Yale Psychiatry Grand Rounds: January 13, 2023

January 13, 2023

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"Optimizing Telehealth for Addiction Care: COVID-19 and Beyond"

Lewei Allison Lin, MD, Associate Professor of Psychiatry and Director of the Addiction Psychiatry Fellowship Program at Michigan Medicine, University of Michigan

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00:00One of the kindest and nicest
00:02introductions I've ever received.
00:04And likewise, I've very much enjoyed
00:07continuing my Yale connections,
00:09especially through as many Dave,
00:11Mark many other folks who are doing
00:13just such amazing addiction work at
00:15the West Haven VA, but also at Yale.
00:18I'm going to share my screen.
00:25And then start in slideshow mode.
00:27Please someone stop me if you're
00:29not seeing this correctly,
00:30but I'm just going to proceed.
00:31I do have to say that my Med school
00:33self would have been super tickled
00:35to know that I would be giving this
00:38presentation a number of years later,
00:40so it does make me laugh.
00:41I was scrolling through the list of
00:43attendees and it was smiling from quite
00:44a number of people that I recognized.
00:46So this really brings me a lot of
00:48joy to be able to have the chance
00:50to talk to you guys here today.
00:52So as Doctor Petrakis mentioned,
00:54my work really focuses on improving
00:56care for patients with opioid and
00:57other substance use disorders,
00:58with a specific focus on telehealth.
01:01And today,
01:01I'm really excited to be able to
01:03talk about optimizing telehealth
01:04for addiction care,
01:05both from lessons that we
01:07learned before COVID,
01:07during COVID and hopefully informing
01:09what care in the future should look like.
01:13These are my disclosures.
01:14In addition to my grant funding,
01:16I consulted for the NC QA with
01:18funding from ALCHEMIES and for
01:20the provider clinical support
01:22system with funding from Sansa.
01:26So most folks I think here have
01:28seen this figure, but I still think
01:30it's an important one to remember.
01:32And the emphasis that I would put is
01:34that long before the pandemic started,
01:36the US was already battling
01:38the overdose epidemic.
01:39It's important to emphasize though
01:40how things have continued to evolve
01:42away from prescription opioids,
01:43which is what started at least
01:46this particular epidemic,
01:47to illicit opioids including heroin and
01:49really mostly in the last five years or so,
01:52fentanyl that have tainted much of the
01:54drug supply in this country including.
01:56But not limited to opioids.
01:58And that brings us to what some of
02:00us call the 4th wave of the overdose
02:02epidemic in the last few years,
02:04which encompasses substances like
02:05stimulants and really people
02:07who are using and overdosing on
02:10multiple or Poly substances.
02:12Regardless,
02:12as the trends change and they
02:14will continue to change,
02:15one thing remains the same and
02:17that's the critical importance of
02:19treating addiction and these days,
02:20the importance of treating our
02:22typical patient who's struggling with
02:23multiple substance use disorders
02:25and other mental health disorders.
02:28Unfortunately, estimates since the start
02:30of the pandemic almost three years ago
02:33now suggest that overdose rates and
02:35substance use continues to increase.
02:37And it's important, I think,
02:38to remember that the pandemic has
02:40not affected our population equally.
02:42Many of us, myself included,
02:44have been largely spared.
02:45You know, transitioning.
02:46My work to zoom was not a big challenge.
02:50But for many of our patients though,
02:52due to many increased stressors
02:53during the last three years,
02:55they're struggling even more.
02:56And there are signs that many people
02:58have turned even more to risky
03:00use of alcohol and drugs to cope,
03:02which is compounded in particular by
03:03disruptions in the healthcare services,
03:05especially early on in the pandemic,
03:07some of which have not rebounded,
03:09which I hope to show.
03:12However, given the many negative
03:14consequences of substance use disorders,
03:16especially untreated,
03:17the important thing for all of us
03:19to emphasize is that we actually
03:21have highly effective treatments.
03:22This includes the three effective medication
03:25treatments for opioid use disorders,
03:27specifically methadone, buprenorphine,
03:28and extended release naltrexone.
03:31We have decades of research how much of
03:33it originating at Yale to show that these
03:36medications not only reduce opioid use,
03:38improve functioning or cost
03:40effective and are associated with
03:42reductions in mortality rates.
03:44And as a psychiatrist,
03:44there's actually not a whole lot of
03:46treatments I deliver where there's
03:48been consistent data to support that.
03:49It actually reduces rates of
03:52death for our patient population.
03:54In addition, of course,
03:56we have numerous other effective
03:58medication and psychotherapy treatments
03:59for other substance use disorders,
04:02including motivational enhancement,
04:03cognitive behavioral therapy,
04:05contingency management for range
04:06of substance use disorders that
04:08equally have decades of research
04:10supporting their effectiveness.
04:14However, although we've had these
04:16effective treatments for some for
04:18a very long time, we know that
04:19some of them can really save lives.
04:21Only a tiny fraction of patients in the
04:24US receive these effective treatments.
04:26Estimates show that about 1/3 of
04:28patients with opioid use disorder receive
04:30the effect of medication treatments.
04:32The rates are slightly higher in the VA,
04:34but not by too much.
04:35But treatment rates are actually
04:37much lower for many of the other
04:39substance use disorders,
04:40including those that are much
04:41more prevalent than opioid use.
04:43This order, for example,
04:45alcohol treatment rates show that
04:47treatment for those diseases
04:49hover close to 10%.
04:50Can you imagine if only 10% of this
04:53country is getting their diabetes treated,
04:55their cancer treated,
04:56or even their depression treated?
04:59But of course, there's the further
05:00challenge in addiction care.
05:02And it's not just about helping
05:03people get started in treatment.
05:05We also have to help people stay
05:08in their addiction care.
05:09For example,
05:10we know that retention or how long
05:12people stay on their medications
05:14for opioid use disorder hovers
05:15at about 50% at three months,
05:17according to some estimates.
05:19And the corollary to that?
05:20Is that we know overdose rates and
05:23other negative outcomes really
05:24jump after people stop treatments
05:26of these medications,
05:27which these medications only
05:29work when people are taking them.
05:31That's a little bit different for
05:32other psychotherapy treatments,
05:33but this is still an important thing,
05:34I think, to emphasize.
05:38And so the key question I think
05:40for all of us to be thinking about
05:42is why are treatment rates for
05:44these effective therapies so low?
05:46And for me it's helpful to think
05:49about it under a rubric or conceptual
05:51model of three main barriers.
05:53The first related to stigma,
05:56second related to the underlying
05:58illness and symptoms of addiction,
05:59and finally related to limited access,
06:02accessibility and other
06:03system related barriers.
06:05I would say stigma remains
06:07a very large barrier.
06:08At the societal level,
06:09at the healthcare system level,
06:11at the Community level,
06:12but also stigma affecting our patients.
06:15One of the things that we still hear
06:17the most is that it took many of our
06:19patients years to overcome the stigma
06:20in order to feel that they had an
06:22illness that could actually be treated.
06:24But this point also,
06:25I think highlights a specific or
06:27unique challenge with substance
06:28use disorders and that is that
06:30the disease itself makes it hard
06:32for people to seek treatment.
