Why don't we go ahead and get started just to make sure everybody knows where they are. This is concurrent paper sessions B. All right, so we're going to have three papers that are going to be presented. I am going to first introduce, I guess the way this is going to go, we usually have very little time for papers, but we only have three papers in this session. So I'm going to give each presenter 12 minutes to present. If they finish early, that's fine. And then there'll be time for questions. There'll be a total of 20 minutes per paper, and then we'll be done, hopefully, within an hour. All right, so the first person who is presenting is Dr. Vinod Rao. Where are you? There you are. Dr. Rao is a board-certified addiction psychiatrist at Mass General Hospital, where he holds the role as a medical director for ambulatory psychiatry, and he's medical director for the West End Clinic. He specializes in treating adult outpatients with substance use disorders and comorbid medical conditions. Dr. Rao earned both his medical degree and PhD, focusing on the neurobiology of biased decision-making from Washington University in St. Louis. He completed his psychiatry residency at MGH McLean and further specialized with a fellowship in addiction psychiatry at Partners Healthcare, now Mass General Brigham. In addition to his clinical practice, he is involved in research projects funded by the FDA and NIH, and he also serves as a physician informaticist at MGH. Welcome. Thank you so much. I appreciate you coming out here on a beautiful Friday afternoon to learn about our explorations in telehealth, stimulant prescriptions for ADHD, and the development of substance use disorders and stimulant use disorders. All right. I have... This doesn't look right. I have no disclosures, and here are some educational objectives. So as we know, during the pandemic there was an increased demand for treatment for ADHD, and online companies have sort of emerged to sort of satisfy that niche. Now, there has been some concern that there have been financial incentives that made it really easy to get some of these stimulants, and because of that, some of these companies have gotten some really public scrutiny. So prior to the pandemic, it was starting to become recognized that telemedicine could be a pretty effective way of delivering psychiatric care in general, and ADHD care in particular. With the pandemic, the Ryan Haight Act was suspended, which, as many of you know, required that for a patient to receive a controlled substance prescription, they had to have met with that prescriber at least one time in person. Now, with that suspension, there had been increase in stimulant prescribing, and what followed was also an increase in substance use and overdose. So that led us to our motivating question. Is telehealth, as opposed to in-person-based prescribing for stimulant medications for ADHD, is that associated with an increased subsequent risk of developing a substance use disorder or a stimulant use disorder? So I'm going to focus carefully on our two main objectives. First, does receiving a stimulant prescription from a provider that the patient has never seen in person by the time of that first stimulant prescription, does that increase the risk of developing a substance or stimulant use disorder? We refer to this as the relationship exposure. In the second aim, we're curious, not so much the whole history of the relationship, but really that first appointment where the patient first gets the stimulant. Is that appointment being a telehealth or in-person appointment, does that determine or impact the risk of developing a substance or a stimulant use disorder? And for this situation, again, it doesn't matter whether the patient has met the provider in person before. We refer to this as the appointment exposure. So just to review, the appointment exposure, we only are keying in on whether the appointment to where the stimulant was started was in-person or telehealth. But for the relationship exposure, we're willing to look further back in time whether the patient has had a in-person visit with the appointment by the time of the first stimulant prescription. So we harvested data from the electronic health record for the Mass General Program health system from the start of the pandemic to March 2020 through August of last year. In our retrospective cohort design, we computed odds ratios to compare the risk of developing substance and stimulant use disorders across these different groups. We then corrected for possible confounders by looking at, by computing logistic regression. And the kinds of confounders we looked at included demographic variables, pre-existing mental health conditions, or other clinical characteristics. Our sample included all patients within the MGB system, age 12 and up, who had an ADHD diagnosis and received a stimulant prescription. We excluded patients, however, who had that ADHD diagnosis or a stimulant prescription prior to the start of the pandemic. We excluded patients whose stimulant prescription was not written by the MGB provider because then we couldn't really know whether those appointments were in person or virtual. And we excluded patients who had a substance use diagnosis excluding nicotine prior to this initiation of the stimulant. So that yielded 7,944 patients. And for the relationship exposure, we found about 91% of the patients had met the provider in person by the time of that first stimulant prescription. The remaining 9% had never met the provider by the time they received that first stimulant. The appointment exposure was pretty close to 50-50 in that half the patients received their first stimulant at an in-person appointment and half the patients received their first prescription at a telehealth appointment. So what do our patients look like? This is a sort of view, and it might