Well, greetings, everyone, and thank you for making the decision to take the board review course and to become certified in addiction medicine through the American Osteopathic Association. This is the board review course from the American Osteopathic Academy of Addiction Medicine, and the discussion for this presentation is telemedicine for substance use disorder, including medications for opioid use disorder. This is a moving landscape by far. My name is Anthony Decker, Tony Decker. I'm an addiction medicine specialist and certified. I live in Phoenix, Arizona, and I have my email at the bottom of the document here, and the last slide has that, too. So we are... We are moving ahead to discuss disclosures. I have no conflicts of interest regarding this educational program. I don't take money from pharmaceuticals or for-profit organizations. I retired after 37 years with the federal government after working with the Indian Health Service, the Department of Defense, with the joint staff in the DC area, the Veterans Administration, but I do not report to nor do I represent any federal organization. I am currently the Chief Medical Officer for the Division of Developmental Disabilities for the state of Arizona for the past three years and probably for the next year. And I do not represent any state organizations in this educational program. Now, keep in mind that telemedicine is a very fluid situation in regard to regulation and practice, partly because of the PHE, the public health emergency that occurred with COVID-19, and also because of the epidemic of opioid overdose deaths that are occurring. Each state is their own jurisdiction, and in some states, the county is the jurisdiction, such as California. This program is effective and up-to-date, effective September 2024. So our objectives for this program, by the completion of this program, you should be able to do the following. Number one, discuss state and national laws regarding the practice of medicine. Remember, that's a state jurisdiction or a county jurisdiction. Prescribing medications, and that includes both controlled through the DEA and the non-controlled medications. Requirements for the Controlled Substance Act, which has changed significantly during and after the PHE. And record-keeping requirements during the use of telemedicine services, keeping in mind that electronic data systems are vulnerable and highly vulnerable, and there's all kinds of bad guys out there that are trying to steal information and misuse and abuse people who you're serving. Document appropriate history and screening activities, including the physical examination. Laboratory evaluation, collaborative practice with other providers in the evaluation and treatment of substance use disorders, including opioid use disorders. And understand that telemedicine differences from private and organizational practice versus opioid treatment programs in the US. And there was just decisions made in the spring of 2024 from SAMHSA and the federal government that allows an expansion or an easing of the restrictions in regard to the Controlled Substance Act and also methadone treatment. So what is the definition of telemedicine? Well, it's interesting because it's a very fluid definition too. In the state of Arizona, the definition of telemedicine and the telemedicine network was highly developed through the University of Arizona back in the 70s, 80s and 90s. The definition is the use of any electronic device and an electronic health record. Well, cell phones are electronic devices. So if you were using a telephone or a cell phone and electronic health record, it qualified as telemedicine. Keeping in mind that wifi and broadband capacity was significantly limited until the early 2000s. Some states define telemedicine as any electronic communication that utilizes a health record, as I said about Arizona, but it is very different and very fluid from jurisdiction to jurisdiction. So bi-directional, synchronous, live action video conferencing, it connects a provider with the patient in a real-time fashion for direct patient care delivery. This is currently the most likely modality recognized by third-party carriers for reimbursement. That allows you to not only have recognition of facial responses and obviously all the audio, but it also allows you to see nonverbal responses and you can even do an examination. Look in the mouth, there are Bluetooth devices, look in the ear, look in the mouth, look in the nose. There's a variety of things that you can do to examine the skin, to look for venipuncture marks, abscesses, boils, things like that. I would not recommend that you do anything that would fall into the category of gynecologic and or genital evaluations. And the reason for that clearly is that the security of transmission is highly suspect in certain carriers. Asynchronous store and forward technology is not bi-directional real-time. It would be, for instance, downloading health records, downloading imaging, downloading photos, or even downloading videos, teaching videos. I think there's a lot of people have patient education components to the telemedicine programs and they tell their patients to look at this and to review this. You can get informed consent signed forms from both commercial or you can develop those yourself. Some jurisdictions do not recognize telephone communication or text messaging or web-based interventions as telemedicine. So again, you will need to know, what is this? And there was a recent decision at the Supreme Court level that has an impact in regard to telemedicine, which now requires a local jurisdiction to make clear what the rules of engagement are. And I do believe that that's going to complicate things, but because it's a very fluid situation, I think that there's going to be reinterpretation and other changes in the future. So in the federal healthcare systems, telemedicine may include a variety of attachments. I worked in the VA and the Department of Defense and they had high levels of telemedicine, Bluetooth connected devices. Typically, the member would go into a waiting room, which was encrypted and saved. That notification would go to the provider. The provider would go into the waiting room. The two would go together into an encrypted meeting area. And if there were any Bluetooth connected devices, which would include scales, blood pressure devices, glucose monitors, pulse ox devices, cameras to examine the body. And it's interesting because the Department of Defense in Alexandria, Virginia, this is going back