and I'd like to welcome you today to today's AOAM, an Opioid Response Networks webinar on changes to methadone treatment at one clinic in Central Pennsylvania by Dr. Sarah Kawasaki, MD. My name is Julie Kamik, and I'll be your moderator for this session. This is the third of a six hour webinar series on hot topics in the treatment of opioid use disorder. I'd like to introduce Dr. Kawasaki, who's the Director of Addiction Services at Pennsylvania Psychiatric Institute, PPI, and an Assistant Professor of Psychiatry and Internal Medicine at Penn State Hershey. She designed and directs the Advancements in Recovery, which is an opioid treatment program at Pennsylvania Psychiatric Institute in Harrisburg. She's board certified in internal medicine and addiction medicine, and has extensive clinical experience in both primary care and addiction medicine, and a career interest in research to improve the delivery of evidence-based treatments to patients with substance use disorders in the community-based treatment settings. PPI is the hub of several hub-and-spoke programs in the state of Pennsylvania set up through Pennsylvania Coordinated Medication Assisted Treatment, or PACMAT. She serves as the Principal Investigator of the Penn State PACMAT, and she oversees the hub-and-spokes in her health system. She's also leading a Project ECHO teaching initiative for the treatment of opioid use disorder, where physicians and advanced practitioners learn how to provide competent care confidently for patients with opioid use disorder. She either leads or is the co-investigator on several studies funded by NIH, SAMHSA, or NIDA, and is part of the Clinical Trials Network Appalachian Node with West Virginia University and the University of Pittsburgh. So I'd like to introduce Dr. Kawasaki. Thank you so much for having me. Thank you to the American Osteopathic Association and to SAMHSA and to the Opioid Response Network. I'm going to share my screen. And hopefully you all can see my presentation. So I'm gonna talk about COVID-19 changes to methadone treatment at my opioid treatment program, or at the opioid treatment program I currently direct. So again, we have to thank the Opioid Response Network and AOA funded through SAMHSA for this talk. I have no disclosures to make. And for the first part of the hour, I'm really going to set the stage for sort of the history of methadone treatment in this country and how it really came to be that we have such interesting regulations federally and statewide, and how that really was upended during COVID-19. And what happened at our clinic as a result of the changes that were made. And I will also give some few basic outcomes of patient stability and recovery during this time period. So the history of addiction in this country is fascinating. And it comes from a really interesting place. Imagine a land in which you could walk into a drug store and literally buy cocaine or heroin off the shelves. And that would have been the turn of the 20th century. You actually got products like Stokes expectorant where you could buy combination of alcohol and opium together. And I probably should look this up, but I feel like that is the etymology of the phrase I'm stoked. It might actually come from this product and I'm curious enough that I'm going to look it up. There's also a Coca-Cola. If you want to stop smoking tobacco, please try Coca-Cola, which is cocaine infused. And then here's a literal heroin to help with pain sold in Baltimore and Detroit. And at the time of the turn of the century, the people that were purchasing these items and becoming addicted to these items, they had a different demographic face than the people that were using it only 10 or 20 years later. And they felt that injecting morphine caused these antitoxins to develop, which then led to the disease of addiction. But with the changing face of the demographics, the Harrison Act was passed, which effectively criminalized addiction and it punished the sale of what came to be known as narcotics, which are these illegal substances. And that was thought to be the end of that, that you put people in jail and you make these products illegal and it won't exist anymore. The problem won't exist anymore. And so the Harrison Act also established the Food and Drug Administration to make sure that products were evaluated for safety and efficacy so people wouldn't die. So there were good parts to the Harrison Act as well. So later, a few years later, a radical doctor, Dr. Lawrence Cole, came up with the crazy idea that addiction could be caused by social issues and trauma and personality disorders. And so he established or helped establish these places that were called narcotic farms. They were actually farms that were created, there were two of them, in Fort Worth, Texas and Lexington, Kentucky. And these places were really interesting. They were co-funded by the US Public Health Service. So through the government, there was money allocated through Congress for this and the Bureau of Prisons. So these were interesting places that you could voluntarily join or admit yourself to or be sentenced to through court. They had farms there, they had meals there, job training, sports, lots of musicians, famous musicians came to stay there and you could form bands there and paint. And you got injected morphine quite frequently for detox. And this was in the 20s. Now in the 30s, what changed is that they started doing