Thank you. Well, welcome, everyone. Good afternoon. So welcome to the CARES Conference. Today, we're going to talk about incorporating and integrating addiction treatments into general psychiatry settings. I am Srinivas Muvvala. I'm an associate professor of psychiatry at Yale. And I'm the associate program director for the Addiction Psychiatry Fellowship. We have two esteemed guests here, my colleagues, Dr. Rianna Jordan. She's an endowed Barbara Wilson associate professor in the Department of Psychiatry, addiction psychiatrist, and associate professor in the Department of Population Health at New York University, Grassman School of Medicine. She also serves as a pillar co-lead for community engagement at New York Langone's Institute for Excellence in Health Equity. As a principal investigator for the Jordan Wellness Collaborative, she leads a research, education, and clinical program that partners with community members to provide optimal access to evidence-based treatments for racial and ethnic minoritized patients with mental health disorders. Dr. Jordan is dedicated in creating spaces and opportunities for more people of color, especially black women in academia who are vastly underrepresented. She has numerous peer-reviewed publications, has been featured at international conferences, and is the proud recipient of various clinical and research awards. The fundamental message of equity and inclusion has informed her of research, clinical work, and leadership duties at NYU and beyond. So we're thankful for you. Yeah, thanks for being here. You're my mentor, so of course I'll do that. Dr. Oluwole Jegede is an assistant professor of psychiatry at Yale School of Medicine and director of the Medication for Addiction Treatment Consultation Clinic at the Connecticut Mental Health Center. And today, we're going to be talking about that clinic as a model for consultation services in addiction and ambulatory settings. Dr. Jegede obtained his medical degree from College of Medicine, University of Ibadan in Nigeria, Master of Public Health, degree in George Washington University. He completed residency in one Brooklyn interfaith program, where he was a REACH scholar and a program by chief resident. He completed his addiction psychiatry fellowship at Yale School of Medicine. As someone who mentored him, he was one of the most productive fellows with regards to publishing that we've had in the recent times. Oluwole's core research interests include addiction pharmacology with emphasis on opioid use disorders and health disparities in patients with substance use disorders. His work also explores the impact of racism and other social determinants of health in minoritized populations with substance use disorders and co-occurring disorders. Thank you, Dr. Jegede, for joining us. Just some disclosures. I consulted for Alkermes previously. I received some funding from Connecticut Department of Mental Health and Addiction Services and SAMHSA. Dr. Jordan received funding from NIH, 4, and SAMHSA. And Dr. Jegede has no conflicts of interest. So today, we will talk about the role of psychiatrists and other medical staff in the treatment of co-occurring substance use and mental health disorders. We'll discuss ways to integrate substance use disorder treatments in general psychiatry and ambulatory settings. We'll discuss the functioning of Medication for Addiction Treatment Consultation Center in general psychiatry ambulatory setting. And we'll describe, hopefully, we could do a workshop, like a session at the end, to discuss ways in which you guys could integrate addiction treatment at your clinical practices. So this is the agenda for today. Each of us will talk for about 20 minutes, followed by a team-based activity for 30 minutes. So integrating mental health and addiction treatment. Why is this important? Well, in 2020, based on the NSDOH data, 138.5 million people aged 12 and older used alcohol in the past month. 61 million people in the US reported binge drinking in the past month. There were 140,000 deaths in the US due to excessive alcohol use. It was estimated that it's about 380 deaths per day. 2 million people in the US have opioid use disorder. And nearly 190 people die each day in the US because of overdose. 59.3 million people used illicit drugs in the past year. That's over 20% of our population. And 40.3 million people met criteria for substance use disorders. Why are we talking about all this? Despite all this, only 2.6 million people, 2.6 million people, that is 6.5%, receive any treatment. And majority of the treatment is provided in specialty addiction treatment settings or by addiction psychiatrists. Now, if this was to happen with diabetes or cancer, it would be a huge public outcry. But because this is addiction, and because there's a lot of stigma, this is swept under the rug. We don't see a primary care physician telling us, well, I don't want to treat diabetes. And I'll just wait for the endocrinologist to treat the diabetes. But when it comes to addiction, we all wait for the addiction psychiatrist or addiction medicine person to come and treat the addiction, because it's not part of our job. So today's talk is focused on trying to make a case that all primary care physicians and addiction psychiatrists and other specialties should integrate and incorporate addiction treatments into their practices. Only 1 in 10 people with addiction receive care. This is particularly worse with people with any and serious mental illness. Those with any mental illness, 5.7% receive treatment for both substance use disorders and mental health. For the interest of time, I'm just going to focus on opioids and alcohol to fall onto today. But again, this is the case with all drug use. You guys have probably seen this slide many times. But the opioid epidemic started in the 90s with the prescription opioid crisis, then the heroin epidemic, followed by this huge rise in the synthetic opioid use and overdose deaths in the recent years. Despite the statistics that we have seen, this was from a study done in Massachusetts where they've looked at over 17,000 folks with opioid use disorder who survived an opioid overdose. And only 3 out of 10 in them received either methadone or buprenorphine or other forms of treatment. And these are not patients with opioid use disorder who need treatment. These are patients who had had prior overdose. And these are high-risk