AAM's monthly presentation of Testimonies in the Trenches. Tonight, we have a really nice presentation on opioid treatment programs from Dr. Elise Wessel. She is an addiction medicine physician practicing at Heritage Behavioral Health Center in Decatur, Illinois. She's board certified in family medicine and completed a family medicine residency at Carle Foundation Hospital in Champaign after completing medical school at A.T. Steeles University in Kirksville. She served as a volunteer in Service to America, the VISTA program at a healthcare for the homeless clinic in Casper, Wyoming through AmeriCorps. She is a fellowship trained addiction medicine physician and graduated from the University of Wisconsin, Madison Addiction Medicine Fellowship Program. She now works in inpatient, outpatient and telehealth care settings, working with people in treatment for substance abuse disorders. She is the Illinois Society of Addiction Medicine President-Elect and she is dedicated to providing education for clinicians, residents and medical students in an effort to banish stigma and form policy and promote evidence-based treatment for people who suffer from the disease of addiction. All right, thank you so much for the introduction. I'm going to share my screen and we'll get started. All right, so during this presentation, I'm, you know, feel free to interrupt and ask questions, provide comments and we should have time at the end for discussion as well. I have no disclosures. The objectives and overall theme of this presentation will be the history of OTPs or opioid treatment programs, otherwise known as methadone clinics, the OTPs current environment and future implications. We'll discuss methadone maintenance and the opioid crisis as well as best practices for patient care in an OTP. So to start off, we'll just review the history of methadone. The Harrison Act of 1914 limited the availability of morphine and coca and other opiates to address the opioid addiction during that time. This also brought about more difficulties for physicians to prescribe these substances, specifically opioids. And so specifically making it illegal to prescribe opioids to people in opioid withdrawal or with opioid use disorder. And so this indirectly influenced how methadone has been regulated for the treatment of opioid use disorder. And that's also why the X waiver came about for buprenorphine. Person who obtained their X waiver were waived for this from the Harrison Act of regulations. But now we no longer have X waivers. So things have been moving in a positive direction in terms of increasing access to life-saving medications of opioid use disorder. Methadone was first developed in the 1930s as an alternative to morphine during World War II. And recall that there was a need for alternative analgesics during this time, especially with the restriction of morphine from the Harrison Act. And then it was initially used in 1960s for opioid use disorder by Dr. Vincent Dole. And then it was FDA approved in 1972. And that's when it was also first regulated to only come from OTPs or methadone clinics. And then methadone and buprenorphine were added to the WHO list of essential medicines in 2005. Methadone for opioid use disorder has been around the longest, and therefore it's been studied the most. So there are a plethora of studies on methadone's effectiveness for the treatment of opioid use disorder. It's been studied in situations including the HIV epidemic. It's been shown to reduce transmission and acquisition of HIV and hepatitis C. It's been shown to improve compliance with treatment for HIV. It's been shown to decrease criminality, improve functionality. And it is recognized as one of the most effective ways to reducing risk for overdose. So again, we have our three FDA approved medications for opioid use disorder, which includes methadone, buprenorphine, and naltrexone. And so methadone clinics, OTPs, are the only healthcare centers that can offer all three forms of MOUD. So just to revisit methadone pharmacology and some of the considerations that people need to discuss with their patient and take into their clinical decision-making when introducing methadone to a patient. So again, it's a full opioid agonist as opposed to buprenorphine, which is the partial agonist. And so as your dose increases on methadone, your therapeutic index becomes narrower. And so for methadone, you do have to take into account more factors than you would with buprenorphine. It has a long and variable half-life, and there is significant variations of methadone metabolism in individuals. You may hear about peak and trough levels in dosing of methadone. However, those really don't have clinical significance. There has been, I've heard of people using peak and trough levels to determine a dose a person needs for split dosing. I know in some states, such as Wisconsin, that legally, in order for people to be able to get split doses of methadone, they have to have a peak and trough level. Nonetheless, peak and trough levels, again, aren't clinically significant in methadone dosing. And the need for split dosing should be based on clinical factors and individualized patient factors. Methadone has a phenomenon called dose stacking. So when any time a methadone dose is altered, specifically increased, a methadone will build upon each other. Discussing that with patients