So thank you all for hanging in there even though the weather is very nice outside now. So I am Alexis Ripfoe, I'm from the University of Colorado School of Medicine. And should we go ahead and we can briefly have each person just give a brief introduction and then at the front of each slide when we do our full sections, we can give all the titles. But also in this workshop is Dr. Ilona Balsanova from University of Nebraska, Dr. Michael Dawes from Boston University Medical Center, and Dr. John Renner also from Boston University. So our workshop today is titled No Wrong Door, Engaging the Difficult to Engage Patient. None of us have any conflicts of interest nor disclosures. And our learning objectives. So at the conclusion we hope you can have a review of some of the current epidemiological trends about substance use disorders, prevalence and treatment rates, examine how to assess social determinants of mental health in the clinical interview and identify their relevance to assessment and treatment using clinical cases, and outline some motivational interviewing skills that can be incorporated into clinical practice in order to engage even the more difficult to engage patients. So you may wonder why we're starting with epidemiology, but I think a point we want to drive home, I think it's easy, and I was actually thinking of this as I walked over, you know, easy for us frequently within medicine to put the onus on our patients of well they're the one being difficult. And you could even probably flip that some more, but I think to try to remember that our patients are always presenting in the context of their experience, their life experience, you know, their cultural background, racial, ethnic, as well as many generations of experience. And so I'll highlight some of the trends that we see both across age groups and ethnicities for substance use disorders before we launch into some, maybe some skills that we can all think about using to engage patients. So much of this, and this is not new news, right, 16% of the population in 2021 met criteria for a substance use disorder, and of those, 12.6% endorsed symptoms consistent with alcohol use disorder, and 10.3% or 24 million of a drug use disorder. So as we know, these are very prevalent disorders. However, if you start to look by race and ethnicity, as at least as collected in the NSDUH data, we see that there is disproportionately more individuals in these minorities that endorse substance use disorder in the past year than in many of the others. And as you can see at the bottom of the slide is the label, so you can know what each one stands for. So the AIAN, so American Indian or Alaska Native, 27.6% met criteria for a substance use disorder, multiracial, 25.9%, and NHOPI for Native Hawaiian or other Pacific Islander, 20.7%. So compared to the national average of 16%, that becomes a pretty substantial increase, so just to keep in mind. And as we are well aware, while there are many, many people that meet criteria for a substance use disorder, very, very few people, if any, receive actual care for it. And so when only 12% by this measure of data in 2019 get some sort of treatment, obviously there's a lot of ways that we're missing the mark of engaging our patients in care. I actually would be very curious, I didn't have a chance to even see if I could find this, so if anyone has previously found this, to know how they ask these questions, because my feeling is the patients or individuals that report and say they don't feel they need any treatment, that's probably not quite true, right? How is the question asked and do they explore in many more ways why they're ambivalent and what factors are contributing to that? Similarly, if only 2% say they need treatment but they don't make an effort, what are the barriers that they're coming up against that are influencing not making an effort and is it actually that they just don't think they could or would be able to make an effort given the other constraints of their life? And so we're left with 1% that say they need treatment and they made an effort to get treatment. Still doesn't even actually say, you know, that 1% did not all necessarily get treatment. Among those that are identified as needing substance use treatment, that 18 to 25-year-old age range stands out, and yet you'll see when we look at the age range for who gets treatment, that's not the largest group receiving treatment. I know my experience has been that's a challenging group to engage and keep engaged, and often the ones that I'm just hoping I keep the door open so that when they are ready to decrease their use or explore stopping using, that they will show back up, and these are often also the patients that keep me up at night worrying about why I haven't heard from them or why they didn't show up to their appointment. And then when you look at by ethnicity who needs treatment, you see similar to those with the highest rate of substance use disorder, the same minority groups meeting criteria for needing treatment. And where are people getting treatment? So the yellow boxes are the locations that are considered specialty care for addiction treatment, and certainly there is a lot of treatment going on in those locations. But self-help and virtual services, and people can get it in more than one location, but a lot of care is happening in self-help groups and virtual services. This was the first year they asked the question about virtual services, I imagine spurred in part by the pandemic and that leading to a lot more virtual care. And virtual services, why it's not included in specialty care is because it includes anything from a telephone, a phone call, a video visit, it can include an email, and it's not just specifically specialty medical care. So it doesn't, similar to self-help group, it might be community-based or peer-based. So who's actually receiving treatment at a specialty facility? It's more often the individuals that are 26 or older. So again, not lining up with where the greater need is on a population basis. And then when you look by ethnicity as far as who received treatment at a specialty facility in the past year, I know it ends up being a lot of numbers and percentages, but to see that among Hispanic and Asians, there's an even smaller percentage of them that are receiving treatment at specialty facilities. And I think we have to ask why that is and what barriers to them receiving care in those locations is. For some of, for the American Indian or Alaskan Native group, obviously percentage-wise it's a big group. It does have a very wide error bar just because of potential errors in the reporting. And as I know was touched on in some of the papers reviewed today, we also know there's great inequity, right, in access to our evidence-based treatments. And so just to drive that home, that in this study that came out in 2019, black patients were 70% less likely to receive buprenorphine at their visit when they controlled for payment methods, sex, and age. And buprenorphine treatment remained concentrated among white persons and those that self-pay or have private insurance. And yet we know, on the one hand, while there can be many advantages that come with opioid free treatment programs, they also have a lot of barriers to care as far as where they're located and who can access them and also have jobs. So we also need to think about are we not, are our patients not engaging because we're not offering them the right treatments or some of our own biases or system issues are not making that possible. We also know, and I know a newer paper from this past year was presented earlier today, but that after an overdose, those in minority groups are a lot less likely to have follow-up visits as compared to non-Hispanic white patients. So again, some missed opportunities for engaging patients. And then the last part I'll also touch on is just thinking within a system in what ways our patients have difficulty engaging in care. And it's hard for systems to stay afloat when overall reimbursement for in-network care is below Medicare rates when it comes to mental health and substance use disorders. So each bar is a year. So the blue from 2013 to 15 and then 2016 to 17. You can see that mental health between 2013 and 17 started trending at least towards the Medicare reimbursement levels. But unfortunately substance use disorder, at least during that period, moved away, right? So getting even less reimbursement at Medicare rate. And as a result, I know it varies a bit by geography, but I know in Colorado we increasingly