Welcome to this workshop titled, The New Multidisciplinary Medical Advocacy Team for Traumatized Medically Complex Addicted Patients, Addiction Psychiatry, Medicine, and ADA Lawyers. We're going to share our disclosures here. I'll let you read them for a minute. And we're going to start with our first talk titled, Overcoming Treatment Barriers. The Americans with Disabilities Act as an Advocacy Tool for Patients with Substance Use Disorder. I'm going to welcome Rebecca Jobe, she's a Senior Staff Attorney with the Legal Action Center and this will be a wonderful talk. Thank you. Thanks everyone for coming to this discussion. So as Dr. Lawful said, I'm going to give you all a little overview of the Americans with Disabilities Act and the protections that it provides for people who have disabilities, including people with substance use disorders, and also some limited protections that there are for people currently using drugs. I'll tell you a little bit about the Legal Action Center, we're a law and policy organization. We're based in New York and help people all over the state and we also do some work across the country and have specific projects going on right now in Kentucky and North Carolina. So what we're going to do today is learn a little bit about the anti-discrimination laws that protect people with substance use disorders and then we'll identify some common forms of discrimination that we often see and who clients come to us and need help with and there's definitely a lot of advocacy we can do around these issues. I'll talk through some legal remedies that are available that you might be able to help a patient with actually or just kind of inform the patient that these are options available to them that they can try and enforce their rights and then I'll also identify some useful resources. So I'm sure everyone is familiar with this statistic, if not this exact quote, but really it's just to kind of like center us in the reality that so many people are dying from overdose and for many of these overdose deaths, those involving opioids, there are medications available to treat substance use disorders, but they are not as available as they should be. And so a lot of the legal work in this area for people with substance use disorders has been about people with opioid use disorder, in part because discrimination against MOUD is very apparent in a way that sometimes it's not for other substance use disorders because the treatment is so obvious that people find out about it. So a lot of the legal work in this space has gone on about access to MOUD, so that's some of what I'll be talking about, but this is really just saying that there's treatments available but because of discrimination people either aren't able to access those treatments for other reasons also or if they do access treatment, they have that treatment taken away from them because of discriminatory reasons. And so I like to just think of all the kind of different ways that we might fight the overdose epidemic, and these are sort of the three ways that I see the legal advocacy and the legal world helping out to stop overdose deaths, and that's one, linking people to care and recovery or really making sure that those linkages are not stopped for impermissible illegal reasons, reducing criminalization, that's super important, not only just in terms of legalization but also in just decoupling the answer to substance use as one that has a carceral and punitive approach, and then also almost the biggest one is reducing stigma because stigma is evidence of discrimination and it practically works to interrupt people's care and make it impossible for them to also sometimes access other parts of life like employment or custody over their children and all sorts of things, unfortunately. Okay, so what are we talking about? What are these anti-discrimination laws? So there's several anti-discrimination laws that protect people with disabilities, and they protect people in all sorts of areas when they're trying to access treatment or healthcare, accessing healthcare, employment, custody rights, almost the whole kind of swath of life comes into play with these anti-discrimination laws, and I'll explain that a little bit more, but I'll go over the realm of laws. The first that you might have heard of, hopefully, is the Americans with Disabilities Act, and that is a federal law that applies to several different types of entities. It applies to, one, state and local governments. This includes prisons, jails, and courts. It applies to places of public accommodation, so any place that is generally open to the public, like a hospital or a restaurant, a hotel, any of these things are public accommodations, and it also applies to employers. And so often you hear people talk about the ADA, and the other laws that are listed here really follow the same structure, and so I'll say who they apply to, but they all kind of function the same way and provide about the same protections. So in addition to the ADA, you have the Rehabilitation Act of 1973, and that applies to places receiving federal funding, and then the Affordable Care Act has an anti-discrimination provision that follows the exact same thing that the Rehabilitation Act does, but it applies to health care entities that are receiving federal funding. And then, specific to housing, there's also a Fair Housing Act that prohibits discrimination. So we have these laws that basically cover everyone. They cover employers, they cover hospitals, they cover skilled nursing facilities, they cover jails, prisons, courts, but what is it that they are saying these entities can't do, and who are they actually protecting? So we know the entities that are not allowed to discriminate, but who are they not allowed to discriminate against? So these laws protect people with disabilities, which has a very specific definition under law. Someone with a disability is someone who has an impairment that substantially limits one or more major life activities. And substance use disorders are generally considered to be disabilities. Every person has to prove that their impairment does limit their own major life activity, but we can basically make a generalization that if someone has a diagnosed opioid use disorder, for example, that that would be an impairment limiting a major life activity, like neurological and brain functioning. So it's pretty well accepted that a substance use disorder is a disability. However, there's a really unfortunate caveat in these laws that say that people who are currently using illegal drugs are excluded from the definition of a disability. So if you're currently using, you unfortunately are not considered to have a disability under the Americans with Disabilities Act and these other anti-discrimination laws. And so this obviously really doesn't pair with a medical sort of lens of how you might think of people being in remission or recovery. It doesn't leave room for just sort of natural returns to use when technically someone could say, oh, you're no longer protected because, you know, you used yesterday, even if it was just one time. So that is very, it's, it's not a great part of these laws. And hopefully that will be changed over time. But there's one more