06:33It's the only medical illness
06:36whereby definition,
06:37the person has a hard time cutting
06:39down and engaging in care despite the
06:42negative consequences that they feel.
06:44So by definition,
06:45addiction makes it really hard for a
06:47person who's already struggling to seek care.
06:50And I think for me what that
06:51means is we actually have to make
06:54addiction care much more accessible,
06:55much more appealing than any other illnesses.
06:58And I think at this point we
07:00know that that's not the case.
07:02According to the National
07:03Survey of Drug Use and Health,
07:04or Nista,
07:05an annual survey population
07:06based survey in the US,
07:08these are all reasons that
07:10contribute to why patients themselves
07:12say are barriers that they are
07:14unable to engage in treatment.
07:16And so for the rest of today,
07:18I'll actually spend this time
07:19focusing on the system level changes
07:21that I think are needed to try to
07:23address some of these disparities.
07:27So one challenge when it comes to
07:29our healthcare system and treatment
07:30access is the inadequate number of
07:32trained clinicians across the US,
07:34but just not just the total number
07:36but really how they're distributed.
07:38So this map shows the density of
07:41addiction psychiatrists across
07:42counties in the US and as you can see,
07:44most of it is Gray,
07:46which means that most of the addiction
07:48psychiatrists in this country,
07:49in this country are concentrated in
07:52densely populated or academic centers
07:54like where New Haven and Ann Arbor.
07:57But the vast majority of counties in
07:58the US do not have a single addiction
08:01psychiatrist and there are obviously
08:03many other addiction clinicians,
08:04including other types of
08:06addiction physicians.
08:07But it's clear that not only access
08:09but accessibility to evidence
08:11based addiction care is sorely
08:12lacking for much of the country.
08:15And it's a major challenge in
08:17particular to get treatment to
08:18where our patients actually are.
08:20I would like to also emphasize
08:22though that the limited access for
08:24addiction care is really exacerbated
08:26by the fact that distance has an
08:28outsized effect for our patients.
08:30Prior studies have shown that longer
08:32distance to treatment is a major
08:34factor for patients discontinuing
08:35care and the impact of distance
08:37to treatment is really magnified
08:39in addiction treatment where we're
08:40oftentimes asking our patients
08:42to come on a regular basis,
08:44even as frequently as weekly and
08:46sometimes for a long period of time,
08:48so months or years,
08:49often when it comes to our medication.
08:51Statements.
08:51So when many of our patients are having
08:54to take multiple buses and shuttles
08:55to make it to a single appointment,
08:58which would be challenging for
08:59any of us to engage in care,
09:01let alone when combined with all
09:03the other barriers that I mentioned,
09:04specifically stigma and the symptoms
09:06that they face as part of their addiction.
09:10And so, given these particular
09:12barriers that I've mentioned,
09:14I think there's a clear need to
09:16make treatment more accessible.
09:17And telehealth has long
09:18been a promising tool,
09:20in particular within psychiatry,
09:22well before COVID.
09:23But the question still remains,
09:24can telehealth actually improve
09:26substance use disorder care?
09:28As Doctor Petrakis mentioned,
09:29there's been a small group of us,
09:31including myself, Doctor Moore,
09:33and others who've been working
09:34in the space well before COVID.
09:36For me, it was mostly because I was
09:38lucky enough to have worked with.
09:40Uh, an attendee who had been using
09:42video to deliver buprenorphine
09:44care in the VA before COVID.
09:46And but that's just a sign that we
09:47have long known that our patients
09:49with addiction struggle with
09:51getting access and staying in care.
09:52COVID just exacerbated that,
09:54but it was really never a new problem.
09:58So although there have been dozens of
10:00studies examining the effectiveness of
10:02telehealth interventions for mental health,
10:04and telehealth really had its birth,
10:06I would say, in psychiatric care,
10:08mental health.
10:09And all of these studies by and
10:11large have shown that telehealth
10:13specifically video delivery care,
10:15which is where most of the
10:17studies are focused on.
10:18That's not to say that other
10:20interventions are not effective,
10:21but that's where the historically
10:22the research is focused is no worse
10:25or non inferior with outcomes
10:27compared to in person care.
10:29However,
10:29we've noted that there have been
10:31far fewer studies of telehealth
10:33studies in patients with substance
10:34use disorders and this motivated a
10:37systematic review that I conducted
10:38with colleagues at the University of
10:40California that was published in 2019.
10:43This review actually went on to
10:44inform policy makers for the medical
10:46so the Medicaid program in the
10:48state of California as they were
10:50making decisions on what types of
10:52telehealth for substance use disorders
10:54or services to cover however,
10:56the overall goal of this study.
10:59Just to examine the evidence on
11:01telemedicine deliver treatment interventions.
11:02So not necessarily other augmenting
11:04kind of interventions,
11:06but really treatment specifically for
11:08patients with substance use disorders.
11:10At that point,
11:11we took a very broad inclusion
11:13criteria because we already knew
11:14about the limited number of
11:16studies that were available.
11:17We included studies that examined a broad
11:19range of outcomes including effectiveness,
11:22but also patient level outcomes
11:24like acceptability, satisfaction,
11:25things that were also from
11:28single arm pilot studies.
11:30And we also included studies that were
11:32both retrospective as well as prospective.
11:34Very few of these studies,
11:35by the way were actually RCT's.
11:37In total at that time,
11:39we only found 13 studies meeting
11:41our broad inclusion criteria,
11:423 focused on tobacco treatment,
11:445 on alcohol and five on
11:46opioid use disorders.
11:47And to briefly summarize,
11:48we found across these studies some indicators
11:51of comparable therapeutic alliance,
11:54particularly with psychotherapy
11:55studies and retention and care,
11:58though there were no fully powered studies.
12:00No prospective studies
12:02actually for any medication,
12:04treatments for substance use
12:05disorders and the overall quality
12:07of methods were somewhat limited.
12:11And so from this review,
12:14we noted that there were a number of areas
12:16that really deserved a further research,
12:19actually quite a number of areas
12:20and we kind of summarized them
12:22into into three large groups.
12:24So most of the studies that we
12:26found were again kind of comparing
12:28video telehealth within person care.
12:30And the question is not only are we
12:33interested in whether or not video
12:34telehealth is no worse than in person care,
12:37but can telehealth actually
12:39extend or increase treatment.
12:41And for different sectors of
12:42the populations and for which
12:44patients also effectiveness of
12:45different models of telehealth.
12:47I think as you'll hear today
12:48from Doctor Moore and myself,
12:50you know the telehealth
12:51that we think of right now,
12:52which is really us talking over zoom,
12:54that's really what I hope to be the tip
12:56of the iceberg and hopefully it gives
12:58room for lots of innovations about
13:00delivering care in new ways to our patients.
13:02And lastly,
13:03also the importance of examining patient
13:05and clinician experiences and preferences,
13:07especially when it comes to telehealth
13:09implementation in the real world.
13:13And so I mentioned that
13:15we included 13 studies.
13:17I also want to highlight two
13:19additional studies that are really
13:21fast focused on telehealth in real
13:23world settings and healthcare
13:25systems prior to the pandemic.