patients that absolutely need treatment. Only 30% of them received the life-saving care. This was a study that I included just to show the power of the treatments that we have. This is a small Swedish study that was done with a randomized 40 patients, 20 to receive buprenorphine maintenance, and 20 to receive detox for 60 days. And you see that the 20 patients in the detox, all of them dropped out of treatment within 60 days, whereas most of them in the maintenance stayed in treatment after 365 days. And what's unfortunate was 4 of the 20 in the detox arm died, whereas all 20 in the maintenance arm were alive at the end of the study. Now, this is the power of the studies, obviously low. But this has been shown in many, many larger studies over the years. And why is SUD undertreated? There's many reasons. The two key reasons identified are stigma and lack of provider education. This is particularly a problem with minority patients. If one is white, they're more likely to get buprenorphine prescribed. And if they have private insurance, they're more likely to get buprenorphine prescribed as compared to those on Medicaid or no insurance. So there's a lot of disparities associated as well. This is straight from the Surgeon General report. In 2016, Dr. Muthi felt that integration of addiction treatment in primary care and other settings is important, that he dedicated an entire piece for that. Traditional separation of substance use disorder treatment with mainstream health care has created obstacles. Individuals seek health care treatment for reasons other than substance use. And evidence supports integration of treatment, improves outcomes, reduces health disparities, reduces health care costs for both patients and families. And integration is all around a winner in improving quality, effectiveness, and efficiency of health care. And there's so many things that could be done at various different settings. Integration could be done at hospital settings, emergency room settings, specialty care, and outpatient care. We're going to focus a lot on outpatient care here. But just to briefly talk about how addiction treatments can be integrated in other places, we've seen the rise in hospital-based addiction consultation services across the country. These have shown to improve patient engagement in treatment, decrease hospital readmissions, reduce service utilization costs, and improve addiction-related outcomes. Although these engage patients within the inpatient service, providing addiction treatment in the hospital and then connect them to outpatient care, this is only ideal for people who are admitted to the hospital. It does not engage people who use drugs in the communities where they live, thus raising a concern about individuals who may never interface with the inpatient service until there is a major medical concern. Coming to emergency rooms, this study was done at Yale, where if you start buprenorphine treatment in the emergency room versus just referring a patient out, these are patients who came in after an overdose, if you start the buprenorphine in the emergency room, the individual is 78% more likely to connect to care as compared to 37% if you do not. So starting early treatment in the emergency room settings is important. And it could be opioid use disorder treatment or any treatment. This was a study, again, done at Yale, looking at primary care interventions for opioid use disorder, comparing detoxification with maintenance treatments. And it's shown that maintenance treatment with opioid use disorder medications can be safely provided in primary care settings. They compared that with CBT. And it's shown that there's no additional benefit of specialized CBT focused on addictions. And grief counseling at the primary care center, along with buprenorphine, is equal to a specialized treatment center providing CBT. It's estimated that one in five deaths in the United States of patients aged 20 to 49 is because of drinking. And the patients that we see in the addictions treatment center are those with severe alcohol use disorder, which is the tip of the triangle that we're talking about. And we are missing a lot of patients who have mild to moderate alcohol use and those with at-risk use in the gray that we are seeing. NIAAA defines at-risk drinking as men who drink greater than four drinks per occasion or greater than 14 drinks per week, and women who drink greater than three drinks per occasion and greater than seven drinks per week. And there's so much that could be done at the general psychiatry and primary care level if you're able to screen, provide brief intervention, and refer them to treatment or provide the treatment ourselves. I'm just going to talk a little bit about things that we could do as a system. Education is important. So this was in 2016, White House Office of National Drug Counsel and Policy asked for improving addictions-based education across medical schools. And we've done that at Yale, where we integrated addictions education into all four years of the medical school training. And this has to be done at all systems, all levels of training, whether it's a GME education or medical school education or CME activities across training other providers nationally and in the states. So coming to our focus today, what is the role of psychiatrists and other mental health providers? I asked a few years ago, we called AAAP and asked, how many addiction psychiatrists are there in the country? They said there's about 1,100, and we don't know if all of them are practicing, right? And we've talked about 20% of the population having substance use disorders that need treatment. And the 1,100 addiction psychiatrists are not enough to even make a dent into that, right? There's significant co-morbidity with substance use disorders and mental illness, anxiety, depression, ADHD, psychosis, increased suicide rates. And we as psychiatrists are uniquely qualified and skilled to provide integrated mental health care and working under lapse prevention. In 2003, 90% of the buprenorphine prescribing was done by psychiatrists. And in 2013, only around 30% of buprenorphine prescribing is done by psychiatrists. And most of the prescribing has shifted to primary care. It's not a bad thing, but it also shows that as a field, we're sort of giving up on addiction treatment and looking for someone else to take care of that. Integrating addiction treatment