caveat to the caveat, which is really important and it doesn't get talked about too much. But what it says is that people who are currently using drugs, even if they aren't considered to have a disability, they can't be denied health care. And so that's really important that there is this protection for the denial of health care. Unfortunately, people who use drugs actually are denied health care quite often. But we're, my, my organization is doing work to try and enforce, you know, those, that provision of these laws. And so I just have a little chart up here that I hope is helpful. But it explains where the problems are. So on the one hand, there's protections, provisions of discrimination for people with substance use disorders. So that would be something like discrimination because someone's taking MOUD. And then on the other hand, which is a smaller sort of section, you cannot deny health services because of someone's current drug use. So those are kind of the two bodies. The one on your left is obviously the much sort of larger protection and the classic protection that people think of when they think these laws. So, you know, we know who's covered, who's protected. What do these laws actually say? They prohibit discrimination. But what is discrimination? It can take many different forms. And so these are some of the examples that are actually listed in the regulations of these laws. And so I'll go through a couple. But all of these things would be discrimination that violate these laws. And so denying participation or services because of someone's substance use disorder, so saying someone cannot access a sniff because they're taking MOUD, that would be denying a service. And that's illegal. Denying equal participation or services. So one example that you might be able to think of is someone who, we have a case about this right now, needs long-term IV antibiotics. And instead of getting a PICC line or being offered a PICC line, as most people would be, they're only offered sniff care because of stigma about their, a stigmatizing assumption that they are going to inject drugs. But that's kind of an example of an unequal benefit. You have to give equal options to all people. Having admission criteria that screen out people. So again, going back to that sniff example of a sniff saying you won't be admitted if you take MOUD, that's clearly discrimination. And then another one that people might be familiar with is denying reasonable modifications or a reasonable accommodation. So this might be a jail who has someone coming in that's taking methadone. And they say, no, no methadone. And the person says, well, can you make an accommodation for me? This is prescribed. I need this medication even though you don't normally do this. That would be a request for reasonable accommodation. And denying that would be illegal. Okay. Now I'm going to talk about just the other sort of big picture thing that is often evidence of discrimination, which is stigma. And so stigma is discrimination. It's also other things, I guess, but it's always evidence of discrimination. I think this is really important because it helps you sort of, no one thinks in the categories I was just going over, you know, you kind of do, but if you're looking for where something has gone wrong, I think using the sniff test is really important. Like this seems wrong. It seems like it's being made based on stigma and maybe not other more appropriate criteria. So I was just wondering if anyone has thoughts about stigma that they've seen and what they would think of is evidence of discrimination potentially. I hope that made sense. Yeah, absolutely. So did everyone hear that? Denying? Okay. I think, at least in our system, it's often that the vision criteria aren't necessarily adhered to, that if you've got a suicidal patient and a substance use patient, it varies over time who's offended. And usually the ones that feel like there's a substance use are the ones that would be less psychiatric in that sense. So they're going to be, if there's not only a number of bad issues, usually someone who's suicidal, not using drugs, is going to be admitted over someone who's substance using and suicidal. I think that's really interesting. And I think it gets at sort of the more abstract forms of stigma that might be occurring. The rehab guide, there was a new guidance. I'm not thinking of the right word, but I don't know if you all saw this. Maybe not. But the Rehabilitation Act, HHS just put out some new guidance about it, or proposed guidance. And it's really interesting because they're trying to point to sort of these more abstract forms of stigma that aren't actually evidence of discrimination. Another example is not allowing people who use drugs autonomy to make their own healthcare decision making. And I think that's a new step for the law to sort of recognize that as illegal. But it's really important. Were you going to? I have many patients who say I cannot come to treatment because I started a job and I'm accumulating points against me if I come to treatment and then I get demoted or I'm losing the job. Oh, that's really interesting. That definitely sounds illegal. Yeah. There are both women who are pregnant and women who are in a treatment setting. There's not been commercial drug screening, for instance, that sort of case-by-case and then case-by-case Yeah, that's a great point. And I think we have to pay more attention to also the intersectionality of some of these issues. Sometimes I feel like some of the discrimination going on is often based in race and class also and that people present a certain way and so they're less likely to get services. And I think it's really important that we kind of start being more intentional about how all of these things interact together. So in the interest of time, I'll move on. I guess the one thing I want to say is just that the flag for me of stigma and sort of improper decision making that is discriminatory is just if something is not being based on medical objective criteria, it's like the best way to sort of say, hey, that might be illegal and it's probably discriminatory, actually. Okay, so now I have a couple of scenarios. I think I actually gave these away already. But I have a couple of true or false scenarios that I just want to go over really quickly. So the first is true or false, jails and prisons do not have to provide methadone to treat OUD as part of their medication services. Just call it out. Yes. So that is false. It violates the ADA as well as constitutional law, the Eighth Amendment. And there's been several cases actually that stand for the idea that this is discriminatory. There's a lot of DOJ settlements. They're very active on this. There was just a new settlement in Kentucky. So it happens all the time. That's the thing that sucks about discrimination. It seems so obvious that it's illegal. But it still happens. And so there's still a need to enforce all these laws and make sure each individual has access to their care. Yeah, I won't go into too much detail about these cases, but just know they're there. And we have a bunch of resources on our website if you ever need to look at precedent or are wondering what all those cases are. Okay, so the next