13:26And the first study is really a
13:28study published by Hayden Huskamp
13:30and colleagues at Harvard.
13:31They examined trends in the use
13:33of telehealth for both mental
13:35health and substance use disorder
13:37treatment including within patients
13:39or using patients who were in
13:42a private insurance systems.
13:44So this did not include patients
13:45who were on Medicaid or Medicare,
13:46but this was a national sample of
13:48patients with private insurance.
13:50And they found that use of telehealth
13:52for both mental health and substance
13:55use disorders increased quite
13:56substantially from 2010 to 2017.
13:58But the use of substance use disorder care,
14:00as you'll see from this figure,
14:02remained much lower than other
14:04mental healthcare pre COVID.
14:06And so there are likely things
14:08about addiction care.
14:09Either the historical systems
14:10that we're used to that have been
14:13used to deliver addiction care,
14:14the elements of treatment,
14:15for example,
14:16including things like urine
14:17toxicology screens,
14:18or even the treatments themselves,
14:20including group therapy and things like that,
14:22that might have made telehealth
14:24adoption lower even before the pandemic.
14:29So the other study I wanted to
14:31highlight is a study by our team.
14:33We examined telehealth specifically
14:34for opioid use disorder treatment of
14:37buprenorphine pre COVID and the BHA.
14:40In that study, we included veterans who
14:42received any buprenorphine treatment
14:44from fiscal year 2012 through 2019 and
14:46similar we saw overall increases until
14:49health use for buprenorphine treatment.
14:51So that by 2019 about 8% of patients
14:54receiving any buprenorphine for OUD
14:56have received some form of telemedicine.
14:58At least once and in this paper we detailed
15:01also characteristics of patients who
15:03received telehealth versus in person care.
15:05But the thing I want to emphasize most of
15:08all is that in the study pre COVID teller,
15:10buprenorphine looked quite different
15:12than it does now prior to COVID and
15:15specifically prior to the support
15:16Act of 2018 telling buprenorphine
15:18was mostly limited to telehealth
15:20from clinicians in a large clinic,
15:23for example, our large healthcare
15:24systems seeing patients via video who
15:26are presenting in a rural clinic.
15:28And not at home,
15:30which is obviously what a large proportion
15:32of telehealth looks like these days.
15:34This is what we were doing in Ann
15:36Arbor starting about five years ago.
15:38We were early adopters because
15:39well before the pandemic,
15:40we realized that although
15:42our large PA system,
15:43which is located in Ann Arbor, MI,
15:45many of our patients were needing care,
15:48especially those who are presenting in
15:49the HVAC box or the community clinics.
15:51For example,
15:52the one in Flint, MI,
15:53really had no addiction providers and
15:55that's kind of what had motivated us to
15:57start seeing patients via telehealth.
15:59Um, back then.
16:00But again,
16:00they were presenting in a
16:03in a community clinic.
16:05But of course came COVID-19 and
16:08that has radically changed the
16:10way Healthcare is delivered.
16:11I think all of us in the healthcare system
16:14have felt this in numerous different ways,
16:16but it's important to think
16:18about exactly what the impacts
16:19are of specific policy changes,
16:21both at the federal and the state level
16:23and the extent of these policy changes.
16:26I summarized the main changes
16:28here in this slide and I just
16:30wanted to highlight a few.
16:32Many of us are specifically familiar
16:34with the Ryan Hate Act exemption,
16:36a federal law which in the current public
16:40health emergency declared as part of COVID.
16:43It's allowed us to prescribe if you've been
16:45morphine and other controlled medications
16:47without an initial in person visit.
16:49But I want to emphasize that it's also not
16:51just that and in fact potentially that
16:54is really one of the smaller impacts.
16:56But a combination of many different
16:58policy changes at the federal and
17:00state levels that have allowed for
17:02substantial increases in telehealth
17:03use that I'm going to be showing.
17:05And in particular,
17:06I would say,
17:07Sam says allowance of phone visits
17:08for the first time for if you've been
17:11orphine treatment was a big impact.
17:13Also major changes in reimbursement.
17:16So prior to COVID,
17:17CMS or the Center for Medicaid and Medicare,
17:20we're really only allowing
17:22telehealth services to be reimbursed
17:24for rural patients with a very
17:26strict definition of morality.
17:27You were presenting in rural clinics,
17:29so all of these changes were needed to
17:32really decrease barriers to telehealth,
17:34and all of these changes
17:36are currently under debate.
17:39And so given all the policy changes
17:41since the start of the pandemic,
17:43I think it's really important to examine
17:45the impacts on treatment longer term.
17:48And a paper from our team that
17:49was recently published in the
17:51American Journal of Psychiatry,
17:52we examined the impact of the
17:54COVID-19 related changes at the
17:55federal level occurring in March of
17:572020 on buprenorphine treatment in
17:59the entire population of veterans
18:01with opioid use disorder in the VHA,
18:03which is also the largest single
18:05addiction provider in this country.
18:08In this figure,
18:09what you'll see is that the blue
18:10line represents in person visits for
18:13buprenorphine treatment and starting
18:14very quickly after March of 2020,
18:16you see a major shift away from in
18:18person visits towards phone visits
18:20which is represented by the Orange
18:22Line and then video visits the green
18:25line with phone continuing to exceed
18:27video visits by February of 2021.
18:29Overall,
18:30we found that over a very short
18:32period of time,
18:33use of telehealth increase from about 10%
18:36of patients to over 80% for buprenorphine.
18:38Treatment with the majority of
18:40those visits being telephone visits.
18:42And at the same time we found that the
18:44monthly number of patients receiving
18:46buprenorphine actually increased slightly,
18:47but mostly due to patients staying
18:49on treatment longer and not due
18:52to more patients initiating here.
18:54So although COVID has greatly disrupted
18:56care across our healthcare system,
18:58I think what these results suggest is
19:00that telehealth has actually helped
19:01to sustain a crucial treatment for
19:03veterans with opioid use disorder,
19:04which is a particularly vulnerable
19:06population who we could have hypothesized
19:08might have actually been a group
19:09to have seen large drops in care.
19:11A big concern for many of us now
19:13is that as care has begins to shift
19:15or many ways have already shifted
19:17back into person due to clinic
19:19policies and changing COVID-19,
19:21could this actually adversely affect?
19:23Over our patients,
19:24many of whom have only known
19:26treatment through telehealth.
19:29And so that prior study looked at examining
19:32shifts and trends throughout the period
19:35one year before COVID to one year after.
19:38But I think the key question that
19:39many of us also are curious about
19:41is how does tell healthcare actually
19:43compare directly with in person
19:45visits and also phone with video and
19:47examining the trends across COVID,
19:49like what I showed before doesn't actually
19:51answer that question because it's also
19:53confounded by the overall effects of COVID,
19:55which obviously affected our
19:56healthcare delivery and patient use,
19:58so in another study.
20:00That we recently published in
20:01our team led by Doctor Frost,
20:03Madeline Frost at University of Washington.
20:06We compare both the characteristics of
20:08patients who use different treatment
20:09modalities and also looked at the
20:11association between the treatment modality
20:13used and important outcome of retention
20:15on buprenorphine treatment across video,
20:18phone and in person visits.