to 2010 to 2015, when I was in charge of Fort Belvoir's addiction programs, they actually had a virtual hospital in one of the high rises right next to the Pentagon. And they had 32 specialties available 24 seven for around the world access. So if you need to talk to an ophthalmologist and share information in regard to a service member or a dependent who had an eye injury or an eye pathology or biopsy results and share the slides or ICU management of a person who's developed severe complications in the intensive care unit, that is available right now via satellite technology around the world. There's also obviously connection with the International Space Station and other forms of electronic communication. Fort Belvoir Community Hospital is now called Fort Alexander. In 2010 or 2011, when they opened their doors, they had two da Vinci machines. And it was not unusual for surgeons at other military hospitals to be doing surgery on patients at Fort Belvoir remotely. Telemedicine can also be used to check pacemakers and internal defibrillators. They can evaluate and monitor shunt function for ventricular peritoneal shunts, G-tube function, J-tube function, GJ functions, other types of indwelling catheters. The Bureau of Prisons and State Department of Corrections, they utilize a high level of telemedicine, obviously for security reasons, but that allows them to bring in specialists at different areas. In the emergency room, teleneurology, telecardiology is the rule, not the exception, especially in rural hospitals where you can have a specialist 24-7 to make a decision if anticoagulants should be used or if a patient's got a STEMI and where the nearest cath lab is. The Indian Health Service and tribal compacted and contracted programs use telemedicine for specialty consultation and care on a regular basis. One of the problems is that many of the clinics that have Wi-Fi contact have intermittent contact, and so it depends on where the location is and the weather conditions and satellite connection and things like that. So what are the components of a telemedicine practice? Well, like I said earlier, understanding the regulations of practice of medicine in each jurisdiction becomes critical. What may be okay in Arizona may not be okay in Maryland. Understand the differences between being a federal employee using telemedicine services versus a state employee versus being a private company employee versus being a private practitioner or a organizational practitioner. Usually when you're a federal employee, you have to function under your state license, but it's not limited to the state that you're actually practicing in because you're on federal property. So when I was practicing at the Gallup Indian Medical Center, I was licensed in Arizona. It was fully appropriate to do so. Now, anyone who has a state or a federal employee is eligible to receive a no-cost DEA only for that activity. So I would have a private DEA that would be used for my private practice and I would have to have a DEA if I'm prescribing or dispensing controlled substances for each state I was in. And I would have one state license and one state DEA, I should say one federal DEA for only my federal practice. When I became a state employee, I'm able to get a DEA just for my state activities. So you cannot use that federal or state-assigned no-cost DEA for your private practice. That's a federal violation. So you need to understand the DEA regulations. And one of the things that all of us is aware of or are aware of is the HIPAA, the Health Information Portability Act and 42 CFR Part 2. And in 2024, they added Part 8. So now those are discussed in confidentiality, but keep in mind that the provision of services for patients in substance abuse disorders has a higher level of protection. So everyone should understand HIPAA and we probably all have to take training to show our certification is up to date. But in addition to that, you have to have a recognition of 42 CFR Part 2, which means that there's a higher level of security and confidentiality that the release of information in the area of substance use disorders is associated with 50% of all the successful litigations in the field of addiction medicine. So I wanna say that again, half of all the successful litigations in addiction medicine are related to 42 CFR Part 2. Part 8 is newer. It does allow the sharing of information with people who are actively engaged in the multidisciplinary evaluation and treatment of an individual. The patient still has rights from the standpoint of saying, I don't want my cardiologist to know that I have a history of cocaine use, even though it's related to their infarction. So you need to work with patients to help them understand their Privacy Act, their HIPAA and their 42 CFR Parts 2 and Part 8 rights. But you also need to have release of information with the exception of the Part 8 changes in April of 24, that say that you can release some information. I would highly recommend that you look at those closely. Be aware of the Loper Bright Enterprises versus the Raimundo US Supreme Court ruling. It has a significant change in administrative law in multiple arenas, particularly how the courts interpret the 1994 Chevron Deference Doctrine and it has an impact on telemedicine because now the local jurisdictions interpretation of clarity in the practice of telemedicine is affected. Now that happened just in June of 2024. So the whole field of telemedicine was, I think, supported by HHS with the new rules that came out in February of 2024, which allowed the evaluation and treatment of an individual for the initiation of buprenorphine with just an audio connection. That's a telephone connection. The Controlled Substance Act requires a physical history and examination. That Controlled Substance Act requirement was eased with the use of buprenorphine for the treatment of opioid use disorder. So I'm gonna get to these changes in the near future, but the landscape is changing. It's gone all the way to the Supreme Court and there have been changes that have an impact on the practice of telemedicine. So first steps first. Before a person decides to do telemedicine, and it seems like I get telephone calls, no less than once every two weeks from doctors and providers. Many of them are nurse practitioners that say, hey, I would like to open a telemedicine buprenorphine clinic and I understand that you're a mentor for this process. I'm like, well, I'm on a mentor program with the ORN, but tell me a little bit about what you're asking. I