has many facilitators and challenges. Our patients come to us for chronic care. They look at us as primary care physicians, as their primary providers. So that provides an opportunity to talk about that screen for addiction. It's cost effective and improves treatment outcomes as we discussed. But the challenges are that mental health providers are underprepared to treat substance use disorders. There's limited resources. And patients do not routinely seek treatment and there's a lot of stigma all around. We know that the relationship between psychiatric and substance use disorders is complex in terms of etiopathology and this shared genetic risk. And there's so much we could do by integrating treatment for both. If you look at the National Comorbidity Survey, more than 50% of those with a lifetime alcohol or substance use disorders also meet criteria for a psychiatric disorder. And over 50% of those with lifetime psychiatric disorder have history of substance use disorder. Despite that, as we discussed, only 5.7% of those with any mental illness receive services for both. And only 9.3% receive services for both serious mental illness and addiction treatment. Silo treatments are barriers to effective outpatient mental health and substance use treatment. And these are the patients who have poorer outcomes, greater risk for homelessness, greater involvement with law enforcement, more frequent inpatient and emergency department visits. So we've focused on improving and integrating addiction treatment in Connecticut. Dr. Jagadeh does it with me. We go to mental health programs across the state of Connecticut and consult with them to improve and incorporate addiction treatments into their facilities. It is done by using various techniques, resources. We meet with the stakeholders, the providers, and the leadership in the program to evaluation and needs assessment. We provide academic detailing and practice facilitation. Academic detailing is where you see pharmacists coming up wearing a nice suit and coming up with these fancy brochures to lure us to prescribe their medications. And when they are doing it with the poor data that they have, why can't we do that with evidence-based treatments that we have? So we try to do that with mental health programs to help them integrate these treatments. We provide consultation, we run learning collaboratives, and various case conferences. There's so many things that we could do in our settings. Prevention treatments, screening as per early intervention, starting medications early, harm reduction approaches, preventing infections, screening for HIV, hep C, involving families, recovery supports, coordinating care across services, legal, child welfare, housing, employment. But we need training. I agree general psychiatrists need help and training to do that and consultation to do that. Instead of silo treatment, we should provide integrated treatment by many professionals with a diverse set of folks who could provide that treatment addressing all aspects of care for our much-needed mental health patients. So we are going to talk about how we try to do that at CMHC, which is the Connecticut Mental Health Center. And Dr. Jordan and Dr. Jagade led this program to incorporate this into our facility and we could use that as an example to integrate addiction treatments to other facilities as well. So I want to thank my colleagues at SATU and CMHC and all my mentors, Dr. Petrakis and Dr. Edens are here. Thank you for your support. I'll pass this on to Dr. Jordan. Perfect. Thank you. Hi guys, I will not be at the podium long because I really do want us to have an opportunity to workshop. But I wanted to start off by saying the power and the people who were here earlier, I'm so glad that you all had the chance to introduce yourselves, but just the power of mentorship and Sri has heard me say this and he hates it, but I need to publicly say, I would not be an addiction psychiatrist if it weren't for him. So when I was a PGY-2 at Yale, I had my rotation in inpatient psychiatry in WS3 and I fell in love with taking care of patients who had substance use disorders, but the compassion and care that he showed to people who had addiction and also co-occurring mental illness was one that really stuck with me for my career. So I say, and I always say this, in front of him and not in front of him, I appreciate him. And what a full circle moment to be presenting with him at AAAP. So Ashe, thank you so much. And mentors are important. And so I'll say that what we do... That's not totally true, but that's pretty exciting. It's true. I create my narrative. It's true. So what I want to do for the next few minutes, and I'll make sure that Dr. Jagadeh has an opportunity to share what he's doing with the MAT Consultation Center now, is just talk about an idea, right? How did I go from a very, I'm not naive, but very bright eyed, optimistic, attending at the time was my first job, to really think about creating this clinic. And one of the things that I wanted to share is a quote from Mae Jemison. She was the first black woman to travel to space. And this really summarizes, I think, the ethos that I have in terms of doing the work that needs to be done for people with addiction. Never be limited by other people's limited imaginations. Never be limited by other people's limited imaginations. If you adopt their attitudes, then the possibility won't exist, because you have already shut it out. So I just want to say that when we think about how do we integrate addiction treatment into whatever setting that we're doing, we cannot be limited by what other people say. Oh, we can't do that. We can't. The bottom line is that people are dying, right? And what are we going to do about it? And we have to think about it. And so that's the spirit and the catalyst that I want us to have today in thinking this through. All right. So the Community Mental Health Center, where we started the Medication Addiction Treatment Consultation Center, is one of the oldest community mental health centers in the United States. I just want you to understand the setting. It has a relationship between not only the Department of Mental Health and Addiction Services in Connecticut, so that's DEMAS, and also the Department of Psychiatry at Yale. So it really is a collaboration. There are state employees at CMHC, but the physicians, the psychiatrists, are all from Yale. I