be a little hard to see, but basically what we're seeing is that about half of the patients were age 26 and up, about a quarter were young adults and a quarter were minors. A little more than half the patients were female. There was a preponderance of white individuals who received treatment. Some of that reflects who are in New England. Some of that reflects known biases and who receives stimulant treatment for ADHD. About a half of the patients had an anxiety use disorder pre-existing, a little more than a third of the patients had a pre-existing depressive diagnosis. And interestingly, less than 30% of the patients received their first stimulant prescription from a behavioral health specialist. So these findings aren't driven by particular expertise and the overlap of substance use and ADHD in our system. Two-thirds of the prescriptions were provided by a primary care. And so what we found was about 5.5% of the patients eventually developed substance use disorder and about 0.2% of the patients eventually developed a stimulant use disorder. So what do we mean by those outcomes? The stimulant use disorder was characterized by a composite. We looked at the specific ICD-10 codes across billing diagnoses, problem lists, or a positive endorsement for stimulants based on whatever patient-reported outcomes measures we happened to collect in our system. And there's a list of that below. For substance use disorders in general, it was similar. Of course, we ignored nicotine, but we broadened the list of ICD-10 codes we would consider. In addition to that, we also considered patients who received a medication that was FDA-approved for a substance use disorder, things like disulfiram or naltrexone or buprenorphine. So what did we find? For Aim 1, the relationship aim, what we're showing is the raw percentages of patients that eventually developed these use disorders. And basically what you see is that these are largely similar, sorry, largely similar when you compare them up and down. And our odds ratios sort of bore that out, they didn't compare, they didn't differ significantly from unity. When we corrected for potential confounders, we saw the same result. So from this first part, patients who never met the patient, sorry, patients who never met the prescriber by the time they received their first stimulant were not at an increased risk of developing a substance use disorder or a stimulant use disorder, according to our data. Here is a closer look at the logistic regression analysis, and if you look at it, you'll see some familiar patterns. You'll see that it's protective for developing a stimulant use disorder, substance use disorder, would be over the age of 26, whereas you might be at a higher risk of developing a substance use disorder if you were male or if you had a preexisting anxiety or bipolar or depressive diagnosis. Or perhaps relatedly, you were also at a higher risk if your initial prescription was prescribed by a behavioral health specialist. I don't think sitting with me in my clinic drove you to drink. So regarding the second aim, regarding the impact of appointments, if you look at the raw percentages, what you might be seeing is a slightly increased risk if you started your stimulant telehealth appointment, and when you look at the odds ratios, you do sort of see a similar effect. And when you correct for covariates, that effect goes away for substance use disorders specifically. However, for stimulant use disorders, there does remain a significant effect that persists. So from this, we would say that starting stimulants at a telehealth visit was associated with an increased risk of stimulant use disorder specifically. However, the effect size is really small. We're talking about 0.4 percent, and if you compute the number needed to harm, I believe it's 266. So a really small effect size. And if you look at the logistic regression analysis, you get the same sort of flavor as we saw before. So I don't want to throw out the baby with the bathwater here. When appropriate diagnostics and follow-ups are used, telehealth can be a very reasonable treatment modality for ADHD with regard to the development of substance use and stimulant use disorders. Having any in-person relationship with the provider didn't impact the risk of developing a stimulant or substance use disorder after accounting for the various covariates. And we did have a – I do want to acknowledge that we did find an increased risk of developing a substance use disorder – I'm sorry, a stimulant use disorder specifically based on the initial stimulant prescription being provided at a telehealth appointment. There are, of course, limitations in our study. There's a striking lack of racial ethnic diversity. Eighty-one percent of our patients were white. That does reflect an unfortunate pattern in our field. With all EHR studies, there's a limitation in that what we're not capturing is substance use disorder. We're capturing whether the medical system identified the substance use disorder. And so there may exist biases in terms of who is coming in for treatment. And last, and certainly not least, our results were gathered from a non-profit academic hospital system. And it's not clear how exactly this would generalize to for-profit models. So with that, thank you all for your attention. Thank you all for our collaborators. Special shout-out to Amy Yule for being in this audience, and our collaborators at the FDA. And here are some references. Thank you. Obviously, the benefits of reducing barriers have been impressive. I would love to do that study for what it's worth I think the one of the seat the current CEO of cerebral was trained at our program so I'm just wondering if you have shared partnered with the DEA and sharing these results I know you mentioned FDA it seems like they're in a unique position to be making the final