20:20In a population of veterans with
20:22opioid use disorder in the one
20:25year post COVID and in that study,
20:27we found that in this period 88% of
20:30veterans received buprenorphine for OUD
20:32receive some form of telehealth visits.
20:34However,
20:35there were still important differences
20:37in who received video versus phone versus
20:39in person visits and characteristics
20:41associated with being less likely to
20:43receive telehealth included being younger,
20:45male, black,
20:46Hispanic,
20:47and having comorbid other STD's.
20:50And among patients who received
20:52any telehealth,
20:53those who were much more likely
20:55to receive phone visits were
20:56older black or homeless patients.
20:58And lastly,
20:59and I would say very importantly,
21:01we found that patients who received
21:02any telehealth in this time period
21:04compared to those who received
21:06only in person visits were actually
21:08more likely to be retained at 90
21:10days compared to patients who
21:12only received in person visits.
21:13And this is a very important
21:15outcome for a lot of us who study
21:17opioid use disorder treatment,
21:18really retention on buprenorphine is what we.
21:21Focus on as being a key outcome measure,
21:23which has been associated with
21:25numerous other benefits for patients.
21:29And so similar findings I want to emphasize
21:32has been seen in non veteran populations.
21:35In a recent study by Chris
21:36Jones at the CDC and colleagues,
21:38they examined Medicare fee for
21:40service patients in the US.
21:41They compared a cohort of patients
21:43with opioid use disorder immediately
21:45prior to the pandemic and another
21:47cohort after the start of the pandemic.
21:49And they found that telehealth
21:51for any opioid use disorder care,
21:53which in their study they were not
21:54able to associate the telehealth
21:56visit directly to the medication treatment.
21:57But really.
21:58Encompassing any OU D care,
22:00they found that telehealth visits
22:02increased from 0.6% to 19.6%,
22:04which is a substantial increase,
22:07I would say,
22:07in a very short period of time
22:09where in healthcare not a whole
22:10lot of things change that quickly,
22:12but as of course lower than the
22:14increase that we saw in the VA.
22:16They also found that receipt of any
22:19telehealth for OUD care was associated
22:21with increased retention on medications
22:24and also they found that receipt of
22:26any telehealth was associated with a
22:29decreased risk for overdose related visits.
22:31So patients were less likely to
22:33be seen in the emergency room,
22:34hospitalized,
22:35inpatient related to overdose,
22:38those who had received any telehealth
22:39compared to those who had not.
22:41Again this is these are not randomized
22:43controlled trials but this is the
22:44best that these are the best methods.
22:46That we have at hand,
22:47especially so shortly after the
22:49start of COVID, all of the data,
22:52this data is suggesting that
22:53telehealth could be associated with
22:55improved outcomes for patients
22:56with opioid use disorder.
23:00And so in summary, I think what we have
23:02learned from these early studies and you
23:04know for most folks in the audience,
23:06you know that research typically
23:07takes a long time. So COVID has been
23:09a real challenge for some of us.
23:11What we're starting to get a sense
23:13is that telehealth for opioid use
23:15disorder treatment largely likely
23:16helps sustain a critical treatment
23:18for a very vulnerable and complex
23:20population during a time when much of
23:22healthcare utilization was decreasing.
23:24Other studies have shown that use of
23:26other medical care were decreasing
23:27actually during the same period
23:29of time these early studies.
23:31Also indicate that telehealth was associated
23:33with potentially improved outcomes,
23:34including improved retention and care,
23:37and potentially even lower overdose rates,
23:39though future studies are really
23:41needed to substantiate that.
23:42And likely the causal mechanism
23:44is due to making it easier
23:46for patients to stay in care.
23:48And I want to emphasize these results
23:50because I think a lot of people here
23:52know that there's been tremendous
23:54national efforts and resources put in
23:56to try to combat the overdose epidemic,
23:58both from NIH,
23:59but really kind of at the state
24:00and federal level when it comes
24:02to service provision.
24:03And these data are some of the first to
24:05indicate that a particular intervention
24:07is actually associated with improved
24:09outcomes among this patient population.
24:11And so This is why it's particularly.
24:13Promising.
24:13There's actually very few things that
24:15we can think about to really improve
24:17outcomes in this patient population.
24:21But I don't want to just stop there.
24:24And so the although I've emphasized
24:27I would say some of the potential
24:30positive impacts from telehealth,
24:32I I think that we also have to
24:34emphasize that the this might not be
24:35the same story for a lot of our other
24:38patient populations including other
24:39patients with substance use disorders.
24:41So in a paper that's currently
24:43under review by our team that's
24:45led by Doctor Paramus Swami,
24:47we examined treatment including
24:49both medications and psychotherapy
24:51among all patients with alcohol
24:53use disorders in the VA.
24:54And as you know,
24:56unlike opioid use disorder
24:57where medications aren't average
24:58are the effective treatments
25:00for alcohol use disorder,
25:01both medication and psychotherapy are
25:04effective in approximately similarly so.
25:06So unfortunately,
25:07what we found in this study is
25:08that there was a dramatic drop in
25:10alcohol use disorder treatment,
25:12specifically in psychotherapy treatment
25:13after the start of the pandemic,
25:15which did not normalize one year after.
25:19So in this figure you see we examine
25:20trends in alcohol use disorder care.
25:22So the entire population of veterans
25:24with alcohol use disorder in the VA
25:26receiving care one year pre to one
25:28year post the start of the pandemic.
25:30And what you see is that soon after
25:32the start of the pandemic there was a
25:34huge drop in in person visits but that
25:36was not replaced fully by video and
25:38in particular phone visits which is
25:40what we saw for medications for OUD.
25:42And in the study we actually found
25:44the rates of medication treatment.
25:45So now so our FDA approved
25:48medications like naltrexone.
25:49Increased during the study period.
25:51But because medications are so
25:52much less often used for alcohol
25:54use disorder than psychotherapy,
25:56the increase in medication did not
25:58substantially change the overall
25:59treatment rates for alcohol use disorder,
26:01which fell about 30% after the
26:03start of the pandemic.
26:05And this is a huge increase when
26:06you think about how prevalent AUD
26:08is and how widespread the impacts
26:10of untreated illness.
26:11And I would say this data suggests
26:13that although it was easy for
26:14us to transition to telehealth
26:15for medication treatment,
26:17there may have been substantial
26:18barriers for psychotherapy.
26:20Which also includes both individual
26:21and group psychotherapy.
26:26So in addition to examining
26:28treatment utilization,
26:29I also want to emphasize the importance
26:31of understanding patient experiences
26:32especially with newer models of care.
26:35In a recent study by our team,
26:36we conducted a semi structured
26:38qualitative interviews with over 30
26:40patients with opioid and alcohol use
26:42disorder to better understand the
26:44patient experiences with telehealth.
26:45And we found that experiences vary widely
26:48and we're actually quite unpredictable
26:50emphasizing that there is not just
26:52A1 size fits all model that's needed.
26:55An experience is really dependent on
26:57patient preferences and what was the
26:59actual feasible alternative for each
27:01patient at each point in their care.
27:03So patients overall described
27:05some advantages to telehealth.
27:07One.