question is true or false, safety-sensitive jobs cannot automatically ban methadone. True. So this violates the ADA. There needs to be an individual assessment. There's a lot of EEOC settlements, the Equal Employment Opportunity Commission. That is somewhere that you could actually always – I would suggest referring patients if they're having employment issues. If you're in New York, you could contact me. But if you're not in New York, the EEOC, they enforce the ADA against most employers. And they've been pretty active on this, especially in terms of MOUD. And maybe they would take a case where someone – actually, we worked on a case where someone was being told that they couldn't go to treatment for alcohol use disorder, so they couldn't go to their groups. And the EEOC wrote an amicus brief, so they're actually pretty interested in this. And they have a local chapter in every state where people can file complaints. And we also have this – this is linked. It's a resource on our website that just kind of goes over people's rights in this space. But absolutely, an individual assessment is always needed. That's the other thing. Stigma, evidence of discrimination, also evidence of discrimination when people are not given an individual assessment. Any sort of blanket ban on MOUD, always discrimination. Any just rash decision without contacting someone's provider, for example, or getting the advice of an addiction specialist. Those are always signs of discrimination. Okay, and the last one – I definitely gave this one away, but SNFs can require people to stop taking MOUD as admission criteria, true or false? Yes, it's happening all the time. I think the DOJ has worked on this in Massachusetts, and there's been like 10 settlements, and it still is happening all the time. We do have success advocating for patients. I think some of it was some skilled nursing facilities is a lack of sort of education, and they think that there's a lot more involved than there might be for them. And, of course, just stigma. But there can be blanket bans. Logistics under the ADA are not a defense. Safety is, but that would fail here. There's no reason that you can't provide methadone safely in a skilled nursing facility. But logistics, those are never an excuse. So even if it's kind of difficult to figure out, you have to, and it's probably not as difficult as they think. And then these are just a couple of resources that we have on skilled nursing facilities and recovery home issues, which it's very much the same. Recovery homes cannot deny access to people taking MOUD, but they often do. So that's my time. I'll say just as a closing remark that these laws apply also to people with other substance use disorders. Just the MOUD discrimination is quite overt, so that's where a lot of legal work goes on. But I think it's really important that we bring these cases and advocate for people who have other types of substance use disorders and do advocacy for people to receive health care who are still using drugs. Yeah. Thanks. At the end. Thank you. I should have said in the beginning, we're going to save questions for the end because we'll have a discussant and all that. It's my pleasure to introduce Dr. Laura Fanucchi. She's an internist and associate professor at the University of Kentucky and the director of the Addiction Medicine Consult Service. Thanks. So it's all related. You all brought up a couple of these issues that this section of the workshop is about. So we're going to go through trends in the hospitalizations for severe infections related to the opioid epidemic and injection drug use, and then talk about gaps in the opioid use disorder care continuum after a hospitalization for injection-related infection. and then I'm going to share with you all some of the work we're doing in an ongoing clinical trial enrolling this patient population in an integrated outpatient care model that includes addiction and infectious disease treatment. So I'll start with a little case. This is Mr. B. He's a 36-year-old man with opioid use disorder, methamphetamine use disorder with injection drug use. He's unhoused at the time of hospitalization, and he tells the team that he could live with his mother if he, quote-unquote, stops using drugs. He has a 10th grade education. He used to work in construction, and he's recently been unemployed. He's had some experience with the carceral system. In terms of his medical and psychiatric history, he has a former alcohol use disorder that has relatively been inactive with hospitalizations in the past for complicated withdrawal, and he previously had a hospitalization for a gunshot wound to the abdomen. He's currently receiving disability for post-traumatic stress disorder diagnosis, and on his prescription drug monitoring program, there are prescriptions for clonazepam and gabapentin, but he says that those have been stolen while he was unhoused. So as part of our screening for our study, we do a lot of assessments, and so we go through the mini-psychiatric interview, and he meets criteria for recurrent major depressive disorder, but not current, and he has no prior history of treatment with MOUD. Currently, his reason for hospitalization is mitral valve endocarditis related to injection drug use. So for some context, it's, you know, most of you are familiar with that there's been a tremendous increase in hospitalizations for injection-related infections in many parts of the country. In Kentucky, we've had a particularly high prevalence. So the dark, so this is Kentucky, and there are some, you can see the hospitalizations rate per 100,000 over the last several years. The endocarditis with drug-related comorbidity is the blue bar, and the rate per 100,000 in some counties in our state is as high as 278 per 100,000 population, which is really very, very high in some of these smaller counties. So there are a lot of problems with hospitalizations for injection-related infections, and they generate kind of a lot of concern from hospital administration, in particular because there's no care continuum that can accommodate medical complexity with high addiction severity and address both of those issues in the post-acute care environment. So if we think about the medical care continuum, we have, you know, outpatient office-based setting and then urgent treatment centers, and we have the hospital, and then post-hospital, what happens to patients? They go to skilled nursing facilities. They might need acute physical rehabilitation. They might go home with home health, or they might go all the way home. But in terms of all of these intermediate places where somebody might have been quite sick, maybe they need more antibiotics for a period of time, maybe they have a wound that needs care, the addiction and potentially need for MOUD creates all of the problems that we were just talking about in the previous talk, that there's so much discrimination in that space. SNFs will say, no, you can't come. It's also predominantly a young patient population, and so in our state, the SNFs don't really have to take young patients. They have plenty of Medicaid-eligible patients that are older, and so they often say age is their reason for not accepting patients. In terms of, well, what about