Yale Psychiatry Grand Rounds: "Integration of Addiction Treatment in Mental Health Care"

March 08, 2024

March 8, 2024

"Integration of Addiction Treatment in Mental Health Care"

Srinivas B. Muvvala, MD, MPH, Associate Professor of Psychiatry; Oluwole Jegede, MD, MPH, Assistant Professor of Psychiatry, Yale School of Medicine

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ID: 11442
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00:00Thank you, Doctor O'Malley,
00:02for the kind introduction and all
00:05the mentorship over the years.
00:07It is really a privilege
00:09to be mentored by you.
00:10Today we're going to talk about
00:12integrating integration of addiction
00:14treatments in mental health care.
00:19We have no conflicts of interest
00:21to disclose the learning objectives
00:23for today's talk will identify
00:25the need to integrate substance
00:27use treatment in mental health,
00:29primary care and other medical settings.
00:33We'll discuss the role of psychiatrists
00:35and other clinicians in the treatment
00:37of Co occurring substance use and
00:39mental health disorders And we'll
00:41describe the functioning of an addiction
00:43treatment consultation clinic in a
00:45general psychiatry ambulatory setting.
00:49Before we dive in, let's look
00:51at the big picture of of the
00:53addiction epidemic in in in America.
00:58Based on 20/20 and SDUH data,
01:02138.5 million people aged 12 and
01:04older used alcohol in the past month.
01:0961.6 million people in the
01:10US reported binge shrinking.
01:12In the past month,
01:15178,000 deaths in the US were
01:16due to excessive alcohol use.
01:17That's 500 deaths per day.
01:21Over 2 million people in the
01:23US have opioid use disorder.
01:25close to 200 people die each
01:27day because of opioid overdose.
01:3159.3 million people used
01:33illicit drugs in the past year.
01:34That is 21.4% of our population,
01:3940.3 million people.
01:41That is 14.5% of our population met
01:44criteria for substance use disorders.
01:45So these folks individuals are having
01:48impairments because of the substance use,
01:52but only 2.6 million individuals that
01:55is 6.5% receive any type of treatment
02:01and unfortunately the majority of the
02:03treatment is provided in speciality
02:05substance use treatment centers.
02:10Now think about it.
02:11If this was diabetes or heart disease,
02:14there would be a national outrage
02:17that only only 6.5% are being treated.
02:22So that's one in 10 People
02:25receive any addictions care,
02:26and for those with any mental
02:29illness and substance use disorders,
02:31it's much less. It's 5.7%.
02:37This was an old paper from 2000,
02:40but much relevant even now.
02:42And Doctor Kleber's group has written
02:46this paper talking about the relapse,
02:49comparing the relapse rates of
02:51various chronic conditions.
02:53And contrary to the the popular
02:56belief that substance use
02:57disorders can be treated well,
02:59the relapse rates are similar
03:02or better with treatment
03:06for drug substance use as compared to
03:08diabetes, hypertension, asthma, etcetera.
03:11So these conditions can be treated and one
03:15of the mistakes that we do as psychiatrists,
03:18as providers is we characterize
03:21substance use as acute condition and
03:23we see a patient in the Ed and tell
03:25them to quit drinking as if that would
03:29that would help the patient, right.
03:30So we have to think about it as a chronic
03:33medical illness such as diabetes,
03:35hypertension and asthma,
03:36which would help us work on prevention
03:39and treatment of these conditions.
03:44We've talked about 500 deaths per day.
03:45That's one in five deaths in the
03:48US for population 20 to 49 years.
03:50Despite this magnitude of the problem,
03:53what we see really in addiction treatment
03:56programs is really the tip of the triangle.
03:58We really are focused on treating
04:02the tip of patients with severe
04:04alcohol use disorders and by the
04:06time we see them, it's quite late.
04:10Unhealthy alcohol use is defined as
04:13those with at risk use as well as
04:15those with alcohol use disorder and
04:17NA AAA definition of at risk use
04:19is when men drink greater than 4
04:22drinks per occasion or greater than
04:2414 drinks per week or women drink
04:26greater than 3 drinks per occasion
04:28or greater than 7 drinks per week.
04:30And we know that if we can screen
04:33these patients and do interventions,
04:36we could prevent the development
04:37of alcohol use disorder.
04:39We could also treat mild to moderate
04:42alcohol disease much more effectively
04:45in general psychiatry and primary
04:48care treatment programs before they
04:50come with a much severe disease
04:52to addiction treatment clinics.
04:56This was a study that was done looking
04:58at brief interventions in primary
05:00care settings and even screening.
05:02Brief interventions and referral
05:04to treatments are quite effective
05:06in reducing alcohol use.
05:10I'm going to focus a lot on
05:14opioids and buprenorphine in
05:16this talk to make my point.
05:18Although we've seen that alcohol
05:20use is a much bigger problem,
05:24but considering that there's
05:25the OPR epidemic going on,
05:27I'll focus on specifically
05:30entrepreneur and prescribing
05:31an OPR dues to discuss today.
05:37So you might have seen this graph.
05:40These are the different
05:41phases of the OPR epidemic.
05:43In the late 90s and early 2000s,
05:46there was this prescription OPR epidemic.
05:48Pain was considered the 5th vital
05:50sign and there was this push to
05:52push prescribe pain medications.
