-making. As a patient, I am much more likely to follow through with a treatment plan that I have chosen and helped develop than one that is just dictated to me. So that shared decision-making piece is really key. And here's where I think the AMNET tools are so fabulous for helping us do that. So what kind of data do you use to inform the shared decision-making process? For diabetes, we use lab results like the hemoglobin A1c or daily glucose finger sticks. In SUD care, traditionally, we've used things like urine drug tests, but that's a relatively late sign. To me, that's like trying to manage hypertension by managing how many TIAs have you had or how many strokes. That's a little late stage for interventions. What I love about AMNET is it provides these patient-reported outcome measures that really allow you to adapt the treatment based on how someone is doing before they relapse. So you may be used to using the PHQ-9 for depression through PsychPro and other mechanisms. What I'd like to focus on today is using the brief addiction monitor or BAM for SUD management. And what I've learned from Dr. Schwartz is that that is the most popular PROM in AMNET today. So I may be preaching a little bit to the choir this afternoon, and I'm anxious to hear from you how you've been using the BAM in your practice. But the idea, again, is it's an ongoing collaborative evaluation of the application of treatments which have been shown in rigorous research to be helpful on average, but may not be effective for any particular individual. This allows you to tailor those evidence-based treatments for individual patients. And I want to give credit to my colleague, Dr. Dominic DeFilippis, who is at the Philadelphia VA and the University of Pennsylvania, who I borrowed these few slides on measurement-based care. Thank you. Next slide. So this is his graphic, which I love. The measurement-based care process is you collect data, whether it's urine drug tests or the BAM or the PHQ-9, routinely. It's not something that's, you build it into your workflow and your practice. And then you share those results with patients and the rest of the care team to inform shared decision-making. And then you act upon whatever shared decision you make, implement it, and then measure again. And so this becomes a cycle. Next slide, please. So those of you who have used it are familiar with the Brief Addiction Monitor, but for those who may not have tried it yet, here's a broad overview. There are three subscales, a substance use scale that has a question specifically around, two questions actually, around alcohol use, binge drinking, and then one with many subparts around drug use. And then there are six other questions that measure risk factors for use, and then six questions that measure protective factors for recovery. So the risk factors for use are physical health problems, insomnia, craving or urges to drink or use drugs, negative emotional straits like depression, anxiety, or anger, risky people, places, and things, and then family and social problems. On the flip side, the protective factors are self-efficacy. If I'm confident that I can stay sober, I'm more likely to stay sober. Attending Alcoholics Anonymous, Narcotics Anonymous, Smart Recovery, other mutual help groups. Productive purposeful activities like school or work, having adequate finances to meet my needs, having spirituality as a important factor in my recovery, and then social support from family and friends for my recovery. Next slide, please. This is just another graphic looking at those 17 items and color coding them. So the risk factors are yellow, like a caution light. The red color is the actual drug and alcohol use, like a stoplight, we wanna stop that. And then the green are the protective factors. We want to increase the protective factors, decrease the drug and alcohol use as well as the risk factors. Next slide, please. So this is just showing an idealized patient who may come seeking regular outpatient treatment, they're actively using drugs and alcohol, their risk for use is high, the light blue bar, and then the green protective factors are low. Over time with therapy, their drug and alcohol use comes down, their risk factors come down and their protective factors come up. Next slide, please. So the wonderful thing about AMNET, that the challenge with something like the BAM, although it's relatively easy to administer, nine minutes on average, if I'm asking the questions, is that nine minutes is a long time in a primary care appointment. It's a long time in a psychiatrist, 30 minute follow-up visit. So is there a way that we could efficiently gather this information and then use the time together more productively on that shared decision-making piece? And this is where AMNET is so amazing. So measurement-based care and AMNET, there are three primary patient recorded outcome measures that we recommend, the Reef Addiction Monitor or BAM, the PHQ-2 plus one, which is a shortened version of the PHQ-9 and then the Visual Analog Scale. There's a wealth of other assessment tools that are available optionally. And you can pick and choose which ones you want to use in your practice. The AMNET tools though, allow the clinicians to view the results of the assessment in real time. And it also makes it really easy for patients to complete their part. They can do it on their smartphone. Next slide, please. So I love this graphic that explains the details of how the information is gathered and then built into the registry and protected from other people, unauthorized people accessing it. But it makes it very accessible for us as the clinicians to work with it with our patients. So I