The role of medication-assisted treatment in behavioral health

0:02

Well, thanks everybody.

0:03
I think we're going to go ahead and get started.

0:06
So my name is Greg Paramantis, Craig Mantis, Parmesan, pair of mattresses, pair of Peaches, last names, you know, Greek.

0:15
So it's a little long and everything, but it's not my last name that's important.

0:18
It's the content we talked about today.

0:20
So I am a clinical pharmacist at Genoa.

0:23
I'm a program manager in the Sud space.

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I've been with Genoa for four years and most recently I was a site manager in Northern Indiana.

0:33
But now I am the program manager for SCD products here at Genoa.

0:38
And then prior to that I've spent about 25 years in traditional pharmacy.

0:42
My Co presenter today is site manager and pharmacy pharmacist Christine King.

0:48
I chose Christine because of her expert knowledge in the subject and then also because we work together with some of the products.

0:56
And I know that I could always count on Christine for great content, thorough information and just being a great resource, especially because she works day-to-day with patients and our providers.

1:08
So I'll go ahead and kick it over to Christine to let her introduce herself.

1:12
Great.

1:12
Thanks, Greg, and I think you will forever be known to me as Greg Praying Mantis from now on.

1:19
But good afternoon, everyone.

1:23
Like Greg said, my name is Christine King.

1:26
I've been a site manager for Genoa for the last 13 years now and both in Saint Petersburg and Newport Richey, Florida.

1:35
I've also been a board certified psychiatric pharmacist for almost 7 years now.

1:42
Psychiatry actually is a relatively new specialty for pharmacist, so there aren't a lot of us around.

1:52
So I'm not surprised if maybe you haven't heard of a board certified psychiatric pharmacist before.

2:00
I think the healthcare industry still kind of struggles with where to put us or what to do with us.

2:07
But in general, we have specialized education and training to help counsel patients, to educate prescribers, to help people with access to medications and also to provide therapeutic recommendations as a collaborative clinical team member rather.

2:31
So thanks, Greg.

2:31
I will kick it back to you to start the presentation, It's Christine King.

2:37
So, you know, just kind of thinking about why we're going to talk about medication assisted therapy or treatment MAT therapy.

2:44
We have to kind of step back and talk about the history and the role that the opioid epidemic played in where we're at today.

2:51
So kind of looking at the first wave of the opioid epidemic in the early 1990s, we saw a rise in prescription opioid use.

2:59
You know, I think everybody's heard the stories and seen the Netflix shows about pill mills and Oxycontin and everything that was kind of tied with that, not as good regulation with it and didn't have full understanding of the medication.

3:13
Fast forward now 20 years later to the early 20 tens, we have our second wave, which is a huge surge in heroin related deaths because you think about all of the protection that was put in place for the opioid prescription writing and dispensing these patients.

3:29
These people still had a need to find some type of opioid, so they had to relate or to get some heroin, unfortunately, which led to a lot of deaths.

3:39
And then just a few short years after wave 2 in 2013 to now we're seeing this third wave and that's a spike in synthetic opioid deaths, especially with fentanyl.

3:48
So just some key statistics that are shown over 800,000 opioid overdose deaths from 1999 to 2020, three 80,000 opioid related deaths just in 2023 alone.

4:00
And synthetic opioids now account for the majority of overdose deaths.

4:05
So we kind of had to talk about some of the background so that we can get to where we're at today and why we're here today to talk about medication assisted treatment.

4:15
So let's just talk about the impact of the relapse.

4:18
So Matt can can reduce opioid related mortality by up to 50% and improve long term recovery outcomes.

4:26
Kind of looking at this slide, looking at the all 'cause mortality death from any reason, if they're on Matt therapy, it's 0.92 deaths per hundred person years.

4:37
After stopping Matt, it's 1.69 deaths per 100 people years.

4:42
And without any treatment at all, it's almost 5 deaths per 100 people years.