see this, I'd be curious other locations, majority of people go out of network, out of their insurance network to receive care for their substance use disorder. And so again, on a population level, we have to think about, well, who can afford to do that? What age are they? What ethnicities? What socioeconomic classes? It might make sense now why we're seeing an older, more white group that tends to be the ones that are more often getting care than others. So this got cut off, but in summary, I think just thinking about there's a great need. We know that. We know that the majority of people that need treatment aren't getting treatment and that that disproportionately affects minorities. I think there's a lot of structural and system issues that precipitate that. There's funding issues as well. And so how can we, in our individual interactions, and that's kind of the next part of this workshop, think about how we can engage our patients and then would welcome the ongoing discussion at the end of both individual and system ways that we can enhance our patients' engagement in their care. Okay. I will, I guess this got turned around, but, oh yeah, so the next part is Dr. Michael Dawes. Hello, everybody. It's great to have you all here today. I'll just give a little background of where I'm coming from with this. I'm at Boston Medical Center and at VA Boston, and since the pandemic we've really been looking at equity-based quality improvement, health services research, and implementation of science because populations we're serving, we're trying to take not just the epidemiological factors that Alexis was mentioning, but how do we shape care to meet the needs? And when we think in terms of the difficult-to-engage patient, how does the system, so that's the question I'm putting before we kind of launch into this section, affect their access, their retention and treatment, those sorts of questions. So we're trying to take conceptual models of how do we take this information in a way that helps change the care delivery system, but also in terms of in your individual care as well as sort of a population-level lens looking at how your system is doing. And there's different examples that we'll touch on, and there's some differences even within VA Boston and Boston Medical Center that we can touch on a bit later. But we're going to review social determinants of mental health, including race and ethnicity as they relate to persons presenting with substance use disorders and other psychiatric disorders. We're going to consider the importance of recognizing and addressing social determinants of mental health as a strategy to engage and retain patients in care. And we're going to talk about practical things we can do at this point in time, as well as aspirational things that are happening. And I'll talk a little bit more, APA has approached myself and several others to, or some people that have worked within APA, or have been representing them, to look at a way of defining social determinants of mental health, and we'll touch on that as well as using this structure. So how do we define social determinants of mental health? Although there's not consensus on the definition of social determinants of mental health or their constructs, the language used to describe social determinants, there are factors that have been sometimes called, in terms of, that have been described as causes of causes of mental health, such that they influence the severity and developmental course of mental illness. Among these are the following that, I won't go into all of them, but you can read them. They include things like adverse life events that we were talking about this morning, poor education, unemployment, poverty, and feudal insecurity. These are from a public health approach. There's also discussions in terms of what are the social determinants that affect the etiology and progression from more of a developmental perspective, as well as what are the social determinants that are most affecting and impacting care delivery. The other thing to really realize is that COVID-19 and the social containment measures that were amplifying the social determinants of mental health during the pandemic are still lasting impacts on mental health during this phase of the endemic portions of COVID-19. This model that you see here was developed by leadership within a number of different community mental health systems and it's been promulgated both in New York and other places across the country. But it's a good conceptual model taking some of what Alexis was talking about in terms of risk factors and risk mechanisms and thinking and kind of putting them in bins so that you can start to think in terms of how do we actually even begin to address that. Social determinants of mental health in this model has four major categories. Social determinants that are developmental problems often interrelated include childhood trauma, lifelong exposure to violence, racism, discrimination, social exclusion, and criminal justice involvement. Economic or related include things like low educational attainment, unemployment, and job insecurity, poverty. Thirdly, basic needs such as housing, food insecurity, inadequate access to transportation, and poor access to health care are categorized that way as well as physical environment that can include neighborhood pollution, climate change, and others that we can talk about. So that's sort of the framework of the categories but then thinking in terms of from a systems level how do you from a public health approach use your spheres of influence in a way that leverages the system to affect change. And I won't go into all of this but I will touch a bit on some of the things that we as psychiatrists could do. First we can include our treatment plans and interventions that address specific social determinants of health such as homelessness. And we can use public health approaches that consider what are our specific spheres of influence in the settings that we're working in. Within a public health community mental health approach, we can influence policy, engage in the research, and help train clinicians to be more aware of the multiple domains of social determinants of mental health and to be agents of change when we are aware of what our patients are needing. Rotter has done a seminal paper looking at five determinants that are of a consensus from a whole host of folks in community mental health settings. And the poll showed that housing, access to health care, criminal justice, limited social support, and adverse childhood experiences were thought to be pretty much the top five in the folks that were taking this survey. But there's a whole host of others that we won't list here, all obviously interrelated but important to consider. So that's just a quick overview of a conceptual model of looking at social determinants of mental health. How do we as clinicians, both in terms of our own practice and if we're teaching residents and fellows, how do we consider this? One that is in the DSM that's underutilized, in my opinion, is the cultural formulation inventory, which includes a need to be curious in terms of asking about and own this space as part of what we're doing in terms of the initial assessments. Although in some ways it adds to the clinical assessment, it also enriches. We should get to know the cultures of our patients, including cultural norms and practices, cultural concepts of distress, cultural syndromes, and the impact of racism on our patients and the cultures in which they live. Included should be a sensitivity to sex and gender differences. And the DSM-5TR particularly has a very good section on that, as well as recommendations for future development. I'll pause here. Also, there's an APA presidential directive in white paper that describes this in much greater detail. And anybody interested, I can give you that information and the references. Within the DSM-5 and TR-5, it says looking at both the prevalence, which we've talked about, the risk and prognostic factors, but also taking that information and looking at the culture-related diagnostic features of specific disorders as opposed to cultural syndromes, including gender and sex diagnostic features are important when you're doing your cultural formulation and treatment and planning, in addition to their relationship to suicidal thoughts and behavior, homicidal ideation, and even drug use and other comorbidities. Furthermore, once you've done this, you can look at this and add Z codes that are not only mental health disorders, but