also want you to know that it's one of the premier places in terms of thinking about recovery-oriented mental health services for over 4,000 people, and it's a site of collaboration. So we have psychiatrists. We have advanced nurse practitioners. There are medical students, psychology, nursing, social work. This is a really nice kind of interdisciplinary place. And so what a wonderful environment in terms of my thinking of how can we have a MAT ambulatory services, service within this context. And this is just an outline, and I'm sorry that it's not projecting as nicely as I can see it, but this is an outline of CMHC. So you have here, I mean, I have a big mouth, so I hope you guys can hear me, but the university and the Department of Mental Health and Addiction, Health and Addiction Services really comes together to form and fund the Connecticut Mental Health Center. And then we also have support from grant-supported addiction fellowships that actually provide the physicians who provide the care at MAT. So we have the SAMHSA, the Substance Use and Mental Health Services Administration that funds the REACH program. I'll talk about that in a little bit. We also have the HRSA grant, and that provides the addiction fellows that are actually running the MAT consultation center. Within CMHC, there are three kind of services. We have inpatient services right in the same building. We have ambulatory or outpatient services. And then we have the acute services or mobile clinical intervention unit. And so within the acute services where people can just come in from the community to get care that day, that is where we ended up housing the MAT service. And part of that is because it was the site of least resistance. A lot of the colleagues that were in the ambulatory service said, you know, Ayanna, we love you and you're a great colleague, but like, we can't do another thing. And so we can't add taking care of or adding addiction assessments to the patients that were already taken care of. So because I wasn't attending in the acute services and I had buy-in from the CEO of CMHC, Dr. Czerniak, I decided to house MAT in that area. So one kind of pearl is thinking about where do you have support and where is there facilitation where you can actually have buy-in. And then thinking about, because I was only in the clinic two and a half days a week, I needed other folks who could see, right, who are addiction trained that could see people with serious mental illness. And that's when a colleague, John Cahill, really helped out. So really thinking who's on board to share the load in terms of seeing patients. One thing that's missing from this slide that's important to mention is that we do have a specialty addiction treatment unit called SATU, where Sri really is the medical director. And so SATU is an outpatient clinic that sees just people, just people with addiction. We know that is a false chasm, but the point is, is that we see a lot of people, but we were trying to form a clinic where folks who had serious mental illness and also co-occurring addiction didn't have to go to two different places, right? So when we're thinking about our patients who already have vulnerabilities in the social determinants of health, who are already dealing with discrimination, difficulty getting to their appointments, may be disorganized, we didn't want to introduce another unconscious barrier for them to get their addiction treatment. So although we had SATU, which is great for people who primarily had substance use disorders, we wanted to have a place where people were already coming for their mental health treatment where they could also be seen for their substance use disorder. Does that make sense? I think that's really important to say. So within the acute services program, we started the MAT service. And I really wanted it to be a consultation center because it had to be understood that we're not here to take the patient over, that this is a shared responsibility. We will start medication for addiction treatment for opiate use disorder, alcohol use disorder, and tobacco use disorder, but the expectation is that this patient will rotate off or go back to you for maintenance of care. And that was really difficult because they really tried to say, oh, Dr. Jordan will see this patient. Dr. Jordan will see this patient. Dr. Jordan. Dr. Jordan is only in the clinic two and a half days a week now, so I can't see all these patients. What I need you all to do is work with me on starting the plan and then agreeing to continue it. And that, again, is another pearl because there was some tension with colleagues in terms of what are the expectations of what a consultation center can do. So that was important. All right. And like I said, in a few minutes we'll talk about the details of that. One of the things that is important, and Sheree kind of covered it in the beginning, is realizing that hospital-based addiction consultation actually does improve outcomes, right? So we know that ACS, or hospital-based addiction consultation, has shown to improve patient engagement, decrease hospital readmissions, reduce service utilization costs, and improve health outcomes. ACS patients, so people who have been able to benefit from this program while on the inpatient service, are more likely to be connected to outpatient care. What we don't understand is, if we are able to intervene on the level before they get to an inpatient service, are those health outcomes enduring? And so this is the first kind of ambulatory service that we know of, and I would really love to hear about what you guys are doing in terms of looking at an ambulatory addiction consultation already housed within a serious mental illness clinic, all right? And so what we're going to be doing is tracking, and Dr. Jegadeh is quite prolific, seeing are the long-term effects of having an intervention in an ambulatory service? So the point is that we wanted to fill a gap in terms of offering these services for people who are already engaging with the mental health service, but were not able to, for a host of reasons, go to the addiction specialty treatment center that we have. What happened before this MAT consultation service? What was going on before the consultation service? Unfortunately, we were adding an extra ask on a very vulnerable population. So before the initiation of MAT, people who had SMI and also had addiction had to