a lot of outcomes research at the farm in Lexington, Kentucky. And they found the first description of abstinence syndrome where people were really craving and restless and far beyond the detox symptoms, they actually had cravings that really sort of took over their day-to-day life. They also used a spoil of war from World War II, methadone, which was a German invention used for soldiers in the field to help with pain. And due to its longer half-life, they found that they didn't have to inject methadone multiple times a day in these folks. They only needed to inject them once a day to help with detox. And what they also found, unfortunately, is that once they stopped detox, once folks returned to the community, there was a 93% relapse rate. So the hospital closed in the 1960s because it was not effective and because it was funded by the government. So you have to end something that's not effective if it's funded by the government. So what happened in the 60s after that was that a health research council was established because there were so many overdoses and they needed to figure out how to stop that from happening. And so a name familiar to many of us, Dr. Vincent Dole led this effort and he started working on methadone as a medication to treat people chronically to help prevent overdoses. So there was a lot of hurdles to get over, legal being one of them, that the Bureau of Prisons and the FBI would not allow for maintenance treatment for folks with opioid use disorders. In fact, any doctor that wouldn't prescribe methadone chronically would actually get arrested. So Dr. Dole started this pilot and wanted to give people methadone treatment, but he had to make sure that he wouldn't get arrested first before starting the trial. So he needed permission from the Bureau of Narcotics and he got that permission, but it still didn't prevent other doctors and professional organizations from dragging his name through the mud and really saying that he was more of a drug dealer than he was an investigator. But what he also did was fought perception of addiction as a failure of morality. So there were all these professional societies, especially the American Medical Association that rejected the idea that addiction was a medical disease. He pushed for it to be taught in medical schools, which is so fascinating. It only took 60 years, but it's finally being taught the way it should be in medical schools, more and more, I should say. And he advocated for maintenance meds as it could help achieve sobriety goals, stuff like continued employment, stable housing, repair of relationships, kinds of things. And so Dr. Dole worked with Dr. Marie Nieswander who also became his wife and Mary Jean Creek, who was another investigator in his laboratory. And so they really found pretty rapidly that methadone was quite effective. And it changed the concept of addiction from moral to medical. So Dr. Creek showed that it was safe, that there was no long-term toxic effects, that constipation was treatable, that was the main side effect. And more importantly, that all the stress responses, the irregular reproductive hormones, the sort of dysfunctional immune system, and the lack of endogenous opioids became normalized if you were on methadone chronically and no longer using illicit heroin. And it led, all this work in the 60s, led to the passage of a comprehensive Drug Abuse Prevention and Control Act of 1970. Now, this act was actually a double-edged sword. So what it primarily did was it scheduled a lot of prescribed medicine and created the schedules that we're aware of today, like schedule one, not approved for human use, schedule two, dispensing severely restricted, and through schedule five. And part of this, a subheading of this control act was the Narcotic Addict Treatment Act of 1974, which allowed or essentially legalized methadone treatment for folks, but only at licensed OTPs with a separate DEA. So before there was no avenue for methadone treatment, but now there was one avenue for methadone treatment and only one avenue, so it was extremely limited. So we're now in the early 70s, it's been 50 years, and so we have a lot of evidence of how methadone works, and we've been able to show that it's been helpful in reducing overdose deaths, keeping people in treatment, keeping people out of jail, and reducing the high-risk behaviors that cause HIV and hepatitis transmission. And that's how we measure it in the literature. And so here are a few papers that looked at that. And so with every paper that I show, there are a gazillion others, because it's just been decades of research work. So this is a nice paper that looked at, does methadone keep people alive? This is from 1990 that followed folks over 20 years previously, since methadone treatment began in clinics and found that all methadone-treated folks with opioid use disorder overall lived overwhelmingly longer than their untreated controls. On the right, it really asked the question, how long do people need to be in methadone treatment? And so it found that those folks that really had felt that they completed treatment, they were doing well, they wanted to come off on their own volition, they actually did quite well if they had shared treatment decisions with their physician versus folks that were involuntarily discharged, they did as poorly as if people had never had treatment in the first place. So how long folks need to be on methadone