that, I always say, you really won't know how you feel on the dose of methadone that you're at until you reach a steady state level, which can be from five to seven days usually, because of that dose stacking phenomenon. And then QTC prolongation comes into play with methadone, as with many other medications. And so it's important to check a baseline EKG, and then at least annually. You can check them more frequently, such as every six months, especially if they're on medications that can also cause QTC prolongation, and there are many. So when the QTC is greater than 500, that's associated with a two to three-fold risk of foresight, the point. And so it's at that point where you need to consider either a dose change, decreasing the dose, as well as discussing the risks of that prolonged QTC with the patient. And I have had some patients say, while understanding and verbalizing that their understanding of the risk for prolonged QTC, that they want to stay on that dose, and that they'll accept that risk. And so patients do have to have a clear understanding of their risks of any medication they're on, but especially when they're at greater risk for a fatal arrhythmia, potentially. And then, of course, whenever there is QTC prolongation, try to mitigate risk factors like the hypomagnesemia. Can other medications be eliminated that prolong QTC that you may or may not need? So just not necessarily stopping the methadone or tapering down a patient rapidly, it should be shared decision-making. And then, of course, methadone has a lot of interactions with medications, so that needs to be taken into account, especially when prescribing new medications or a patient needs treatment for latent TB, for example. Rifampin significantly increases the metabolism of methadone, and so usually the, so I've had a couple examples of this, a patient with latent TB, and then a person with endocarditis. Both were on methadone for opioid use disorder. Both had significant changes in their methadone metabolism, and so we had to titrate their dose. And then once they were no longer requiring the therapy, then slowly decreasing that dose back to their stabilizing dose. And so it can be helpful to work with pharmacists on this to come up with a safe plan. A lot of psychotropics can be sedating, and so especially in older individuals on methadone for opioid use disorder, the old adage, start low and go slow, and I do the same with people on methadone. So especially when they're on necessary medications for their mental health, which will help them in their own recovery and not return to use. I don't think it's an indication not to prescribe an SRI or another psychotropic, but again, just monitoring closely for the effects. All right, and then this was a meta-analysis done in 2017, and it compared, it showed methadone and buprenorphine. This slide just shows methadone. You'll see that the shaded in blue markers are in treatment, which is defined as on methadone, and then the open, the white markers are considered out of treatment or not on methadone. And so overwhelmingly, it showed that methadone reduced all-cause mortality and then also reduced overdose rates. And so again, it tests to the safety and efficacy of methadone. And I think that's important too, because I think that methadone can be stigmatized, especially with people who are not used to managing methadone. I used to see that in the hospital setting where people were just uncomfortable in managing the doses that are needed for people with, for opioid use disorder treatment. And so it's a matter of education and helping people get more comfortable with the idea of methadone for opioid use disorder. So what is the goal dose of methadone for a patient? So historically, it's been 80 to 120 milligrams a day. The goal of methadone is to have resolution of opioid withdrawal symptoms and decrease cravings. Now with fentanyl, I am finding that the, the stabilizing dose of methadone does sometimes need to be higher. And this has, this is similar to what I've discussed with my colleagues about, and also, and then some studies have asked this as well. And so what is the goal dose of methadone in the age of fentanyl and fentanyl analogs? I'm not sure. I do think though, at times, it does need to be higher than 120. Again, it's recommended that there are no dose limits for methadone that is, you know, not patient-centered care and are arbitrary. You know, there is, we don't really have a good answer at this time. And so again, it's speaking with the patients, figuring out their needs. If a patient isn't using, they are having cravings, would I automatically increase somebody's methadone dose? No, I would talk about, you know, what triggered the cravings? Are they meeting with a counselor? How, what are their coping skills? And so that is, I think, important to take into account when talking about adjusting somebody's methadone dose. And then I did list some studies here that showed higher retention rates for methadone as compared to buprenorphine. Methadone is considered first line for patients with significant risk factors, so that can include treatment dropout and overdose, injection opioid use, social instability with a higher need for structure, concurrent mental illness, and then also of course people who were not able to tolerate buprenorphine for whatever reason. We'll talk more