go to the satellite treatment center, SATU, which is not in the same place. It still lies in the city of New Haven, but it is in a different neighborhood, right? And so they would have to either have another appointment or they would have to find transportation to go. Like, it was not easy. Also, unfortunately, what we found is that their mental illness was being treated, right? Their schizophrenia or their bipolar disorder with psychotic features, but unfortunately, there wasn't optimal treatment for their substance use disorders. So we would have patients that would come in. Oftentimes, they would visibly be under the influence of some substance, and yet they were not receiving the treatment that they needed. So it was clear that this was an opportunity to do something. So the creation of the clinic. Let's just say not everyone was enthusiastic about treating patients with co-occurring disorders. And so really thinking about what is your why, right? Why are you doing the work that you do? It's hard, y'all. It is so hard to take care of patients, but also take care of patients when you don't have the collective support of your colleagues. So I think one of the take-home points that I need to relay to you all is think about who can support you in efforts of integrating addiction treatment in whatever part of the hospital system you're working, because it's not easy. And so I had to have one-on-one meetings with the CEO of CMHC to think about why is this beneficial not just to patients, but to the organization as a whole. I also made myself available to every single psychiatrist within the Connecticut Mental Health Center to let them know, I'm not adding another, you know, thing to your workload, but I'm trying to optimize health outcomes for our patients. And at the end of the day, that's what people genuinely want, is to see our patients thrive. And once they saw that we would not only help them along the way, we wouldn't just dump them and have this additional task, but also provide education, and Dr. Jagade will talk about this, within the MAT Consultation Center, there are actually, we implemented a monthly educational service that talked about things like medications for opiate use disorder, medications for alcohol use disorder, medications for tobacco use disorder, how do you do SBIRT, so that they understood that they were not in this alone. So make yourself available to your colleagues so that they can see the shared vision of what you're doing. And then finally, we wanted to really create as low of a barrier system as possible. So we didn't make it have a very robust assessment that they had to do for an hour and a half to be able to see patients. It really is, the MAT Consultation Center is open during these hours, Wednesday from this time to this time. And if you have anyone that you think qualified, they can come. And we rotated those qualifications in terms of who could start. So that is kind of how we created the clinic. I'm going to turn it over to Dr. Jagade, who is going to talk about where the clinic is now. I do want to give a shout out to Dr. Fabiola, because she was one of the REACH Fellows and also HRSA Fellows. REACH stands for Recognizing and Eliminating Disparities in Addiction through Culturally Informed Healthcare. That's a program that we developed in collaboration with AAAP that said, hey, not only do we need to take care of people with mental illness and addiction, but there has to be a special focus on patients from racial and ethnic minoritized backgrounds, because we know that they face overwhelming barriers. And so we train medical students, residents, nurse practitioners, and physician assistants in ways to take care of racial and ethnic minoritized programs. Dr. Petrakis has been wonderful in allowing those REACH Fellows to work in the MAT Consultation Clinic. So having funding so that we can have physicians and other providers to do this work is key. So I want you guys to begin to think about what can I do at my institution, and we'll talk about that. Okay, Dr. Jagade, also a REACH Fellow, I'm just saying, and there are REACH Fellows in the audience. So I'm so happy you guys are here. Thank you. Thank you, Ayanna. As Dr. Jagade gets ready to talk, I wanted to emphasize that although the consultation center is to provide consultation for the treatment of patients, we know what it's really for is to provide consultation for the psychiatrist in the clinic. And that's the goal, is for them to be more and more familiar with the treatment so that they could take up. And the hope is eventually we will not need the MAT Clinic as much as we do now. We're not quite there yet, but that's the hope. Yeah, for sure. Wow. What a treat. Coming after Dr. Jordan and Dr. Movala, you can imagine being a mentee for these two people. It's just amazing what they've impacted in my life personally. And thank you so much for coming, although the word Jagade is my name. And I'll just go through this real quick in the next couple of minutes. So I guess the first place to start would be to discuss this survey of barriers and facilitators amongst people, amongst prescribers who are actually ex-waiver to prescribe buprenorphine. We all talk about how we don't have enough ex-waiver practitioners, and we don't. But that's only where the story begins. There's also the fact that people who are ex-waiver to prescribe buprenorphine, they also want mentorship, they want support. Even though they have the DE, ex-waiver, they need us as addiction practitioners, addiction professionals to support them. And this is what we're talking about today. So the consultation clinic staff was drawn from the MCI, which Dr. Jordan has talked about. We have one addiction physician, which is 0.2 full-time employee with broad certification in addiction psychiatry or addiction medicine, i.e. me. And one staff nurse who was also employed by the state of Connecticut. So it talks about the collaboration between the state and the university. One staff nurse, also 0.2 full-time employee. And the really fabulous addiction psychiatry fellows who, without whom we wouldn't have been able to do this, I have them sitting here. We're going to shout out to them in a minute. One to two a year who provide us 0.1 full-time employee. And we also have, within a couple of months that Dr. Jordan started this program, we became very attractive to trainees. We have medical students