treatment really should be up to them. And this article is one of the ones that show that. The people asked, or I'm sorry, scientists have asked, does it keep people in treatment? Absolutely. So this is an article from 1979 that randomized 100 heroin addicts to detox versus maintenance and found that the folks that got detoxed, only 10% remained in treatment at 32 weeks and 2% remained in treatment at three years versus 76% retention rate at 32 weeks for folks that were on methadone treatment. So incredibly effective at keeping people in treatment. Does it keep people out of jail? This is a really very small study, but I think a pretty notable study from 1969 that looked at folks that were coming out of prison. They randomized half to getting methadone treatment and half to treatment as usual and found that almost everybody who got treatment as usual were re-incarcerated versus only a quarter of the people getting methadone treatment. So methadone actually keeps people out of jail and there's no question that methadone at this point reduces high-risk behaviors that lead to HIV and hepatitis transmission. This is a great meta-analysis looking at 8,000 methadone patients and found that it significantly reduces the high-risk behaviors of HIV and seroconversion. And because of that, it really needs to be part and parcel in every sort of public health plan for any major municipality when you're talking about ways to mitigate HIV spread. And so what about the comparison between methadone and buprenorphine? So it shows, this was a Cochrane review that looked at 31 studies and 5,500 participants. And you can see on the left, the forest plot looking at all these studies and found that methadone was better at retention and treatment versus buprenorphine overall, although buprenorphine was much better than placebo. So both are good treatments, methadone slightly superior than buprenorphine. And so, a lot of perception or negative perception of methadone stems from overdoses and diversion and crime rates. And what does the evidence really say about these things? And so in 2011, there was a study done out of Vermont that looked at 76 methadone overdoses and found that only two cases were from methadone treatment, that the rest were actually from methadone prescriptions being prescribed for pain out of pain clinics. And you can tell the difference because methadone from methadone treatment is either liquid or from dispersible diskettes versus methadone coming from pain clinics, which are tablets. And on average across the country, because Vermont is unique, that only 20% of methadone related overdoses from methadone come from opioid treatment programs, that the overwhelming majority come from methadone that's diverted from pain clinics, which is less regulated. So more on diversion from pain clinics, methadone accounted for only 2% of opioid prescriptions in 2009, but was involved in 30% of overdose deaths. So really important to understand the difference between prescriptions and distribution. And so what do we do about it? Well, I mean, there are ways to prevent diversion of methadone, and I think opioid treatment programs actually do a good job in preventing methadone diversion because you can supervise consumption, and that's what they do at methadone clinics. It's often a directly observed therapy. You can make sure that any take-home formulations are abuse deterrent, and you can, of course, counsel practitioners to counsel patients to not sell meds. And then another thought was, well, maybe we should have another medication like buprenorphine naloxone, which has an antagonist added, so it would prevent injection and diversion. And not only that, it's sort of, how do we rethink diversion? What is diversion truly a function of? It's more a function of the lack of treatment access, that some people really don't have access to methadone treatment, and so they're buying it off the street because they don't have access in that way. There are other ways to encourage adherence, such as contingency management, where you reward people for attending appointments, and that has been shown to work. You can increase reimbursement for healthcare providers, and you can also increase criminal penalties for misuse or diversion, and all of these elements can actually help mitigate diversion, which is the point of studying it and trying to make it better. Because we know it keeps people alive, so it's really important that we not, when people look at opioid treatments as a scourge themselves, it really undermines the positive work that it actually does in a society for lowering overdose deaths. So what about crime rates? So this is a paper written in 2016 that compared criminal charges between methadone maintenance and office-based buprenorphine two years prior to treatment versus two years after initiating treatment. And there was significant reductions in the methadone group in all charges and drug charges, but there were no significant reductions in the buprenorphine group. So methadone is actually singularly helpful in reducing crime rates. And this was also shown in a study from Australia that looked at greater than 30 days after treatment of methadone that they saw crime rates drop, really sink like a stone. I mean, drop by 75% in some cases. So pretty, pretty robust. And it's not clear why that is, buprenorphine by prescription gives individuals more things to sell right away, more doses to