4:47
So that kind of shows just all 'cause mortality that staying on Matt cuts the risk of deaths by more than 80% compared to compared to no treatment at all.

4:56
Looking at overdose, overdose mortality, death from overdose specifically, while on that it's 0.24 deaths per 100 people per year after stopping at rises just a little bit to 0.68 deaths per 100 people per year and then without treatment, 2.3 deaths per 100 people per year.

5:15
So again, Matt dramatically reduces the risk of dying from an overdose.

5:20
So Matt works and we just have to, you know, find a way to work on it together, right.

5:27
So with that, we're going to go ahead and ask you all a question.

5:30
What is the biggest barrier you face your clinic faces in that therapy, in that services?

5:37
Is it lack of trained staff?

5:39
Is it limited patient education?

5:42
Is it regulatory or, or reimbursement challenges?

5:45
Is it medication access issues?

5:47
Or if it's something other, can you please put it in the chat?

5:53
Then we'll discuss the results once they're posted.

5:57
Oh, and also, Greg, I'm sorry to interrupt.

6:00
I don't believe I mentioned that throughout the presentation.

6:05
If anyone has any questions, please type your question into the chat so we can respond to that.

6:13
Thank you.

6:14
Good call out.

6:24
Great.

6:25
So mostly what we see is thinks we're still having some people poll.

6:30
So that's pretty cool.

6:32
Nice to see this live as it goes through.

6:36
So it looks like at 41%, it's a lack of trained staff, which I could fully understand.

6:42
There's a lot of changes, there's a lot of regulation.

6:45
We're going to talk about some of that today and and overcoming some of those barriers.

6:50
The next largest percentage is regulatory or reimbursement challenges.

6:54
Again, it goes with the training, it goes with the all the paperwork that has to go with it and with that time.

7:01
And obviously reimbursement challenges are always a concern whether we're talking about when we're talking about prescriptions as well.

7:08
The next largest percentage is 19% of medication access issues.

7:13
We see that a lot.

7:14
We see a lot with these medications.

7:16
There's some new ones out there that are over $1000 retail just for for one dose.

7:22
So we know there's some access issues as well.

7:25
And then at 15% limited patient education, we always know that that's going to be a barrier to care and we'll talk about some of the ways that we can talk about moving forward with that.

7:35
So thanks everybody for your responses.

7:37
I appreciate it.

7:41
So let's, let's talk about understanding medication assisted treatment or MAT and why is this important?

7:47
You know, as a pharmacist, I, I have this one word in this slide medication, right?

7:51
My eyes light up.

7:53
Drugs are my world.

7:54
It's how I work.

7:55
But when we understand mad, mad has really evolved from, you know, where we were in the 20 tens to where we're at today.

8:04
It's not just medication, it's a, it's a teamwork approach, It's a holistic approach.

8:09
It's trying anything that may work.

8:11
And we're going to talk about some of those things, but I like how we're just using an, I know in healthcare we use acronyms for everything, but instead of just taking the, the, the word medication assisted treatment and calling it that, it's truly is a collaborative piece and it's a A-Team approach that's not just write one prescription, give, get the patient their medication, get a dose and they're going to be better.

8:34
Kind of like, you know, maybe like with cholesterol, blood, blood pressure, we really need to work all together.

8:39
And it's more than just medication that does that.

8:44
So kind of looking at the overview of Matt treatment and therapy.

8:48
So there's comprehensive treatment approaches.

8:50
Matt combines FDA approved medications with counseling to address physical and psychological addiction aspects.

8:57
There's the effectiveness of it that it reduces relapse, improves retention and lowers overdose risk for opioid use disorder patients, which we saw it in one of the previous slides already.

9:09
And then the role of providers, healthcare providers expand Med access by integrating it into primary care and educating patients.

9:16
And obviously, you know just the pharmacy piece of it as well as many of you are tied to Genoa, have Genoa pharmacies within.