about that later, too, and why people may transition from buprenorphine to methadone. OTPs are considered a higher level of care than office-based treatment just because of the regulations. It can provide a lot of structure. Some people do benefit from that. The daily dosing, the sometimes a requirement of meeting with counselors before being able to get your dose for that day, and that I think comes with positives and negatives, and we'll talk more about that later. And so moving on, I always get the question from learners, from counselors, from a lot of different kinds of people in healthcare about what medication is best for my patient. Would you, do you think it's buprenorphine, do you think it's methadone? Usually these questions come in the context of preconceived notions and stigma, especially with methadone. I always remind people that the number needed to treat for methadone and buprenorphine is two, which is amazing. And so, you know, my answer to that is, you know, I make this decision with my patient. The patients need to be informed about all their treatment options, the risk versus benefits, what worked in the past, what have they tried, and also what is available in their area. Again, there are treatment deserts. I work in rural Illinois. We have patients come from hours away, and so it's a significant amount of time that people are spending driving just to get their methadone dose. And so we'll talk about that as a barrier as well in a little bit. Ultimately, what is the best medication for my patient? It's whatever they are willing to take. And so, you know, if I, you know, I could recommend like, oh, I think, you know, buprenorphine would be better for you because of so-and-so. But if they're like, no, I want to try methadone, then, you know, if they're willing to take it, then something that can decrease the risk for overdose and death, I'm on board typically. So the history of OTPs, again, often called methadone clinics. It is the only healthcare facility that can offer all three forms of OUD or medications for OUD. Methadone and buprenorphine all are considered first-line treatments for opioid use disorder, whereas excenterolese naltrexone is considered second-line. Vivitrol or excenterolese naltrexone was studied in people who started the medication or the injection in a residential care setting. I think people who are in this line of practice know how difficult it can be for a person to get started on excenterolese naltrexone in an outpatient setting and due to the washout period, which is, it's difficult to get through, especially if people have, you know, things they need to do in like work, childcare, and not be at home very safe for a week, even with symptomatic treatment. Methadone for opioid use disorder must be dispensed by a licensed OTP. There's the exception of hospitals. For patients on methadone for opioid use disorder prior to being admitted to a hospital for whatever reason, they can continue that. The hospital usually calls and verifies the dose. OTPs can have very limited hours of operation. I know some clinics that are open at 5 a.m. or 6 a.m. and then close at 10 a.m. or close at noon, and so there can, and then close on weekends, too, so there can be a delay in care of getting the patient their methadone in a hospital setting. This sets up really the scene for an AMA discharge. One of the most common reasons for AMA discharges from hospital settings are untreated withdrawal, and so now their methadone for opioid use disorder can be incorporated into PDMPs, so I think that can make it easier for other healthcare providers to ensure that the patients are getting their needs met. In methadone clinics, there are counselors, and they tend to incorporate counseling and behavioral therapies. They are, OTPs are highly federally regulated, and then there are significant variations in regulations by state, and then within the state as well. I think that if you go to an OTP, you'll find different policies and procedures and regulations. They aren't standardized. Yes, there are the federal regulations, but there are pretty significant variabilities within each OTP, and so some of them act more punitively. Some of them act more or more quality of life focused, and so, for example, I've known some clinics who accept no patients who are on prescribed benzodiazepines or accept patients who are taking non-prescribed benzodiazepines. There is a term called administrative withdrawals where a person is tapered off their methadone against their will, essentially, because they're not meeting certain expectations such as attending individual group counseling appointments or they have a comorbid substance use disorder and are using stimulants or, again, benzodiazepines or using alcohol, and while there are significant safety issues, these policies tend to increase poor outcomes of patients, including overdose and death. I listed some of the federal regulations for an OTP, so technically, they limit the initial dose of 30 milligrams as an induction dose, and you can administer additional 10 milligrams after three hours if the patient is experiencing opioid withdrawal syndrome, and of course they will be. Like, 30 milligrams is nothing when you've been shooting a gram of fentanyl a day, right, and so the methadone induction phase is a period of dropout and overdose for people, and so there