sell right away, but also buprenorphine is a partial agonist. And so it may just be that that medication is not strong enough for what people need. So I've given you all this evidence and it's really astonishing still that only a quarter of the folks with opioid use disorder end up on methadone treatment and most are not receiving any medication at all. And part of it, I bring up the history of methadone and the laws that were passed and how they were passed because stigma is really a big, bears big responsibility for why not enough people are on methadone treatment. And the stigma can happen at multiple levels individually through the medical community, doctors, not every doctor knows how to prescribe buprenorphine or they won't take the course or even if they don't have to take the course anymore, they're still not doing it. There are, you know, there's lots of variability in quality in how they prescribe. And some doctors will say, you know, I love buprenorphine, but I hate methadone. I mean, who has feelings about the medications they prescribe, right? Like if we had feelings about, you know, amlodipine versus lisinopril, that would be ridiculous, but here we are. So, you know, and then there's also, you know, just the pejorative terms used on patients that come to EDs frequently for drug seeking, calling them frequent flyers and, you know, just saying, well, Jeremy's back, lock up your dilaudid instead of using it as an opportunity to really help folks get into treatment. Stigma pervades the treatment community, as we know, that there's a perception from 12-step programs that patients aren't drug-free. There are these terms clean versus dirty for urines. There's a concern that bad behavior gets rewarded with medication treatment, and the concern for diversion outweighs the concern for treatment. You know, so it's pretty interesting, and I have to counsel patients a lot that when they go to peer recovery meetings that they don't need to reveal the medications that they're on because they're just medications like everything else that they would take. So, you know, out of that comes a stigma with that pervades policy. And, you know, you have this history with methadone, it goes through varying levels of stigma, you know, even treatment gets stigmatized in that way. And this was an excellent article written in 2019 that shows how Byzantine these regulations are from a federal and state perspective, that standards are created federally by SAMHSA and CSAT, but state and local regulations govern the facility operations, clinical care and staffing, and there are 50 states. And so this paper actually painstakingly goes through all the 50 state regulations and tries to, you know, put together a pattern or lack thereof. And so they have this great table that showed, you know, degree to which the most common state level opioid treatment program regulations are considered best practices by SAMHSA. And so I focus on this one, limits on unsupervised dosing. If they are more restrictive than the federal limits, which I'll go over in a little bit, that it can create barriers for patient retention and take-home meds are critical for patient retention. So that's, you know, what they found in their findings and I'll talk about how that affected our clinic in a little bit. And this paper goes on and finds that there were 89 different regulations across 50 states, but the most common regulations were in fewer than a quarter of all the states and 60% were inconsistent with best practices. So, you know, the variability in number and type of OTP was not related to state size, was instead just related to geographic location. And they concluded by saying state laws may be creating barriers to access and retention and treatment. So pretty dizzying overall. So to go over what these regulations are, federally, these are the rules that you need to get take-home doses. And, you know, I'm sure many of you may be familiar with how methadone clinics work, but in general, it is a directly observed therapy for a certain length of time. And then with negative urines and with consistency in treatment, you have the ability to earn bottles that you don't have to take in front of the nurses every day. And so depending on the state that you're in, you get a different number of bottles for a different number of time in, for a different amount of time in clinic that you can take home with you. And so they're called take-home doses. And federally, you need to meet the following set of parameters in order to qualify. You need the absence of recent abuse of drugs, regularity of clinic attendance, absence of serious behavioral problems at the clinic, absence of known recent criminal activity, stability of patient's home environment, the assurance the medication can be safely stored, and wherever or whether the rehabilitative benefit outweighs the potential risks of diversion. So in other words, they have a new job, the job is incompatible with dosing hours, they're also giving negative urines, this sounds like a great time to start giving that person take-homes. So federally, if the previous measures are met with a patient, during the first 90 days of treatment, you are entitled to a single dose each week. In the second 90 days, you can get two doses per week. In the third 90 days, you can get three doses per week. In the remaining months of the first year, you can get up to a week of medication, and after the