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

March 08, 2024

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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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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.