05:54It was the quality metrics for many
05:58hospitals to evaluate pain and and
06:00provide pain medications that led
06:02to a pretty significant prescription
06:05opioid epidemic at that time followed
06:08by which by the time we realized and
06:10we started correcting that there's
06:12this huge heroin epidemic and
06:14overdose death rates because of that.
06:16And then we've had very good treatments
06:19come in methadone buprenorphine
06:20that have been effective and public
06:22health campaigns have been effective.
06:24But then we start having these
06:27synthetic opioids like fentanyl and
06:30and fentanyl logs which resulted in
06:33exponential increase in in death rates.
06:36And now there's probably a fourth wave
06:39of Poly substance associated mortality.
06:43This was an old Swedish study and
06:46this is one of the initial studies
06:49with buprenorphine where they
06:52randomized 40 patients,
06:5420 to receive you know detoxification
06:58from bookanorphine within 45 to
07:0160 days and then 20 patients to
07:04to be continued on bookanorphine
07:05treatment for the entire year.
07:09And all the 20 patients in the
07:14detoxification arm dropped out of
07:16treatment within 60 days and majority
07:18of the patients about 80 to 85% of those
07:21in the maintenance stayed in treatment.
07:25After a year of of this you you
07:27don't need complicated statistics
07:29to prove that buprenorphine works
07:31and there's many clinical trials,
07:34randomized clinical trials meta analysis
07:37that showed that buprenorphine is
07:39effective in fact for opioid reduction,
07:41the number needed to treat is 2.
07:43We don't hear those numbers in in a
07:45lot of medications in in practice yet
07:49this was a quote from Doctor Walter
07:52Ling from UCLAI replaced the word
07:57addict with people who use substances.
08:00So we as a society,
08:01society basically don't like people
08:03who use substance to have something
08:05that gets them even a little bit high.
08:07We think people with substance use
08:09disorder should get off drugs by
08:11strenuously hauling upon their bootstraps
08:13so that they should stay off no matter what.
08:17Policy makers and some clinicians continue
08:20to promote detoxification as treatment,
08:22even though detoxification does nothing
08:24to help people stay off of drugs.
08:29This was a study that was
08:31done in Massachusetts.
08:32This was a retrospective cohort
08:34study where they've looked at opioid
08:37overdose survivors being admitted to
08:41hospitals have been brought to the
08:43emergency rooms and unfortunately
08:45when even when they looked at the
08:50charts after year of those who've
08:53had a prior overdose and these
08:55are high risk patients who came
08:57to our facilities for treatment,
08:59only three out of them out of 10
09:02received medications for opioid use
09:04disorder when we know in this study itself,
09:06it showed that methadone would reduce
09:08mortality by 53% and buprenorphine by 37%.
09:13So why is this happening?
09:14There's many factors.
09:18We're not going to go into all of them,
09:19but all of them boil down
09:22to two major, major factors,
09:27stigma and lack of provider education.
09:33This was this was from a
09:35Surgeon General's report, Vivek.
09:36Dr. Vivek Muthi prioritized
09:38integration of addiction treatment
09:40into mainstream mental health,
09:42and he released this report
09:44a couple of years ago.
09:46What he said was traditional
09:48separation of substance use
09:49without treatment from Main St.
09:53Mainstream healthcare has created
09:55obstacles in the individual seek
09:58healthcare for other reasons
10:00than substance use evidence
10:02supports integrated treatments,
10:04improves outcomes,
10:05reduces health disparities and
10:06reduces healthcare costs for
10:08both patients and families.
10:12Our current addiction workforce does
10:14not have the capacity to meet the
10:17existing need for integrated healthcare.
10:20The General Healthcare workforce on the
10:22other hand is under trained to deal
10:24with the substance use related problems.
10:26So we need urgently need a larger,
10:28more diverse workforce to provide a much
10:32more personalized and integrated care.
10:36Now how do we integrate
10:38substance use treatment into into
10:40various healthcare settings?
10:42We could do it at hospital settings,
10:44in patient settings,
10:45emergency room settings,
10:47speciality care settings and
10:49outpatient ambulatory settings.
10:50I'm going to talk about
10:51some work that we did.
10:58Hospital based addiction consultation
10:59centers have come across the country, right.
11:04They've been shown to improve
11:05patient engagement and treatment,
11:07decreased hospital readmissions,
11:08reduce service utilization costs and
11:11improve addiction related outcomes.
11:14They engage with patients while on
11:15the inpatient service, providing
11:16addiction treatment in the hospital,
11:18then connecting them to outpatient care.
11:20There's also bridge clinics that have started
11:23and and there's evidence for them as well.
11:26Although these traditional
11:27traditional clinics are ideal for
11:29patients admitted to the hospital,
11:32it does not engage people with who use
11:35drugs in the communities where they live.
11:38So raising a concern about individuals who
11:40may never interface with the hospital system,
11:47emergency room settings again are great
11:49place to to start initiate treatment.
11:51If we talk about Glenorphine,
11:54this was a study that was done
11:56at Yale and it was done by Doctor
12:00Tanofrio and Doctor Filene's group.
12:03And they've looked at starting
12:05Glenorphine in the Ed versus referring
12:08a patient to outpatient care, right.
12:10And patients are 78%.