wanna make a lot of money without seeing patients. Well, it's not gonna work. So I'm not gonna recommend anything for you to do. The reality is you need to make sure that you have first the desire and the capacity to work with patients who have substance use disorders. Anybody who says it's easy, well, I'll admit, prescribing buprenorphine is easy. In the past, there was a required eight hour course. That requirement is gone. There is no XDEA requirement anymore. Since 2022, that was dropped. So prescribing buprenorphine, cakewalk. Treating addiction, complicated. And so I wanna make sure that the right people are looking at this in the right way. But from a technology standpoint, if you have a very poor router, or if you have an intermittent bandwidth, or if you decide that you can set up your own system and tag into somebody and borrow your neighbor's wifi, these are all really, really bad ideas. So you need to have a secure, adequate system. Our current technology is G5, although that is changing rapidly. And fiber optics allow very high rates of transmission. So you have seamless video communication. We have four people in our house that are using telemedicine services with bi-directional contact and a 5G fiber optic connection. I know that our system gets overwhelmed at times. Security with an encrypted transmission and storage capacity in secure settings for health information is a critical issue. Everyone has heard about the malware and the viral penetrations that occur and the scamming that's going on with multinational criminals, essentially holding hostage hospitals and universities and government programs. So if you think your system is perfect and cannot be penetrated, you better think again. And I would recommend that you go with commercial services that have some ongoing updates that maximize the security of your systems. Staff training. People who have their passwords stuck on their laptop screen, bad idea. Most secure systems make you change your passwords on a regular basis. You cannot have a password that has more than four symbols that are the same as your previous password. So you can't say password one, password two, password three. It sounds crazy, but even in the federal system, we would have people who would leave their passwords stuck on their laptop. And we actually instructed the service member security guards, check every laptop, if there's stuff stuck on it, photograph it and report it to us because that's something we have to prevent from happening. So staff training and certification on HIPAA, Privacy Act, 42 CFR, part two and part eight, all part of the deal. And many of these trainings are free at no cost, but you gotta be able to do that. Understanding about phishing, spearing, all those other ways that people get into your system. Yesterday, I got an email that says, your time card is not complete. Please enter your time card information. And I thought, a little suspicious. So we have a little symbol on our state operators. It's a fish hook. So I clicked on that and it says, you're right. This was a phishing attempt. And I'm like, those rascals. So just be aware that it's not a innocuous environment that we practice in. Member documented informed consent for participation and acceptance of security systems. So you have to have informed consent for your Privacy Act. And your patient actually gets a document from you indicating your Privacy Act participation. What is HIPAA and how is it being honored in your office, even in an electronic office. If you don't have one piece of paper in your office, you still have huge amounts of data that have to be protected. And understanding what 42 CFR Part 2 is, their rights in regard to confidentiality. The wife cannot call up and say, hey, George can't make it into his appointment, but he wanted to know what his drug screen showed. Unless you have a documented, and that means written or electronic signed, and there's ways for people to sign right on the little pressure pad on their laptop or on the screen. That information is potentially a problem. People use in litigation, especially child custody and child support, the opposite members substance use history as ammunition. This is one of the areas why doctors get into trouble in regard to releasing information to relatives and things like that. Contingency plans for system breakdown and security failures. I mean, one of the things is you already have a consent to your members or to people who you're serving in regard to what the current security system is for Privacy Act HIPAA and 42 CFR. But if there's a breakdown, you have an obligation to tell them. So it's better to deal with that ahead of time than it is to deal with that after the fact. And then are you going to go to paper? Do you actually have paper to be able to go to a system when Wi-Fi goes down or there's a solar flare and everything goes belly up or satellite gets knocked out? So you need to have some contingency plans. I would recommend that you actually have them written down as a policy for your practice. So we already talked about Privacy Act HIPAA and 42 CFR. The use of additional devices is important too, that some patients will say, well, I bought this new glucose monitor, it connects to my computer, can I send you that? Well, you have to decide, are you going to practice diabetes management in addition to addiction medicine? I'm a family doc, so I do that. So I do more than just addiction medicine services, but you have to decide because it's not a device that you purchased and it is an entry into your system. And so it does become a challenge. I mean, I know that when my wife and I are talking, we just magically started talking about burial or cremation. And my cell phone starts sending me all this information on cremation. And so we're being monitored whether we like it or not. If you have an electronic system in your home, I don't know if it was my refrigerator or my cell phone or what. Other devices all the way up to DaVinci machines and other types of communication devices are part of that. You'll have to decide how much do you want to have in that system? I believe technology will get to the point that toxicology screening, whether it's by through transderm or it's by saliva or urine testing could be an electronic device that's actually at the home, could be corrupted. But the thing is, technology is changing literally on a daily basis. Looking for the weak links in your system. And that is an important issue. Stolen devices, stolen laptops, stolen IDs. That's