27:08An interesting one I wanted to
27:09point out is that some people felt a
27:12decreased feeling of stigma or shame
27:13or being judged for their substance
27:16use disorders when they were seeing
27:17their clinicians remotely and not
27:19having to wait in waiting rooms.
27:21However,
27:21they also noted numerous disadvantages,
27:23including a decreased sense of connection.
27:25Report at times.
27:28And for some people,
27:29and then also numerous ongoing
27:31logistical barriers,
27:32including unreliable Internet services,
27:34limited resources in this
27:37particular population.
27:38So I think overall what we're learning
27:40is that COVID created a really,
27:42I think, bizarre,
27:43interesting experiment that none
27:44of us would have asked for.
27:47But before,
27:47COVID said in there was very
27:49little experience with telehealth,
27:51and that occurred only in early
27:53adopter settings.
27:54However, after the start of COVID,
27:56there was also not much.
27:57Voice,
27:58it felt like there wasn't a
28:00lot of choice for us both as
28:02clinicians or as patients.
28:04But in a world I would hope going forward,
28:07I I hope that we can learn some
28:09of these lessons and then think
28:10about what are the actual options
28:12we can offer to patients.
28:13And hopefully that it could occur in
28:15a hybrid setting where some patients
28:17were really prioritizing for one
28:18treatment modality versus another.
28:20And we're also trying to consider
28:21what are reasonable options that
28:23we want to give our patients.
28:27OK. So I've actually had the luck
28:29and the opportunity to have this
28:31type of talk or conversation with
28:34quite a number of large clinician
28:36audiences across clinicians with
28:38different types of in in different
28:40areas of substance abuse treatment,
28:42substance use disorder treatment.
28:43And it's clear that there are many questions
28:46that clinicians are struggling with now.
28:48So and many of them really are
28:51not necessarily being guided by a
28:53lot of the data, some of the data
28:54that I just put this presented.
28:56And I think what I hear most is that
28:58clinicians experience tremendous
28:59uncertainty about what they should do
29:01or offer to their patients right now.
29:04On the one hand,
29:05some clinicians have seen their no
29:06show rates really drop when they've
29:08offered more flexible appointments,
29:10including via phone or video,
29:12but there's also discomfort.
29:14Sometimes about talking taking
29:15care of patients who we might
29:18have never seen in person.
29:19And that also brings up questions like
29:21how important is the physical exam?
29:23When should a physical exam be done?
29:25How often?
29:26There's also very little in the way
29:28of guidelines to guide general opioid
29:30or other substance use disorder care,
29:32which is a similar challenge we
29:34face in general mental healthcare.
29:36Questions like how often and what's the
29:39utility of your in toxicology screens
29:41comes up in general addiction care,
29:43but these questions are further
29:44magnified and come up even more
29:46often when it comes to telehealth.
29:48And at the same time,
29:49as the pandemic has evolved,
29:50our clinics are evolving again and
29:52there's a feeling that the goal
29:54with a lot of things about the
29:55pandemic is to return to quote.
29:57Normal defined as what
29:59things were like before.
30:01However, some of us are asking,
30:03you know what,
30:03what does that actually mean
30:05and may that actually disrupt
30:06care for some of our patients.
30:08And the hard part though is as things change,
30:11it's hard to really have the data to
30:14understand what should be happening
30:16because we're not using data
30:18necessarily to inform that process.
30:20And lastly,
30:22you know,
30:23I think what I've emphasized are
30:24going to be persistent challenges
30:26for a lot of our patients is that
30:28the logistical barriers around
30:30technology will still persist.
30:31One thing that I didn't mention before
30:33is that in the VA we actually can
30:36give free tablets to our veterans
30:37who need it in order to help them
30:39access a video delivered care.
30:41This is what I believe is probably
30:42one of the only healthcare systems
30:44that we're doing this for.
30:46We also have great technical
30:48assistance for patients to help
30:49them understand how to connect.
30:51Yet despite all of these support services,
30:53obviously we still see challenges
30:55for patients and also disparities
30:57in which patients are able to
30:59use video services with a lot of
31:01our addiction patients.
31:02Only able to access phone based care.
31:06And so at the same time as having all
31:08of these clinically related questions,
31:11I think this is a really interesting
31:13challenge that we have pretty much
31:15the same policy related questions
31:17that are being asked simultaneously
31:18and that are also very challenging.
31:22And I just want to summarize some
31:23of the debates that are happening
31:25at the federal and the state level.
31:26So a lot of us know that the public
31:28health emergency exemption of the
31:30Ryan Hate Act that allowed us to
31:32treat patients with controlled
31:33medications over video telehealth.
31:35Without an initial in person
31:37visit that will likely expire.
31:38Obviously,
31:39as the PHE for the pandemic expires,
31:43there are other pH that we can use,
31:45for example the overdose pH.
31:48However,
31:48that's not a permanent solution
31:49and there needs to be a more
31:52permanent decision on whether or
31:53not an initial in person visit is
31:55required for telehealth for patients
31:57receiving control medications.
31:58And even before COVID to help
32:01support telehealth for OUD,
32:02the support act of 2018 had required the DEA.
32:06To define rules for a special
32:08registration process for telehealth for
32:09addiction care and to define what will
32:11be allowed for those clinics who did that.
32:13But the deadline has now passed
32:16without further steps and I think
32:18a lot of it has to do with this.
32:21These challenges and this uncertainty
32:23about what constitutes good quality
32:25care and the pros and cons of using
32:27telehealth that remain unanswered.
32:29There are other federal
32:30pathways outside of the DA.
32:32For example,
32:33Samsung last month updated
32:35federal rules for OTP's,
32:36or opioid treatment programs,
32:37also known as methadone Clinics,
32:39which has allowed methadone
32:41clinics to continue to start
32:43buprenorphine care via telehealth.
32:44But I think most of us think that the
32:46impacts of those policy changes are
32:47limited because the vast majority of
32:49you've been working here in this country.
32:51Prescribed outside of Otps,
32:52for example,
32:53by those of us in office space settings.
32:56And just as important to these federal
32:59level questions about what's allowed
33:01is also reimbursement questions.
33:03So CMS has said that they're going to
33:06extend telehealth reimbursement of phone
33:07and video visits through the end of 2023,
33:10but that obviously leaves a
33:12lot of uncertainty about what
33:13will happen in the future.
33:15And lastly,
33:15there's so much confusion around the
33:17differences in changing state laws.
33:19So bordering states like Ohio and
33:21Michigan can have different policies
33:23completely and as part of a group at the
33:25American Society of Addiction Medicine.
33:27We recently released a public
33:28policy statement summarizing some
33:30of these key policy questions,
33:32and also provided some overall
33:34recommendations for addiction care.
33:36But again, to emphasize in part,
33:38we do need more data to guide what
33:40good policy should look like.
33:41But in some ways,
33:42these things are being debated
33:43so actively and so quickly,
33:45it's challenging to provide that data.
33:49OK, so I've discussed the
33:51background in prior literature and
33:52what telehealth has looked like.
33:54Now I want to focus a little bit on what I
33:56hope telehealth looks like in the future.
33:58One of the things that I've emphasized
34:00is a real question for the field of
34:02addiction is how do we increase care
34:04at the same time as sustaining or
34:06even improving the quality of care
34:08when it helps to and that should
34:10also help patients stay in care.