decision on this I know they've kicked it down the can down the road for two more years but you know the head of the DEA is a very nice well-meaning person but she's an attorney she doesn't have any medical background I think they're really struggling with this with lack of this kind of data that you guys have so thoughtfully gathered and just wondered if there's any partnership there with them yeah we were very fortunate to have the DEA be involved in our study we were we collaborate with this whole group and we meet with the FDA monthly and so they were able to give us some feedback in our design phase and they have heard a preliminary version of this data as well thank you thanks it's a really interesting project could you say something about why you think that the first visit might be more of risk for people to develop substance disorder the reason we ask that is partly because oh the Ryan hate act basically has up until it was suspended required people to have their first visit in person and that was a big barrier to telemedicine if that goes away obviously you'd have a big impact on a lot of people's care not just for stimulants but also for buprenorphine and other medications I guess I'm wondering do you think that there's anything specific to stimulants about the importance of the first visit based on the mechanisms that you postulate or would it also impact buprenorphine or would that be different yeah so I hesitate a little bit to take this to mean that the first thing that there is a clinically meaningful impact and honestly I don't really know what's so special I about that first appointment we can speculate that it's something about the nature of the connection you can maybe look at some of the nonverbals in a different sort of way that may impact your willingness to prescribe in the way that may be different because people might be I think people are more concerned about diversion of stimulants rather than diversion of say buprenorphine there are maybe not everyone feels that way but I think there is conversation going on at the federal level about very specifically making a carve-out for buprenorphine around some of these regulations we don't know what's going to happen with Brian Haith longer-term I guess last question just in your system do they require a toxicology test before getting a stimulant on the first visit or is that having to do with it so no this is like our system is really broad we have many thousands of people many many clinics and there aren't really consistent standards of care in that regard some clinicians may do that but it's not there's no systematic but you think the results would be reproducible in areas where a stimulant use disorder was more prominent like saying like the Western Northwest or something like that that's a great question it would be difficult to for me to speculate on that but yeah this isn't directly what you talked about but do you do you believe that there may be any changes to the prevalence or the incidence of stimulant use disorders or substance use disorder disorders given the the supply issues with the stimulants adderall by then all these and possible changes in prescribing practices due to physical supply yeah so this is again outside of what we're doing so my speculation yes I think there was a demand for treatment for sometimes I hesitate to call it ADHD but focus issues because some the diagnosis it's unclear to what fidelity that's being made but I think the cat's out of the bag that these tools exist and people want them and if they can't get them people will be creative and so as those supply issues are there I believe it to be associated with an increase in but I don't I don't have data to back up I think in your in the data you showed a what a point four percent absolute risk for developing a stimulant use disorder is that right for for the subset that started on a telehealth appointment yeah could you comment on the relative risk I think it was the relative risk was quite a bit higher if I'm not mistaken right or fivefold increase it more than that the for the other group it was point to to I believe so you're right the relative so for me that's one of the reasons why I don't like the relative risk was driven by so few patients if you it's not available right now but there were two in the control group the the in-person the patient said received it in person only two of 3,000 actually develop a stimulant use disorder so if you were to actually look at the sensitivity analysis on that the the confidence intervals on that would be quite broad yeah it really would be so I think we to really get at that question we can we really need a larger data set thank you so much thank you so much for that so next I'm happy to present dr. Justin Morales Justin Morales is a PGY for psychiatry resident at NYU and his final year of residency training in psychiatry and I happen to know that there's a lot more to dr. Morales than just that so it's a pretty understated introduction but he's going to be talking about low-dose buprenorphine induction for opioid use disorder a post hoc analysis how you guys doing glad to be here and so yeah today I'll be talking about low-dose buprenorphine inductions for opioid use disorder so as far as the disclosures I nor the other authors on this paper have any disclosures so from an educational objective standpoint we want to talk about the efficacy and safety of low-dose buprenorphine induction so be LDB the impact of reducing opioid use managing withdrawal enhancing recovery rates but also assessing the dosing strategies withdrawal symptoms adverse outcomes and see if there's any sort of demographical or regional variance in the outcomes that we saw so given this is the annual addiction conference I don't think we need to go into extensive history as far as opioid epidemic epidemic we're all very aware