they're included in the DSM and should be used in clinical assessments, both because you can get added benefits when we're talking about financing, oftentimes these are paid through Medicaid and other insurances, and they also give richness to the actual assessment of your patient. So how do we use this information? If you actually go through the cultural formulation with a trainee or with your own practice, you can look at the cultural identity of the patient, the cultural concepts that the patient brings to the evaluation, psychosocial stressors and cultural features, as well as the overall cultural assessment. The cultural formulation inventory can actually take an hour or more to administer. You may not have time to assess all these components, but selecting selective salient parts that you feel are important can add identity and cultural richness to help better understand your patient. And if you're only going to pick a few sections, the cultural identity section just adds a few minutes more to your assessment, and you can link that on the website there to the DSM5.org, and it does add a lot to the formulation. And how do you use this in terms of treatment planning? You should look at this and think about it in terms of the information and give self-reflection in terms of understanding your own cultural identity, and that is key. You need also to compare your own cultural identity to that of your patient, which impacts the therapeutic relationship. We need to monitor the transference and countertransference in supervision as we examine our own explicit and implicit biases. We need to remain curious and continue to increase our knowledge and skills to understand the use of the cultural factors that promote cultural flourishing and human flourishing. In addition to understanding broadly our patients' cultures and social determinants of mental health, we need to assess and access information that helps address structural components. Specifically, when training residents and fellows, we should focus on the doctor-patient interactions as well as the doctor-community relationship. We as teachers and supervisors need to build capacity to support social determinants of mental health in the assessments, as we should also create curriculum that focuses on interactions between the social determinants and health and well-being, and grow in our digital literacy to the use of new technologies and data. And multiple types of assessment should be used and included in our clinical assessments, including self-report, informant report, objective measures, community-based information. We should aim to use multi-trait, multi-method psychometric approaches to integrate individual and community-level variables. Providing holistic evaluation provides two levels of understanding, both the individual and the environmental. For those interested in learning more, this may be sounding overwhelming, but actually the Royal College of Psychiatrists in the UK are developing just such a curriculum. And I recommend that you look at that in terms of shaping your training of the next generation of psychiatrists that work with folks that need help in these areas. To summarize, to assess cultural factors and social determinants of mental health in clinical practice, we as clinicians need to focus not only on the patient-clinician relationship. We also need to consider how to provide patient-centered care that continually strives to better understand how clinicians, systems of care, and communities can meet the biopsychosocial, spiritual needs of our patients. Although there is much work to be done, we can begin to change agents in our institutions and communities. We also need to be early adapters to using new technologies and tools that are in development to better assess social determinants of mental health. I will just add a couple caveats. For example, I'm talking with some folks, this is already in play with the folks that are looking at this. There's several work groups. The psychotic disorders have already done some position statements on doing the scope as well as how to assess. And there are a number of folks asking for folks within addiction psychiatry to be working on a part of these works groups. So I'll pause there. Okay, good afternoon. I am Alona Balasanova. I am at the University of Nebraska Medical Center. And I did want to just start by saying to follow up something Dr. Ritvo mentioned earlier, which is that it is the difficult to engage patient. It is not the difficult patient. This is what I always teach my medical students. There's no such thing as difficult patients. What is difficult are our interactions with them. So that's something to keep in mind as you're listening to this next portion of our talk, which will be about motivational interviewing. And you're getting a handout right now, which hopefully there's enough for everyone. If not, please share. And we will talk a little bit about some specific motivational interviewing skills that we can incorporate into our clinical practice without being experts, that we can utilize to engage patients who may be difficult to engage. So a brief history. Carl Rogers, there he is. So Carl Rogers really revolutionized this idea of person-centered care and person-centered psychotherapy. And so motivational interviewing really arose from that movement with William Miller, Theresa Moyers, and Stephen Rolnick. The way that motivational interviewing differs is that it does have more of a directive approach than exploratory person-centered psychotherapy. While originally these three were kind of the culprits behind it, ultimately the book was written by Miller and Rolnick, as we know MI today. And so MI is typically, I've had students ask me if it's a myocardial infarction. It is not, legitimately. So I think sometimes we take it for granted that we know what these acronyms are and not everybody does. So MI is motivational interviewing. And it is a collaborative, person-centered approach. And it's a form of guiding to elicit and strengthen motivation for change. So it has several core elements, right? And so here's this overlap, Venn diagram type situation here about the spirit of MI. So it's really a particular kind of conversation. You're having a conversation with your patient, but it's a conversation about change. And it's collaborative, so you're collaborating with your patient. And it's also evocative. So you are actually evoking from the patient that what is already there, right? You're not instilling anything. You're just trying to draw out the motivation the patient has inside of them. And the spirit of MI is important because more than the technical interventions, which is why I say you don't have to be an expert, it's really characterized by the spirit and this way of being with your patients, right? Like that is more important, your approach, your presence, right? That is the context within which the techniques are employed and is actually far more important than the techniques themselves. So the active ingredients of MI are a clinician's accurate empathy. So it's critically important to be able to reflect accurately with empathy what the patient is bringing to you. There are some variabilities in trial outcomes, in part, we think, because of differences in their definition of clinician empathy and also within clinician empathy themselves. There's an emphasis on collaboration, trust, and mutual respect. So really your patient is your partner, right? You are on equal footing. And paying attention, critical attention, to a patient's language during the session. So really looking for change talk, and we're gonna talk a little bit about what that means. MI in particular is useful when patients are difficult to engage, but that happens typically when ambivalence is high. So people are really stuck in mixed feelings, right? They may want to stop using and at the same time that use is serving a purpose and so they're stuck, they have these mixed feelings about it. Their confidence may be low and people doubt their abilities to grow or to change. Their desire may be low, right? And people may be uncertain about whether or not they even want to make a change. And importance could also be low and the benefits of change and disadvantage of the current situation are unclear. Like I said, perhaps it is playing a purpose right now and that purpose is more important than the alternative. So ambivalence is one of the central concepts within MI and resolving ambivalence. And ambivalence is very ubiquitous. It's very relevant to everything we do as