going to residential substance use disorder treatment? But a lot of those places are not set up to handle the medical complexity. They don't have the nursing experience to handle an indwelling catheter or wound care, and so in addition, a lot of this patient population has housing instability, and there are no, at the moment, payer models that address medical respite. So there are some cities that have medical respite, either through foundation or sometimes faith-based organizations, but that's not common. So the other question that always comes up is, well, for patients that are able to go to a living environment that is relatively safe, can they receive outpatient perineural antibiotic therapy, so OPAT, through an indwelling catheter? And then that brings up the whole other question, well, as somebody who has a history of recent injection drug use, are they safe to leave the hospital with an indwelling catheter? And there are a lot of assumptions about what that individual person may or may not use their catheter for, and that gets back to some of these other discriminatory-based issues. So for Mr. B, he's seen by the Inpatient Addiction Consult Service right after he's admitted, and he's already in opioid withdrawal with an elevated COWS. Buprenorphine is initiated right away, and he starts to feel better, and things are going well with his initiation. And then seven days after admission, during the night, nursing finds him intoxicated, and the chart says that he had an uncapped needle in the bed. Even though he's awake-ish and slurring, he receives naloxone, and security is called in the night to search his room. He's asked to provide a urine sample and to sign a behavioral agreement. If any of you work in acute care hospitals, this is not uncommon, and there's a lot of conversation. This conversation comes up a lot about behavioral contracts, behavioral agreements, and hospital substance use. So the hospital isn't exactly a therapeutic environment for people with active substance use disorders. Not only are there the risks of hospital-acquired infections and being in the hospital for a long time, it's very difficult to be in the hospital for a long time. Patients frequently leave before their medical condition is stabilized. Substance use disorder is inconsistently provided in U.S. hospitals. It's only been in the past five to ten years that it's been more of a movement of addiction consult services and helping acute care hospitals provide MOUD. There's a lot of stigma, so patients frequently report really difficult interactions with various medical staff. They're often accused of using, even if they're not feeling, if maybe they're just not feeling well and irritable because they're not feeling well. There is inpatient substance use, and someone's hospitalized and they have a very active substance use disorder. It is a behavior that's part of their underlying medical condition, and it's not surprising, but it's really criminalized in the inpatient setting. And then, of course, there are these assumptions made about whether the patient population is quote-unquote safe to receive an indwelling catheter for several weeks at a time. Behavior contracts or agreements are put in place, which really have very punitive implications. Patients are told if you keep using drugs, you may be discharged from the hospital without completing your medical care. We've had patients actually have the police called on them and brought to prison directly from the hospital. So behavior is seen as the problem rather than a symptom of the problem. So other than continuing to work on improving stigma and improving care of patients that are with substance use disorders that are hospitalized and trying to prevent some of these infections from happening in the first place, you know, with increased access to syringe service programs and access to treatment, are there other alternatives to the long hospitalization? So I mentioned some of these. Residential addiction treatment. So we, and there's another site in Portland, we have a couple of residential addiction treatment facilities that we've worked with to increase their staffing and training to be able to accommodate indwelling catheters. And so patients can go to a couple of facilities where they can continue to receive buprenorphine and finish their IV antibiotic therapy. The problem is patients often don't want to go. So it's very low. They don't want to go from the hospital to a 30-day residential stay, even if they can finish their antibiotics there, and that's not something that can be required. Skilled nursing facilities, as we talked about, are not a great alternative. Can we switch to oral antibiotics for some of this patient population? So that's a whole ongoing area of inquiry in infectious disease right now, maybe, for some of these infections. There's a lot of movement towards that. So what about OPAT? So in 2018, we did a pilot study, which was the first randomized clinical trial of OPAT in persons with opioid use disorder. And I'm using the acronym CERI, so in severe injection-related infections. We enrolled 20 patients to, and randomized them one-to-one to early discharge with the PIC, plus buprenorphine treatment versus usual care. And our primary outcome was illicit opioid use in the 12 weeks after discharge, and it was a successful pilot. So overall, there was all patients finished their IV antibiotic courses, then there was actually decreased illicit opioid use in the group that left the hospital early. We successfully completed about three weeks of outpatient parenteral antibiotic therapy, and therefore the length of stay in that group was about three weeks shorter. And there were no major adverse events in our small 20-participant study. So we used that preliminary data for a larger randomized clinical trial, which is ongoing right now, and we call it BOPAT, buprenorphine plus OPAT. So we're evaluating an improved integrated outpatient care model compared to treatment as usual in patients with opioid use disorder and severe injection-related infections on both opioid use disorder and infection outcomes. And we're including a health and economic evaluation, as well as a qualitative evaluation to contextualize the outcomes. So our study design is a randomized parallel group superiority trial in hospitalized adults with opioid use disorder and severe infections who are accepting a buprenorphine treatment, and we stratify by sex, current stimulant use disorder, and we group the injection-related infection into subgroups based on the population expected mortality. As you can imagine, mitral or aortic valve endocarditis has a much higher mortality rate than some vertebral osteomyelitis, but we're enrolling both patient populations, so we wanted to make sure to balance the mortality risk in the two groups as much as we could. And so they're screened and randomized in the hospital one-to-one to BOPAT or treatment as usual, and then we follow both groups for 12 weeks after discharge. The BOPAT group leaves the hospital once they're medically stable with the PICC line, and they continue to receive IV antibiotic therapy and treatment for their opioid use disorder. And our key outcomes are illicit opioid use in that 12 weeks, IV