but more so what I'm going to highlight is the specific trend of the increased of highly potent synthetic opioids like fentanyl that are increasing the overall overdose deaths so there's about 67,000 of 105,000 within one annual year span which accounts for about 64% and so as we're aware there have been a lot of changes in the variety of spectrums of treatment with naloxone being available over the corner x-wave our x-wavers being removed new buprenorphine formulations LAIs implants but obviously I'll be talking about the low-dose buprenorphine induction strategies today so looking at that there is what's called the Bernese method when considering low-dose buprenorphine that is minimizing withdrawal discomfort be via small incremental doses without requiring prior opioid abstinence and not requiring severe opioid withdrawal of these HPSOs which again mostly pertaining to fentanyl typically speaking that's usually in the range of 0.2 milligrams sublingually but obviously again there are various different formulations that buprenorphine can be given but generally speaking we recognize that there's enhancements in the treatment and uptake and retention most of these provided in different clinical settings this can be done in an outpatient setting where they give blister packaging where you know you can instruct patients to take specific spectrums of their medications at specific times and then obviously in the inpatient and also emergency departments and then also with this because you're using small doses of buprenorphine it kind of broadens the populations that you can treat pregnancy had patients who are high on methadone and again fentanyl or HPSO users so briefly just go over methodology you know comprehensive literature search including most of the literature modalities PubMed and base things like that we did use the mesh and entry keyword keywords meaning you know looking at buprenorphine a lot of and or parentheses quotation marks and we the cutoff for our study was May 1st and then we were looking at English and specifically papers that in general articles that we're looking at the induction of low-dose buprenorphine as well as adverse outcomes and case reports and case series were included but one caveat was that while we didn't include a meta-analysis we did review them to ensure that previously included literature was also going to be reviewed for a potential inclusion in our study so this is just a flowchart going through our breakdown of the literature so it's just around 2,000 articles and journals that were that were initially started about 300 were duplicates the initial screening was just looking at the titles and abstracts just to see if they were appropriate from there we excluded about 1,200 out of the roughly 400 those were the ones that were actually read and screened for appropriateness based on the prior inclusion criteria and we got down to 19 that we actually included in our data set so this is a broad strokes of the results that were that I'll be focusing on today so of those 19 there were 46 patients 45 did complete the low-dose induction there was a low-dose initiation there was one that did not there were five cases of overdose in the initial setting of their intakes naturally you know these individuals who were coming in for their opioid treatments did have other substances which we'll talk about it's kind of over there in the lower graph on the left naloxone was used in three of those cases as it pertains to the overdose and precipitative withdrawal was actually did occur in four cases the primary diagnosis was opioid use disorder although heroin misuse and others were occurred and there were several co-administrations of other substances crystal meth cocaine and other amphetamines of clonidine as well again majority of the cases that we were looking at were in North America or though there were that group of five that were out in Europe the use was generally regular daily consistent use there was some a smaller population of habitual use kind of just like on weekends but in a more what could be considered recreational fashion and then looking at the more specific demographics it was roughly even split male-female 26 to 20 and the average age was 44 with the internal quartile range of 20 years so this is looking at the actual dosing and the the way that these the buprenorphine was given so transdermal sublingual buccal and IV and you can see the end under it as well as the averages of each of those so 0.0075 for transdermal 0.5 for sublingual buccal is 0.2 and IV was there was actually only one case but it was 0.1 and on the right you can see the max and the minimum kind of going to the ranges as well so what we were ultimately looking at again is trying to discern you know the induction success rate so 45 of the 46 subjects did have a successful induction one did fail the one that failed was actually a participant that did also have a precipitated withdrawal which we believe was a related factor and I'll discuss a little bit more but again there were a lot of other additional treatments and medications that were provided similar as I imagined that that you may utilize in your own practice methadone clonidine Ativan and you know Zofran a lot of other medications as well listed all there so to kind of you know summarize everything that we've been looking at we recognize that this is a very promising alternative with a high success rate there were some variations again looking at the fact that most of the studies and participants that we were that were included in this were in America but there were some regional elements and then looking at the averages that we were able to see sublingual is 0.5 milligrams buccal is 0.2 and transdermal 0.0075 milligrams but one of the caveats that we did notice when we were looking at it was that for those four cases that did