34:12And the one of the biggest
34:14worries that comes up,
34:15especially from regulators like
34:16the FDA is telehealth as another
34:20innovative model could increase access,
34:22but does it potentially
34:24result in lower quality care?
34:25I think this is a key question for
34:27all of us to be thinking about.
34:29But I want to remind us that it's
34:30important to think about access
34:32and quality as two separate
34:33independent dimensions.
34:34Because I would like to say that we
34:36could have good quality in person care.
34:37We could have poor quality in personal care,
34:40including pill mills that existed
34:43well before COVID.
34:45And in parallel,
34:46as the overdose epidemic evolves,
34:48the way we deliver care for opioid
34:49use disorder and other substance
34:51use disorders is also evolving.
34:52And the challenges that we need to
34:54find a way to care for very large
34:56complicated population who are primarily
34:58using fentanyl and using multiple substances.
35:01And this means we can't just discontinue
35:03medication treatment just because
35:04someone is using another substance.
35:06And it also means that we have to evolve
35:08the way we deliver all addiction care,
35:09including both in person and telehealth.
35:12For me, I think about telehealth
35:14as part of a fairly flexible.
35:16Model of care delivery
35:17using multiple modalities.
35:19For example,
35:19for our current population of
35:20patients who are primarily using
35:22fentanyl as the induction or the
35:24starting phase of medication
35:25treatment can be more unpredictable.
35:27So although we have newer
35:28induction models for our patients,
35:30there's a real utility I think in a
35:32more flexible treatment model where I
35:34can have you know our clinic staff or
35:36myself give patients multiple phone calls,
35:38especially during times of instability,
35:40but then bring them back in person only
35:42when we feel like they're needed and
35:44using toxicology screens as part of a tool,
35:46but not as.
35:47The only tool we rely on when we
35:50think about how patients are doing.
35:52So as I've shown,
35:53we're starting to have data from studies,
35:56but I as I've also shown,
35:58we need answers to some of these questions,
36:00pragmatic clinical questions
36:01at the same time.
36:03And recently myself and a
36:05colleague in addiction medicine,
36:07physician from family
36:08medicine Doctor Chris Frank,
36:10we developed with support from the
36:12provider clinical support System,
36:14a toolkit geared towards helping
36:16clinicians and policymakers
36:17think about some of these issues.
36:19This is really one example.
36:21It's publicly available.
36:22But what I'm hoping to highlight
36:24is that for our field of academic,
36:27you know,
36:28addiction psychiatrists and faculty members.
36:31This is an area where all this
36:32at the same
36:33time is gathering data.
36:34We also have to be thinking about
36:37helping our clinicians to deliver
36:38the best quality care that they can.
36:41So I know I'm running out of time,
36:42so I'm going to go through
36:43these a little bit faster.
36:45So I think I've also alluded to the
36:47fact that the future of telehealth,
36:49I hope is not telehealth as
36:51it looks like during COVID.
36:52You know, zoom visits with our patients I
36:55think are not rocket science whatsoever.
36:57But we in particular,
36:59I think we can't expect this form
37:01of telehealth to actually increase
37:02treatment and we're having data that's
37:05starting to suggest that, right.
37:06So the VA care that I mentioned
37:08although overall number of patients
37:09increased that was mostly due to.
37:11Patients staying on treatment longer
37:13and not more patients engaging in care.
37:15I think what we need to do in order to
37:17actually get more patients into care.
37:19So to actually help and address
37:21the needs of the 90% of patients
37:22who are non treatment seeking,
37:23not actually seeing addiction
37:25physicians or clinicians like some of
37:28us here is we actually need to think
37:30about the changing the model that we
37:32actually deliver and reach patients.
37:34And so I want to highlight some of
37:36our team's recent work in this.
37:38The first example is a new model of
37:41care that we have piloted called the
37:43INREACH model we've designed this to be.
37:45Implemented in healthcare systems
37:47to proactively identify outreach,
37:50help increase motivation for patients
37:52seen in primary care settings and
37:54then we actually offer them care,
37:56more accessible care delivered
37:57via telehealth.
37:58So it's not just screening and
38:00intervening to increase their motivation,
38:01it's actually giving them care at the
38:05same time and care that's flexible and
38:08accessible and also patient oriented
38:10when it comes to treatment goals and
38:13we're currently studying this model in.
38:15A are A1 funded by NIH AAA and this
38:18is a study that I lead with a close
38:21colleague of mine, Doctor Aaron Bonner,
38:24a clinical psychologist.
38:25And a separate funded trial by an I AAA,
38:28we're taking it one step further
38:30and testing different virtually
38:31delivered interventions in this case
38:33including a patient health portal.
38:35So all of us have used patient health
38:37portals to communicate with our PCP's
38:39and we're really using the patient
38:41health portal in a broader way.
38:43We're actually delivering an intervention,
38:45so a counseling intervention to
38:46try to engage patients using the
38:48patient health portal,
38:49which we know the vast majority of our
38:52patients in our health care systems use
38:54and in a trial with the smart design.
38:57We're really testing different combinations
38:58of engagement and treatment strategies,
39:00stepping up care only for patients who
39:02are needed as an example of like another
39:05kind of a future more innovative model
39:08that really incorporates telehealth,
39:10but not really telehealth
39:11as we've seen it so far.
39:14And lastly,
39:14I'll highlight our most one
39:15of our most recent studies and
39:17this is the study that I Co
39:19lead with Derek doctor, Laura Coughlin,
39:21another clinical psychologist called My Best.
39:24And in this study,
39:25we're really focused on that group of
39:27patients who are our most complex patients,
39:29so patients using Poly substances,
39:31including primarily opioids and stimulants.
39:34And really in this study,
39:35we're using novel methods.
39:36So this is not a clinical trial,
39:38it's a prospective cohort study.
39:40We're trying to understand
39:41their novel drivers,
39:42motivators for why they use substances,
39:45especially risky combinations,
39:46but also why they seek care
39:48in different forms of care.
39:50And the goal of this is to
39:53understand how where can we engage.
39:55Patients who are traditionally not
39:57engaged in care and using novel
39:59behavioral economic constructs
40:00to understand kind of when
40:02patients might be more ready,
40:03less ready,
40:04what are the drivers of their
40:06substance use versus their motivation
40:07to engage in care in order to
40:09inform future interventions that
40:11can be really tailored and targeted
40:13to where patients might be most
40:14ready to engage in treatment?
40:19So I think I've talked a lot about
40:21the various forms of telehealth,
40:23what telehealth looked like before,
40:24what telehealth looks like currently,
40:26and really highlighting all the current
40:28challenges that need a lot of our
40:31expertise in order to inform what hopefully
40:33care will look like in the future.
40:35I think without this work,
40:37what I am afraid of is that care will
40:39actually just go back to what it was
40:41like before without taking advantage of
40:43some of the lessons that we've learned.
40:45Ultimately though, I think that.