humans. There's actually a great book that came out by, I can't remember whether it was Miller or Rolnick, one or the other. It's called On Second Thought. It's like a little, like a chapter book. It's great, but it talks about how ambivalence really plays a central role in all of our lives in absolutely every decision that we make. So this idea of resolving ambivalence about behavior change is very important. This is a trans-theoretical model of change, right? And so this is one we have seen many times before. We start with pre-contemplation as we continue through the cycle. Relapse, we're really trying to get away from saying because of the stigmatizing connotations and really a return to use is what that should be characterized by and a fall back into your prior patterns of behavior, right, as opposed to the behavior change. So MI can actually be useful at every inflection point within the cycle, right? Moving the needle from pre-contemplation to contemplation, moving it from contemplation to preparation, et cetera. So that is where MI is particularly useful. So the spirit of MI that I have mentioned earlier is this idea of collaboration. It's a collaborative conversation. You're not confronting somebody, right? There was that TV show Intervention. We all know about it. It was terrible, didn't work, obviously. But we don't wanna do that, right? We don't wanna confront patients because it's not helpful, right? Like we're not gonna chastise them. That doesn't solve anything. So we wanna really accept patient behavior, patient behaviors, patient objectives. We don't wanna try to convince them or convert them into our line of thought, which oftentimes can be challenging when you have the writing reflex and you feel like you want what you think is in the patient's best interest, but that's something that we need to check within ourselves. So again, evocation versus education. So we don't want to give a lecture to a patient, right? We want to actually elicit their own beliefs and values so that way our treatment can be concordant with patient-centered values. We also don't wanna instill or install anything. Again, that is not there. We wanna evoke what is actually within the patient. And then this idea of autonomy versus authority. As clinicians, as physicians, other healthcare providers, we are so used to being the authority figure. And it's important that we lower ourselves and humble ourselves to being on equal footing with the patient because while I may be the expert on the science, the patient is the expert on the patient. And that is something critically important to remember as we engage in these discussions here and as you see your patients. So really the expectation of personal responsibility and giving that patient autonomy and agency over their own lives, right? You don't have to protect them. You can meet them halfway. So this is on your handout, ORS. MI has a lot of acronyms. MI itself is an acronym and then it also has a lot of acronyms. So ORS is one of those acronyms. It's on your handout. I actually really love this because it is so applicable to all walks of medicine. So asking open-ended questions. We learned that in Med School 101, right? Like when you're taking a history, you ask open-ended questions. You also wanna build rapport, also Med School 101, right? You want to make your patient feel understood. You wanna build a therapeutic alliance, right? And you can do that while also displaying accurate empathy. You also then want to reflectively listen to identify any discrepancies that the patient may have in what they're saying in their narrative. So I'm hearing that your meds don't seem to work right. And then also you mentioned that you don't take them when you drink and you drink every day. So help me understand, right? Like identifying those discrepancies can be very helpful. And then summarizing. So reinforcing the commitments that the patient has made to change and reminding them that this is a doable goal. This is the goal that they have set for themselves, right? So you decided to set a phone reminder to be sure to take your medications as just one example. So these are really the building blocks of motivational interviewing and things that you can employ and just sneak into your day-to-day practice that's going to help you engage with your patients. So there's four central processes in MI, right? Engaging. So establishing a productive working relationship with your patient, right? Understanding and accurately reflecting the person's experience and perspective while affirming strengths and supporting autonomy, right? This is not a deficits-based approach like most of medicine. This is actually a strengths-based approach. You also want to focus the agenda. This is how this differs from original regerian therapy, right, you actually have an agenda and you have a shared purpose that is negotiated and it gives clinicians permission to move that in that direction, right? The conversation about change because you have both now negotiated that that's what this is going to be about. Evoking. So here you are gently exploring and helping the person build their own why for change. Not your why, not because, you know, it's gonna kill them, but what the patient's why is. And eliciting their ideas and motivations. So ambivalence is normalized, right? Remembering we all have ambivalence. Do I press snooze or not? Like that's an ambivalent situation, right? We all face that, at least I do. And you want to explore those things without judgment. And as a result then, that ambivalence can be resolved ultimately. So this really requires, like I said, skillful attention to the person's talk about change and we're getting there, I promise, about what change talk looks like. Planning. Here we are exploring the how of change when the therapist supports the person to develop a plan based on the person's own insights and expertise. This is an optional part. It may not necessarily be required, but something you can include for sort of the technical aspects of MI. So again, driving home these principles. Expressing empathy. Supporting self-efficacy of the individual, right? Like they can do it. We trust them to make decisions that are good for them. Rolling with resistance is a big one because there will be a lot of resistance and you have to learn how to roll with it as a clinician. Otherwise you're gonna get stuck and you're not gonna be able to be productive in service for the patient. And then developing discrepancy. Identifying those things that the patient is saying in their narrative that actually are counter what their own stated goals are, right? So now we're talking about change talk. So how do we figure out what that is, right? Again, more acronyms. This is D.A.R.N., D.A.R.N.C.A.T. is actually the acronym. So D.A.R.N. is this part. This is the preparatory change talk. So desire, when a patient talks about their desire. I want to change, right? Patients will mention things about what their wants are. Their ability to change when they actually realize I can change, I can do this. They can articulate their reasons for change. So it's important to change because blah, blah, blah. I need to change, right? Or I should change because, you know, I don't want to get another DUI or whatever it may be. And then we have the implementation change talk. This is the CAT, so the D.A.R.N.C.A.T. So implementation change talk is a little bit more serious. Here you're making a commitment, right? Like I will make these changes. I will go to the gym every day, right? Whatever it may be. Activation, I'm ready, I'm prepared, I'm willing, really those active terms. And then the actual taking steps to change. Like I am taking these specific actions. I am outlining what those actions are. I am going to drive to the gym, right? Like those sorts of things. And that's just one example. The gym's such a common, exercise is another such common thing that everybody has ambivalence about. At least, again, I do. So strategies for evoking change talk. There's a lot of strategies. This is also all on your handout. These strategies are awesome. Because if you read through them, they're actually quite simple. Most of them are very easily implementable into your day-to-day practice. And so there are several specific ones I did want to just highlight. So asking evocative questions, we already talked about that. Exploring a decisional balance, right? Like what would be the benefits of changing and what would be the benefits of not changing, right? Like we never really look at that other side, but there are