Yale Psychiatry Grand Rounds: January 13, 2023

Transcript

• 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.