won't go through it in detail. You have probably seen this before, but the important part is that the hard work of managing the data or pulling it from the electronic healthcare record is done by AMNET for you so that you don't have to devote staff time to managing a registry or have someone on your own staff with the expertise to pull data out of an electronic healthcare record system. Next slide, please. So what I love is this is what the patient reported outcome measure assignment. It's so easy to do. You just click the ones that you want to assign for a particular patient. And next slide. And then your patient receives through the patient portal the questions that you want to administer. And this is just a sample of some of the BAM questions. So even with my reading glasses, I'm having a hard time, but in the past 30 days, how much were you bothered by cravings or urges to drink alcohol or use drugs? And that's one of the items that's sort of categorical that patient chooses amongst five choices. Others are continuous variables like in the past 30 days, how many days did you attend self-help meetings like AA or NA to support your recovery? And there they type in the specific number of days. Next slide, please. So this is also just showing a screenshot of what it would look like on a desktop or laptop computer. Next slide, please. And then this shows the outcomes. So here's for the MNET BAM. You can see the risk score of 61, the use score of 32 and the protective score of 93. So for me, that patient is in a good space. Their protective subscale is outweighing their risk subscale and their use is hopefully lower than where they started out. Next slide, please. And then I love this part. This is the part we were never able to master in VA and it's showing a graph of changes over time. So this, the MNET will feed this back to you that you can share with your patients how they have been progressing over time. In this particular screenshot, the risk factors are in light blue, the use is in green and the protective factors are in black. But you can see that over time, risk was going up and down in this patient. This is going to be a more realistic progression of scores, but use, although it had some ups and downs is generally trending down and protective factors are generally trending up. And this is the type of outcome that we hope for. Next slide, thank you. So measurement-based care at MNET, I love these tools. My, when I first saw them, I got so enthusiastic. I am looking forward to hearing from you about whether you feel that this has increased your patient engagement. What we have found in VA with measurement-based care is that patients who are engaged in this shared decision-making are more likely to be retained in treatment. And then also just improve quality of care for all the reasons that we've just talked about. And then the nice thing about MNET is that data is also stored and can be aggregated so that you can look at your patient panel as a whole or your clinic or healthcare system as a whole for how you're doing with a metric that you select like patient engagement. Next slide, please. So, AMNET has some quality measures built in. Initiation, the percentage of patients with one follow-up visit within 14 days of starting a medication. Engagement is the percentage of patients with two follow-up visits within 30 days of starting medications. And then retention, those percentage of patients who adhere to medication for six straight months, which fits into a national quality metric that is being floated around with that opioid use disorder cascade of care. And the beautiful thing about this is that this can be extracted by AMNET from your electronic healthcare record system. And so it makes it so easy to be able to look at the macro level as well while you're working with patients on the individual level. Next slide, please. So, again, just like we saw with the individual patients for measurement-based care, the performance on quality measures are also displayed in a clinician dashboard that can help inform quality improvement efforts. And over time, new quality measures can be developed. So just like we did in VHA, where we saw some progress in implementing medications for opioid use disorder, but we knew we wanted to keep going and improve it even further, this data that you get from AMNET can help you and your team brainstorm other next steps. Next slide, please. So for more information on AMNET, please visit psychiatry.org slash AMNET. And if you have additional questions, please contact our AMNET team. And I think next slide is going to be yes. So I also wanted to take this opportunity to make you aware, if you're not already, about some other resources that are already paid for with your taxpayer dollars. The PCSSX, sorry, Providers Clinical Support System, Experts or Exchange, they provide six webinars with experts in OUD treatment and in implementation science to guide you and your team. So it's sort of a slimmed-down version of what we did in SCOUT with an implementation team that will give you six webinars and tips and the opportunity to talk with the experts, as well as some individual consultation. Next slide. PCSS can provide individual mentorship for you one-on-one. And there's the information about how to access that on the web. And one more, I think. Yes, the Opioid Response Network. This is also technical assistance and individual consultation in implementing changes in a large clinic or practice. And there's the contact information for the Opioid Response Network. Next slide. Okay. I just want to thank all of my collaborators. I've mentioned already Eric Hawkins, Hilde Hagedorn, Adam