9:24
We play a large role in that as well as part of providers and working together in that teamwork atmosphere.

9:32
So let's talk about some of the latest trends that we see out in MAP therapy.

9:37
One is AI and genetic personalization.

9:41
And you know, I thought that was interesting, like AI, what can AI do to help us in these latest trends format?

9:47
But you know, think about a patient that may, may be new to you.

9:51
They've been all over the place on therapy for prescriptions, for behavioral health, for social work, for anything that's out there.

10:00
And just, you know, maybe uploading some of that information into AI and being open to what it what it spits out.

10:07
It may be an option.

10:08
Maybe it's just something that you didn't think of as first line or maybe it's something that came in that, you know, gave you an option to say, hey, you know, I haven't really thought about that.

10:17
And with AII know, you can ask for the specific journals and everything that's related to it.

10:23
So it'll give you the the impact that the, that the study had.

10:27
So it's some good information.

10:29
And I thought that was interesting that AI plays a large role in the latest trends.

10:34
Next we see #2 telehealth accessibility, right?

10:37
Telehealth.

10:37
We first think of rural populations and the need for healthcare and rural populations.

10:42
And there's a huge need for primary care providers in rural health.

10:46
So telehealth plays a huge role there.

10:49
Totally makes sense, you know, get it.

10:51
But also with busy populations, right, Everybody's busy these days.

10:55
People are working multiple jobs, they've got activities with kids.

10:59
You know, how do you find time to make your appointments?

11:03
So if somebody's on the East Coast, you know, maybe telehealth is good because they have time in their day and they have somebody on the West Coast that they could use.

11:12
So I thought it was interesting to see with also busy populations, how telehealth could increase access for patients.

11:18
I'm going to skip over three.

11:19
I'm going to go to #4 just because I like to be that way.

11:22
Peer recovery coaching, I don't think it's really a latest trend.

11:26
I think it's still a popular trend like NA or Narcotics Anonymous or any of those things.

11:31
But peer coaching by individuals with experience offers mentorship, bridging clinical treatment and daily life support.

11:39
Again, it's really important that we work together.

11:42
We see what opportunities are available for all the patients and what works for one may not work for other, vice versa.

11:49
So that pure recovery coaching really plays a big role in that.

11:53
The one that I thought was probably the most interesting to me in the latest trends was the holistic therapies integration, yoga, acupuncture, meditation, they're all integrated into that to promote mind body healing and long term recovery.

12:06
You know, it's not something that we would normally bill for as a as a service, right?

12:10
So we really don't think about it all the time, but it really is true.

12:13
You know, I have a lot of friends that do yoga, but they also go and get their prescriptions or they do acupuncture, meditation in in combination with all the regular processes that are out there.

12:24
So again, thinking about this as we as we work as some of the latest trends in math and again, being open to it and making suggestions.

12:34
Next I want to talk about compliance.

12:36
I think we kind of heard about it a little bit already in couple of the slides that I presented.

12:41
I'm going to go ahead and read some stuff and then we'll kind of see how the the graph kind of correlates to what I'm reading, but I want to make sure I get the numbers right.

12:49
So the graph illustrates a significant decline in patient retention over a six month period in that therapy.

12:56
Initially engagement is strong with 100% of patients remaining in treatment at month one.

13:00
However, by month 2, retention drops to approximately 85% and continues to decline to 70% by month 3.

13:08
This early drop suggests challenges such as maintaining motivation, managing side effects, and addressing psychosocial barriers.

13:15
By month for retention decreases further to about 55%, marking a critical threshold where nearly half of the patients have disengaged.

13:24
This is a pivotal point for intervention where enhanced support, counseling or peer engagement could be beneficial.

13:30
The trend continues downward with approximately 45% of patients remaining by month five and only 35% by month 6.

13:39
This data underscores the importance of long term compliance strategies including personalized care plans, regular follow-ups, and community support.