one of the reasons why passwords are changed on a regular basis. And then informed consent for medications for opioid use disorder and understood protocols, missed appointments, refusal to have urine drug screening. We're gonna get to that in a little while, but you need to have these things thought out ahead of time. So from a logistics standpoint, you must be aware of the regulations for telemedicine. And like I said, this is a changing landscape. The Loper Bright changes, we don't even know what's gonna happen with those, but we'll get into some of the state and federal changes that have occurred recently. Crossing state boundaries. You're practicing in Illinois. A patient moves to Indiana. You don't have a license in Indiana. Can you continue to provide telemedicine services? In regard to buprenorphine, the answer is most likely yes. But again, each jurisdiction makes those decisions. And so if you go back to the Ryan Haight case, that was a 18 year old boy in California, Southern California, who overdosed on hydrocodone and died. And the investigation revealed that he had gotten prescribed medications from someone who never examined him and a online pharmacy delivered the medication to him. There was a federal act that was passed. Now we've had some easing of those requirements because of the public health emergency with COVID-19, but we still have significant requirements. To prescribe, you have to have a valid unrestricted license that allows you to prescribe. If that substance is a scheduled med and buprenorphine is a schedule three medication, you have to have a DEA. It does not have, there is no requirement now for an ex-DEA, but you have to have a valid DEA that allows you to prescribe. The Controlled Substance Act, the, and there's also a Controlled Substance Act at the state level in many states require that you have a CSA certificate and or a Bureau of Narcotics and Dangerous Drugs certificate in addition, that's a state certification, in addition to a DEA. Missouri has that situation where I'm licensed and previously practiced. Continuing education requirements. If you're part of a system, most systems will say, well, you have to do a Privacy Act HIPAA every year. You have to do patient confidentiality. You have to do patient rights. You have to do a whole list of things. Keep those certifications in one file. Could be an electronic file, but you can pull those up and show that you're up to date with your continuing requirements. Those requirements, by the way, also are state derived in regard to pain management, implicit bias. I go to a list. Every state has their own list of things that have to be done. Your state osteopathic and state medical association many times have a catch up on your certification day where you can get that done. If you're a member of the organization, typically you get that at no cost. How do you monitor people? Well, that's a big issue because if you physically have never seen a person, you've only seen them through telemedicine, how do you verify that they're getting urine drug screen, which is part of a competent substance abuse treatment program. Ethyl glucuronide, ethyl sulfide, phosphatidyl ethyl, hair and nail evaluations. You don't have to get to that level, but I'm on the state overdose committee for Arizona. And we just reviewed 10 cases last week of American Indians who died from fentanyl overdoses. All 10 had intoxicating levels of ethanol in their system at the same time. So comorbid use of other substances go along with complications in the field of substance abuse treatment. I don't have anybody who's just a fentanyl user. Everybody I take care of are fentanyl and methamphetamine or fentanyl and cocaine, and then alcohol added in. How do you document the history and the physical examination? Well, if you have bi-directional video communication, your head is right there in the screen. As you can see my little head on the side of this presentation. You can also see the patient. And most people communicate by nonverbal communication. So when you ask the question, have you ever been in treatment for substance use disorder in the past? Not really, I didn't really count that. Well, you need to dig deeper. You need to find out what's the details of that. Just because they signed out three days later and they say, well, I didn't really want to. My parents forced me to do it when I was 18 years old if I wanted to stay at the house. So I don't call that treatment. Well, that would be considered a corroborating piece of information in regard to this person's substance abuse history or substance use history. So it does become important to get reasonable history, which includes not only the past social history, past medical history, but also past substance abuse history. And that includes tobacco, vaping, and a whole variety of things that people may use inappropriately. I had an officer in the army who was grinding up two pounds of poppy seeds per day, extracting the morphine with vinegar, and then drinking the supernatant. So there's all kinds of ways that people can get into trouble. And it may not be an illegal substance, but it may be for a misuse or abuse situation. Back to UDSs, you can make arrangements with labs that people will come in, show their ID, and they can have labs on a as needed basis. In other words, you talk to somebody and their pupils are severely pinpoint and you're thinking, well, and the person's got a slow cycle motor speed, they're nodding, they're doing all kinds of things. You say, hey, listen, let's go ahead and get a talk screen tomorrow morning. I'll get you an order in there. Now, if the person says, I'm too busy for that, I can't do this, you're making me pay too much money, you're getting some kickback from the lab, those would be considered not too good signs. I mean, the reality is you have a relationship, which is a dance with your patient. You wanna be as positive as possible to help them make and help them capable of maintaining recovery. But at the same time, you have to check, you have an obligation to check. So someone who says, I never checked the pharmacy drug monitoring program, I never asked for any urine drug screens, I trust my patients, you're not really doing good medicine. I mean, the bottom line is there are standards of practice and those standards need to be adhered to. Psychotherapy and other team members. Now, my wife is a clinical psychologist. She says, you're a really good doctor, do the doctoring part, please don't do the therapy part because it doubles my work