first year of continuous treatment, you can get two weeks. And after two years, you can get one month's supply of take-home medicine. So these are the federal regulations. At the end of the federal regulations, it says, if their state regulations are more restrictive, we cede to the state regulations. So every state has it slightly differently, and Pennsylvania is a particular animal within these regulations. So this is the take-home privileges, as it's written for the state of Pennsylvania, that a narcotic treatment program may permit a patient to reduce attendance for observation to three times weekly and receive no more than a two-day take-home supply of medication. This is essentially every other day plus weekends, if they have had satisfactory adherence to the rules for at least three months. So after 90 days, you can get every other day take-homes and weekends. So that sounds pretty good. But if a patient wants to have one more take-home a week, you need to be in treatment for at least two years. So if you want to reduce your pickup days to twice weekly, you need to be in methadone treatment for at least two years in Pennsylvania. And in order to get one week, you need to demonstrate satisfactory adherence for at least three years. And that's it. If you want to get two weeks of medication, you need to have a medical or transportation or other reason to get two weeks of medicine. And that needs to be approved federally through the Extranet, which is an extra set of bureaucratic steps that then the State Opioid Treatment Authority needs to approve once the federal government has approved it. So what happened March 16th of 2020 was this amazingly brief, you know, with all those regulations, all the whys and heretofores, SAMHSA releases this half-page memo just nationally and basically says for all states, the state may request blanket exceptions for all stable patients in an OTP to receive 28 days of take-homes. And the state may request up to 14 days of take-homes for those patients who are less stable, but who the OTP believes can safely handle the take-home medication. So that's pretty vague and it offers, you know, a lot of clinical discretion. So suddenly we went from a very restrictive state to, you know, the federal rules, which kind of made me feel like Oprah a little bit, you know, that the people that could get one week at three years could suddenly get one month if I felt like that was reasonable. Even if they would come at two times a week at two years, they could get a month. And if they were getting three times a week, if I felt that they were stable enough, I could give them a month. And that was, you know, suddenly incredibly liberating. But, you know, I wasn't super liberal about that. So talking about my, the clinic that I work at, Advancement and Recovery, it's at the Pennsylvania Psychiatric Institute, which is a joint venture of Penn State Health and UPMC Pinnacle. We are a methadone clinic, which provides methadone, buprenorphine onsite, extended release naltrexone, extended release buprenorphine, counseling. And we are a hub and spoke program. So we work with several different entities in the region, including primary care clinics, mental health clinics, drug-free counseling facilities, regional emergency departments, and all of these regional emergency departments prescribe buprenorphine. We work with inpatient med-surg units that initiate buprenorphine treatment, pain management clinics that want to refer patients to us. We've worked with a couple of inpatient detox facilities, which we know don't have good outcomes, who have decided to allow for medication and do treatment induction versus detox. So we've been helpful for those programs and those patients. And we work with probation and parole drug courts. And so we use all forms of medication for opioid use disorder. We have counseling onsite and a certified recovery specialist. And for care management staffing, we work with peer recovery specialists that really help with executive functioning. So making sure that patients are making appointments, attending appointments. If they have transportation needs, they really help out with that. And if they need transition from spoke to hub or hub to spoke, that is what they help with as well. So we work with two full-time hub and spoke care managers that will not only help patients make appointments for future appointments, but if there are urgent care visits needed, so let's say a spoke has an appointment, but it's five days away, they'll make an urgent visit with us within 24 hours to get the patient on medication so that they can go out to the spoke on medication, they're more likely to stay in treatment. And they will accompany patients to hub appointments as well. So just to give you an idea of our clinic, we opened in November of 2017. So we're nearly four years old. We've treated over 3,000 individuals since our clinic opened. We see 700 individuals annually. And of those 500 are active patients, about 50% methadone, 40% buprenorphine, 5% naltrexone. And the other 200 patients are the urgent care visits or bridge to spoke sites. And our payer mix is pretty standard, except we do have a decent amount of commercial payers as well. So our retention is pretty good. It's better than the national average. For methadone, we see on average about an eight and a half month patient retention. For buprenorphine, it's seven and a half months. And for naltrexone, it's actually six months. This is extended release naltrexone. So pre-pandemic, we had 193 active methadone patients. So it was pretty small at that point. 