have the precipitated withdrawal they were on the higher end of the spectrum of their respective modality use and so kind of recognizing that going at a slower starting at a lower pace does kind of help prevent that from happening and can you know ultimately to the more successful outcomes but we recognize there were some limitations with the study again this is all retrospective there was no gray literature it was only English-speaking which we believe is why you know most of the literature was in America and because of that that kind of limits the demographics that are going to be able to be utilized and therefore the general generalizability so hoping to get some you know prospective clinical trials in the near future these are the references that I included for this and yeah thank you to everybody in the staff you gave the initial dose sublingual how does that can you say anything about how you proceed once you've given the initial dose can you talk about that so that wasn't one of the focuses that we were looking on we were trying to find the initial ranges that were kind of utilized in these studies so I can't comment on that because the varieties of the papers that that we included had different protocols within themselves I can I can comment a little bit on that actually just published a review article on amazing initiatives and I would say that what you said exactly I think real hard, and it works fine. My question for you, though, was about the four cases of precipitated withdrawal. So there is no generally agreed upon consensus for the definition of precipitated withdrawal. The proposed idea is six points on the cow scale over 45 or 60 minutes. I don't remember exactly. Did you individually review the cases they described as being precipitated withdrawal, or did you just essentially take the initial author's statement that it was precipitated withdrawal as fact? Yeah, so it was actually more of the latter than the former. Some of the papers didn't actually get into extensive detail. Well, they had their own definitions, but to your point, they kind of varied as well. So it was more so the acceptance that they documented it as a withdrawal. Thank you. Yeah, this may not have come up, but was there anything that So, it was something that we looked into specifically to see the involvement. I don't remember commentary as far as actual data that we could present to suggest the involvement, but we did try to make sure that that was included in our understanding of the inclusion and exclusion of the papers. Well, thank you all. I appreciate the opportunity. Last, let's, am I on, I am, y'all can hear me? Okay, last but certainly not least, Precious Obehi-Eseaton, you can pronounce it. Dr. Eseaton is a psychiatry resident at the University of Texas Health Science Center at Houston. She's gaining advanced training in psychiatry and contributing to the mental health field through her work in clinical settings. She is going to be presenting on substance use disorders in hospitalized transgender patients in the United States, a national population-based study. Thank you for coming out to listen to me. So I'll be presenting substance use disorder among hospitalized transgender patients. For disclosures, I do not have disclosures now. So what we aim to study today was the prevalence of various types of substance use disorders in hospitalized transgender adult patients compared to the general hospitalized adult population. And we also wanted to study baseline characteristics of hospitalized transgender patients. So a little background will be that previous studies had showed that there's an increased co-occurrence substance use disorders amongst transgender patients, transgender adults. However, the national population studies are scarce on the prevalence of various types of substance use disorders in hospitalized transgender patients. And that's what we aim to study today. Sorry. So we obtained our data from the National Inpatient Sample data 2016 and 2017. The NIS is the largest hospitalization database in the United States. It is actually created by the Agency for Healthcare Research and Quality. So what this agency sought to do is actually to create evidence-based research so that we can have better quality of healthcare, make it safer, more accessible and equitable within the United States. And the Agency for Healthcare Research and Quality have a database that's called the HCOP database. The HCOP database has several types of database. We have the Kids Inpatient database. We have the Nationwide Emergency Department database. We have the National Readmission database. And we also have the Nationwide Ambulatory Surgery database. And also we have the NIS, which is what we are going to be using to discuss today. It is actually a nationally representative stratified sample of approximately 20% of the U.S. community hospitals. And so when we talk about the community hospitals, we're talking about multispecialty general hospitals, academic centers, and the hospitals that are excluded from these database include federal hospitals, like the VA, like long-term rehabilitation centers, standalone psychiatric facilities. So these hospitals do not give us database into the HCOP database. The hospitalizations are weighted to provide a national estimate because we said it's coming from 20% of community hospitals. And so we weighted, so it's more like representative of the entire U.S. population. In the NIS database, we have like a primary diagnosis, which is the reason why one is hospitalized. And then we can have as much as 39 secondary diagnosis. So what we did was that we had two groups. We had the study population, and then we had the control population. For one to be in the study population means that that has to be like an adult patient that's age 18 and above. And we had to have a diagnosis of