when you do that. So unless you're trained in psychotherapy, I would recommend that you not do psychotherapy. Now, I think it's completely appropriate for a person to practice addiction medicine, to be compassionate, to be available, to be compatible, but at the same time, to make sure that the other behavioral health needs and comorbid conditions are the rule, not the exception in the field of substance use treatment. So having other people who are engaged, they don't have to be your employee, they don't even have to be affiliated with you. If the member says, well, I've been to a counselor before, I like working with that person, get releases of information so the two of you can communicate in case systems fall apart. And intermittent loss of recovery is of great concern in the field of telemedicine because patients actually die from this disease. And that's something we're trying to prevent. So I always say a good therapist is worth their weight in gold, so treat them really well, but make sure you have all the required releases. 42 CFR part two, I'm sorry, 42 CFR part eight has eased the requirement, but I still feel that having a release of information is important and a bidirectional release because if the therapist calls you up and say, hey, listen, John Doe has missed the last three appointments, I'm very concerned about him. That should also be of significant concern to you. Now, when it comes to prescribing and dispensing, and when I say dispensing, we're talking specifically of opioid treatment programs. Methadone is not a drug that is prescribed for opioid use disorder, it is dispensed. Methadone can be used as a pain medication. It's a very effective pain medication. It is high patient to patient variability and high temporal to temporal variability in the same patient, meaning that the half-life can be as short as two to four hours or can be as long as 96 hours, depending on the person and depending on the time. That results in some people overdosing on methadone. Now, at the same time, my personal feeling is that methadone is a drug of high utility in the field of fentanyl. Buprenorphine has the ability to decrease the effect of fentanyl, but there's still some mu receptor agonism with fentanyl in a patient who's taking 16 milligrams a day of buprenorphine. So we have lost patients. In other words, patients have deceased because of fentanyl overdoses in the presence of buprenorphine. Not unusual for us to find buprenorphine on post-mortem toxicology. At the same time, the person who is intermittently using fentanyl is at very high risk because they are losing their habituation. The person who's chewing up eight to 10 blues a day is more likely to be able to tolerate that level. Even though the pill to pill variation is huge, 56% of all the fentanyl interdicted in 2023 was interdicted in the state of Arizona. We're number one. But the thing is, is that, so, I mean, we just had a bust in Nogales last week of 5 million tablets and 60% of those tablets for a naive person are a fatal overdose. So when you're prescribing non-scheduled medication, naloxone spray does not even need a prescription. Now you can still write a prescription. Some patients say their insurance requires a prescription to get naloxone nasal spray for insurance to pay for it, but you can go into any pharmacy and just say, I'd like to get a box of two naloxone nasal sprays. You may have to pay the $45 to get that, but that to me is easily worth a life. And, but if you decide to prescribe it, you don't need a DEA. You do not need a DEA to prescribe naltrexone. I would recommend that you have that, a DEA, if you're working with substance use disorders, but it's not a requirement for non-scheduled medications. Keep in mind, there are some medications that people forget are schedule five, such as pregabalit as a good example of that. So when you're prescribing medication, if it is a controlled substance, you must have a DEA. There is no ex-DEA requirement if you are at an opioid treatment program. An opioid treatment program has had significant easing of the dispensing of methadone with the most recent Health and Human Services final rule. We're gonna get into that in the next slide. Collaborative practice. If you have a person who is prescribing scheduled medications, they need to have their own DEA. I get this question on a fairly regular basis when a nurse practitioner or a PA does not have a DEA, but wants to prescribe controlled substances under the physician's DEA. I would strongly recommend that you not do that. Same thing goes when you have trainees. You have, now medical students are not eligible to get a DEA, residents are. So if you have a person who's in a residency at a ACGME approved program, they should have a DEA at the end of year one. Now, sometimes there's issues in regard to who pays for it, but the reality is that practice of using somebody else's DEA or using the institution's DEA is significantly frowned upon by the DEA. So I know that medical students many times will write for prescriptions and then use the institution's DEA. That's a no-go. That needs to be done by a licensed provider. It could be a trainee licensed provider or any other licensed provider. Rural hospitals are getting into residency practice. And so more and more doctors are having residents and medical students report to them, do not give anyone a stack of physical copy prescriptions. Now those are rare and few and far between, but sometimes the system crashes and there's always a stack of prescription pads in somebody's drawer. Do not give anyone signed blank DEA prescriptions. And the reason for that is there's been a long line of your penmanship is different than the penmanship of the trainees, including medical students, nurses, not nurse practitioners. In other words, other people who should not be prescribing medication, but there's a long line of doctors who've gotten into trouble by giving a stack of pre-signed prescriptions. Even if you're not gonna be at a hospital or a clinic and you say, hey, listen, I've got five signed DEA prescriptions in the back of my drawer. If you need them, go ahead and take them. Don't, don't do that. Collaborative practice, many states require you to identify the middle-level practitioners that you're working with. So whether it's a nurse practitioner, DMP, physician assistant, make sure that you have very clear boundaries to what that collaborative practice is and that you've identified that you have them. I would also make sure that your malpractice carrier