40:47What I like to emphasize,
40:49it's not really just about telehealth or
40:50it's not really about telehealth at all,
40:52but really about how do we use telehealth
40:54as a tool or really any tools in
40:57order to try to reach and engage more
40:59patients with substance use disorders,
41:01untreated substance use disorder,
41:03most of whom are obviously going
41:05to be ambivalent about any care,
41:07creating more accessible treatment
41:08options so that we can actually reach
41:12a patient population who are likely
41:14suffering the burden of untreated
41:16substance use disorders and the key.
41:18The unique challenges that they face.
41:21So I'm going to stop there.
41:22I appreciate your time and I'm going
41:24to turn it over actually to as many.
41:26But I also want to say something
41:28really brief about Doctor Moore.
41:30I think Doctor Moore and I met maybe
41:31five or six years ago at a triple AP.
41:33And we've had, you know,
41:36so many conversations at this point,
41:37like philosophical conversations
41:39about telehealth that before COVID
41:41were very philosophical.
41:43And suddenly, you know,
41:44after the start of COVID,
41:45they became not philosophical at all,
41:47I would say.
41:47And I would really highlight his
41:49work as being very innovative.
41:51Practical,
41:51clinical thinking in terms of
41:54how to address policy issues,
41:56but actually how to overcome them and
41:59care for really vulnerable populations.
42:02Starting well before COVID too.
42:04So I'll turn it over.
42:06Thank
42:06you, Allison. That was great.
42:07Umm, David is going to do a brief overview
42:10and then we'll have time for questions.
42:11And there's actually one already in the
42:13chat if you just wanted to take a look
42:15at it. So I'm just going to do very brief.
42:18For those of you who don't know David Moore,
42:19he's one of our own faculty members.
42:22He went to undergrad at
42:24the University of Virginia,
42:25got an MD and PhD from the
42:27University of Pennsylvania.
42:28Then he came to Yale to do his residency.
42:30Those of you probably know him through
42:32his different roles.
42:33Then he was chief resident
42:34in emergency medicine.
42:36And then did a quality and safety fellowship
42:38over here at the VA. He joined the
42:40faculty in 2017. At the same time,
42:42he became director of the Vision
42:44One Telemental Health hub.
42:45And then two years later,
42:47he became director of the Vision
42:49One Clinical Resource hub.
42:51I just want to say that he was
42:53essentially pushed into the deep end
42:55when he joined the faculty here.
42:57And lucky for us,
42:58he was able to swim and navigate the
43:00choppy waters of administration at the VA.
43:02He's one of the few.
43:03There are these clinical resource hubs
43:04throughout the VA he's one of the few.
43:06Psychiatrists, so it's what
43:08started as a telemental health hub,
43:10now became a telehealth hub
43:12that includes primary care,
43:13specialty care like cardiology.
43:15So he has,
43:16I want to echo what Allison said,
43:17he has done sort of an amazing job
43:19of building this from the ground up.
43:21So he's just going to give us a
43:23brief overview of that and then
43:24we'll have some time for questions.
43:25So David?
43:29Thanks as mini and and and thanks
43:32Allison I want to echo while I bring up.
43:35My slides, here we go.
43:39You know how great it's been working
43:41with with Allison and just wanted to
43:44check are my slides sharing right now?
43:47Yes, yeah, they look good. And.
43:55Another thing and I realized there we
43:56are going to bring up, I advance her.
43:59So I can. Move them forward.
44:02This will be very brief and
44:04what it will be is in. Oops.
44:07There we go, an overview of some of the
44:09efforts here via Connecticut and Yale.
44:11And I can't say how thankful I am for
44:15working with Allison over the last
44:17several years starting at AAA P but.
44:22Really a lot of the things that
44:23I'm going to talk about here are
44:25build on some of the foundations
44:27that Allison and and folks like
44:29Allison are are bringing to this
44:31in both research and evaluation.
44:33Also wanted to thank his meanie meanie
44:37who really had the foresight of
44:40bringing telehealth into the mental
44:42health service line of a Connecticut
44:45and has supported me and others at
44:49a Connecticut doing this work so.
44:51I have no conflicts of interest.
44:54And very brief overview.
44:55I'm probably going to skip a few
44:57slides and I apologize for that just so
44:59there's time for question and answer,
45:01answer really the thing that I've
45:03been focused on and others at via
45:06Connecticut have been focused on.
45:08Is this fundamental problem that
45:10there is a mismatch between where?
45:13People live and where often they're
45:16providers live and that this is
45:19really exacerbated in populations
45:21that are most at risk.
45:23Often I'll talk about rural health,
45:26but this is it's not just a problem
45:29of rurality that that there there
45:31is a mismatch and it's something
45:33that telehealth can overcome,
45:35but it's not just telehealth.
45:37So I direct the clinical resource
45:39hub service line at a Connecticut
45:41and it's really a team.
45:43I'm a psychiatrist who's responsible
45:46for medical providers and,
45:48and really I rely on the great.
45:52You know, the great teams at VA,
45:54Connecticut and Yale School of Medicine.
45:57I'm also going to mention something
45:59called the National Mental Health
46:02and Suicide Prevention ECHO.
46:04It really,
46:05that's focused if folks are familiar
46:07with Project Echo on the idea that we
46:09need to train people to use evidence
46:12based practices and that's led by.
46:14Folks like Alan Edens,
46:16all this slide going over this.
46:18And it's focused on on getting rural sites,
46:21but non rural sites as well to
46:23adopt evidence based practices.
46:25And then I'm going to shift gears
46:28just to highlight the national Tele
46:30Nephrology hub and spoke network.
46:32I think one thing that in mental
46:35health is always good to remind
46:37ourselves is that the patients we
46:39work with are much more likely to
46:41die and suffer and have morbidity
46:44from medical conditions than the
46:47general population.
46:49Mental illnesses interact with and
46:53exacerbate medical conditions and
46:55that decrease access to medical
46:57problems is going to be much worse
47:00in the populations we work with.
47:04I'm going to briefly put up this slide.
47:07This is really a thank you slide
47:09acknowledgement slide to a lot of
47:11people in the clinical resource
47:12hub doing substance use work.
47:14The the nephrologist and evaluators
47:16working in the hub and spoke
47:19network and then the ECHO team.
47:21And you'll see a lot of familiar faces here,
47:24but for the sake of time,
47:24I'm going to skip over it.
47:26One other person I want to highlight here
47:28who's not on this slide is Mark Rosen,
47:30who directs the addiction psychiatrist
47:32firm and a Connecticut I worked with.
47:34The conduit,
47:35which is a national implementation
47:38facilitation grant that that
47:39just wrapped up last year,
47:41but he's continuing to study the
47:44implementation of Tele buprenorphine and
47:46really is a leader in this field and I'm
47:50really thankful for his guidance and.
47:53In support as we started our nephrol or our,
47:56excuse me,
47:57our buprenorphine hub.
48:00Really briefly, this is a map
48:02of the clinical resource hub and
48:04what you'll notice is it began
48:06as a mental health hub in blue.
48:08These are the unique veterans
48:10treated each quarter.
48:11It's by fiscal year,
48:12which is a little funny in the VA,
48:13but I think the take away is that
48:16mental health grew but so did primary
48:18care and then specialty medicine
48:20as well and then what and what this
48:23really reflects is especially during
48:25the pandemic that all aspects of care.