obviously benefits to not changing. Otherwise, the patient would have changed by now, right? And so identifying that. Looking at the good things and not so good things. Asking for examples. And then looking back, you know, think about a time before all of this happened. What did things look like back then? These are, the second half are a little bit more of my favorites. So looking forward. You know, if things continue the way they are, you know, what are they gonna be like? Or if you're 100% successful in making the changes that you want, what would that look like, right? I often like to say if we had a magic wand right now and we were to wave it and make everything exactly the way you wanted it, what would that look like, right? Like what would you be doing? Where would you be? What would things be like? Querying the extremes. So what are the worst things that might happen if you make this change? What are the best things that might happen if you make this change? And this is my all-time favorite, the change ruler or the change ladder. I honestly think this is like a Jedi mind trick because it will get the patient to convince you why they want to change. It's super cool. So basically, you ask the person on a scale of one to 10, you could say how important it is. I typically like to say how confident are you that you will be able to make the change that they identify? And whatever number they say, you say, why not a smaller number? So if they say, you know, I'm seven out of 10, right, confidence. Okay, well, why not a four, right? And then they convince you why it's not a four. They convince you why they actually want to do this and why they're going to do this. It's really cool. Try it out, it's really cool. And so that's a really fun one to use, I think. Exploring goals and values, and then also coming alongside. This one, I would say, I would really reserve for if you've had specific MI training and you know what you're doing. This is not one I would typically recommend. It's not one that I typically use, but this is actually one where you side with kind of the devil's advocate and in a very kind of stone-faced way. And then the patient's sometimes a little taken aback and shocked that you did that. And so then again, they proceed to convince you why that shouldn't be. And so it's again, another way to get at that. I find that using the change ruler is a softer way and also easier way, frankly, to do that. But you have all of these strategies, okay? So please keep them in mind as we move forward to our case presentations. And we'll call back Dr. Rippo. Thank you. Actually, the good news is we have plenty of time because we have two cases here, but then we're hoping to kind of open it up and have, I know in just listening to this, I thought of several patients I have that I would love people's input on and would love others to give examples of patients that they have found difficult to engage and maybe how you've approached overcoming that, both from a kind of a systems-wide level in your evaluation, thinking of social determinants health, and then finally maybe using some of these MI skills. So the first that I will read, this is from Dr. Renner. So Fred was a 36-year-old married firefighter in a Boston suburb. He also operated a small construction business on the side. He was an Iraq combat veteran who joined the fire department five years ago. Last January, he injured his back at work and was given a prescription for oxycodone. Within weeks, he began overtaking his medication and eventually began supplementing it with pills he was buying on the street, and soon he started snorting heroin. When he was referred for treatment, he also admitted that he had been drinking excessively when he first returned from combat, but said he stopped drinking after he began misusing opioids. After being stabilized on buprenorphine, Fred was able to return to work and did well for the next six months. Unfortunately, he relapsed after a fire department buddy died tragically when Fred had been unable to rescue him from a fire. During the next year, he had two further relapses, misusing both alcohol and snorting heroin. He did not stay on buprenorphine consistently and was eventually laid off by the fire department. Fred tried attending NA along with our bup clinic, but did not engage successfully. For the fourth time, he is now applying for bup treatment. So some questions, what would you do? What is missing in Fred's treatment? Is this a failure of buprenorphine? Should he try to return to the fire department? And I'll let Dr. Renner come up and also discuss a little bit. Thank you, Alexis. There's stairs over here. I just couldn't step up. Thank you. Well, thank you for coming. We have some chairs up front if people want to move up. Before we start focusing on the case, I wanted to just try and broaden our discussion a little bit. For those of you who have been around for a while, I think if you think back on how did methadone start, there was a real concern that the wrong people were gonna take methadone and that we had to really evaluate and be careful. People had to prove that they'd been addicted for a year. There are all kinds of barriers that we put up to keep people out of methadone treatment. Well, those barriers are still there. And if you were at some of the presentations this morning, you saw that we're doing a really rotten job about getting people on methadone or buprenorphine or naltrexone. And we didn't talk much about the fact that even if we get them on it, we can't keep them on it. So that the problem is really not that the quote wrong people are getting these medications. The problem is that the right people aren't getting the medications and not staying on the medicine. So I'd like you to think about how we run our programs. I'd like you to think about, we had a very nice presentation from Ilona about what you can do on a one-to-one basis in terms of motivational interviewing and how you can work with patients. But I would like you to just think a little broadly about what there is about our systems that make it so difficult. When we first started buprenorphine training, we spent hours doing patient assessment. You had all kinds of hoops that you had to jump through before you proved yourself the right patient to be on buprenorphine. Well, now we're admitting you half an hour after we see you and we're recognizing that that's actually working. And that what we need to do is figure out ways to get people in treatment immediately, as quickly as possible, and not put them through two weeks of hoops before we admit them into the treatment and just hope they don't die of fentanyl before that happens. So I think we have to reconceptualize how we think about engaging our patients and what we're doing with our patients. And I think that that individual relationship, when you first set foot in the door, that individual relationship you build with them while they're part of treatment is really critical for helping them get through this resistance and then stick with treatment. And motivational interviewing is the most powerful tool that we have for doing that. But I want you to think about these things because I think that this is a much broader question than whether we're doing enough motivational interviewing or not, because we've got wonderful meds, meds that work very well. And we are not really getting anywhere near the number of patients on treatment that we need. And even if they get it, we're not keeping them in treatment. So I'm giving away my biases on this. But I'd like you to think about, Alexis, can we bring that case up again in terms of slides? We did the back arrow. Let's see. OK. All right. So we'll talk about a firefighter here. I'd like you to think about this case. And I'd like you to think about, what do you think it is that's making it hard for him to stick with treatment? Why do you think he's not been able to make a successful adjustment to buprenorphine treatment? Why does he keep relapsing? Anybody have any thoughts or comments? Yeah. It's not untreated PTSD. It's untreated PTSD. Yeah. Want to say that louder? Untreated PTSD. And where do you come to that conclusion? Where does that come from? Any stressor is throwing him right back into use. And it has to be concomitant treatment and not just one, either substance or PTSD. He needs treatment for both. How many of you people work in the VA? Show of hands. So we've got a fair number of VA people. It's certainly very common within our addiction treatments to have co-occurring PTSD. And it's also very