is aware that you have a collaborative practice. In some states, they don't have complete practice rights. So you need to be aware of that relationship. There's rapid movement of regulations at the county level in the state of California, at the state level, all states, and at the US possession level. And federal level. What happens when a person travels outside the US? This entire presentation is strictly on US regulation. Canada has been prescribing methadone for years and has actually done very well with it. But there's an epidemic of opioid use disorder sweeping across Canada as we speak. And penetration from Canada into the US and penetration from the US into Canada is occurring on a regular basis, and by the cartels that are in both the US and Canada. What happens when there's a loss of recovery? This is a big issue. Addiction's a chronic relapsing disease. So that's one of the reasons why we do ongoing toxicology testing. The purpose of testing is not to catch somebody. This should be a discussion. How is your recovery going? Are you going to meetings? Is there anything going on in your life that's been a challenge? If you're seeing 10 people an hour and you get six minutes of what you're taking for those six minutes to document, that's not good medicine. I mean, let's just face it. Those individuals ultimately get caught. So you don't want to do that. But if you're doing good medicine, you're spending some reasonable set of time with a member, 10 to 15 minutes at a minimum, you should be able to ask these questions. And you want to look at eye contact. You want to look at pupillary size. If you have a significant catecholamine discharge when you've asked a question, tell me how your recovery's doing. My wife and I are not doing good. I actually moved out last month. I'm living with a friend in their basement. Watch them. That's a critical time in their recovery. And support them if they're having other issues. Behavioral health supports, comorbidity with behavioral health disorders, whether it's anxiety disorder, antisocial personality disorder, depression. And these are all things that are dangerous to recovery. The monitoring system we already talked about with toxicology screening. What are the warning signs? Well, when there's stress, you know, a person loses their job. Somebody gets sick. Keep in mind, you know, there's an old rule in medicine. Don't go down alone. Take all your friends with you. Specialty consultation is critically important. If you have somebody and on your examination, they roll their sleeves up and they have all these cut marks on their arm, say, hold on, what's going on there? Oh, I fell down. It looks like there's, hold it up to the camera. Well, it looks like those are cut marks. Oh, I was really depressed, doc. I mean, things are just not going well. And be supportive, but remember what my wife said, don't do therapy. You know what? A lot of times in life, there's some times that you need to talk to someone else. It's not really my specialty. I'm an addiction doc, but I've got a great therapist. Can we make arrangements for you to talk to her? And so what happens is there's a, that relationship becomes important. Urine toxicology screening when the member, with the member is not to catch them. It's to work with them. Most patients, if they have a reasonable relationship with you, will actually tell you, well, there's going to be marijuana there. I was at a bus stop and this guy was smoking marijuana next to me, and I think I breathed some of the smoke. That's not going to make your urine positive. So, but it's an opportunity. It's a chance discussion that is manipulated by you, the treating physician, to help this member remain in recovery or achieve recovery again. Laboratory evaluations. I mean, buprenorphine and end-stage liver disease do not go well together. If you notice you have jaundiced sclera, you're going to want to ask more questions. Viral illnesses, not just COVID, HIV, Hep C. You know, we have MPOCs going across the country right now. Chronic pain, a severe stimulant to loss or recovery. And then inadequate treatment of chronic pain is important. Other substance uses. Other supports, either virtual, I'm talking behavioral health supports, or face-to-face. Some therapists say, I need to have at least one contact face-to-face with a patient. Part of it is you got to sign all these forms, but the other part of it is they want to see the person one time. Health maintenance becomes an important part. If you're working with just the addiction side, that's your choice, but somebody has to have a primary care provider. And so if their diabetes is out of control, their sugars are 400 all the time, that's going to have an impact on their overall health. And then as telemedicine benefits wane, or they become contraindicated. So when the benefits change, and that's changing right now, some plans are saying, we will not cover telephone contact. We will not cover text messaging. You can't say, need your refill? Hope you're doing well. And that's considered the medical visit. That's not bidirectional communication unless the patient responds, and it's not considered telemedicine by some third-party carriers. Or what happens if you have a person who is deteriorating? And they say, well, I just got out of the hospital. I signed out AMA. They said that I was depressed, but I didn't take that overdose to kill myself. I was just upset. You got to realize if you're over your head, you're over your head. So don't hesitate to say, I need to know this. Now, I know the physical address of all my members. Now, they talk to me on the phone, on the Wi-Fi at McDonald's when they're in the parking lot in the car. But at least I know. I said, where are you at right now? He said, oh, I'm over at the McDonald's in Kingman. I said, oh, the one that's right there in 66? Yeah, that one. I said, okay, and then we continue. But if something goes wrong, I also know the public safety number for Kingman, Arizona. So if the patient tells me I can't handle this anymore, I just don't want to live, you know, fuck you. I'm out now. You know, you don't really care about me and the patient's obviously unbalanced. I'm gonna move ahead and say, listen, George, I got to tell you something right now. I'm very worried about you. And I typically have a second phone. Unfortunately, I always have two phones with me. So I can call public safety if I need to. And I can count the number of times on one hand in the past 20 years I've had to do that. But you have to have