are different ways to start a person on methadone to reduce this risk, and taking into account that methadone steady state level is reached around five to seven days, the dose stacking phenomena, medication interaction, so on and so forth, and so, you know, in a controlled environment like a residential setting or a hospital setting, you can oftentimes increase the dose at a faster rate just because of the monitoring available, and so ATOD does have some guidelines for starting people on methadone. You can, you know, just start at 30, go to 40, 50, and then hold for several days until they reach that steady state level, and increase by five to 10 milligrams every three to five to seven days, so there are different ways, and based on, again, taking the patient's needs and comorbidities into account. For OTPs, eight urine drug tests are required each year. Per year, oftentimes there are a lot more than that, and I question this a lot in my own facility, like why, and, you know, the answer is because we've always done that. You know, a lot of my patients tell me what they're using, and we know what they're using. It can be helpful to know what, it is helpful, actually, to know what's in their drug supply, depending on the type of urine test that is obtained, but, you know, we don't have a clea wave xylazine or fentanyl for urine drug testing, so there are limitations to our current urine drug tests, and then there was a large study of the state variability of regulations for OTPs, and I put an example of some of them, and so this one, again, also going back, there are regulations for take-home doses, and we'll talk more about that, too, especially with the COVID-19 flexibilities, so it is, so, again, OTPs, you have to go for daily dosing until you meet certain requirements, and depending on the facility, they can be, it can take a long time to get take-homes. You know, there, it can take years just to get two weeks of take-homes. It can take years to get 28 days of take-homes, which is the max. So, in the dark blue states here, they have additional criteria imposed for take-home doses or more strict guidelines in order for people to get take-homes, whereas the lighter blue, they have no additional stability or criteria beyond the federal regulations. Wyoming has no Wyoming has no data. Wyoming has no OTPs. The next slide is, the dark blue states' goal is stopping the methadone, discontinuation of the methadone as a treatment goal, and then the lighter blue states that discontinuation of methadone is not specified as a goal, and then no data, and so, you know, I think we know now that being on buprenorphine or methadone indefinitely is accepted and is actually recommended because of the overdose crisis that we're in and the overdose risk of stopping a medication for use disorder if somebody were, if they were to return to use. And so, there are also more variable study like states that limit the number of OTPs that can be, that can, that are allowed in a state, zoning restrictions, and so it's interesting if you take a look. Again, while wide variability between states and then, of course, within states as well, like I said. Okay, so going back to the strict regulations on OTPs, there are a couple different documentaries made about methadone. One is called Liquid Handcuffs, another is called Swallow This, and so it really attests to the lengths people have to go to to take methadone and to be on methadone. If you need, if you want to take a vacation, for example, you have to apply to get take-homes, you have to get permission to get take-homes. If you're not approved for take-homes, you have to find wherever you're going on vacation, you have to see if there's a methadone clinic in the area where you're going so you can guest dose, and then you have to do a bunch of paperwork for guest dosing, and so it takes a lot of planning. And then, you know, from a harm reduction lens, why is it easier to get fentanyl than methadone? I had one patient who told me, who was like, when I'm, when I wake up in the morning and I'm sick, it's a lot easier for me to go next door and get some fentanyl than it is to come all the way to clinic, get a bus, and take two buses, which can take a couple hours, and come to the methadone clinic, and get my methadone, and then go about my day, go about my life. Then it, so, and that makes perfect sense, you know, and I think there are ethical considerations, too, of the regulations on OTPs. The advent of OTPs did come about in the 1970s, which is when the, you know, racialized drug war was beginning, and so I think people are considering these regulations for good reason. It's interesting, too, because there is no evidence that requiring daily or nearly daily attendance to methadone clinics improves patient outcomes. It's just perceived. And then, you know, whenever people get take-homes, it's perceived as an overdose risk. And especially when the COVID-19 flexibility guidelines came out. So COVID-19 isn't the first really significant public health issue that affects people's ability to get their medications or healthcare needs met. And nor will it be the last. There was a study done after Hurricane Sandy on people who inject drugs in New York City on the HIV transmission rate and access to healthcare, including methadone at OTPs. And so the hurricane and, you know, the lack of planning