10 patients had qualified for one week take homes, keeping in mind we hadn't been open yet for three years. So many of these folks had transferred in from other clinics and had accumulated greater than three years of time in treatment. 12 patients qualified for twice weekly pickups and 31 patients qualified for every other day pickups. So we had to really rapidly change our policy for COVID-19 spacing. And the idea was that we wanted to make sure that the stable patients weren't getting exposed to COVID-19 and that the unstable patients wouldn't die of overdose. So again, it wasn't a win if we could keep people safe from COVID-19, but then they would die from overdose. So all the unstable patients needed to be watched, but we needed to space them out better. So we made these decisions that the length of time in program, an individual must be in treatment longer than two months to qualify for any kinds of take homes, you know, greater than, or one day closed a week. Our tox results mattered too. If folks were testing positive for illicit benzos or fentanyl, they were not getting take homes because that was still a sign of instability and that dose adjustments were needed. But if they were testing positive for stimulants, a max of two week take home supply could be given to those folks if they were showing stability in their daily attendance and in seeing medical visits and counseling visits. And so March 21st of 2020, we initially gave 10 patients four week take homes, 38 patients two week take homes and 18 patients one week take homes. And over the course of the year, you can see that, you know, things generally while they increased, so the red line is the total number of patients receiving any amount of take home bottles, whether it's one week, two weeks or four weeks. And things went from 50 to about 110 people. So they doubled over the course of the year. Most of that doubling came from two week take home bottles and one month as well. The one week tend to stay relatively stable over time. There were some patients that floated in, some patients that shifted lines throughout treatment, but generally speaking, it was pretty stable. So discharge comparisons are actually what's most interesting to me, that we compared the discharge characteristics from 2019 to 2020, right before the pandemic and 2020 to 2021. So over the same time period, the 2019 to 2020 showed 62 discharges and 2020 to 2021 showed 43. And so these are promising numerators, but the denominators changed as well. And in March of 2020, we had 150 active methadone clients, but as of March of 2021, we had 232 active methadone clients so there was 54% more methadone patients a year later. And so when you put the numerators over the denominators, we dropped our attrition rates by 50%. So that was pretty impressive. And considering that the evidence or the federal guidelines really don't recommend making these treatments more restrictive take homes, that's really the proof was in the pudding that our clinic did very well with dropout rates. And is it only that the rules changed that we were able to keep patients longer? I don't know. It could be the pandemic, maybe there was more limited access to drugs, maybe there was a higher fear of overdose. In our region, there's a lot of fentanyl and so people generally did have a fear of overdose and those seeking treatment may have been more motivated because of that. And one point to make is that a lot of folks that had previously been in sustained recovery had a relapse during COVID because things were so stressful. So many of those folks that were seeking treatment were actually had years of sobriety. So it's possible that these were different patients and the retention rates can't be explained by the relaxed take home bottles alone. So in follow-up, what has happened since the Department of Drug and Alcohol Programs in Pennsylvania announced the return to regulations prior to the pandemic to take effect at the end of September. So they're trying to put the toothpaste back in the tube and that has been really disappointing for patients and really disappointing for me as a provider. I think it's really hard to tell patients that look great and are doing really well that somehow the state thinks that they don't deserve the success that they've earned. And so all the take homes were revoked except for a few exceptions such as transportation hardship, medical hardship and employment hardship. But I'll have to do a lot of extranet submissions to make sure that they can get these exceptions approved. So what to do in the future is to really advocate for new legislation to be passed in Pennsylvania or some sort of federal government overreach would be great right about now. Cause I don't know that our legislature is completely up to the task. I would hope that they would be but I don't have a huge amount of confidence in our legislature. And I plan to publish our findings and make sure that I can be an advocate for better regulations in the state and just make sure that patients who are doing well in recovery aren't stigmatized for it. So with that, I thank you very much for allowing me to speak on the topic and I'm happy to answer any questions. Hey, thank you so much for that presentation. It was very enlightening