that capacity. And sometimes telemedicine is just not working. So predicting risk. One of the things is when behavioral health deteriorates, everything seems to deteriorate. Life events, medical degradation. A medical degradation would be either diabetes gets more out of control, that surgery they had in their back failed, and now they're having even worse pain. Changes that occur on the pharmacy drug monitoring program. Now, every time I do a refill, for any of my members, I check the PDMP. In Arizona, it's called the CSPMP. And if I see a new provider on that list, because they'll tell you what control substances they had, what data was filled, what pharmacy was filled at, and what prescriber wrote for it. And if I identify, why did you go to Nevada to get hydrocodones? Oh, I was in Las Vegas. I was dancing. I slipped and fell. I got a fractured ankle. The ER gave me a prescription. Now, keep in mind, the PDMP does not include any medication that is dispensed. So it will not include methadone from an OTP. It will not include opioids that are given in a urgent care or a clinic or emergency room if it's dispensed. So if they broke their ankle and they're writhing in pain, the doc gives them 50 mics of fentanyl IV so they can put them in a posterior mold and get them out of the door. That will not be in the PDMP, but any prescribed opioids will, the prescribed controlled substances. Just regular aging. I turned 71 in two days. I am not the man I was 20 years ago, that's for sure. And so that can cause cognitive changes, but it can also cause physical changes. Teenagers are at risk. And it's that because we're seeing with the epidemic a dramatic increase in adolescent and young adult overdoses. 50% of the 1600 people who died in 2022 in Maricopa County were within one month of their incarceration discharge date. That's 800 people died from fentanyl overdoses in 2022 within one month of their incarceration discharge. People who are post-incarceration are extremely high risk. And that's just not Maricopa County, that's across the country we're seeing this. More and more department of corrections are providing either buprenorphine and or other medications. Cardiometabolic syndrome, obesity, cardiovascular disease, ischemic heart disease, end-stage liver disease and chronic kidney disease. These are all things that have impact. End-stage liver disease is a contraindication for buprenorphine therapy. Orally controlled diabetes. It not only changes their physical health, but it changes their cognitive capacity. And then when to refer up, don't go down alone, take your friends with you, make sure that you do the things that are necessary. Telemedicine versus in-person evaluations. Here's the thing that's a problem. Of all the people who have substance use disorders, only 15% are offered comprehensive evaluation and treatment. This course, I said, is only for US jurisdictions. I do work with my Canadian counterparts. There is a growing problem going on in Canada. Dropping the XDEA has not increased the number of people who are willing to prescribe buprenorphine. Now that is a big shock because everyone thought, well, the XDEA is a government inhibition to prescribing buprenorphine. Well, we dropped that requirement two years ago and we have not seen an increase in number of people who are willing to prescribe for medications for opioid use disorder. The public health emergency that was caused by COVID-19 provided multiple legal changes in the availability of telemedicine services for the use of buprenorphine for opioid use disorder. The practice of medicine in each state is determined by that state's medical board. Some states opened up their doors. They said, people from other jurisdictions, if they have an unrestricted license in Missouri, they can practice in Arizona. Arizona did that. They even said, we'll give you a telemedicine license for free. That offer is not available anymore, but that was actually one of the things that Arizona did, as did New Mexico. The fluid nature of the Food and Drug Administration, the Drug Enforcement Agency, and the state medical boards exemplifies a recent US Supreme Court decision, the Loper-Bright decision, June 30th of 2024. Not too long ago. Continues to depend on local jurisdictions to find telemedicine access and limitations. It must be quote, reasonably clear. Well, I'll tell you right now, if you have 10 lawyers, you're gonna have 10 different opinions of that situation. So our current buprenorphine regulations, XDEA was dropped in 2022. Anyone with an unrestricted DEA can prescribe buprenorphine for opioid use disorder, or you can also prescribe it for pain. Now that's off label, but it can be used for pain. And there actually are some buprenorphine systems, such as Buprenex, injectable buprenorphine for pain. Sublingual and multiple long-acting injectable formulations currently exist for buprenorphine. I believe there are 14 different manufacturers for buprenorphine products right now. As of September, 2024, telemedicine distribution and management of methadone treatment programs through opioid treatment program systems is available. I'm gonna talk about that in detail as we get on, because that's only through OTPs. Naltrexone's available for the treatment of alcohol use disorder and opioid use disorder. It has multiple off-label uses, including microdosing for pain management and for weight loss. The medication is available by prescription only, but does not require DEA. And naloxone nasal spray is available in all states without a prescription. Individual and family members may request naloxone from any pharmacy. Now, the Ryan Haight Online Pharmacy Consumer Protection Act goes back to Ryan Haight, who I mentioned earlier in this presentation. And that is, it was an 18-year-old, very successful student, physically active, sports, everything that was going right. He ordered hydrocodone from a online physician who had never seen him, and a online pharmacy sent him the hydrocodone. The mom found him dead in bed. There was a federal legislation that prohibits the provision of controlled substances without a history and physical and a prescription. History and physical and a prescription. So when you look at this process, we now know that those requirements have been eased dramatically in regard to the treatment of medications with opioid use disorder. Prior to the pandemic, Medicaid programs limited the types of technology that could be used for telehealth. That's all changed now. There's a significant concern about patient