now. Every six weeks, we have medical students from Yale. We have, of course, the fellows. And last year, we actually had a PGY-4 who did a block of rotation with us for six months. So we want to believe we're doing something for them to want to come to us. And what are the services that we offer? We accept patients, refer us from the ambulatory teams. We provide addiction-specific consultation for staff. We're very big on that. We give substance use disorder assessment and evaluation, comprehensive addiction treatments, and academic detailing from what Dr. Movala has told us. And we're really, really big on this. This is one of our core, the core things that we do is providing sort of education, centerwide education for staff and also for the community. And now I'll show this in a few slides. When Dr. Jordan was doing this, she was seeing patients one half day a week. You know, that was when the clinic was really there. But I've also tried to expand that a little bit, and I added a second day, yay. So we have about eight hours a week now for the actual clinic visits. But really what happens is when I get referrals, and I just want to show this consultation flow, and one of the things we'll talk about today is you design your own consultation flow. How do you want your consultation service to run? So when I get referrals from my colleagues, what we do is in this, through email, it could be a call. It could just be curbside. One or two things could happen. The patient could see us in clinic, or it could just be like just collaborating with them over a secure email. So if the patients are going to come to us in clinic, then it would be one of these two clinic days where we do all this stuff that we already talked about, motivational and interviewing. And we are also, Dr. Jordan, we're planning to start contingency management, which one of our fellows already wrote up a proposal to start. And we, of course, initiate addiction psychopharmacology, including propranorphine inductions and maintenance. And of course, we do a lot of specific public awareness programs for overdose prevention and reducing stigma in the community. And like Dr. Jordan said, the idea is for us to do more with little. We have to maintain the consultation system, sort of understand that this is a consultation. We don't want to own the patient. We want to sort of get the patient stabilized, whatever stabilization is, stabilize them and send them back to their team so we can have more patients in the clinic. And we did this, we have a referral form now. When I took over from Dr. Jordan, the idea, it was more of a physician-based referral system. So we thought about how to improve that consultation service. So we included the clinician-based system, where clinicians, you know, LCSWs, the RNs that take care of the patient, can in fact refer patients to us, but of course with consultation with the physicians. So we designed this very simple form and because we, you know, distributed this to our colleagues and they could just send this to us with consultations and we consult with them and determine which way to go for the patient. And I get asked this a lot. People just assumed this was an opioid use disorder clinic and we told them, well, this is addiction consultation service. It didn't matter what type of addiction the patient had, we would still see them. And in addition to that, we also did clinic and home induction for Suboxone. We do micro-inductions and back-up maintenance, of course, for Suboxone and academic detailing. We provide a lot of providers, staff education, center-wide addiction training, and we're a training hub for fellows, residents, and medical students. And we also designed a little bit of a curriculum for trainees, addiction psychiatry fellows, psychiatry residents, and EMD students. We have a little curriculum that we sort of designed to be able to show that we're actually teaching them something. In our addiction seminar series, our fellows do this. We go through, every month we do addiction psychiatry addiction seminars. That has actually attracted a lot of people from the community. Now we have some local colleges who are now turning to attend our seminar series. Yes, from Quinnipiac, from Southern State, Connecticut. They come into, even from Yale New Haven Hospital. We now have people tuning in via Zoom to attend our seminar series. We go through strengthening of systems of care, opioid overdose deaths, cocaine use disorders, harm reduction, health inequities and addiction. Am I good on time? Okay, good. Health inequities and addiction, overview of emerging drugs, and we just go through all this seminar series, which will benefit to the community. One of our fellows, Dr. Fabiola, designed this last year. This was our community response to the opioid epidemic, the fentanyl epidemic in New Haven community. It was so bad that we needed to do something. She designed this. This is one of the ways that we have been responsible, you know, responsive, I would say, to the needs of our community. Implementation challenges. Other than taking over from Dr. Jordan, which was very challenging, our main challenge was to create a service that would seamlessly integrate into an existing system, so that we're not putting a burden on the community, on our center. So our capacity was built over time through staff education. It took some time for us to obtain the buying from clinicians and administrators. And also, one thing I found is, even though we tell patients they understand from the start that this is a consultation service, they don't want to leave us. They want to stay with the service, even when they are now, if you will, stable. They don't want to just go back to their initial doctor. Of course, they go there for their psychiatric needs, but they want to keep coming back to us. But our service is such that we can't contain everybody who wants to stay with us. So that's been a challenge, but that's a good challenge, I guess. So I want to present a very brief bio data from the patients we have right now, which is about 849. And we find that we have 59.2% of our patients are aged between 18 to 40. 