12:14There's a 78% chance of patients
12:17connecting to outpatient treatment if
12:19buprenorphine is started in the Ed
12:21when they come in versus only 37% if
12:25they're just referred to treatment.
12:30So emergency room setting is a focus
12:32for starting addiction treatments.
12:33As many individuals interface with
12:36medical care in this setting,
12:39it provides a unique opportunity
12:41to start evidence based treatment
12:44and connecting to the community.
12:46Studies have shown that Ed initiated as
12:48we discussed Ed initiated buprenorphine
12:50improves healthcare outcomes.
12:54But the initiation of buprenorphine
12:56or any addiction treatment in the Ed
12:58requires addressing many challenges and
13:00one of the big thing is capacity building
13:03and connecting with our patient teams.
13:05It it involves educating the ER providers
13:08as well as the community providers
13:10and partnering with programs so that
13:13they could be referred to because they
13:15can't just start buprenorphine and and
13:17not have a facility to refer them to.
13:21This was another study that was
13:25done in that looked at primary
13:27care buprenorphine initiation and
13:29taper versus maintenance treatment
13:31and what it showed is that with
13:34with some medication management
13:39buprenorphine treatment can be provided
13:40in primary care settings without
13:42elaborate counseling and stuff like that.
13:48I was involved with doctor Jennifer
13:52Edelman and Doctor Filene's group in in
13:56doing a randomized in doing a clinical
14:00trial on implementation facilitation
14:02involving four large HIV clinics
14:05in the Northeast US, one at Brown,
14:07one in New York and and two in Connecticut.
14:10And what we have seen is that by a practice
14:16facilitation implementation facilitation,
14:18we can change the preferences of
14:22people in prescribing buprenorphine.
14:25He initially folks wanted to prefer
14:29patients outside for treatment,
14:31but as the study went on
14:33by the maintenance phase,
14:34they were willing to actually prefer to
14:37provide treatment with within their centers.
14:44Looking at Co occurring disorders,
14:46psychiatric and substance use disorders,
14:49we know we we see this all the time.
14:51We know that the relationship
14:53between psychiatric and substance
14:55use disorders is complex.
14:56There's bidirectional causality,
14:58shared genetic risk factors,
15:01they share vulnerabilities and you
15:04know clinical course and treatment
15:06challenges are very similar.
15:09Patients may be self medicating
15:11themselves to deal with the adverse
15:13effects of psychotropic medications.
15:14We know our patients with schizophrenia,
15:16we smoke more cigarettes
15:18than general population
15:23and it could be a a way for of of
15:26social acceptance for for those with
15:28mental illness who are more isolated
15:30to belong to a group of people,
15:32Let's say some people who are using
15:34cannabis or something like that.
15:36Looking at the National Comorbidity Survey,
15:40over 50% of those with psychiatric
15:44conditions have substance use disorders
15:46and over 50% of those with substance use
15:49disorders have psychiatric diagnosis.
15:56This was based on the NSDUH data.
15:59There's about 17 million people with
16:01any mental illness and substance use
16:04disorders together, and about 5.7
16:06million people with substance use,
16:08desires and serious mental illness.
16:12Despite this,
16:16only 5.7%, as we discussed with any
16:19mental illness and substance use Disorder
16:21received treatment for both and 9.3%.
16:24So close to one in 10 people with serious
16:27mental illness and substance use disorder
16:30received treatment for both conditions.
16:36Those with comorbid substance use disorders
16:39and psychiatric conditions have severe,
16:41more severe symptoms, poor outcomes.
16:43There's greater risk of homelessness.
16:46There's greater involvement with law,
16:47law enforcement and this higher utilization,
16:51healthcare utilization costs,
16:53higher mortality and morbidity.
16:57And the treatments have
16:59been traditionally siloed,
17:01which have been the biggest
17:04barrier for integrating care.
17:07We've published an op-ed with
17:09Doctor Petrarchus and Dr. Edens.
17:13This was in 2018 and we talked about
17:15what role should psychiatrists have
17:18in responding to the opioid epidemic.
17:21In summary, we call triple AP and
17:22ask this about how many addiction
17:24psychiatrists are there in the country.
17:25They said around 1100,
17:29we're talking about 25% of our
17:32population using drugs and we have 1100
17:34addiction psychiatrists in this country.
17:36And as a field,
17:38we are looking to the addiction
17:40psychiatrist to provide treatment.
17:42If this was CHF or or or or
17:46some other medical condition,
17:49that would be totally unacceptable.
17:53The significant comorbidity as
17:54we discussed anxiety, depression,
17:56ADHD, psychosis and suicide.
17:59A national survey of psychiatrist
18:02indicates that more than 80% were
18:05uncomfortable with providing office
18:07based burpanorphine treatment.
18:09There was shift of burpanorphine
18:11prescribing to primary care psychiatrist.
18:14We're prescribing 90 moreover 90% of Open
18:18North in 2003 that fell to 32.8% in 2013.
18:25We are skilled, we are knowledgeable,
18:27we've and we are prepared
18:31to treat the condition.
18:32So we have to embrace,
18:34we have to take a leap forward to
18:37embrace addiction treatments and
18:38integrate them into our practices.
18:41This was a recent publication
18:44that looked at buprenorphine
18:47fills by prescribing clinicians.