antibiotic completion, and then a cost-effectiveness outcome. We include adults with opioid use disorder in one of these severe infections that requires at least two weeks of IV antibiotics, and they need to be medically stable enough to go home. So if they are so physically ill from their infection that they will need acute medical rehabilitation, we're not enrolling that patient. And they have to accept buprenorphine treatment, so we have a number of patients that are choosing methadone treatment, and unfortunately then we can't enroll them in this study. They have to have a home environment that's safe enough to take care of a line at home, so they have to have running water and refrigeration to be able to store the antibiotics. And then we have a number of medical exclusion criteria, largely for safety of the participants. We ask explicitly as part of our screening procedures whether having the line affects cravings or desire to use, and we're not enrolling people who say that they're worried about their safety with the line, and we've had a few people say that. And then because we ask people to come back twice a week while they have the line in, they need to live within about an hour, hour and a half from where we provide care in Lexington. So again, during the hospitalization, the patients have an infectious disease consult for their infection, an addiction medicine consult. They initiate buprenorphine and they receive the line, and after discharge, the BOPAT group gets buprenorphine treatment integrated with treatment of their infection, and in that group, they come back and see us twice a week while they have the line in, so that's more frequent clinical visits than standard OPAT and standard OBOT treatment, right? And we also do the care of the line in our clinic, so getting back to discrimination, it's very uncommon that home health agencies will be willing to accept this patient population and do the dressing changes at the house. So we do the dressing changes for the line once a week in our clinic. People randomized to treatment as usual get standard follow-up for both opioid use disorder and their infection. So Mr. B was enrolled in our study. He actually was randomized to the outpatient intervention and was discharged with the line in. He had a 20-day hospitalization, and at the time of discharge, he had 24 days left in his planned antibiotic course. He was seen twice weekly until the antibiotics finished, and then weekly. He received buprenorphine treatment, 24 milligrams sublingual, for three months and then decided to, with his provider, to transition to extended-release buprenorphine and was still in treatment at the time that he finished study participation after six months. So briefly, we're about 60% through our planned enrollment. We've randomized. Now it's a little bit more than 48, but the common exclusion criteria are a lot of social determinants of health, so distance, people don't have transportation, they don't have safe housing. A lot of patients leave patient-directed before we're able to complete screening. They may not want buprenorphine treatment. They prefer methadone, or maybe they don't want MOUD at all, and a minority have not wanted to participate in a study or had concerns about their own safety going home with a line. So I wanted to share just a little bit of our 12-week safety data, because I think that's the biggest question that comes up, well, is this safe? People are very worried about this line. So because it's such a medically sick patient population, we've had some deaths in the study, which we anticipated, but none of them have been in the outpatient space when they've had a line in. And then we've had a number of readmissions related to an injection-related infection, and in both groups, things are fairly balanced between the two groups right now. And there have been some hospitalizations for reasons not related to the infection, as well as a few non-fatal overdoses. The PICC problem, I just bring that up, but it was not a serious adverse event. It's an adverse event in that one person had bacteremia, and there was one person in treatment as usual that had in-hospital use of the line, actually while they were still in the hospital. So overall, this study is ongoing, and some kind of preliminary observations are that social determinants of health, like housing and transportation, are fully a third of our exclusions, and it's a major barrier to just OPAT and outpatient models generally. You can't safely manage an indwelling catheter in someone who's unhoused, and so it brings back these questions about medical respite and other safe environments that people can complete a course of IV antibiotic therapy if that's necessary. There's been a lot of stigma and misunderstanding from the medical team each year with new faculty and new hospital medicine physicians that come in. We are explaining again that, yes, we're actually going to let some patients go home with the line, and they're enrolled in the study, and no, it's okay. They're not personally liable if they let the patient go home. As this case illustrates, there's still a lot of criminalization of addiction in the hospital, particularly within hospital use, and though we've made progress, it does still happen, and then a pretty major limitation is for people that want methadone. So right now, there's no integrated models for people wanting methadone treatment that need prolonged courses of IV antibiotic therapy. So hopefully, as we continue enrolling this study, we'll help demonstrate whether this model is safe and feasible and is part of the options that we can develop to improve the care continuum post-hospitalizations for this vulnerable population. That's it. Thank you. Great, thank you. I'm Michelle Lofval. I'm a psychiatrist, and I'm our outpatient medical director of the Bridge Clinic. We're a lot of the patients when they're discharged from the hospital or they're coming from the emergency room, they'll come to this outpatient low-barrier clinic. So I'm going to talk about some of the traumatic experiences, rates of PTSD and other psychiatric disorders among hospitalized persons with these serious infections and opiate use disorders. This is where we frequently are interacting with our internal medicine surgical hospitalist and also making phone calls to the Legal Action Center or emailing the attorneys that we like that help us, and they're not here to harm us. They're here to help advocate for our patients. That is just a huge thing that we wanted to bring to the conference, too, is that you answer questions. We know Rebecca. She literally is part of our team, the Legal Action Center, because we didn't know when we started this. Dr. South has really taken this on, and Dr. Fanucchi, too, because there were just so many red flags going on when they were seeing these people in the hospital with these significant addiction that we know is a legitimate illness. So our learning objectives here are to describe the types of trauma among persons who are hospitalized with infections in OUD, how they complicate the transition, but how they could be an opportunity to kind of humanize our population, too, to other persons that are learning and impacting them, and to learn at least two approaches to help patients receive continued medical treatment, which includes psychiatric treatment also. When I say medical, I'm not excluding psychiatry. When they're going from hospital to post-hospital care. So I'm going to talk about Mr. Y. He's a 40-year-old male who injects drugs. He's had three prior opiate-related overdoses. He also has a stimulant use disorder, hospitalized with sepsis, recurrent MRSA, tricuspid valve endocarditis, got pulmonary emboli, and he's been hospitalized before and left as an administrative discharge for the same infection. I think they were suspected in hospital substance use, and he was told that the police were going to be called, and so he took off before the police came. A few social supports outside of other people who inject drugs. His parents are deceased, one of cancer, one due to a fatal overdose. 