13:48
Compliance and Matt is not solely clinical and encompasses behavioral and emotional aspects.

13:53
Effective retention strategy should be implemented early and sustained throughout the treatment journey.

13:58
The implications for practice are clear.

14:01
Fostering the supportive environment and integrating motivational interviewing, telehealth, check insurance, and family involvement can significantly improve inherence.

14:10
So we all need to evaluate existing systems and brainstorm innovative strategies to support patient needs beyond the additional stages of treatment.

14:18
So again, just looking for a month one to month 6 and the huge decrease.

14:22
So what can we do to keep these patients compliant and that teamwork approach that we're going to talk about next.

14:29
So next, I'm going to pass it over to Christine to go over some of the other regiments that are out there.

14:35
Great.

14:35
Thanks again, Greg.

14:37
So we're going to focus in a little bit now and we're going to talk about some of the MAT medications that we use.

14:46
So as you can see on this slide, we present 4 common treatment modalities and these are kind of listed in order of their length of time on the market.

15:01
So the oldest to the newest treatments that we have.

15:05
So the the different options do require varying levels of supervision.

15:12
They have different patient adherence rates and different regulations.

15:18
So first listed here you see methadone.

15:22
So methadone, as many of you know, is an oral opioid medication traditionally used to decrease cravings for opioids if abuse and to prevent opioid withdrawal.

15:36
Most people have heard of methadone clinics, and these are clinics where individuals would go to receive their methadone treatment.

15:48
And these clinics, they typically come with a variety of restrictions.

15:53
Zoning can be incredibly difficult in opening methadone clinics.

15:58
Unfortunately, they're faced with a lot of stigma.

16:03
So a lot of times you'll see communities not wanting these facilities.

16:11
Also, it can be restrictive for patients as well because patients have to show up to the clinic for their medication and often be observed taking the medication.

16:23
So sometimes a patient can be required to show up daily for for that medication.

16:32
Next on the list, as kind of our medications evolve, you can see oral buprenorphine.

16:40
And in my experience, this really became kind of the staple of MAT.

16:50
So oral buprenorphine is a partial opioid agonist, which means that it's abuse potential is going to be a little bit less than methadone.

17:02
It is available as a sublingual tablet or a sublingual film strip.

17:09
It's manufactured as both buprenorphine only products as well as in combination with naloxone, which is an antagonist medication that prevents it from being abused.

17:23
So in a very similar way to methadone, oral buprenorphine is going to replace any opioids of abuse and prevent withdrawal, unlike methadone.

17:36
And kind of the reason buprenorphine products replaced methadone in a lot of treatment settings is that it can be dispensed in an outpatient setting by a pharmacy.

17:48
So this gives the patient the autonomy to oversee the administration and the handling of their own drug outside of having to show up to that clinic everyday.

18:01
So moving forward, you see naltrexone that is an opioid antagonist.

18:08
So basically this medication works in order to help decrease cravings for a drug as well as if a patient were to happen to take an opioid, it could potentially precipitate withdrawal.

18:27
So outside of the oral naltrexone tablets, we also have a long acting injectable product which you may be familiar with under the trade name Vivitrol.

18:39
So this is an intramuscular injection.

18:42
It is a long acting injection that lasts for an entire month.

18:47
I think the trend has been over the recent years to encourage long acting injectables because it can offer convenience for the patient of not having to take a daily medication and also for the healthcare team and the prescriber.

19:07
It can take away the guesswork of knowing if your patient skipped their medication or if they've been consistently taking their medication.

19:18
So finally, we're going to get to kind of the newest front, which is very exciting for us in the pharmacy world.

19:26
Now we have a long acting injectable buprenorphine and these are available under 2 trade names.

19:34
You can see here both Sublocade and Brixati, they're both administered subcutaneously and they're available in both weekly and monthly doses.

19:47
So really these long acting buprenorphine injections combine the best of both worlds.