48:29Umm experience decreased access,
48:31both from provider turnover but
48:34just from disruption of services.
48:36And it's largely based at VA Connecticut.
48:39And this is a an estimate of the
48:43network of services that are provided
48:46largely through video into the home,
48:48but also video in the clinic,
48:50which is that top graphic.
48:54This is a high level
48:56description of the services.
48:57We call ourselves a hub
48:59or really we're a network.
49:01The majority of services come
49:03from VA Connecticut and they're
49:05supported by Yale faculty.
49:06But we can see is we also bring in
49:09a really high quality providers
49:11from White River Junction, Vt,
49:13Boston and Providence and and even
49:15Maine which often receives our services.
49:18We we we collaborate with
49:20cardiologists up there,
49:21we try to focus on foundational services.
49:24Things like mental health,
49:26primary care,
49:26substance use and substance use,
49:28excuse me,
49:29and and pain and really substance
49:31use is a foundational service in
49:33the VA and and we've really built
49:35that program out intentionally.
49:37But we also really do make an effort
49:39to make sure that there's good access
49:42to specialty medical programs as well,
49:44including renal, cardiology,
49:46liver and surgical services.
49:51Our our substance use team and
49:52actually that I left two people off
49:54accidentally and that was an intentional.
49:56Kristen Serowik, a psychologist,
49:58and Christine Lozano are
49:59both on the Yale faculty.
50:01They're part of this team right now.
50:04I was going to highlight the prescribers
50:07just because just because I think it
50:10complements Doctor Lynn's talk and
50:12and really what they're doing and and
50:14what what the efforts in psychiatry
50:17and prescribing has been has to
50:19try to bring a virtual prescriber.
50:22Into a local substance use team
50:24that substance use care and most
50:26and for especially for the most
50:28complex patients really is inner
50:30professional in both nursing,
50:31social work therapy and schedulers.
50:34And and there's a component of this
50:36that has to be in person and over
50:39the last several years since the
50:41beginning of the pandemic we what
50:43we saw was that there was enormous
50:45turnover of prescribers in substance
50:47use settings and that several sites
50:50actually lost their prescribers.
50:51So the Manchester NH.
50:53System, a large clinic in Worcester,
50:55MA and actually a residential
50:57program in Bedford,
50:58MA.
50:58And so we set up clinics and over
51:01the past two years we've been able
51:04to work with about 400 veterans
51:06and outpatient settings,
51:08three hundreds of of those
51:10receiving medications for opiate
51:11use disorder from our prescribers.
51:14And then about 200 veterans and residential
51:16settings that had lost their prescribers.
51:19And for the sake of time,
51:21I'm going to advance kind of quickly,
51:23but one of the key points is
51:24I think that we do have done a
51:26really good job and actually a
51:28better job of getting people onto
51:30medications for opiate use disorder.
51:32Our prescribers are filling more
51:34Narcan and there are also prescribing
51:37more medications for alcohol use
51:40disorder than the local VA's are
51:42doing and one of the limitations.
51:44Is that it probably needs more
51:46nursing support since we don't
51:47have people on the ground.
51:48There are no addiction
51:50psychiatrists at these sites.
51:55I'm going to briefly touch on this idea that.
51:59Complex care is interprofessional
52:02again, and that if.
52:05The VA's or communities or facilities
52:07are going to implement complex care.
52:10It actually requires a lot of training.
52:13That things like ketamine as ketamine,
52:15that are priorities to implement
52:18at BA's across the country or
52:21facilities across the country,
52:22that they need to have training to do that
52:24from people experienced with it at Yale,
52:27we take that for granted.
52:28So one of the things.
52:31We've been working on in the National
52:33mental health and suicide prevention ECHO
52:34and I'm going to mention everyone involved,
52:36Ellen Edens,
52:37Gabriella Garcia Besado, Toral Surdi,
52:40Brent Moore and Minoxidil Razia,
52:44all on the faculty at Yale,
52:45but also a host of other people have
52:48been working at making practical
52:51simulation based trainings and case based
52:54trainings and really high priority.
52:57Programs and some of this is kind of
52:59case based interactive trainings and
53:02what we call echoes and substance use
53:05mental health and LGBTQ plus mental
53:08health but also things that are more
53:10intensive than interprofessional
53:12focused on ketamine, esketamine,
53:14substance use,
53:15Co occurring liver and substance
53:18use disorders and stimulants and
53:21Co occurring cardiac toxicity and
53:24from those stimulants and.
53:27And and these programs are all
53:30multi hour multiday trainings that
53:33are focused on training providers
53:35not just prescribers but the whole
53:38team at a remote facilities who
53:41don't have that expertise on site.
53:45And then finally,
53:46this is going to be very brief because I'm,
53:48I think we're out of time is this is
53:52actually a really important point is
53:54that while there are you know people
53:56struggle in substance use to get
53:58treatments out and mental health in
53:59general to the patients who need them,
54:02mental health is really way ahead
54:04of the game.
54:05And that during the pandemic specialty
54:07medicine had to really try to build
54:10new programs that never existed.
54:12We we had this in mental health
54:14to a certain extent.
54:15And one of the things that we tried
54:18to do in our clinical resource hub
54:20was get renal care out to veterans
54:23nationally and I want to highlight
54:24this map on the left and and then
54:27I'm probably going to end because
54:28what we did was we,
54:30we we got a grant from the Office
54:33of Rural Health to develop.
54:36A network of nephrology hubs and it's based.
54:40The first two were based at Boston and
54:43Connecticut and went to highlight Ramon
54:45Venezio and and Susan Crowley both.
54:48So Susan Dr.
54:49Crowley is based at Yale and is the
54:51chief of the Nephrology program and
54:54the National Kidney Disease lead and
54:57and what what they've been doing
54:58and we've been trying to figure
55:00out is and when we wouldn't have
55:02done without our initial work in
55:04the treatment of opiate use.
55:06Disorders because there are
55:08actually large parallels in in
55:10implementing complex services.
55:13And what we learned in the
55:15treatment of opioid use disorders
55:16is really applied to renal disease.
55:18And if you look at the map
55:20map on the list, if, if,
55:21if a VA is in the white or light green,
55:25it really lacks access to renal care.
55:28There's either no renal care or very
55:30little renal care and not enough
55:32for the population and it's the
55:34rural sites and those rural sites.
55:36No one had access in the community
55:38and so this network and the and this
55:41grant is focused on implementation.
55:43It's it's a multi,
55:44it's a 5 year program to expand the
55:47Boston and nephrology hubs, but.
55:52Grow new hubs and so. I want to skip
55:56this slide just for the sake of time.
55:59And it's going to be a multi site grant
56:01and then over each year we're going
56:03to add in new hubs starting on the
56:06southeast and out West and and hopefully
56:08develop a network of hubs of doing this.
56:10And I think that's my last slide but you
56:12know hopefully what folks take away is that.
56:14Um at Yale and VA Connecticut
56:16and the VA in general.
56:21There there really has been a lot
56:23of progress and effort and success,
56:26but there is definitely a lot of
56:28more work to do and all hit mute.
56:30And I don't know if there's more questions
56:33and I think we're about out of time.
56:35Thank you, David.