and inaccessibility of needle exchange services or syringe service programs being able to get your methadone somewhere else, like a pharmacy, that led to a increase of HIV transmission. And then of course, people with that return to use, they had a treatment dropout too. And so we know that with treatment dropout increases risk for overdose. And so there are significant implications from this study. And so when COVID happened, you know, a couple of years later, and SAMHSA extended, so SAMHSA developed the COVID-19 flexibility guidelines. And these actually have been extended and there are currently plans to make them permanent. In the state of Illinois, super, our regulatory agency adopted them as well. So what are these flexibilities? Basically that people can granted blanket authority to provide all stable patients and stable is determined by the medical provider or the program director. And so it's up to interpretation, which I think things that can be helpful. So patients, stable patients can take up to 28 days of take-home doses, which again is the max. Patients who are less stable, but capable of safeguarding and handling their doses were eligible for up to 14 days of take-home. And so these are listed the criteria. So the absence of active substance use disorder, other physical behavioral health conditions that increase the risk of patient harm. And that includes, you know, psychiatric and medical comorbidities, especially such as COPD that increases the potential for overdose. Regular attendance, you know, what does that mean for each clinic? Oh, so regular attendance for supervised medication administration is gonna be your dosing in front of the window. And does the patient have a home to take the medication to and safely store? People who are unhoused are more vulnerable to their medications getting stolen. And I think that we have all had those patients. And so this, again, is working towards permanence of these, flexibility and guidelines. And there have been studies that showed that this flexibility did not increase diversion rates, did not increase overdose rates. I think those are conflated fears that people have because in reality, they do not occur at a greater level. So current legislation to address the barriers related to access to methadone is the Modernizing Opioid Treatment Access Act. And so it seeks to expand the unsupervised use of methadone by dispensing methadone from a pharmacy. Again, you know, there's usually a pharmacy in every small town or at least nearby, whereas there's not an OTP in every small town. Again, I have patients who come hours away and that's a significant time commitment. And it permits the use of telehealth to prescribe methadone. And so I think this is an important piece of legislation that has been introduced. It is getting a lot of criticism at this time. Change can be scary, change is hard. I talk to my patients about that all the time, but I think it's definitely worth it because we know that methadone saves lives. So earlier I talked about methadone and the PDMP. Methadone for opioid use disorder is historically not part of the PDMP. In Illinois, we are required to ask our patients if they want methadone listed in the PDMP and they do have the option to say no. Currently in the OTP where I am working, or the last time I had the data collected, we have 162 participants. 148 have signed the consents and agreed to have the methadone listed in the PDMP and five chose not to. And the five who chose not to were due to stigma concerns. We don't have the option to have methadone listed due to stigma concerns, which is the majority of people's concerns. And then of course, it's really important for PDMPs to only be accessed by healthcare professionals. And I think it's important to protect our patients, especially those on medications for opioid use disorder from legal entities. Like in some places, cops or police have access to PDMPs. And so, this is all about patient safety and providing the best care that we can for our patients. And when we talk about the PDMP listing methadone for opioid use disorder, we talk about how it can be helpful, it can, especially when patients are in the hospital setting and you can't verify their dose because the clinic is closed because of the crazy hours, it's not the end all be all in terms of reducing bad outcomes from prescribing perhaps. But I think it can definitely be a patient safety measure. So what can you do in an OTP for patients? You know, pretty much whatever's in your scope of practice. I implement harm reduction into my practice and harm reduction is not just about using clean needles and paraphernalia, but it's also about, you know, providing prep for HIV and improving the overall quality of life of a person, you know, people who have abscesses, people who have had endocarditis, you know, those are traumatic experiences for them within the healthcare system. Methadone has been viewed as harm reduction as well. And then of course, you know, you can't, I always tell my patients, you can't revive yourself, let a loved one know if you're going to use or a friend so they can check in on you if they don't have that. This hotline is wonderful. They stay on the line with you. If you don't respond in a certain amount of time, 911 is called. Overdose prevention sites like the ones in New York and have shown a increased