18:49And if you look at psychiatry as a field,
18:54we have plateau and our buprenorphine
18:57prescribing hasn't increased
18:59from 2003 to 2021,
19:01whereas other medical specialities
19:04have embraced it and they've
19:06owned it and then they've started
19:08treating addiction better.
19:14So there's many challenges
19:17and facilitators to.
19:19So this was a study that I was
19:21looking at national database.
19:23This was actually done by
19:26Health and Human Secretary
19:28Assistance Secretary's office.
19:29So this was the study by the government
19:31looking at insurance databases
19:32and and looking at booking off in
19:35prescriptions based on the field.
19:42You know our our patients see
19:43us as primary care physicians.
19:45They don't go anywhere else,
19:46they don't go to see primary care physicians.
19:48We we are the primary providers for
19:50our patients and they come to us and
19:53they don't talk about substance use.
19:55For us to integrate this treatment into
19:57our practices, it's cost effective
20:00and improves treatment outcomes.
20:02Our mental health providers are under
20:04prepared to treat substance use disorders.
20:07We have limited resources.
20:08I, I, yeah, again, I'm,
20:10I'm so stick to what psychiatrists do.
20:12They're very busy.
20:14They're under resource
20:17what patients tell us.
20:19We want you to treat for both conditions.
20:21We want you you you are our
20:23primary care physicians.
20:24We want you to treat us.
20:26But there's a lot of stigma and the
20:28stigma is just not with our psychiatry
20:30providers but also patients have a
20:31lot of stigma and asking for help.
20:35And there's so many things we
20:37could do from prevention services
20:39to screening and interventions
20:41to medications to harm reduction.
20:44We could take up a
20:46multidisciplinary approach,
20:47involve pharmacists and clinic social
20:51workers and other clinicians into
20:53this focus on preventing infections,
20:55focus on long term care,
20:57recovery supports and cognitive
20:59care with other agencies as well.
21:03This is how we are looking at the
21:05problem is keeping the onus on the
21:08patient and asking them to change.
21:10That has to change and we have to take
21:13a much more interfered approach into
21:15professional approach and we have to
21:18have a much more diverse workforce
21:20to represent who we are treating
21:23and be able to treat our patients.
21:28So what we know is that if we
21:31provide education early on at
21:33the to the medical students,
21:34to the residents,
21:36they're more likely to change
21:38and it is much more difficult
21:40to train established physicians
21:42and other clinicians who've been
21:45practicing for a while.
21:47But we have to provide education
21:49at every level at the medical
21:51student education level,
21:52the graduated medical education
21:54level and at the healthcare
21:56professional education level.
22:04I'm going to talk about some of the
22:07work I did with with many others
22:10in in in providing and improving
22:13education in this in this area as
22:17a result of the gap and the issues
22:19surrounding the prescription opioid
22:20use and provider or prescribing.
22:22In 2016, there was a call from
22:25Office of National Drug Counts
22:27Control and Policy asking US medical
22:30schools to take a pledge to improve
22:33education in chronic pain management
22:36and opioid prescribing
22:39yields. One of the 61 schools who did not
22:44sign the pledge and in fact they took over.
22:48So that we we're just not going to
22:50sign a mere pledge but we we are going
22:52to improve how we provide medical
22:55education in in in opioid prescribing
22:57and addiction treatment to our students.
23:02So we got a doctor Prakas and Dr.
23:06O'Connor got a call from Doctor Schwartz
23:10in the office of education and I am
23:13Doctor Tetra from addiction medicine.
23:16We Co chaired the committee that
23:19overhauled the along with providers
23:22from Pediatrics emergency medicine
23:26students that overhaul the addiction
23:28education in in the medical school and
23:32we were able to establish an addiction
23:34thread that runs through all four
23:36years of the medical school training.
23:44I'm I'm privileged to be a part of the
23:47department which prioritizes addiction
23:49education and and the division of
23:53addiction which has great teachers
23:54and we were able to incorporate
23:57addiction education into every year of
24:00of the psychiatry residency training.
24:02Starting with a preliminary course
24:04to introduce folks to substance use
24:06disorder treatment to a six weeks
24:10addiction psychiatry rotation,
24:11to a core addiction seminar in
24:14the third year and providing A
24:17longitudinal experience by offering
24:19electives in in PG by 4.
24:22Mind you, the requirement,
24:24still a CGME requirement,
24:26is just a one month of inpatient addiction
24:28experience for residency training which
24:30which is not going to help at all.
24:35And just to mention about the fellowship,
24:39we train 10 fellows each year and you know
24:46we've we have different tracks at the VA,
24:48at the APP Foundation and a track,
24:52a new community track at CMSC.
24:55And we've been able to train
24:59hundreds of addiction psychiatrists.
25:01And and looking at the
25:03mission of of the fellowship,
25:05it is just not to train another
25:07addiction like a psychiatrist is going
25:08to see patients which is important,
25:10but also those who will develop
25:14programs and they've done that
25:16nationally and internationally.
25:17After they left the fellowship,
25:20I'll focus on the HERSA track.
25:23We received funding Dr.
25:25Petrarchus and Dr.
25:26Tetra or PIS for that through through HERSA,
25:32which is Health Resources service
25:35Administration to increase
25:36our numbers in the fellowship.