common to have policemen and firemen and people who come home from combat and then go looking for a job, which does nothing except trigger their PTSD. And in this patient's case, he was involved in a very bad fire. And one of his buddies died. He went in to try and rescue the man from the fire and tried to drag him out of the building and failed. The man eventually died. But also, as a fireman, you go to accidents. How many babies do you see that are dead along the side of the road because of accidents? So you're constantly being exposed to things like that. But being a tough firefighter was critical to his self-esteem and his personal image. And it literally took about three years working with him to get him to see what was going on and get him to recognize that he had to make a choice, because he could not continue the work that he wanted to do and succeed either with the PTSD treatment or his addiction treatment, because it just became a cycle that kept being repeated. And so I wonder how you would approach the problem with this guy. If he were your patient, what do you think you would do with him? Any thoughts? Does he have a family? Good question. Yes. Just maybe by way of a more basic assessment, I would be interested in having a family member or family members, key people in his family, in for an assessment, in for maybe their perception of what was going on in addition to looking at untreated PTSD and a motivational interviewing sort of approach. I mean, that's pretty typical for the way I operate very often. If I find myself up against a brick wall having addressed some of the things that we've already talked about, I'd like to have family. So you would use the family, if you will, to provide that kind of support. I mean, recognizing, of course, that that can also be distancing for some patients, and depending on where they're at in the process of their treatment and engaging with you. But I'd want to get family. I would ask what the opiates do for him. What do the opiates do for him? I'd like to see what he gets out of it. And then we could trace it back to why that needs to be. Is it memories? Is it the feelings that he's having? Unable to sleep? How painful is this? I'd ask all those questions. What do they do for you? It became also the alcohol, and a mixture or flipping between the opiates and the alcohol. Because if he wanted to sleep, it had to be something, because he couldn't sleep otherwise. So it was just a constant relapse back and forth. So I think this patient, of course, treating concurrent mental illness is important. Utilizing whatever social support the patient can have, that's great, involving family. But I think this patient is unique. He is seeking for fourth treatment. So think about this, positive things. He is motivated. He's motivated to come for help. Something's going on in his life, right? He is here. We should praise him for coming back. Because in our clinic, we have like 550 active MOUD patients. So a pretty large clinic. And we have also do some research. Actually, in our clinic, the highest number is more than like seven or eight. So why patients? We only have 12% of patients in treatment. I mean, in this conference, two days, we focus on how to help patients, this 12% of patients. I think the most important thing is we should focus on 88% of patients. So those who never came to hospital for help. So this patient is motivated. We should have a lot of things we can do to help this patient. That's what I think. Thank you. Gentleman in back there. Thank you. So there's something that we already identified, which seems to be the problem for him. We said PTSD. And I feel this patient basically getting help with that and thinking that he already has the motivation to get help with his substance use. But addressing the PTSD could be the first step to take because that seems to be like a hindrance every time that he tries to gain sobriety or he jumps into a different substance. So getting the treatment for the PTSD possibly through therapy might be a way to go. And then addressing the substance, it does, even if you treat the substances and not treat the PTSD, guess what? He's probably going to go back to some drug or even something else. He will probably develop a new stuff to cope with his stress. So that's what I would do. I have a quick question. What was the dose of buprenorphine that he was stabilized on? Boy. I would suspect probably about 100 or 110, something like that. For buprenorphine? Yeah, I'm sorry. No. He was on. I'm sorry, I'm on guard of you. He was probably on 20, something like that. Do you think part of him relapsing was that maybe you had to go higher up on his dose? I'm not sure. I'm not sure. The way I was addressing part of the problems with it, we increased his dose. And I was not really comfortable going on much higher than that. But what I did do was push very hard for him to get involved in NA. And that really made a huge difference for him. We had a buprenorphine group of all combat veterans his age that he attended regularly. And he got involved in NA groups. One NA group that was really firefighters. And he was eventually able to disconnect him from the fire department and get him out of that job and get him out of that triggering situation. But he maintained those relationships. So he was getting the group support that he needed, if you will. And then along the way, we gave him specific treatment for PTSD, which he was able to stick with. And it took him probably about three years. But he eventually settled down and has been actually doing quite well now. But I think getting him out of the job he was in, getting him a different job, getting him very active in self-help programs were sort of critical to making the meds work and making it possible for him to do that. I was going to ask him what he liked or didn't like about NA. You kind of said what I was going to suggest. But then also ask him if he would think that maybe being in a group that was more with veterans or more people that he could connect with would be beneficial. It seems like a lot of people will try one group and it won't work. And then they'll say, OK, well, I tried it. That doesn't work for me. But then just talking to him about the different kinds of groups and trying to engage with him about what worked, what didn't, and why it might work if it was a different setting. It sounds like that worked for him. Well, I think we were very fortunate because we had a pretty strong group that were all guys at that point in their 25s and 30s. And they all were combat vets. And there were two or three other people who were fire department or police officers or things like that. So it was a good environment for him to feel safe and comfortable with kind of thing. I have a question for the group. What do folks think about him being laid off from the fire department? How might that impact his treatment in terms of social determinants? So why he did not do well, did not engage, did not engage successfully? Because I know people on MAT sometimes still are stigmatized in NA meetings. So they don't want to even disclose their own, at least in our state. Some NA meetings, the patients are very reluctantly talking about their MAT treatment. So we're trying our best to create group groups or different groups to help them engage. So another question for you, quick, is that are you allowed to use more than 16 milligrams of Suboxone? Because in our state, it's still, unfortunately, the insurance doesn't cover more than 16. In our VA, we could do whatever we wanted. I mean, we very rarely went over 32. But they would let us do it. West Virginia? So Michael, you asked about him being laid off from his job and the impact of that. So I think that could be huge. The other thing is we've been talking about, if he does have co-occurring post-traumatic stress disorder, and that's impairing his ability to do his job, but it's a job-related disability, I would be advocating for him to get such a disability. He ended up suing the city of Boston. OK. Because also, he was engaged in treatment at a time when, if you were found to be on buprenorphine or something like that, you would get fired by the city. I think it's permitted nowadays. But when he was in active treatment at that point, it was not permitted. So there are a lot of external things that had to be resolved to make things work for him. We've been talking about buprenorphine, and I think it's really helpful. I'm also wondering what his view was on the alcohol and whether he thinks that he would need treatment for