about the history of opioid treatment programs and about what you've been doing at your clinic since COVID pandemic. We do have one question so far entered in the Q&A box and it is, what is your policy about the use of THC for patients with or without medical marijuana certificates? So this is a complicated question. I think, so Pennsylvania is a medical marijuana state. And so for folks that have a marijuana card that's not something that we factor in to their ability to earn take homes. And really with, for some people they have cards. So it's a tricky question. I think that whenever it's asked at ATOD meetings and other national society meetings, there's a lot of hand-waving going on. And I think that it's because, I think people are sort of like, why are you testing for marijuana? I think the less that you know, the better the outcome you can have. I would say that there's, arguably there's really no clinical difference between somebody that has the medical marijuana card versus people that don't, except that they had the 250 bucks or however much it costs to purchase it. So, from that perspective, I don't think that there should be a difference. But with that said, our clinic has a policy that you need a card in order to get take homes. Thank you. Our next question was, do you provide or did you provide telehealth services during the pandemic? And if so, are you still providing it? I work in a methadone program too. And some of my patients have chosen to come back to face-to-face, but I have the majority that continues telehealth. So we did use a lot of telehealth services. We are not still providing it. There are many payers in the state that have stopped reimbursing for telehealth services. And so, because of that, we have stopped doing that. I wish that they still existed. I wish that we could still get reimbursed. I found that I was able to connect with folks on a different level through telehealth and so we were using it a lot. Next one is, what are the methadone dose ranges for maintenance currently? And how did these compare to dosage levels in previous years? It's a great, great question. So dose ranges are from right now, I have patients ranging from 50 milligrams to 250 milligrams. Fentanyl has really changed the game. There are folks with a really high degree of tolerance. And because of that, I think that whereas folks would have done better with 100 milligrams less of methadone in years past, they need it now. It's a really big struggle. I'm doing a lot of EKGs. Okay. Do you discharge people from your practice if the patient is non-compliant? So what do you mean by non-compliant? Well, I guess I'm not sure what the participant wonders, but I would guess like if they're having positive urines for other substances or continued with opioids, or maybe if they're not doing their therapy or a combination of those things, maybe several days absent from dosing. Yeah, so with the absence, if they're absent from dosing, then at that point, we'll say to them, what would you like to do? Because clearly methadone treatment's not working for you or you haven't found the means, what's going on? Do you need help with transportation? Do you need help with housing? Sort of finding out, trying to troubleshoot. Every patient is different. Every situation is different. And so we try to work with the patient individually to see what they need. If they need to go inpatient for a week or two before coming back out just to stabilize and get a new lease on life, then that's what we'll help them facilitate. For folks that are testing positive for other substances, I mean, we treat addiction. So I don't wanna be kicking people out for the very reason they're here to be treated in the first place. So that just gets continued counseling. If there needs to be an inpatient program to take care of them, we do that. We send them there. There's another question. Is there a treatment adverse outcomes for patients on methadone or buprenorphine plus marijuana? Many of our patients have positive UDS for marijuana. So I think I answered this previously that you need a marijuana card and then it's sort of not looked at. So, I mean, what's interesting is that people will get marijuana cards and then they'll purchase marijuana illicitly because it's cheaper. So I think that, so I'm not on the side of let's restrict take-home doses for marijuana use, because I just don't think that it's productive in any way at this point. And it certainly doesn't cause any additive risk. And sometimes in some people, they've also tested positive for small doses of fentanyl with illicit marijuana. And in that case, I do, in our little region, sometimes the illicit marijuana comes spiked with fentanyl. So for those folks, I educate them and make sure that they know and I don't give them any take-homes. Okay, I think maybe what the person was asking too is just from the literature that you're familiar with, have there been any kind of correlations perhaps with marijuana use and retention and treatment in an OTP or maybe worse outcomes, whatever kind of outcomes they might be studying? Yeah, not that I've seen, no adverse outcomes with retention and treatment, no adverse outcomes with respect to overdose. You might see folks with a lot of anxiety, sort of the general adverse outcomes of marijuana use chronically are there for sure. But sort of from a harm reduction perspective, if you have helped somebody go from