25:38So we've gotten 2 addiction psychiatry
25:40fellows each year and that was
25:43very instrumental in what Doctor
25:44Jagged is going to talk about.
25:46In establishing the Medication
25:47for Addiction Treatment clinic,
25:51we've done some global health work.
25:52This was a collaboration
25:55between Yale School of Medicine,
25:57Yale School of Public Health
25:59and University of Jordan.
26:01And we have been able to collaborate
26:04with the School of Pharmacy and
26:06and medical school there in
26:08establishing a giant training
26:09program for addiction education.
26:13I'll talk a little bit about my
26:15work that we were able to do with
26:18Connecticut Department of Mental Health
26:21and Addiction Services in improving
26:23addiction care across the state.
26:26This started off in 2016 with Doctor
26:28Schadenfeld who was here and we started
26:31off doing this work right before he left.
26:35And Dimas received the
26:37Samsung grant to improve
26:42opioid prescribe, buprenorphine
26:44prescribing in outpatient
26:46treatment programs particularly.
26:48And we focused on 4 high risk
26:51areas which had the highest
26:52overdose rates at that time.
26:57This one is the Wheeler Clinic in New
26:59in Plainville, CMHA in New Britain,
27:03May Call Center in Torrington and
27:05Community Health Resources in Wyndham.
27:08And this later expanded to involve all
27:10local mental health agencies in Connecticut.
27:15And I've been doing this work since 2016.
27:19It's been 80 years now and it
27:22was well received and it involves
27:25consultation and practice facilitation.
27:30Initially we went to treatment programs,
27:34did evaluation and needs assessments.
27:36We met with stakeholders including providers
27:39and leadership at these facilities.
27:42We did practice facilitation which is a
27:46multi competent implementation strategy
27:48used to improve the capacity for practices.
27:53Well, we did academic detailing.
27:54You see these medical representatives
27:56coming in with brochures and pamphlets,
28:00but if we do that with evidence based
28:03practices and to educate the providers
28:05in these facilities of of improving their
28:08capacity to provide opioid use disorder
28:10treatment and other addiction treatment,
28:13we've started learning
28:14collaborators across the state.
28:15These are group learning sessions
28:19primarily aimed at sharing best
28:21practices amongst latest local mental
28:24health agencies in Connecticut.
28:26There's many educational sessions
28:27that we organized including
28:29lectures and case conferences and
28:31I also along with Doctor Jaggeday,
28:33we do many curbside consultations and
28:36mentoring for providers across the state.
28:38Well, this led to this situation
28:42now where all local mental health
28:46agencies provide integrated addiction
28:48treatment and all of them prescribe
28:50open morphine across the state,
28:53some more than the other.
28:54And I really want to thank Dimas leadership,
28:58the Commissioner and Dr.
29:00DK and others for providing
29:02opening the doors and providing
29:04us the opportunity to do so.
29:06This is an example of a Co occurring desires
29:09conference that we do every two weeks.
29:12So any local mental health agency
29:15can submit this form to us and
29:17we meet with the leadership,
29:19the the staff and the providers and
29:24sometimes even the patient to do
29:26a consult where we discuss what's
29:27going on with the patient and how to
29:30integrate substance use treatment with
29:31their psychiatric care and their practice.
29:36This is a sample agenda for
29:39a learning collaborative.
29:40We start off with any updates
29:43on all those data in the state,
29:46any new campaigns in the state.
29:48We have best practices that
29:51each clinic discusses.
29:52We talked about any new
29:54guidelines that came came through.
29:55But also we have people who are
29:57experts in the field come and talk
29:59to the providers in the state.
30:00And in this case it was Doctor Regan
30:02who was talking about pain management
30:03for individuals with opioid use desire.
30:10So we've, I've talked about the work we've
30:12done across the state of Connecticut
30:14and Doctor Jaggedy is going to come
30:16and talk about what we did at CMFC.
30:19It's basically incorporating all
30:22those principles that we have used in
30:25state to start a new program and even
30:27innovative new unique program at CMXCI.
30:30Do want to give a shout out
30:31to Doctor Rihanna Jordan,
30:32who was the first psychiatrist
30:33and who initiated this program,
30:35which Doctor Jaggedy was able
30:37to expand much more.
30:39And he's going to come and talk about,
30:50thank you so much, Doctor Muvala for
30:53being my own consultant and my mentor.
30:58So today I'm going to be talking about
31:00how we've operationalized some of what
31:02Doctor Muvala was talking about at
31:05our Connecticut Mental Health Center.
31:07Over the next 20 minutes or so,
31:09I talked about the conceptualization,
31:11formation, composition,
31:12function and structure of the Medication for
31:16Addition addiction treatment clinic at CMAC.
31:20And I also talked about a preliminary
31:22data that is what's part of
31:25our work that is still ongoing.
31:28In last year 2023,
31:31everyone in the field got very excited when
31:34the X waiver was really abolished by the DEA.
31:38But to be honest with you,
31:39this was just a beginning of
31:44of of the this is more,
31:46there's there's so much more
31:47to just removing the X waiver.
31:50So I was wondering what were the barriers
31:53to prescribing Grouponorphine before
31:55the X waiver was removed and after?
31:57And a common thread I found was that
32:01before the removal of the X waiver,
32:02this is a study by Holly Lanham
32:05and colleagues,
32:05they found that prescribers
32:10wanted support, prescribers want to support,
32:13prescribers wanted mentorship
32:17by addiction professionals,
32:20addiction trained specialists.