67.3% are males, 44.9% are black African-Americans, 93.9% are single, and over 30% are unstable housing or homeless. And 85% are unemployed. And we have all our patients are either Medicare, Medicaid, or no insurance. You can already see just from this that it is a really pile of data. You can already see that, you know, the social determinants of health here. We are dealing with people who indeed have challenges, you know, social and economic challenges, to put it very mildly. And also just the sheer burden of psychiatric comorbidity that our patients have, and also the substance use comorbidity. We see here, of course, all our patients have psychiatric comorbidities, 61.2% in the schizophrenia spectrum, 26.5% with major depressive disorder. And we see there the top substance use disorders are opioids, stimulants, and alcohol that are referred to us. And in addition to that, we also, over the course of about 10 months, we saw that 45% of our patients went to the ED for any course, all course ED presentation. But we're glad that we didn't record any overdose fatalities. And three months retention was about 57%. And abstinence, which we defined as three consecutive negative urines, about 57%. And initial drug positivity rates, I just want to highlight here fentanyl, about 26.5%. Initially, our presentation had positive fentanyl. And in summary, we think this is an innovative model of addiction treatment in ambulatory settings. We think our model integrates substance use disorder treatment into general psychiatric setting. And we have tried to maintain a fidelity to consultation, harm reduction, and open access models. We provide support for psychiatric providers who may not be willing or unable to treat substance use disorders. And we think that this model is likely easy to replicate and scalable. Very importantly, I want to mention a few people here. John Cahill, which Dr. Jordan mentioned, he's the director of the MCI. He's been very helpful. He's also addiction medicine trained. He's been very helpful in supporting me and supporting the work that we do. Dr. Fabiola Billacruz was my fellow last year. She's incredible. If you haven't met her, don't worry, you will very soon. She's just absolutely awesome. Ryan Wade was in my fellowship class. He was actually the first fellow, yes, with Dr. Jordan. He's awesome. He's still in Connecticut. He's local. Connie Schall is addiction medicine, I'm sorry, internal medicine and psychiatry trained. And Connie's there, Connie? Yeah, that's Connie Schall. She works with me right now. And Dr. Ebony Caldwell, just absolutely fabulous, Ebony Caldwell. Also REAP Scholar. Also REAP Scholar. And she's also one of the guys responsible for those data that I presented. And Jennifer Mastriano is not here. She's the RN. She's just, I am blessed to have Jennifer Mastriano. I don't know what I'd do without her. And thank you for coming. We really appreciate your time. Alright, so great job. So what we're going to do now is ask you all to, Shree, you want to pass these out. We ask you to please fill this out because we want to use this data. You don't have to put your name or anything like that. But just please complete it. And then after you complete it, then we'll come around and collect it for sure. Amazing. You're most welcome. Some REAP Scholars coming in. You are most welcome, gentlemen. And so after you complete this, what we're going to do is just break off in groups of six. I'll ask you guys to count to six. And I'm just going to ask a few questions that I want you all to discuss. So fill this out first. We'll give you about five minutes. We're doing great on time. We promise we will have you done by three o'clock to enjoy the sunshine, go by the pool, whatever you need to do. Great. Thank you so much. We just were walking around and great discussions. I'm sorry that we had to cut this off, but hopefully we could discuss as a large group of what we've talked about in the small groups. Yeah, so we're just going to come back. You guys don't have to move. But I do want to hear a couple of groups that I went to. I heard some really interesting discussions around how could this even work? What are some of the challenges that exist at the individual settings? And I want to push us to think about, yes, all of those challenges exist. That is true. But how can we start? Right. We have to start given the challenge. And so I want to maybe hear from Myra's group around what are some of the things that you guys came up with? What did you discuss? So a lot of the conversation was around the different. Yes, so a lot of the conversation was around our different settings and the challenges that exist in our different settings, whether it's being in a hospital system that doesn't have a lot of really any outpatient psychiatric services in general. So that's one model for a hospital system, whether it's being primarily in a VA based system where you have a lot of resources, but then your parallel system in the community is lacking those resources. And how do you bridge it? Being in a low resource system in terms of just the area where you're practicing, being the only waivered or utilizing your waiver, a physician utilizing their waiver within like a four hour radius and not having other colleagues that you can collaborate, having a long wait list on your own. So even just the time to develop a consultation service doesn't exist or the staffing. So these are some of the challenges that came up in our group. And ways that we thought about thinking about sort of adapting to our individual settings included the use of trainees, right? So in that low resource area where you're the only physician, how and there are interested trainees who are willing to jump in and be a part. How can you utilize that as a way to expand your workforce? Having the incorporation of a multidisciplinary team, whether that's an addiction counselor, LCSW or someone that works along with you so that when you finally get that one physician that's a few miles away from you, you wavered and you get their patients stabilized, then they have an addiction counselor that is available to them for support. So they feel less alone. And then the burden is less on that primary prescriber physician who started the consultation service. Other things that we said that could be ways to get around our challenges. That was excellent. Excellent. Thank you so much. Group three. All right. What about group five? What did you all talk about? Group five. And I know y'all, so don't make me call on you. Ellen, you know I was coming to you. I love you, girl. Yes. Let me see if I can do a good job talking about this. First, I am so happy to be here. I'm