19:54
So we're going to be able to prevent withdrawal as well as providing that dose inconvenience and eliminating any adherence gaps.

20:05
So moving forward, we're going to take another poll here.

20:10
So which patient population do you frequently service with MAT services?

20:19
So these the choices here are adults with opioid use disorder.

20:24
This could be either inpatient, outpatient, potentially residential.

20:29
Our second choice and I think one of the tougher patient populations to find services for are adolescents with substance use challenges.

20:40
It could be justice involved populations either post incarceration or I know sometimes there are bridge programs for people kind of at the end of their incarceration.

20:53
And then there's another category.

20:55
If you have a unique example, please answer there.

21:00
And so we can see, OK, So that was very quick.

21:11
OK.

21:12
And I can see that most of you have a very similar experience to mine and that the majority of my practice is adults with opioid use disorder, whether they be in crisis unit, residential or outpatient.

21:29
Some someone also mentioned Co occurring outpatient mental health.

21:34
So yes, dual diagnosis or multiple diagnosis is very common, particularly in the community mental health world where I practice.

21:45
OK, justice involved as well.

21:49
OK, great.

21:50
So I see a lot of your experiences are are very similar to to what I see in my community.

21:58
Great, thank you for that.

22:01
All right, so next we're going to hone in a little bit more and we're going to talk about those long acting injectable buprenorphine products.

22:11
So as I said before, they're available under 2 trade names.

22:16
They're subcutaneous doses, variable doses either weekly or monthly.

22:23
So going forward, I want to talk a little bit about clinical outcomes.

22:28
So injectable buprenorphine shows 40% opioid abstinence at six months.

22:35
So that is very significant and I think we'll start to see further clinical results as time moves forward.

22:47
These are relatively new products, but considering the the mechanism and how it's administered, it shouldn't surprise us of that we have such a favorable outcome.

22:59
So medication does reach steady state in about four to six months for either product and people tend to maintain that steady state for over a year.

23:12
As I said, those weekly or monthly regimens can support autonomy and retention.

23:18
And also when we know those patients are coming into clinic for their injection while they're getting their injection, it provides a perfect opportunity to check in with the patient to counsel them on any injection side effects.

23:35
And there's also variability of injection site that the patient can have some participation and some buy in with.

23:44
So that can help improve adherence as well.

23:49
And I want to talk to the point where injectable Bute shows 40% opioid abstinence at six months, kind of keeping in mind that compliance chart that we had at the beginning where we only have 35% of patients that actually make it on therapy by month 6.

24:04
So I think that's a good correlation to bring the two together that if we can get them to that six month phase, we get that abstinence that much quicker and it will increase outcomes in the long run.

24:15
So thanks for bringing that up, Christine.

24:17
Yes, absolutely.

24:18
Thanks Greg.

24:21
So now we're going to talk a little bit about real world impact of MAT.

24:26
So again, speaking from my own clinical experience, I find that for patients willing to commit and to really buy in to buprenorphine as a long acting injectable, they do find a greater sense of security that ultimately I think makes them less likely to relapse.

24:50
And also we have the security that we know they're not missing their oral doses.

24:57
Actually I'd like to share.

24:58
I recently had a patient who had been stable really for a long time on Suboxone strips and she was doing well, but sometimes I could tell she struggled a little bit with some anxieties.

25:15
So we actually switched her over to one of the Sub Q buprenorphine products and she's just really done very well.

25:26
She used to have a lot of anxiety about either losing or having her Suboxone stolen.

25:33
I've also had patients tell me that they were fearful that law enforcement was going to confiscate their their medication, their Suboxone, or their Subutex.

25:45
And unfortunately this does happen sometimes.

25:49
So we see this in the community.

25:52
So this same patient, she once actually, she came into the pharmacy, she had actually washed and dried some of her Suboxone strips in her laundry and she came to me and she's like, Christine, what do I do with these?