32:22And this is one of the main barriers that
32:25was also reported after the X was removed.
32:28This is a study by Christopher Jones
32:31and colleagues and they also had the
32:34same situation where prescribers talked
32:36about how although they were X waiver,
32:39although they didn't need X waivers anymore,
32:42they still needed prescriber,
32:44They still needed addiction professionals,
32:47addiction trained people,
32:51consultants to consult with.
32:56So like I said, I'm going to talk about
32:58how we've tried to operationalize this,
33:00how we try to do this at the CMAC.
33:02You may know that the CMAC is the oldest,
33:05one of the oldest community mental
33:06health centers in the United States,
33:08founded in 1966 with an enduring
33:11collaboration with the Connecticut State
33:13Developmental Health and Addiction Services
33:16and the development psychiatry at Yale.
33:19One of those areas,
33:20the unique areas of collaboration is the
33:23provision of physician staffing through
33:25Yale and other CMS employees through Dimas.
33:29We provide a recovery oriented
33:31mental health care for over 4000
33:34patients every year and we cite as
33:37the hub for trainees in psychiatry,
33:40primary care psychology, nursing,
33:41social work and chaplaincy.
33:43Now having said all that,
33:45we also have a satellite clinic
33:48that's the substance use treatment
33:50unit or otherwise well before called
33:53substance abuse training unit where
33:55Doctor Muvala is the director.
33:57So patients with addiction,
33:59with addiction and substance use disorders,
34:01that is CMHC you know referred to SATU.
34:05You know SATU like I said is a part
34:09of CMHC providing addiction care
34:11for the greater New Haven area,
34:13state-of-the-art services,
34:14evaluation and treatment of our
34:16common substance use disorders,
34:18comprehensive addiction,
34:19psychiatric care,
34:20multitudes in your approach to
34:22addictions education and really
34:24state of the earth research.
34:26However, just thinking about this,
34:28I've talked about two barriers
34:30that have found the foundation
34:32of what we did in at CMHC.
34:34One is I said earlier,
34:36professionals people were ex
34:38wavered who were poised to prescribe
34:40butenorphine but don't have the support,
34:43#2 is just the the distance
34:46from the CMAC to Sachin.
34:49It's another barrier that
34:50we needed to overcome.
34:51So what we then did was not only Co locate
34:56an addiction treatment at 34 Park St.
34:59where CMAC is,
35:01but actually integrated treatment
35:03like a patient is sitting across you.
35:05You're not just going to refer the patient.
35:07The goal we have is that you
35:10actually begin to treat the patient.
35:12So like I said,
35:14before the initiation of the
35:15MET consultation service,
35:17patient had to be referred to Satchu.
35:19This was suboptimal and given the
35:21additional barriers that many of our
35:24patients have social vulnerabilities,
35:25it was just better for us to
35:28eliminate those barriers and bring
35:29the treatment to the patient.
35:33And Doctor Mughala mentioned this
35:35earlier is the MAT Consultation
35:38service actually was mirrored after
35:42the known well researched Inpatient
35:46addiction Consultation service.
35:47This is ambulatory based and will
35:50begin to fill the gap of addiction
35:53services within the very highly evolved
35:55mental health system like CMAC.
35:59Just to give you an idea
36:00of what we're talking about,
36:03this is by no means official,
36:05but it gives you an idea of how the
36:08CMH is set up and how we're fitting
36:10to an already existing system.
36:13Like I said, the Department of Psychiatry
36:15at Yale and the DMS came together to
36:18fund CMHC with the grant the House
36:21of Grants Supported supporting the
36:23Addiction Fellowship and the MET
36:25service well located in the Clinical
36:27Intervention Clinic of the CMAC.
36:29One of the challenges we had was how
36:32to bring in the system, you know,
36:35a service without disrupting
36:37an already well oiled system.
36:39Now as you can see here,
36:43the Clinical Intervention Clinic
36:45was already providing some
36:48consultation services within CMAC.
36:50So it made sense for us to locate
36:53the new service within an already
36:56consultation based service and
36:58you know leveraging the staff,
37:01leveraging the resources.
37:05Now where do we get most
37:06of our consultations from?
37:07They're outpatient teams and
37:09outpatient programs within CMEC.
37:11We get most of our consultations from
37:14the outpatient service from inpatient
37:18and even acute services or MCI with
37:21the Mobile Crisis Intervention Unit.
37:25How about a clinical structure And our teams,
37:28the core staff of the MET clinic was drawn
37:31from the MCI because we're leveraging.
37:33Again, we're leveraging the fact
37:35that staff of the MCI are already
37:38providing some consultation,
37:39one addiction psychiatrist 0.2 FTE or
37:43two addiction psychiatrist 0.1 FTE each.
37:47What certification is addiction
37:49psychiatry or addiction medicine?
37:51One stop nurse which is a 0.2 FT Now I
37:54want to give a shout out to Demas here
37:57because this is actually Demas nurse.
37:59It's like she works at the MCI and
38:02Double S as also the MET clinic nurse.
38:06Talk about, you know, doing more with less.
38:10We now have through the Hassa Grant
38:13and the Department of Psychiatry one
38:16to two addiction psychiatry fellows
38:18who give us 0.1 FTE of their time.