10th grade education. His work, mostly construction. About more than 10 arrests, mostly drug-related. Not violent, not currently on probation or parole. Lots of traumas. Witnessed fatal overdoses of loved ones, physical abuse as a child. He believes that he could die from this current infection, and he really wants to complete PICC antibiotics this time. It was made clear to him when he came back through the ER, like, very, very ill, that, you know, this is a very significant infection that could take his life. He denies any PTSD symptoms, despite all these traumas, you know, and he's almost somewhat offended, saying, no way, you know, I'm tough. He endorses thoughts of SI in the past, you know, really, because he says he was just tired of his life, of having the addiction. He was screened and offered MOUD by the Addiction Consult Service. He reports a recovery coach and nurse navigator that were part of that team were particularly helpful explaining his options, and he decides to choose to start buprenorphine, and he does well in the hospital with regards to his OUDs in the hospital to get his IV antibiotics. He leaves the hospital with a PICC 14 days, after 14 days, with a plan to go to the Outpatient ID and Addiction Medicine Psychiatry Clinic, that's basically our bridge clinic, where Dr. Funuki explained we'll do the PICC line dressing changes, we'll work with infectious disease to draw the labs through their line that they need to monitor the infection. But the police pick him up on an old warrant and he goes to jail with the pick line. We get called at the clinic and we're hearing that the jail does not have the antibiotic medications and will not get it for him. So they're really kind of suggesting that they're not going to be treating his infection. And the jail also doesn't allow buprenorphine. And he's scared he will die because of untreated infection or return to use. So question is, what would you do if this was your outpatient? Any thoughts? Like, ah, it's one of those days, right, you're here, you're like, oh, my gosh. So you decide to cry? Cry? Yeah, yeah. Yes? Do you have any legal advice that could help me out? Yeah, see, call a colleague. See if there's someone else that can help you out. Call the supervisor. Ask them to do that. The supervisor or the director of the jail. Of the jail. Yeah. Excellent. What would you say to them? Help me understand more about his condition and his case. Excellent. Very good. For his infection and his return to use. Thank you. Opioid use disorder. Cool. All right. You're a smart group. So persons with OUD obviously, you know, have a high prevalence of trauma exposures and PTSD and serious medical illnesses where patients who are often hospitalized for long durations can also be life-threatening and be perceived as traumas that by the individual and also increase risk for PTSD and you can look in the literature and see these cases relate to SARS, COVID, and also endocarditis. So inpatient hospitals are often very ill-equipped not only to effectively work with people who inject drugs but also with having comorbid psychiatric illnesses. I think this contributes to the AMA discharges or patient-directed not uncommon. And the hospital really has been thought of as a very risky environment, a social and physical setting whereby factors external to the individual can bring harm. This may be a particularly risky environment for people who inject drugs and have mental illness. We're seeing in this hospital coming together an interplay between the physical, social, economic, and policy factors, all working at different levels, local hospital policies, state and federal policies. And so I just wanted to put words to this. I think we all go like this frequently and call and everything, but I think putting some of the formal words and terms can be helpful to be advocates to try and get change within your teams and with your administrators. And so one of the things that we've always kind of gone back to when we start to stumble on our words is the four medical ethics. This can help explain to people why you're having a problem because I think most people understand the four medical ethics and agree with them. Autonomy, the right for an individual to make his or her choice. So for example, a person with OUD would like to start buprenorphine or methadone. They should have autonomy to make that choice. Anyone remember another medical ethic? Beneficence. Excellent. So that's the principle of acting with the best interest of your patient in mind. So explaining PTSD, OUD treatment options to patients, hoping for the best, planning for the worst, informing the patient about the role of an assistant U.S. attorney also, potentially. Potentially getting a proactive consent. We get consent to release information to others. If you have someone who you think might be at risk for having an untoward consequence, do you think maybe you want to proactively let them know that there's an attorney that could advocate for them in the hospital setting and have them sign a consent to release medical information to that assistant U.S. attorney? It's public information who that is and how you could do that. Justice is the concept that emphasizes fairness and equality among individuals. So, you know, having an early morning, evening, or walk-in hours at a clinic to try and accommodate all in your community. Does anyone remember the fourth medical ethic? There you go. Non-malfeasance. The principle that above all, do no harm, as stated in the Hippocratic Oath. So an example here, you know, if you're working in the hospital on the addiction psychiatry service, addiction medicine, ceasing referrals to a resource once you know it doesn't employ evidence-based practices. I think we all know places that just automatically refuse to provide MOUD and if you have your patient on MOUD and they want to continue on it, why would you refer to that resource? So I'm just going to share with you some baseline demographic and other information about the participants that you haven't yet seen that Laura told you about from that study. You know, they're young for having these serious injection related infections with a big range from 22 to 60. About two-thirds male in Kentucky. There's a large white population. So it is a predominantly white sample and largely Medicaid. We are Medicaid expansion state and we're