26:06
You know, I can't like I need my medication.

26:09
I know it's a controlled substance.

26:10
I can't get early refills.

26:12
So it, it really took some kind of snaggling to figure out how we were gonna get her medication replaced for her.

26:23
So thankfully now she doesn't have to worry about carrying meds around with her everywhere and she doesn't have to worry about taking it three times a day like she was.

26:33
So now she comes in just once a month, she gets her injection and she's good to go.

26:39
She comes into the privacy of the clinic and she's good for a whole month.

26:44
So ultimately, I find the option of an Lai can help reduce the stigma of MAT as well.

26:53
I've had some patients tell me that they really tend to feel stigmatized or they they feel anxious if someone finds out, for example, that they're picking up these medications at the pharmacy or that that somebody sees them in possession or using these medications.

27:13
So I think for all those reasons, that long acting injectable option is a really great one for patients.

27:26
So now I'm going to throw it back over to Greg and he will go ahead and take it away with the next slide.

27:36
Thanks, Greg.

27:37
All right.

27:37
And for those experiences too, Christine, we really appreciate those real world experiences that you have and how they impact us, us all, so we can think about different ways of helping our patients, right.

27:48
So just want to kind of follow up just a little bit on the injectable buprenorphine piece.

27:52
There's been some recent policy changes that now allow trained pharmacist to administer these products at the pharmacy.

27:59
And we're getting some great feedback where the pharmacist that are doing this find that the patients find the pharmacy is a great spot for them.

28:08
They already know the pharmacy team as well.

28:10
They come in, they get their their injection and just like they're used to getting a flu shot at a retail pharmacy as well.

28:17
Obviously there's additional paperwork and everything that goes with it, but they like the flexibility of coming to the pharmacy and just the scheduling that's available.

28:25
There's expanded access, especially in rural and underserved areas via telehealth.

28:30
Again, having that pharmacist that could administer in some of these places for injectable buprenorphine where where telehealth is and the roll spots and then just the role of the pharmacist.

28:42
The other still some, some REMS work and some protocols that need to be coordinated and done with and then coordinated again with the prescriber for treatment options and what the next steps are.

28:55
So let's move forward a little bit and talk about integrated care models and behavioral health.

29:00
Again, it's not just one prescription, one pill, 1 result.

29:04
It's it is really integrated care model and how we all work together to come up with a solution that's best for each individual patient.

29:14
So let's talk about some of the models we have collaborative, collaborative and primary care models.

29:19
So collaborative care models use team based approach, integrating primary care providers, behavioral health specialist and case managers, case managers for coordinating patient care.

29:30
There's primary care behavioral health embeds behavioral health consultants directly into primary care to provide immediate mental health access for patients.

29:39
Kind of sounds familiar, Maybe that's a lot where Genoa is embedded in a lot of primary care behavioral health spaces.

29:46
And then also the benefits of integrated care.

29:48
Integrated care models improve outcomes, enhance provider collaboration, reduce cost and support tailored interventions for complex needs.

29:56
And again, how do we all work together, not just thinking about or or thinking about adding pharmacy into all these groups.

30:04
How do you add a pharmacy?

30:05
And how do you, how does the pharmacy team help benefit these programs, especially like Jenna was when they're embedded in a lot of their primary care behavioral health spaces along with you folks?

30:21
Well, let's talk about CMS innovation and integration.

30:25
As we know, CMS Center for Medicare and Medicaid Services does a lot of determination of everything that we do everyday.

30:31
So we really would need to see what they're talking about.

30:35
They have a a program called Innovation and Behavioral Health Model that forms interprofessional teams combining behavioral, physical health and social support services to provide comprehensive care.

30:47
There's health IT and data sharing.

30:49
So it supports development of IT infrastructure to enhance data sharing and care coordination around providers.

30:56
You know, just thinking about health IT and you know, a patient that may come to you doesn't give you the full history, but once you start to look at some of this data sharing and information, you get a full scope.