38:21And then as soon as we rolled
38:25out our service became very,
38:26very much attractive to trainees.
38:28And now we have trainees or medical students,
38:33addiction Psychiatric fellows,
38:34even APR and students.
38:40What are some of the objectives of our
38:43MAT consultation clinic to bridge the
38:45gap in the treatment of individuals,
38:47severe mental illness and
38:48substance use disorders?
38:49We are like a bridge clinic but not in the
38:51traditional sense of the bridge clinic.
38:53We're bridging between the
38:55provider and the patient.
38:57And I want to tell you more about
38:58this in a minute is we we take
39:00care of the patient up until
39:02they're stable and then we refer
39:04the patient back to the provider.
39:06So we can take more and
39:10to provide support for physicians
39:11and clinician who may not be
39:14comfortable with or who lacks
39:15the expertise to treat SU DS.
39:17However, our main point like I
39:18said is not just to Co locate.
39:20The program is actually to integrate
39:23the system to integrated treatment so
39:25that the physicians and the clinicians
39:28are actually treating the patients.
39:31And then we want to create
39:32a low barrier system for addiction
39:35treatment using harm reduction model.
39:37We want to foster an Ave.
39:39for patients who may be pre
39:41contemplative about seeking treatment
39:43or who may want information on how
39:45to optimize safety during drug use.
39:48When you come into the clinic,
39:50it doesn't matter what time of the day it is,
39:52There's an addiction psychiatrist
39:53who's willing to talk to you and
39:55that is the point we're making here.
39:56Low barrier system, no door is closed.
39:59Whether we start to or through HCM and C,
40:02we're seeing the patients.
40:05So some of our activities
40:07include academic detailing.
40:09We don't wait for consultations to happen.
40:12We take the consultation to the providers.
40:14You know how you know farmer.
40:16People with farmer come to you
40:18to tell you about medications.
40:19We also go to our colleagues and tell them
40:21about what is doing addictions and xylazine,
40:24what is it, you know,
40:25local data and how to properly
40:28treat the patients.
40:29We provide addiction specific
40:31assessments and evaluation and
40:34comprehensive addiction treatments.
40:36Not only MHC,
40:37we have harm reduction,
40:40motivational interviewing and contingency
40:43management and also education
40:45and training monthly center wide
40:48addiction service addiction seminars,
40:50Yale medical student rotation and physician
40:53and psychiatry residence education.
40:59So how does the consultation work?
41:01Just very briefly,
41:03the referring clinic evaluates
41:05the patient and then we determine
41:09are they able to take care of the
41:10patient or would they want me,
41:12the physician to consult with them.
41:15And based on
41:18based on this four quadrants model,
41:20we're able to determine who is it,
41:24you know that we want to come to the clinic,
41:28the MET clinic in person or who would
41:31be more beneficial for us to just
41:33have a curbside with a physician.
41:36And this is based really on a level
41:39of severity and not necessarily the
41:42diagnosis of the patient to book.
41:44Go back to my previous slide.
41:45So if we determine that a
41:47patient would come to the clinic,
41:49we evaluate the patient,
41:50we institute treatment and we continue
41:52to stabilize the patient and at the
41:54same time the patients that continues
41:56to follow the primary physician
41:58for their mental health needs.
42:01After a while just in concordance
42:05with the model of consultation,
42:09the patient's referred back to the
42:11clinician to continue addiction
42:13treatments at some point.
42:15In addition to that,
42:16we continue ongoing collaboration
42:18and cause curbside consultations.
42:23We developed a very simple
42:25referral form.
42:26This can be filled in 30 seconds.
42:28You know if we decide that the person
42:30was going to come to the clinic,
42:32you just give us the name,
42:33the reason for referral or the
42:35information referring team,
42:36the referring Dr.
42:37and the clinician.
42:38And we empowered the clinician to
42:40make the referral in consultation
42:43with the primary doctor.
42:48Education is part of one of the strongest
42:50things that we do and I'm happy to
42:53announce that even the local colleges,
42:55Southern Connecticut College,
42:57Gateway College, Yale,
42:59New Haven Hospital staff have attended some
43:02of these our monthly center wide seminars.
43:05We have topics ranging from
43:08strengthening systems of care for
43:10people with SU DS in the community,
43:13opioid overdose deaths,
43:14cocaine use disorder, harm reduction,
43:17terminological preferences
43:18and language using addictions,
43:21medical complication of SU DS,
43:23cannabis, alcohol,
43:24health inequities and even emergent
43:26medical drugs in the community.
43:32One of our fellows did this for just what
43:36part of our community responsiveness
43:38during the Fentanyl epidemic which
43:40still ongoing and this is one of the
43:43fires that was developed and we give
43:44this to patients in the community.
43:49Part of what some of what we do a
43:51couple of just a couple of days
43:54ago we had a community fair where
43:56I went with some of the fellows.
43:58These are Doctor Kelly Park, Dr.
44:02Crystal Lo Biozo, Dr.
44:03Terrence to mentor.
44:05We attended this community fair
44:07where we discussed addictions
44:09and we discussed harm reduction.
44:15And then I also, because we now have like
44:18a real cohort of trainees who want to
44:21benefit from what we do at the MEC clinic,
44:24we have a curriculum for them
44:26addictions to captive fellows.