happy about that. Employed prior to hospitalization, most not, but about a quarter. Most do not have a high school education, very low income, and lots of stimulant use disorder. It's primarily methamphetamine. And when we look at the types of infections, we see endocarditis, osteomyelitis, septic arthritis, and other types of infection. And the medical more composite score is quite high on the ASI. And I just want to note that the drug use composite is not as high. Sometimes I think part of this is because the composite score is looking at last 30 days prior to when you're doing this. And a lot of people drastically cut down their drug use before they're hospitalized because they're feeling so sick and they're trying not to go to the hospital. Okay, and then can you think of what do you think the most common traumatic experience is among the sample that they that they report as being the trauma? And do you think it would be child abuse, or do you think it would be a life-threatening illness? Overdose death. So I was really curious about this. I really wasn't sure what it was. But the most common was the life-threatening illness. And then second to that was witnessing a situation where someone was seriously injured or killed, or feared that someone would be injured, seriously injured or killed, followed by a car accident. But lots of different types of traumatic experiences. And then when we look at the screening results from, we use the BTQ, which helps screen for traumas that put at risk for PTSD. What we see is that our patients really have not just one, but they frequently have more than three traumas. So that are meeting this criterion. And then when we move on and do the primary care PTSD screen for DSM-5, these are five items asking about nightmares, intrusive thoughts of trauma, avoidance behaviors, derealization, hypervigilance, and guilt, or feeling blame about the trauma. What we see is that about a third of the sample is screening positive. So it's a resilient population despite all the traumas in lots of ways. But I think it's also speaks to, you know, the need that maybe we're not seeing the the symptoms. So it's an important to kind of follow up with patients over time. But again, humanizes the population. We completed a mini on all of the participants and 10% met the criteria on the mini for PTSD. We do see some elevated screens. About a third are having screening positive on the GAD-7 and PHQ-9. And otherwise, you're seeing the common psychiatric diagnoses of mood and anxiety disorders as you would expect. When we do the Columbia suicides screening, what we see with passive death wishes, that a little over a third are endorsing that as a lifetime with the idea that 16 of them are saying that they're really having these sort of thoughts due to wanting to end the pain that they're experiencing. It's not to be seeking attention or revenge on others. And then those with active SI with a method and no intent and without a plan. Some intent in those with a plan and intent. You can see those numbers here. And overall, there is significant risk with the population. It is really, I think, emphasizes the need to screen them for this. There is significant lethality with plans of overdose and hanging. So, in summary, our study patients have significant risk factors for poor health outcomes. These include, but are not limited to, severe opiate use disorder and stimulant use disorder, the infection, limited income, lots of traumatic events, and medical illness being the most common. And despite the high frequency of trauma observed, most participants didn't meet diagnostic criteria. Demonstrating personal resilience. We've seen very high rates of demonstrating personal resilience. We've seen barriers to successful transition, like with Mr. Y. And so sometimes what we did in this case was actually exactly what you suggested. Dr. Finucchi actually has done this several times. This case is not the exact case. It's kind of a conglomeration of many people. But it's amazing how fast they can get discharged from jail when you have someone talking to a judge or their jailor explaining that, you know, explaining the ADA to them and that this is, you know, withholding the antibiotic could kill the patient. It's a significant illness, as well as withholding the medication for opiate use disorder, too. So, some approaches that we've been thinking about to help with the transition period, really trying to normalize harm reduction, providing naloxone at the bedside in the hospital, and giving upon discharge. If you're planning and anticipating a difficult transition, considering long-acting injectable treatments. That's something that we've just published a small case series on. Dr. South is the lead author on that. And having a list of outpatient settings IOPs that do provide standard care treatment, and even considering getting some MOUs in place, so that way your other hospital teams can have those and know where to refer your case managers. Employing and training recovery coaches, peer support specialists, and nurse care navigators to follow during the transition. This is also becoming increasingly popular. It's important that you train, though, this workforce so that they know the evidence base. And this can really help improve health literacy about their medical illnesses and treatment options and help you can train them also on the basics of their protections with the ADA. Let them know what their rights are. Explain to them what a disability is, and how they should be treated, and what some common examples of discrimination are. Help address barriers to care, such as transportation, and alert physicians if there are issues requiring a call or physician from a physician to an accepting physicians. So a question could be, you know, oh, it sounds like you might be saying you have a blanket policy stating you won't treat PTSD if they're on methadone. Is that what you're saying? Educate patients on the role of the Assistant U.S. Attorney's Office, and how they may help. You can, like we talked about, have them sign a consent. So in this case, the study team really was very, acted as an advocate. It didn't take a long time, but it did take time out of the day, and the judge handling the case ended up dismissing the patient from jail. So I just wanted to make these acknowledgments here, and I'm going to now pass this off to Dr. Anna Maria South, and she's going to talk about engaging and educating the future physicians on the ADA, and Dr. South is a hospitalist, and also a member of the Addiction Consult Service. All right. Thank you, Dr. LaFleur. So why do we need to talk about educating other physicians about the ADA, right? I derive a large part of my professional identity as a clinician educator, but also because this really ties together the three portions of the talk we have seen, right? Rebecca pointed out to us that we all see discrimination happening, but unfortunately, it's happening so frequently that sometimes we are failing to identify it as discrimination and just see it as part of the current clinical practice. Dr. Finucchi pointed out that a lot of these patients are seen in the hospital. They're seen by a wide variety of specialists, and then Dr. LaFleur