alcohol and if the alcohol treatment was offered. He acknowledged alcohol was a problem. And I think before the fire department dealt with the fact that he was on buprenorphine, they had sent him for a month alcohol rehab program, which in the Boston politics, it's perfectly acceptable to be alcoholic, and they will pay for detox, and they will pay for rehab, and whatever. But don't get in trouble with opiates. That was not an acceptable kind of thing. Hi, this is Matt from Milwaukee. I work at the VA. I've got a couple of police officers and a corrections officer, and they all have PTSD. And it seems like a lot of them don't feel comfortable mixing with the general addiction patients, kind of like the stigma that there is with health professionals like our colleagues. There's a stigma they don't want to be judged. They don't want to be someone kind of trying to fire them. I'm wondering if there's anywhere in the country that's had a first responder police related kind of diversion program McLean has something like that. I don't know if anybody here is here from McLean, but I think they've actually got a program for law enforcement and for people like that. Does the state sponsor that at all, or is it just McLean? I have no idea how. I think it's probably paid for by the unions, and I think it's privately run by McLean Hospital. But I think you make a good point, because I think we were fortunate because we had a group of sort of like-minded guys who were all combat vets who were not particularly sociopathic, and were sort of engaged. I want to do something for the community, or I want to work for the fire department. So they supported a more constructive mode of behavior kind of stuff. And it was very interesting, because I eventually found out that they would spot people who were not telling the truth very quickly, and I would find out from them later that there were some guys, they would say, that guy was never in combat. He may have been in the military, but he was never in combat. And he was just making up stories to try and fit in with the group kind of thing, but he didn't fool most of them kind of thing. Fooled me, but he didn't fool them. Hi. I was just going to comment, I've worked with a number of police officers, paramedics, and the culture of the department really varies. It seems like from jurisdiction to jurisdiction, there have been a few that have been hugely supportive, where there's actually, within the department, there's sort of mentorship going on, and support around tragedies, and if you have addiction, go to this person, and they're going to help you out, and others where there's really, you just don't talk about what happens. So I don't know if there's a way to kind of instill a little more support within some of these systems. Well, I think it just brings back the point that this is something beyond the things that we usually worry about as clinicians, and that we deal with in our treatment programs, that I think that we have to start paying attention to how does somebody support their family, and where do they work, and how is that going to work with their treatment, or is it going to work with their treatment? And what is it when we talk about getting people in treatment, we have to deal with some of those realities to make it possible for the treatment environment to work with the patient. Any other comments or questions about this case? If this person was being seen at my particular VA, we would want him to think about going to our residential unit for stabilization, further treatment. A lot of these folks, in my experience, you never really get to see them. I mean, no one gets to see them in a state where they're not either under the influence of a substance or recovering from that. And sometimes I think it's helpful to remove the person from, you know. No, it is. And also with him, it meant putting up with him disappearing several times. It meant with readmitting him maybe four or five times to the program, and not penalize him for what happened, but welcome him back when he was able to participate in treatment again. No. OK. Lexis, can we move on to the next case? Yeah. I think that's a good idea. Is it in sequence? Yeah, if you want to make a comment while we transition. I just had a couple thoughts about your case. You know, one is, you know, his major relapse, there was a grief response. And that doesn't necessarily have to be with PTSD. And, you know, realizing our population is under a chronic level of grief because people are dying, who they're related to, their children are dying, their parents, from addiction, of course, or violence, or suicide. You know, it's almost like our patients in a community mental health dual diagnosis setting are almost like in a combat zone, and losing people in these grief responses. So I think that connects with the bigger point that I take away is, you know, it's really a dual diagnosis case. I mean, is he a smoker, too? So he's got three addictions, probably, you know, maybe two mental illnesses, a very complex comorbid case. And, you know, realizing that our patients evolve, they evolve between diagnoses, different comorbid sets. And how you keep them in care and keep them with you is that you can handle all that. In other words, you're an addiction psychiatrist. You know how to take care of however they're going to evolve. And I think our systems of care try to pigeonhole not just patients, but doctors, and how they practice. And patients are too complex for that, and they can't get help as soon as the diagnostic picture changes to alcohol, or depression, or PTSD. So it's really, I think, the implicit lesson I like in your case is how it really calls for a vast enlargement of addiction. Psychiatry is the backbone of psychiatry, not just a rarefied field. OK. You planted him. OK, the next case. So this is actually summarized from a entire, like, booklet that SAMHSA has focusing more on treating Alaska Native population. I actually know at my institution we have an entire group that is contracted and does telehealth work. And a lot of it is addiction to Alaska. And that a lot of the population they're treating or helping treat is Alaskan Native. So Philip is a 34-year-old Alaskan Native male who moved to the city approximately six months ago from a remote village. He's been living in the camp on the outskirts of town with other people who are experiencing homelessness. He was self-referred to a Native program after participating in a one-day, one-stop event for individuals who are experiencing homelessness to access services. He was provided transportation to the treatment services and agreed to enter detox. He has never been in treatment. He fears that it would be like being in jail and is worried that everyone would be prejudiced toward him, as he has heard several people in town refer to, quote, the drunk Natives downtown. He wants his freedom, yet he recognizes that he needs help. He reports that he feels that no one will understand his cultural ways and how they affect his life. As an example, Philip explains that he believes he was, quote, wronged someone. He has wronged someone in the past, and that is why his life is like this. Although he cannot identify the person he has wronged, he is sure that he has been disrespectful or is paying for it now for some wrongdoing in his family. Not only him, but his family. Yeah. Since moving to the city, he has been unable to find a job. Although he had been living with friends, he has been camping with other individuals who are homeless in a park outside of town for the past two months. Philip reports that he does not like living in the camp. Although he knows how to survive in camp and has done so most of his life, he's fearful of being beaten up, freezing to death, and being arrested. He worries his drinking will lead to these consequences, as it has for other people living this way. He reports that he no longer wants to live close to a city. He just wants to stop drinking so he can return to his village. But he does not have the money to return home, and he's not sure that he would be welcomed. He's had no contact with his family for months. So. And also, just to think about Phil presenting, but he doesn't want to toss his case to any guy's position. And in order for anybody to want to take a stand on him, what would be important is Phil's treatment. It seems like he's really nervous about entering treatment, and there's also this cultural aspect that he's worried people are not going to understand his culture and returning home. So I would see if