44:27We have about 1:00 to 2:00 a year on
44:29a PGY threes and pgy fours the same
44:32number and up to we have a Yale medical
44:35student rotate with us every six weeks.
44:40But we've had challenges in implementation.
44:44Our first challenge was actually
44:46how to create a system that
44:49integrates seamlessly into an
44:51existing structure without causing
44:53so much disruption, if you will.
44:57We've been able to do this,
44:58however, with the support of CMHC,
45:01the support of the administration.
45:05We built capacity over time
45:07through staff education.
45:08It took time for buying from
45:11clinician administration,
45:12but this was done over time.
45:15So one of the challenges we've also had
45:18is infidelity with the consultation model.
45:22Many, many patients don't
45:23want to leave the clinic.
45:25They want to stay with us, you know,
45:27while they continue to follow
45:28with their primary clinicians.
45:29However, if we continue to do this,
45:32we won't have capacity to go on.
45:33So what we enforce, what we try to
45:36enforce is we get the patient stabilized,
45:39we send them back to the clinicians so
45:41we can get more room for more patients.
45:45A good problem that we've had is being
45:48limited speeds accommodate trainees.
45:49How many trainees want to rotate with us,
45:52but we're trying to expand the
45:54service also with sustainability.
45:57We need addictions like character
45:59fellows and we need the harsher funding
46:02to continue Doctor Petrarchus so we can
46:04continue to have them serve our community.
46:10Over the two years of our
46:12experience at the MSC clinic,
46:14we published this paper with Doctor Muvala,
46:18Doctor John Cahill,
46:19Ryan Wade and Doctor Jordan just to describe
46:22our experience at creating this clinic.
46:25And this was very well received,
46:30just some numbers.
46:31Over the last two years we've seen about
46:35over 1000 distinct clinical encounters,
46:39thankfully zero reported overdose mortality.
46:43Talking about the patients
46:45who come through our clinic,
46:47we get about two to three cup
46:50sides every week and I was looking
46:52at the numbers the other day,
46:5457% of our patients have at least
46:58three consecutive negative urines,
47:00which is I leave you to judge that
47:06as far as diagnosis, we have quite the
47:09psychiatric burden in our patients.
47:11More than 70, maybe 80% of our
47:14patients have in the schizophrenia
47:17spectrum and the same number have
47:21opioids and stimulants are the primary
47:25substance use disorder diagnosis.
47:30Part of my academic interest
47:32is really in around expanding
47:35care disparities, you know,
47:38social discernment of health,
47:39structural determinations
47:40and things of that sort.
47:41And I find this graph very compelling.
47:45This is from Puja Lagisetti 2019.
47:48You would see from here that most
47:51people who are minoritized and
47:56who have public insurance don't
48:00get prescribed Groupanorphine,
48:02but we're trying to reverse that.
48:04And I'm so pleased to show
48:05you this next chart.
48:10You can see most of our patients
48:13are minorities, black and Hispanic.
48:16Most of them are on Medicare and
48:19Medicaid or no insurance at all.
48:21So we're trying to reverse this.
48:23We give it to the community and
48:24we're on help us spread the work.
48:26We're open for work.
48:28If you have anyone, you know, OK,
48:31whatever addictions they may have,
48:33we're here to serve them.
48:38So very briefly, I've told you
48:40that we think we have a model
48:43here that is a consultation model,
48:45not in the hospital but in the
48:48community mental Health Center with
48:51fidelity to the concentration model.
48:53We're trying to integrate our substance
48:55restrictment into general psychiatric
48:57setting and there are no wrong doors.
49:00Whichever way the patient comes in,
49:02they're going to interfere with
49:04an addiction specialist providing
49:05support for our psychiatric providers
49:07who may not be willing or unable
49:10to treat substance use disorders.
49:11And we think that this model is
49:14easily replicable and scalable.
49:17And we do have some
49:19ongoing projects going on.
49:20Doctor Terrence Ambry,
49:22PGY 3 is looking at providers
49:25perspectives of our MHC consultation clinic.
49:28Doctor Terrence Dementia is an
49:30addictions of captive fellow.
49:31He is currently working on the
49:33Qi project and Doctor Anthony
49:35Caldwell was one of our our fellows.
49:37She's now the Gene Spurlock fellow in DC
49:40She was working on education projects
49:44on CM and I'm working on hopefully
49:47expanding the clinic in the next few years.
49:51I want to thank Doctor Jordan who.
49:54This was a pet project this was Fission.
49:57I'm so grateful to her and it's
50:02she has two big shoes to fill.
50:04So anyway that's Doctor Jordan
50:06great with her.
50:07Doctor John Cahill is the director of MCI.
50:11We integrated within his clinic his
50:14program and he's been very supported.
50:17Dr. Fabiola Cruz and Jeremy Welles,
50:20also addiction psychiatrist who work with me,
50:23the MAP Clinic nurse Jennifer
50:25Mastriano shout out to her.
50:27She makes everything running.
50:28She keeps the records.
50:29She she does everything.
50:31Our past fellows Ryan Wade, Fabiola,
50:34Abila Cruz, Ebony Caldwell, Connie Chao,
50:38current fellows Terence Dementa,
50:40Olivetto, Radu and our other trainees.
50:44I'll invite her to thank you.