pointed out that this is a patient population that has a high proportion of comorbid psychiatric illnesses, but also that often we as physicians are not able to find the words to actually put into words what the discrimination is that's occurring. So the goal of me developing this lecture for my colleagues was to give them a lot of tools in their tool bag to identify these discriminations, name them, and then know what they can do to work against them. So at the conclusion of my portion of the talk, I hope that I'm going to review the current data that we have from our institution about what physicians know about the Americans with Disabilities Act, and I'm going to go through some of the scenarios that I discussed with my colleagues and see what you guys know after attending the first portion of this talk. So I know you all have different clinical backgrounds, but for this case, we're going to assume that you're an addiction psychiatrist and that you have a patient with opioid use disorder that's on buprenorphine, and this patient is seeking treatment for PTSD. The patient prefers to have a separate provider for their MOUD management and their PTSD, because I know a lot of people can manage both, but this is patient preference here. So you refer the patient to a different outpatient psychiatrist for their management of their PTSD. The patient calls the outpatient clinic and wants to make an appointment, and is told, of course, the clinic would be happy to see them. However, they have to be off buprenorphine for six months prior before they can establish care. So going back to Dr. Lawful reviewing the medical ethics with us, does this seem like a just treatment of the patient, like the principle of justice was upheld? No, right? I see a lot of heads shaking. Do you think that this is a potential violation of the Americans with Disabilities Act, as Rebecca explained it to us? Absolutely. Can anyone explain why? I hear some murmurs, but I can't make it out. Yes, that's a great question, right? Like sometimes we don't know what is a violation and what's not. And I would encourage you to go back to what Rebecca said. If there's a blanket policy that is not an individual assessment, it is probably a violation, right? So it sounds like this clinic has a blanket policy in place, maybe has a blanket policy in place. Like where does the six-month rule come from, right? And then, is there anything you can think of to advocate for this patient? Yes. Yes, absolutely, right? Reach out to that psychiatrist and say, hey, why do they need to be off their buprenorphine? What else could you do? Yes, absolutely, right? See if there's somewhere else the patient can go. Make sure they get the care they need. Okay. And this is also something, you know, that is a potential ADA violation. So you could reach out to your friends at the Legal Action Center or other, the assistant U.S. attorney for your district and talk to them and say, hey, what do you think? Is this a potential violation? Is this something that should be reported? And it actually turns out this case, this is a real case of a patient in Kentucky. And this was an ADA violation. So what happened is that clinic had a practice of pulling everyone's CASPER, which is our internal opioid prescribing, like for the state program. And they looked to see if the patients were prescribed opioids or buprenorphine. And if that was the case, they wrote on there, in six months if off. So it was actually written on the actual document that was pulled. And that led to a settlement that I have cited here at the bottom of the slide. And in the settlement, basically it said that this was discriminatory practice and that the clinic was not allowed to withhold medical care from a patient for being on MOUD. As Rebecca explained to us, that's an ADA violation. And if for whatever reason they were not able to treat the underlying condition because of the opioid use disorder, they had to still assess the patient and then refer them to somebody else that can. So a way to think about that, too, for example, if an orthopedic surgeon specializes in knee surgery and someone comes to them wanting shoulder surgery, they would still be obligated to like refer that patient and say, hey, go to this clinic instead to do your shoulder surgery. And in addition, the clinic also had to educate their entire staff on what the ADA was and what discrimination under the ADA was. And then they had to put up flyers and notices everywhere for patients to say, we are going to be in compliance with the ADA. And if you are being discriminated against, here's where you file a report. So why did I choose this case? Well, first of all, I chose it because it was in Kentucky. So where I practice and where I'm familiar with. I also chose it because as Dr. Lawful said, this is a patient population that experiences a lot of trauma. And a lot of patients might have a comorbid opioid use disorder and PTSD diagnosis. But then I also wanted to highlight it because this was a case where the patient actually made the report to the assistant U.S. attorney for our district. And that's noted in the public settlement. And the patient here, I just want to highlight the resilience that this patient had, right? They were in an extremely vulnerable situation where they were experiencing active symptoms of their PTSD. And because they were being discriminated against, their symptoms actually worsened. And this patient became suicidal, their depression worsened, but despite all of that, they were able to maintain their recovery. So I just want to highlight the resilience this patient has. But then also, I hear that answer commonly, refer this patient somewhere else where they can get treatment. But that doesn't diminish the fact, right, that they were experiencing discrimination and the discrimination alone was extremely harmful to the patient. And that leads me to why is it so important that physicians understand the ADA? Our patients are going through a lot. They are dealing with their opioid use disorder, their PTSD, and now they also have to advocate for themselves. So a lot of times it's easier for us to take that role as the advocate for them. So some of these are going to be low-hanging fruit. This is a recall from what do you remember from Rebecca's talk. Is there any clinical scenarios where you can imagine an ADA violation that you could report is occurring? I see some nodding. What are you thinking? Yeah, so getting someone to a SNF for IV antibiotics if they're on MOUD, and that's something we see in Kentucky, too, and as Rebecca mentioned, there's multiple settlements. I think that's actually probably one of the areas where there's the most settlements that I'm aware of. And still, even though there's so many settlements, people are still discriminating against our patients. Any other scenario? Yes? Yeah, right. So certainly something that smells like, is this discrimination against this patient? Absolutely right. I think that is one of the very common ADA violations that we see that people

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rights protection

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opioid use disorder

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