Gordon, Jennifer Burden, and the entire SCOUT team for that national initiative that I did a deep dive into. Also, the folks at NIDA and the American Psychiatric Association and the AMNET team here, Dr. Clark, Dr. Schwartz, Dr. Gibson, Dr. Fauci, and the entire AMNET team. Another shout-out to my colleagues at the Philadelphia VA and the VA Center for Excellence in Substance Addiction Treatment and Education, Dominic DeFilippis and Jim McKay. And then our colleagues at SAMHSA and at AAAP that administer the Provider's Clinical Support System and the Opioid Response Network. Thank you. And with that, I'd like to pause for questions. Thank you so much. So first I'm going to – Drexel, thank you so much for that great presentation. So what I'm going to do is look to see if I see any questions in the – see if there are any questions in the chat box. But a comment that just said, thank you. You dropped so many gems. Could hardly put my pen down. So that came from one of our attendees. So if there are any questions, you can type them in the Q&A or in the chat box, and we will get those questions to Dr. Drexler. And answer as much as we can. We do have another 15 minutes. Okay. So there's one – not really a question, but a comment in the Q&A that just says, I work as a treatment provider in a drug court. I'm not sure if sharing information is allowed, but I love this idea. Okay. Ah. So I am so delighted that you have joined us, Debra. I – drug court – treatment providers and drug courts are amazing and doing amazing work in helping some of the most vulnerable in our society do amazing work in recovery. And I know there are these contingencies, and you would know best about your own court situation, the limits of confidentiality. And it's interesting as far as whether someone participating in a drug court would feel comfortable endorsing the items on the BAM about drug and alcohol use if it's not zero. However, the other 12 items, the ones that query about risk factors and protective factors, I think would be really helpful. And doing that kind of shared decision-making on how they're doing with attending mutual help meetings or whether they're hanging out with risky people, places, and things, all of that information I think would be very valuable. And so you might think about how you could tailor using the BAM for your clients and helping to intervene early before it actually – those risk factors lead back to actual drug or alcohol use. Thank you. So I'm seeing – one is just a question, can we get the slides? And we do – what do we do? I know we do have the slides on our – we do end up having it in our repository of educational material. I'll find out more about sharing of the slides. I think that should be fine, but I'll get back to you. So that was from Ernesto. I will get back to you. And then the – just a comment that was made. I was honored to be a nurse care manager and worked with BMC and Colleen on the PROUD trial, which implemented OBAT, office-based addiction treatment across the nation. We're in Washington State, and we're one of the six sites that participated from 2018 to 2021. Then another question actually that came in from Danielle Scott, is there an oral lead-in before injectable naltrexone? Is there an oral lead-in before injectable naltrexone? Oh, that's a great question. Great question. Thank you, Danielle, for that question. You can do it either way. You don't have to have an oral lead-in. But if you and your patients are more comfortable, I have done that. What we typically do if we're not doing the oral lead-in for the injectable naltrexone is to do a naloxone challenge test to make sure that the patient is not going to go into opioid withdrawal with the long-acting injection. But another method is to do an oral naltrexone challenge. So, you know, starting with a low dose of the naltrexone, maybe splitting a 50-milligram tablet. Of course, first asking the patient if they've been absent from opioids an adequate period of time, depending on how long-acting the opioid is that they've been on. Giving them a maybe half dose of the oral tablet to see how that goes. And then maybe a full dose. And once they have tolerated 50 milligrams of oral naltrexone, then they are ready for injectable naltrexone. Lots of questions coming in now. Yes, there are. And I'm trying to manage them in the chat box versus the Q&A and kind of following when the items come in. So there's one from Sarah Channel. How can we get the BAM survey to use in outpatient clinics? Or can this only be used through MNET? So how can they get access? Is it a freely available assessment tool? How can they get it to use in outpatient clinics? Absolutely, it is. So when you get the slides, I have on one of those early BAM slides the reference from Cacciacola is the first author. But also if you Google Dominic DeFilippis or James McKay, I think is how he is on the manuscripts, and the brief addiction monitor, it should come up. It was developed with your taxpayer dollars. So it is freely available. There's no copyrights or other licensure issues with it. You can use it. And it is available probably if you Google it, you can find it. Of course, you won't get the beautiful outcome graph without using MNET. There's another question from David Roberts. Is there a recognized substance use related quality of life measure that could be tracked in a practice? Oh, that's a great question. So I might open this up to Dr. Clark, who is really more of an expert than I am. Would you like to respond, Diana? I'm actually trying to think about, because in developing, we've done another set of work on developing quality measures for behavioral health and looking for