safety, fraud, quality, the cost process, because there's all kinds of entrepreneurial systems that are trying to take advantage of the situation. And during the public health emergency, state and federal agencies temporarily ceased many of those telehealth restrictions. State and federal policymakers and payers are now considering which of these flexibilities should be maintained. So one of the big questions was, can methadone be dispensed via telehealth? Opioid treatment programs, methadone clinics, may initiate treatment using buprenorphine via audio only or audio-visual telehealth. That's also opened up to the rest of the country, keeping in mind that the practice of medicine is determined by the state and that the Loper-Bright changes at the Supreme Court has thrown a wrench in the machinery because it allows the local jurisdiction to determine what acceptable practice is. Opioid treatment programs can continue methadone via audio-visual telehealth without an in-person examination. Used to be, you had to go down to the opioid treatment program, you had to wait in line, you had to go up to a window, they had to verify who you were, they had to ask how you're doing, you had to go to the counseling session with a big group of people, then you went over to the window, you got your dose in a liquid form, you had to swallow it, you had to open up your mouth, show that you weren't just cheeking it, and then you went on your way. That system is different now. So the final rule, remove the requirement for opioid use disorder patients to have a history of addiction lasting a year to qualify for treatment. It also struck the need for patients under 18 to have two unsuccessful treatments to receive care and OTP. The final rule is limited to opioid treatment programs. It's not applied to other types of addiction treatment and the programs are not subject to more stringent accreditation licensure and operational standards that fall on OTPs. Beware of minor consent laws. These are statutory, which means they're state-specific. I'll give an example. When I practiced in Chicago, Illinois allowed the discussion of contraception. Indiana did not. So I was at a hospital whose front yard was in Illinois and whose hospital was in Indiana. We had all my training experiences on the lawn at the old R. Lydia Mercy Hospital in Dyer, Indiana. Now, California Medicaid survey in 2020 was a very interesting project. What it did was, so in California, addiction treatment is county-based and county governments have to give permission for telehealth delivered addiction treatment. So prior to the pandemic, very few counties had approved it. In March, 2020, several counties quickly shifted in regard to the pandemic. The survey of California Medicaid clinicians providing substance use disorders came from a study that was done from September to November, 2020. Of the 412 eligible providers, 100 responded for only about a quarter of the population. Hey, Patty. The more than half of the 100 responded had multiple facilities in California and one organization had a facility in each of the 58 counties in California. Of the 100 responding, 64% provided outpatient treatment, 37 provided residential treatment, eight provided methadone, 25% provided buprenorphine treatment. They also evaluated the people who didn't respond. So 100 out of 412 responded, but of the other ones, most of them were residential treatment programs. And of the residential treatment programs, what was interesting is that in 2020, only 25% of those residential providers provided buprenorphine, 49% of the responding organizations provided buprenorphine. So it's interesting that we have this change. And this has been an ongoing issue of non-medication treatment. So HHS final rule, February 13, 2024. The new HHS rule permanently allows patients to begin treatment with buprenorphine via telehealth. So this is an important rule because it says it's permanent. Now keep in mind, it's still very fluid. So we'll say permanent in quotes. This rule allows more flexibility for take-home methadone doses too. And it reduces total clinic visits to the opioid treatment program. The new rule for methadone allows an opioid treatment program to administer a seven-day take-home dose during the first two weeks of treatment and up to 14 days on day 15, up to 28 days after day 31. That means that a person could actually be in methadone treatment through an OTP and only have to come in for the medications every 28 days after the first month of stabilization. Now I put the hyperlink in the slides here that talk about telemedicine buprenorphine prescribing becoming permanent. Canada has a telemedicine prescribing of methadone for years and continue to do so doing quite well. Vancouver and British Columbia seem to be leading the way in that area. Toronto right now is having an epidemic of fentanyl. These are the references that I have for today. And many of these are hyperlinks. I also have the last website here is a organization that deals with telemedicine services. It goes through a variety of things. I do not advocate for that particular website, but it does have a nice organized process. And there are several website educational vignettes in regard to what's going on with telemedicine in the US. So what have we discussed? We have gone over the issues of telemedicine post-COVID, the HHS new rules, the requirements for a good assessment can still be done by telemedicine. The recognition that the practice of medicine is state-based and in California, county-based, and you need to know what the jurisdictions and the rules of engagement are. There's certain risky populations. I would put adolescents and young adults in there. I put pregnant women in there. I would put patients who have comorbid psychiatric issues and people who have chronic pain syndrome, pain problems. Post-incarceration, very high risk population. I wanna thank you for taking this program. I wanna thank you for your interest in becoming certified in addiction medicine. This country desperately needs more people who are willing to take care of members who have substance use disorders. And I hope that things go well. So I put my name and my telephone number and my email address on the last page here. If there's anything else that's an issue, please let me know. Thank you very much.

telemedicine

substance use disorder

American Osteopathic Academy of Addiction Medicine

Controlled Substance Act

COVID-19

opioid overdose epidemic

buprenorphine

informed consent

HHS final rule

addiction medicine