heroin and cocaine to methadone and marijuana, that's two thumbs up from me. We have a comment here saying, the state of methadone treatment in this country is such a travesty. I really appreciate your education. From an OTP in Austin, Texas, I'm shocked at how restrictive OTPs are in Pennsylvania. We successfully gave much more take-home doses. I couldn't agree more. I think that that's, yeah, wow. So Texas, Texas was in the news today. Sorry, sorry, you guys. It's pretty harsh down there for other reasons. And then we have, how do you handle UDS with telehealth? So great question. So our methadone patients were still coming into clinic pretty frequently. So we just disassociated UDSs with medical appointments and we're more associating them with nurse dosing visits. So if our methadone folks were coming in twice a week or once weekly or every other week, every time they came in for extended take-homes, they would have urines. So we always had those data before we did telehealth. We, for buprenorphine patients, sometimes I would have them come in, you know, like every other month or every third month. So I would space their visits, but I would still get urines. And that was just to make sure that they weren't selling their bup. Do you know when telehealth is going away completely by the state? I don't know for sure. I think, I don't know when Medicaid is going to get rid of it. Maybe Dr. Kamek, if you know the answer to that. There's a bulletin that just came out and this is for Pennsylvania only. So sorry for our other participants here from other states, but the Office of Mental Health Substance Abuse Services said that telehealth and even telephonic communications or treatment can continue past the September 30th period. And so that was just issued on 8-26. So if you look online to search Office of Mental Health and Substance Abuse Services for that, and so they will be continuing or allowed still in Pennsylvania. But maybe pair. Right. Yeah, so we're a little bit different in our area. I'm in Pittsburgh and we haven't had any real restrictions from third-party payers saying that they're not going to do telehealth anymore. Maybe there's going to be a restriction on telephonic only visits, but not necessarily if it's going to be two-way audio video. Right, right. And so we have about four minutes left. Let's see. Here's an interesting one. Do you anticipate pushback regarding UDS with buprenorphine after 9-30, 21? I guess this is in. Yeah, I do. I worry about the state of emergency in Pennsylvania after 9-30. I mean, I think that there are a lot of great things that were accomplished during the state of emergency and it's a shame that it's going to go away. So, you know, I think that we have a lot of advocacy work to do. You know, Pennsylvania legislature, it's a challenge. Okay, and then one last question that we'll get to today. And then if you have any questions, you can enter them on our website, the education website for AOA for all the participants. So this one is a little off topic. At our, or what point of care UDS do you use for fentanyl for initial assessments? The vast majority available on the market are for forensic use only. I've only found one that's FDA approved, not sure if it's CLIA waived and the cost. Yeah, I don't think that there are any fentanyl CLIA waived approved tests. We use a point of care fentanyl that's non CLIA waived. That's like, I think it's like $2 a test or something like that. In addition for folks that are getting extended take homes and for initial visits, but that's what we use. There's nothing on the market yet. I mean, every conference I've been to, it's like, it's coming, you know, and I haven't seen it. So it takes a long time. There's one question that came in, are all the patients who are on the higher level of doses checked for current cardiac issues? Yes, I do an irresponsible amount of EKGs. I really make sure that folks are not taking extra medicines that could compromise their QT, or, you know, if there's any situation where the QT gets prolonged, I cut their dose. Sometimes I have to send them inpatient, but it's, you know, it's a tricky situation with the high tolerances that people are showing to fentanyl and wanting to make sure that they get the dose that they need so that they're not using. Okay, so I think we have the questions that have been submitted so far today. If you have any that you want to submit for our session next week, please go to our AOAM website, the education section, and enter those there. On that website too is where you're going to complete your survey to get CME. So you'll be able to do that today and sign up for next week's webinar as well. If you don't have a question, but maybe an interesting case that you'd like to pose for Dr. Kawasaki for next week, maybe you work at an OTP and you have a patient issue and want to see how she would have handled it or talk about how you handled it and then get some feedback on it, you can submit that on the website and we will see you again next week for the case discussion and question and answer session at five o'clock Eastern time on this website. So thank you again, Dr. Kawasaki, for your excellent presentation and I look forward to seeing you again next week. Thank you so much.

methadone treatment

opioid treatment program

COVID-19 pandemic

regulations

stigma

take-home medication policies

attrition rates

legislation

telehealth services