different quality of life assessment tools. And you do have the World Health Organization brief quality of life assessment tool that many people seem to like, and a lot has been written about it. And of course, it's freely available, because that's one of the important things, to find something that's freely available. And it's not specific to substance use. It's more general. But I think it's really a good assessment tool. And as I said, it's very brief. It's six items. And I know Dr. Schwartz is also on the, I know he's in the participant list. So Dr. Schwartz, if you can think of anything else, you can just type it in the chat, and then we will read it out. Because I don't think we can actually allow you to speak, I think. I'm not sure. Or maybe I can. So let me get to the next question, and while I try to figure that out. And this question says, from Deborah Newman again, said, can you comment on medications that were used in this population for other use disorders, for cocaine, methamphetamines, et cetera? Okay. Great question. Thank you, Deborah, for all the great questions. For stimulant use disorders, there is no FDA-approved medication. What has a really wonderful effect size, though, is contingency management. So that's what we have been implementing in VA. I can't tell you that every VA is using it yet, but most of the specialty care programs in VHA offer contingency management for stimulant use disorder. And if you're not familiar with that, let me just briefly say the rewards of using a drug, you know, the stimulation you get in your brain is immediate. The rewards of staying sober take weeks and months and sometimes years to realize. And it's that discrepancy that often makes it so hard to gain some traction in recovery, especially from substance use disorders. So the idea with contingency management is to bring the rewards of abstinence more proximal. And so for every negative urine drug test, you get some reward. And the way we've done it in VHA is with a fishbowl technique where we have slips of paper, half of them just say good job, keep up the good work, some inspiring message, and then half of them actually have a prize value associated with them. And the more consecutive negative urine drug tests you provide, then the more draws from the fishbowl and the better your chances of getting one of those actual prizes. And the prizes are also graded so that half of them are very modest, like a dollar coupon for the VA store. But there's one jumbo prize that might be $200 at the VA store. So those kinds of contingency management, some clinics have implemented having a prize cabinet in their clinic. But that has a very powerful, robust effect size and can really help folks early in recovery from stimulant use disorders to gain some traction. For other medications, we absolutely provide medications for alcohol use disorders, oral and injectable naltrexone, acamprosate, disulfiram, which are all FDA approved for that indication, but we even recommend tapiramate has a few more side effects, so it's not often first line, but there's good, strong evidence that it's helpful. And then for tobacco use disorder, which is the leading preventable cause of premature death nationwide and worldwide, so we also offer nicotine replacement therapy and varenicline and bupropion. Great question. So Dr. Schwartz, I moved you so you were able to speak if you wanted to. Yes, that was a really good question about the quality of life scales. And for the most part, the HUQUAL breath from the WHO or the short form 12 and the other iterations of it, which are general quality of life scales are used in research. There's a new scale that was developed in Australia that is specific for drug use treatment. It's the drug use quality of life scale. And that's undergoing testing. And that might be of interest to take a look at it if you Google that. But I think there really is a need for a validated specific quality of life scale for drug use in the U.S. Thanks, Dr. Schwartz. Sure. So we have no more questions. So I don't know if anybody else from the team, let me look at the chat. I'm looking at Q&A, but let me double check the chat box as well. And I see no more questions. Anybody else have anything to say? We have five more minutes to go, but we are also okay with giving people back five minutes of their time. So any additional questions, comments? Okay. So nothing has come in. Okay. So I'm going to take this moment to say thank you so much, Dr. Drexler, for joining us today and for giving such an amazing webinar. I would like to thank the attendees for joining us today. And for those who are already part of MNET, great, thank you for your interest in joining MNET and participating in this important endeavor. And for those who have not joined MNET as yet but are thinking about it, I'm hoping some of your doubts and some of the questions you may have got answered today and you're willing to move forward and join MNET. Dr. Schwartz, do you want to have any closing comments before we sign off today? I just want to thank Dr. Drexler for a wonderful presentation and for the attendees for the excellent discussion. And thank our collaborators at ASAM, at APA, and NIDA, who have been working on this project with Friends Research Institute. Thanks, everyone. And then also to thank AAAP for, you know, helping with some of this marketing of MNET and also helping with this webinar that we had today. So thank you so much. Goodbye, everyone. Thank you.

measurement-based care

assessing outcomes

office-based addiction treatment

Brief Addiction Monitor

patient-reported outcome measure

substance use

risk factors

protective factors

recovery