31:08
So it's good to understand what the background of what these patients have actually tried and started.

31:13
I really like this one a lot.

31:15
It's the no wrong door approach.

31:17
It ensures patients receive comprehensive care regardless of their entry point into behavioral health systems.

31:23
And you know, we kind of talked about it with the latest trends, whether it's AI, whether it's yoga, whether it's telehealth, or even just peer coaching.

31:32
And then it just addressing social determinants.

31:36
It incorporates social factors like housing and transportation to offer holistic behavioral health management.

31:45
Moving on, let's talk a little bit about some of the tool kit and training that's available for providers.

31:50
So they're structured input.

31:51
The structured implementation approach.

31:54
Implementing that requires required education, stigma reduction, and outcome monitoring for effective primary care integration, provider education and training.

32:04
Training covers medication protocols, patient engagement, cultural competence, and obtaining unnecessary waivers.

32:11
Toolkit resources.

32:12
There's plenty of toolkits out there that are available from expert organizations that offer practical guidance emphasizing whole person care and evidence based practices and then also clinic workflow and optimization.

32:24
Addressing staffing, workflow integration and data tracking.

32:28
Support Sustained optimize map programs.

32:31
So again, we talked a little bit before about how it's working together with all the clinicians that are available, but then within your own practice, how do you start to work and look at each different step to make sure that each patient is taken care of and how do we like just addressing workflow?

32:47
I was kind of surprised when I saw some of that information, but it makes sense, right?

32:51
Addressing staffing and knowing some of the things that go on, understanding the regulations that happening, not just the training and everything else, but all the tool kit resources that are there to help us think outside the box and that no wrong, wrong door approach.

33:06
So just some key takeaways from today, Matt.

33:09
Significantly improves outcomes for individuals with opioid use disorder.

33:14
I think we saw that drastically throughout the presentation today.

33:18
Integration into primary care and behavioral health models is essential for expanding access.

33:24
So again, it's not just A1 prescription, one dose approach, it's not just one provider, it's all of the clinicians.

33:31
It's working as a team, coming together and trying anything that will work, right.

33:37
Throw it at the wall, see if it sticks type of model because everybody could be different.

33:41
And if we have one thing that helps, maybe it will, it will be working for this patient.

33:46
Provider education, patient centered care and innovative approaches like injectable buprenorphine are transforming treatment delivery.

33:53
So we have to think outside the box as new things come along, as there's new opportunities, new medications, AI, everything that's out there we need to think about to see if we can work together.

34:04
And then most importantly, let's continue working together to improve lives through compassionate, evidence based care.

34:10
So with that, I want to thank you for your time today.

34:13
I also want to thank my Co presenter Christine for her valuable information and her expertise.

34:19
I hope you've learned a few things from today's presentation and if there's questions that we haven't answered, we will definitely follow up with you and get back to you.

34:28
Thank you, everyone.

34:28
Actually, Oh, I'm sorry, just one second, Greg.

34:32
Actually we did just have a question pop up in the chat and actually this is a great question.

34:40
So someone asked if we have any suggestions for patients who have sickle cell disease and opioid addiction.

34:49
So this is a tough one.

34:54
I yeah, I mean, I have patients with different physical handicaps and disabilities and challenges that have traditionally been pain patients.

35:09
I know traditionally for sickle cell morphine pumps, I think are probably the most commonly used and recommended as far As for folks with addiction, I'm not sure if there are any cut and dried guidelines, but I can definitely look into that for you and, and we can maybe get you an answer for that, that if there is one out there.

35:43
We also of the question, how is the pharmacist integrated in the clinical team and documentation?

35:52
So great question as well.

35:55
Thank you for that.

35:57
So I think it really depends on the setting.

36:01
For example, where I work, I manage the outpatient pharmacy and I service our residential recovery units.

36:12
We also have an inpatient pharmacist that works for my clinic.