risk for increased treatment for treatment, decreased risk for criminality and which are again, fears of OPSs. So, and then you can find like vein care, education for patients and a lot of different other things. And also I asked about the patient, what are their goals of getting treatment? Which is really important to understand where they're coming from and the context they're coming from. Always check hepatitis HIV screenings, OTPs do require TB testing. And then of course, providing condoms, just having education on safe sex available to them is important. Okay. And then I also treat hepatitis C where I am, where I practice, I still see have patients who come to me and say, oh, I can't get treated by my infectious disease doctor because I tested positive for cocaine. That is against liver disease and infectious disease society guidelines. And so I think treating hepatitis C alongside treating their obesity disorder can be really, really exciting for patients. They're very appreciative of it. And treatment's pretty easy. And also in Illinois as of July 1st, there are no PAs for hepatitis C treatment, which is amazing. Okay. Now, another thing that I do is transition people from methadone to buprenorphine or vice versa. So why would a person be switching from methadone to buprenorphine if a patient is moving states? I've had this happen actually a couple of times and there's no OTP within a hundred miles of their location. And so I transitioned them to buprenorphine and they were able to get with a buprenorphine provider in their town that they were moving to. If a patient is in jail and sentenced to prison where they don't have access to MOED, I had a case where a patient was on methadone, we switched them to sublingual buprenorphine and then administered sublocade. So they would have less withdrawal, if any, from the sublocades, long half-life. OTPs are not conducive to patient's lifestyle. Work obligations, transportation issues, childcare, so on and so forth. And buprenorphine is generally much more compatible with a person's lifestyle. Improved pain management I found as well, especially with the ability to provide, easier ability to provide split dosing with buprenorphine. Why switch from buprenorphine to methadone? Maybe buprenorphine is not working for them. Again, OTPs are considered a higher level of care with the structure that is provided from the daily dosing. Is there continued use of opiates or fentanyl? Have ongoing withdrawal symptoms and cravings despite being on the max buprenorphine dose? So there can be more reasons. And so it's easy to switch from buprenorphine to methadone, right? Can be more complicated from switching from methadone to buprenorphine. And so this is an example from the California Bridge Treatment Protocols. I have done both micro-dose or low-dose inductions and the macro-dose inductions. The key to this is patient education and patient expectations. I do a lot of time going, spend a lot of time going over the various protocols with people and on how to be successful with switching the medications. And so I'm not going to spend much more time on that because I want to save some time for questions. These are resources that I find, have found very helpful. And some of them are Illinois specific, including the ILPQC, which is mothers affected by substance use. This is the California Bridge Protocol, but you'll get a copy of these slides. With that, I'm going to stop sharing and open up for questions, discussion, comments, whatever. Thank you. Thank you. And anybody that has any questions, you can either post them on the chat or the Q and A, or just, you know, at this point, just come out and unmute and talk about them. No one can unmute on this one. Like I can't unmute somebody if they hold their hand up, but it would be easier if they put it in the Q and A. And then, of course, any other topics related to this that you may want to ask Dr. Wessel questions about, please feel free. We have one question specifically about the transitions from methadone to bup. We'll hit that one first. Yeah. So for methadone to bup, so I do do typically the low-dose crosstaper. Yes, I can show that. Oh, here it is. Oh, okay. So this is the low-dose, the seven-day sublingual crosstaper. And so I continue their methadone. I don't decrease their dose. It really is not going to make a difference if they're on 80 versus 120 versus 150. And so I'll start, again, explain multiple times with the patient on how to do this and give them directions. This is from the California Bridge Protocol. You can vary this if you want. I found this to be helpful, though. So basically, this is exactly what you see. So on day one, you prescribe two milligram films. They take a quarter of it and continue their methadone. And so it gradually increases over the course of a week. And then on day eight, that's when they'll no longer take any methadone or it can be weed. So I typically just stop it and then do like a macro-dose type of situation. And so I know Sarah Honan is saying, you don't taper to 31st, that's been a source of confusion. So in fellowship, I was taught like, oh, for transitioning from methadone to buprenorphine, you have to taper them down to 30 milligrams. They have to be on 30 milligrams for two weeks or less. And then they have to stop for seven days. And then they can do their buprenorphine