there's a peer recovery support mentor that identifies also as Alaska Native that could help him through the process to establish trust and share their hopefully positive experience and maybe open up him to actually engaging with care and with the healthcare system. So you really would begin dealing with his culture directly before you might begin detox or begin some other kind of addition treatment? Depending on how willing he is to actually detox. If he's not at all willing and nervous to start that process, I think it's very context dependent, but maybe. If he was that nervous and not worried about it, I'd say, hey, let's go. Not be critical. It's okay. It's okay. The first thing that I would try and prioritize for Phillip, if possible, in the city, is trying to find some form of shelter for him, if that's possible. I think that's probably the greatest foundation to begin building on and then start to build from there, focus on connecting with social support, other resources, then think about starting some sort of rehabilitation program treatment. But if that's possible in the city, tapping into resources that are available, I think that's the best place to start. Might be a little bit idealistic, but that's what I would want to do first. Depending on the size of the city, I mean, for years we've had the need to run a shelter in Boston. One of the tribes who came had a number of people who moved to Boston. They actually had 17 and a half or so. This case and the whole collection of patients who never come to treatment speak to the issue of credibility. And I think if patients believe that they could get help, that their lives will be improved, they're more likely to come into treatment. And so I think as a discipline, we need to establish our credibility as people who can assist in improving people's lives. And maybe with this case, meeting the needs of the patient, all aspects of the care of the patient, meeting their needs as adequately as possible. Hey, I was in Alaska last summer for vacation. Was this person in a city in Alaska? Or are they actually... They were from a remote village, but had moved into the city. Okay, there's not many cities in Alaska, right? There's Anchorage and there's Fairbanks up there, and there's a bunch of them along the south, Juneau. That's how you find cities. So I don't know how much... I don't know if the VA... I worked for the VA, so we're kind of spoiled. There's some sober living stuff we have in Milwaukee. I don't know if VA has any resources. The patient's not a veteran, but I don't know if there's any sober living up towards the larger cities. And also, I wonder if there's... Because people are in Alaska, you kind of take care of each other, maybe sober households or households in a certain region that people would maybe be able to live with or... I don't know. It's just an idea. In terms of the question, I would also wonder about if there's anything like AA or MNA specifically to... Is this where... So my usual MI approach with it would be with this guy about what is it that he feels would work for him and what is it that would come in the way of it. Having him recognize the biggest barrier would make it easier for us to overcome it together. So how would you culturally approach that? I mean, how might that affect the motivational interviewing in the formulation? So I would start with having him educate me about the culture because, obviously, I don't know enough about the culture and his perception of what would... That's why his perception would come in to be more important. I was just going to comment. Somebody... You had said bringing in a peer that knows the culture, but also potentially a spiritual leader in the community would be really helpful for this patient to kind of address some of those beliefs that he has around having wronged somebody. One of the references Anna Jordan talked about, there's actually a... She's got one that's worked within her community, but there's also using Native American and Indian approaches that there's actually some stuff that's been funded by, I believe it's SAMHSA, but I'm not 100% sure, but there are models out there for how do you reach indigenous peoples. So it's not just the formulation, it's how does that affect the care and how do you use what community resources you have. I feel like an undersourced thing is people that have worldviews, faith systems, that sometimes we need to embrace those people, and they are probably as much a part of the treatment as anything. So a bunch of points. First of all, why did he move to the city? What was he hoping would happen as a result of his being there? We don't know much about his background. He hasn't been able to find a job, but what kind of job is he looking for? There are treatment programs that are specifically geared to Alaska natives and Native Americans, both in Alaska and in the lower 48. They're not that hard to find, and it's not hard to get people into them. Alaska will ship a lot of people down to the lower 48 for medical care of all types, including for treatment. And in the treatment program where I work, yes, we do take people from Alaska. So that's not unusual at all. Where do you work? Well, I live in a remote area of Washington State. And we're remote, but people fly into Portland, and we go pick them up. And also in Elma, Washington, which is just off the I-5 corridor, there is a treatment program specifically for Native Americans, and there is one in Seattle as well. So the resources are there. In Washington State, our Department of Social and Health Services publishes every year a listing of every single licensed treatment program in the state by county, listed by the cities in each county, and also tells what their specialties are. I wouldn't be surprised if all of the other states had this sort of thing, but it's not highly publicized. And the reason I know about it is I started my career as a chemical dependency counselor and got exposed to a lot of resources that other people in the treatment chain wouldn't know about. Somebody just made a point about pastoral care, which is excellent, and I think we don't do enough about that. I'm currently treating a firefighter who has severe PTSD, and his actions with his daughter when she was using led to her death, and he cannot forgive himself. I've called in a pastor to meet with him several times, and he says it helps. The medication is starting to help also. Another thing is find out, of course, what is important to this man. I have learned from doing a clinical experience in Alaska and staying with a friend who was married to an Alaska native, now deceased, that every kid in the village plays basketball. And so I would probably be shooting hoops with this guy and talking with him while doing so because that would be meeting him on his level. And whatever hook we can do to meet a patient on his or her level is a point for recovery. And back to the previous case, in the treatment program where I work, we have a very tight treatment team. It's really a delight to work with them, and our philosophy is we want to do it one and done. We want to give you everything you need to be able to remain abstinent and achieve your goals when you leave. But when people come back, and some of them do, we just don't use the revolving door as our treatment model. But when people come back, I always greet them warmly and say, I'm so glad you're here. I'm so glad you knew we would want to help you again. People, their shoulders drop. They relax like they're not going to get chastised for coming back. Let's find out what the problem was and how we can move through it. Any other comments? When I started doing this work many years ago, one of my mentors was an addiction medicine doc at Cambridge City Hospital, and he used to begin his treatment with people. He had sort of a spiel that he gave people the first visit, and it always included something similar to what you said, that no matter what happens, you are always welcome back. We will stick with you, no matter what kind of trouble you get with, no matter how many relapses, you can always come back. And that was sort of part of the initial introduction to him as a caregiver, and I think it was very powerful. Any other comments? Thank you.

medical professionals

difficult-to-engage patients

substance use disorders

treatment rates

social determinants of mental health

motivational interviewing

core elements of MI

patient cases

co-occurring mental health issues

cultural sensitivity

specific populations

individualized approach to treatment