36:18
And that pharmacist, she actually rounds with the clinical team and she conducts patient education sessions.

36:29
And you know, she has her own SOAP notes just like any other clinician would as far as like nursing staff, caseworkers, therapists, physicians, etcetera.

36:43
For myself in particular, as outpatient, I do a lot of consultation for providers, caseworkers, administrators, etcetera.

36:55
So anything I missed there, Greg?

37:00
Oh, I think you did a great job of answering those.

37:02
Maybe I'll once 11 more piece about the documentation piece.

37:06
You know, for outpatient with injectable buprenorphine, there's different consent forms that we document.

37:13
There's the physician notification letter that's sent out with every injectable that has the documentation piece as well for feedback back to the provider and notification.

37:22
So just wanted to comment on that.

37:27
OK.

37:28
I have another question coming in.

37:31
In the setting where I work, by and large, most patients are taking Suboxone films and not Sublocade.

37:39
Should patients be offered Sublocade initially or tried on Suboxone first?

37:45
Also, where can I locate these pharmacists who administer MAT?

37:51
So Greg, I think I'll take the first part of this question and maybe you should take the second.

37:58
So in general, I am a fan of long acting injectables, whether they be for MAT or whether they be for serious mental illness that they be offered as an option first time and every time.

38:18
Now in the beginning of recovery and in the beginning of opioid use disorder treatment, supplicating may not be initially clinically appropriate.

38:31
So of course, at first you're going to want to make sure, number one, that these patients have a tolerability to the medication.

38:42
And then #2 you want to make sure that you're not going to precipitate withdrawal.

38:47
For example, I had a patient once who even though she she had her UDS, she tested negative for everything.

38:59
You know, she said she didn't have any other drugs on board.

39:03
Well, it turned out she didn't realize that the supplement kratom can actually precipitate opioid withdrawal if somebody takes a partial agonist or an antagonist like naltrexone along with that.

39:18
So had that patient not had that oral trial ahead of time, then that patient would have had a much more serious withdrawal period than just that single oral dose of Suboxone.

39:33
So you know, definitely I think oral 1st and then at every encounter as they progress in the recovery, we're talking to the injection about the injection option with them.

39:47
So Greg, how would you recommend that people can locate pharmacists who can administer MAT?

39:54
And let me just step back for a moment.

39:56
For both injectable buprenorphine products, you have to have at least one dose of oral Suboxone within 24 hours of the first injection just to make sure there's no allergic reaction to to the oral to the buprenorphine product itself.

40:10
So that is a requirement for for both products.

40:14
And then where can I locate pharmacists who administer Matt therapy?

40:18
You can go to the manufacturer's website for the provider piece.

40:21
And then they do have like a physician or a pin locator, pharmacy locator, administration locator piece.

40:29
But most importantly, talk to your general pharmacist.

40:32
There's certain things that we can do or certain information that we can get back to you.

40:36
So your general pharmacist is always a good resource as well.

40:40
Also see a comment in the notes or the questions about what's the recommendation be first on Suboxone oral, then transition to injectable or can we go straight to injectable?

40:50
I think we kind of covered that a little bit based on what Christine said, but at least one oral dose of buprenorphine needs to be administered before patients can go straight to injectable.

41:02
And then just kind of noting that with both products, there's either a rapid induction phase or a weekly dose that is available to see how patients tolerate it before moving on to a full monthly dose as well.

41:17
Great, awesome.

41:19
Yeah.

41:19
So if there aren't any other questions, I know Megan had put in the the chat about what the next steps are if people some people asked about are we able to print it?

41:30
So the recording will be sent out to all registrants without the within the next week and you can pull the resources from there.

41:36
So again, we appreciate your time today.

41:38
We thank you for your attention and your questions.

41:42
Again, I hope, I hope you learned something and it was good for us too.

41:47
So thanks again and have a good day.

41:52
Thank you.