transsexualism or personal history of sex reassignment using the ICD-10 codes. Now for this transsexualism, the ICD-10 code was F640. Well, the F640 actually coded for, which is transsexualism, actually coded for gender dysphoric patients and also transgender patients. So we do not have like an ICD-10 code dedicated to just transgender patients. So we made use of that ICD-10 code and primary history of sex reassignment. We also use the chi-squared to compare prevalence of coexisting substance use disorder among adults, hospitalized transgender patient, and the general hospitalized population. We also use this data version 16 to analyze this HCOP database. Now, because one of the beauties of NIS is the fact that you do not have to have an IRB review because it's all depersonalized data. So that makes it a lot easier for you to have your hands on a lot, like a large database. So what we got was that, of course, we have 60.6 million hospitalizations of adults for adult patients contained in the NIS. That's the 2016 and the 2017. Out of these 60.6 million hospitalizations, 9,800 patients were transgender patients. And of the 9,800 patients, majority of them were white, which was 65.6%. And 37.5% were privately insured, which is also the majority, with a mean age of 40 years. So this is what we got as a result. So we found out that hospitalized transgender patient has greater prevalence of nicotine use with a prevalence of 24.3% as compared to the control population of 17.3%. Now, if you see all the substance use disorders that way, so you'll find that they were all increased as compared to the study population, and they were all statistically significant. So, okay, we have a lot, so I don't know if I have to go through all that. So in conclusion, we found that that hospitalized adult transgender patient have an increased prevalence of various substance use disorder compared to the general adult population. And therefore, so they have to be screened when they are hospitalized, taking into consideration that these data that we got were not from standalone psychiatric hospitals, but from general hospitals. So those who screen positive should be provided counseling and resource to seek help. So one of the limitation, one of the strengths of our studies will be that we have like a large sample size. And so when you have a large sample size, it increases the power of your study. And also it's a national and population-based study. And so it's actually representative of the entire population. A limitation of our study will be that it is a retrospective study. And so it cannot establish causality. So you cannot say because you're a transgender patient, it means that you have increased substance. It's going to make you to have increased substance use disorder. Also, it is an administrative database. And so it is actually subjected to coding errors. Another limitation would be that it studies hospitalizations. So it doesn't study individuals. So it means that one individual can have multiple hospitalizations. It also does not have lab values or results and also radiological results. Okay, you expected the alcohol-related disorder to be higher? Yeah, the prevalence, like more like 12%, something like that, just based on other national studies. Okay, well, this is the 2016 and 2017 data, so probably like as the years have gone by, they could have increased, but based on the data that we got, this was the prevalence. hospitalization, right? Yes, so as far as you have like the diagnosis, it doesn't matter if you if it was the primary or the secondary diagnosis. So when they come into the hospital, it didn't matter why they were coming in. As far as they carried that diagnosis, it was captured in the research. Even if it was one of the secondary? Yes, it didn't have to be primary diagnosis. As far as you had that accident, you were included in the So that's one of the limitations of the study. Thank you. Near the very end, you made a comment about we need to be cautious about how we interpret the results and the associations that you found. Can you repeat that? I didn't quite catch what you said. Okay. So what I said was that because it is a retrospective study, it does not, you can not, you can not make a causality out of it. It's more like an association. So you cannot say it's that being transgender makes you have substance use disorder. So you cannot establish causality with a retrospective research, that's what I meant. And a follow-up question, maybe based on reading that you did on this topic, what are some of the hypotheses about the nature and reasons for this kind of association? So I would believe that because majority of our patients, transgender patients, would have gone through years of gender dysphoria. So there could be things like they could have had like anxiety, had depression, they could have used like substance use as a coping mechanism to like help through these years. And also like in the years like dealing with stigma and being scared of coming out to like tell people who you are, that could be something that could also like make them more anxious and make them use substances more like a coping mechanism. No, so when we were running the analysis, it was difficult to establish sex because it had a lot of unfilled colon. So you didn't know if it was male to female transgender or female to male transgender, and so we excluded it. So with that, thank you for coming to concurrent paper session B. You get about 45 minutes back.

psychiatry

addiction

stigma

telehealth

stimulant use disorders

workshop

Alona Balasanova

patient care

language influence

low-dose buprenorphine

ADHD

transgender patients

inclusive language

addiction treatment

healthcare accessibility

ADHD stimulants

substance use disorders

buprenorphine induction

opioid use disorder

prevalence rates

retrospective study