so happy to see everybody. Okay. So we had a really nice discussion. Also very varied in where we're coming from. VA, private practice. Some of us have paper charts still, which was interesting. Hospital systems. And so, you know, I think one thing that we really, one thing that came up was just having some leadership support. So, and we know to just, you met with a lot of people. And so meeting with people and building that I think sounds like something that could overcome some of the challenges. We also talked about a care manager or a navigator to help direct patients to different levels of care. I personally talked a lot about this stepped care approach that I've learned a lot in the VA system. And that a lot of times there's an idea that addictions require specialty care. So just changing the model around, which is the point of the consultation. But that feels like an educational thing and sometimes more of an academic detailing, meeting with people one-on-one to try and change that shift. We also talked some about how peer support specialists could potentially help. But acknowledge too that that requires institutional provision and a lot of supervision and boundaries and structures and that kind of thing when you do incorporate peer supports. But that that could be helpful. We specifically noted clinical pharmacists that have been really helpful in many of our settings. And I think that's something that we talked about. They cannot prescribe buprenorphine for opiate use disorder. But short of that, they often can help initiate just one, you know, the plan. They can take over the plan once a plan is enacted and do a lot of that education for the patient and for other providers. Daryl mentioned starting small. So start low, go slow. You know, and just do what you can. If all you can do is focus on alcohol use disorder pharmacotherapy, you kind of start there. So I thought that that was a really good suggestion as well. And then I think, you know, to your point, Ayana, that idea that like I can't do one more thing and just trying to, I'm putting, these are my words, but trying to be more like a reporter or somebody who's doing a politician who basically changes the narrative and says together we're going to increase quality and health care of patients and just stop talking about that conversation of I'm asking you to do more with something else. We talked about. Amazing. Thank you so much. That was awesome. I'm feeling really reinvigorated by this group. So I really thank you guys for your ideas. I didn't even think about the role of peer support specialist as another champion and also pharmacy, such a huge and under-resourced, you know, staff member. So I love that. Is there anybody else that is pressing to share what their group learned? I think the point about this academic detailing and re- like switching the narrative in terms of thinking about it's about saving lives, it's about helping people improve their quality of life and how can we do this. And if I can't have a robust consultation center, maybe I just see for one hour a week people who have tobacco use disorder and I can start there, right? We don't want to totally forget there are other substances that we can address and so if you don't have an ex-waiver, you can think about alcohol use disorder, cocaine use disorder, contingency management. So thank you for that. Other folks, is there anybody else pressing? Yeah, please, I'd love to hear from this group. Is this group four? We're four. Group four, represent. Some of the other things, I mean, I don't want to repeat much but a lot were the physical structures. So there's a lot of different practices here but a lot of people feeling a complete disconnect either from disconnect to addiction services or other general psych services. I think the biggest implementation problem was leadership, big leadership vacuum. Not feeling like, folks feel like they could not bring that up to leadership or really have conversations to build a more productive conversation at all. Yeah. That's a big one. Yeah. I appreciate that and I think not having, like feeling isolated and feeling like there's no one on board to lead is a huge issue and that's where I think plugging into professional societies and really reaching out to AAAP and saying like, listen, I am in Boogaloo, Illinois and I need help and I need support and I think what we've seen from COVID-19 is that we don't have to be physically in the same place to get support and plugging into our professional organizations to say, can I just get supervision? I'm going to literally put my shackle up, metaphorically, literally and start seeing these patients and can I get supervision and AAAP can provide that via telehealth. So I love that. It's like, how do you get support when you feel alone and when you may not have support from the leadership? All right, guys. Just one more thing. That came up here as well, use of technology and that's done so well at the VA and we should harness the use of technology in providing telehealth and one of the things we see in Connecticut at remote places is that there's no psychiatrists or medical providers to start buprenorphine or treatments but what if we could provide consultation from let's say a nearby city to the towns that would change a lot of different things. We want to let you go on time. I know there's a question but I just want to get a video that has people saying addiction treatment works. This is for, I'm going to hashtag it, AAAP 2022. You guys are amazing. A beautiful group, truly. And so on the count of three, wait, wait, wait. All right, on the count of three, what are we saying? Addiction treatment works, guys. Ready? Wait. One, two, three. Addiction treatment works. Amazing. Yes, yes. Dr. Jordan, just to reinforce your last point, AAAP and ADPERT, the network of program directors has been collaborating on ways to improve virtual consulting for education programs. We've got a workshop tomorrow afternoon on that and a poster about that. So come and see me. I think it's the afternoon workshop slot. Dr. Balsanova and myself and Dr. Renner. Perfect. Thank you. Good job.

Medication for Addiction Treatment Consultation Center

General psychiatry ambulatory setting

Co-occurring substance use and mental health disorders

Comprehensive addiction treatments

Equity and inclusion in healthcare

Stigma

Provider education

Telehealth

Collaboration