induction. Realistically, you're going to get a lot of treatment dropout from this. And you don't have to do it this way. There are much easier ways for patients. And then also you can skip that whole washout period, which again, a person is going to be uncomfortable. And yes, I do provide symptomatic management for withdrawal symptoms with either lofexidine and clonidine, disceclamine, and so on and so forth, on the whole jam. If people are still using heroin, these low-dose cross-taper starts are another way to get people started on buprenorphine. And another way to get people started on buprenorphine in the advent of fentanyl, well, fentanyl is a short-acting opioid. It is highly lipophilic. It can seep in and out of circulation. And so that's where you run into trouble, too, with having precipitate withdrawal with starting buprenorphine on somebody who is using fentanyl, which is in all the drug supplies. There's a couple different macrodose protocols. You can find they'll get eight milligrams sublingual every hour for four doses. You can give 16, and then an hour later, give another 16. Yes, this is similar to a microdosing protocol, absolutely, Sarah. What max dose of methadone have you used to use the bridge? I'm trying to think of the more recent one. I think it was on for this patient who moved across the country. I think he was on a pretty high, I want to say around 160, maybe. And he did fine. I mean, it's not discomfort-free, and I explained that to my patients, but we do manage their symptoms. They're able to be functional. And so, yeah, I do think it's helpful. I would caution trying these in people who are unstable at baseline, maybe have chaotic lives. I don't think it's not a reason to try. But from my experience, I had a patient who did not tolerate, does not tolerate discomfort well, has a lot of trauma, not a lot of support. I had wanted to, and she had been willing to try to go to buprenorphine due to her inability to come to dose on methadone consistently. However, it didn't work out, but that's okay. And maybe I should have tried a macrodose protocol with her, and maybe I will. And, you know, in, in fellowship. I rotated through through a couple different OTPs, and, and again they they varied wildly within one city in Madison. And I, and I think, you know, I was biased as a fellow, and until I started gaining more experience and then I realized how helpful methadone can be and is some people just do not tolerate buprenorphine and just do not do well on buprenorphine. And it's good, it's nice to have options right. And so, and then I started working in OTP and I love it. I'm. It is definitely higher duty population. I think that does come with the territory. But I think it. And you can make it what you want it to be, and, and being able to, you know, treat Hep C, provide prep. I have had many patients tell me oh I didn't even know this existed this is great I can prevent getting HIV. It's been rewarding, for sure. And I work with a great group of counselors to. What is your buprenorphine success rate with fentanyl users. I think the biggest barrier is getting them on to buprenorphine. So, um, in Illinois, we have. So again, I'm heavily involved in the Illinois Society of addiction medicine and so we've run into a lot of prior authorizations for prescribing more than 24 milligrams a day of buprenorphine, you know for for Medicaid Medicare recipients. And so I'll try to be quick about this because I know it's six but you know we are finding the need to increase doses even beyond 32 milligrams of buprenorphine, because of the fentanyl issue. And, and so we did we drafted a letter to HHS to to address our concerns because, because I think everybody's running into this problem with with fentanyl needing higher doses, not just methanol but with buprenorphine as well and so I do think the buprenorphine, if you can get somebody inducted on to buprenorphine. I think that's one of the biggest barriers but you know there are a lot of resources out there I do. It's like I'm promoting California bridge but I, I think they provide a lot of excellent information, and you can find a lot of different kinds of protocols available to if you look for them. So yeah, and I would be happy to start an OTP physician group that would be cool. I because I'm always, you know, asking my colleagues like what they're doing, what kind of doses they're seeing, because sometimes I do feel isolated especially in my rural community. And so I think yeah, that'd be cool. All right. Well thank you so much, everybody, and I will see you again. Perhaps. Thank you very much, Dr. Wessel. I just wanted to kind of plug in for next month's presentation to right now that's scheduled for August 10 at 6pm by Dr. Anthony Decker. Next topic is going to be veteran and active duty military issues and substance use disorder. So that should be a very, very good presentation as well. It's been a great presentation here Nina Do you have anything you wanted to bring up or talk about before we know. No, thank you all very much for your participation. Thank you Dr. Wessel Thank you Dr. Conrad wonderful presentation. Absolutely.

Dr. Elise Wessel

addiction medicine physician

opioid treatment programs

methadone

buprenorphine

naltrexone

medication-assisted treatment

state regulations for OTPs

harm reduction strategies

co-occurring conditions