Good afternoon, or evening. Welcome to our second webinar in our series, Testimonies from the Trenches, Innovations in Clinical Practice. My name is John Lepley, and this webinar series was put together by our education committee at the AOAAM. And so I certainly want to thank Adam Scioli, Elise Wessel, and Max Pavlok for the hard work in putting this series together. And of course, I want to thank Judy Pfeiffer for coordinating our meetings and generally keeping us in line and getting our materials submitted within the deadlines needed. These webinars involve a brief didactic presentation followed by an interactive discussion. The didactic presentation is recorded, but the discussion that follows is not. We want that discussion to be free form, and feel free to speak your mind, and certainly feel free to change your mind on the topic at hand. We want to hear from attendees, and we want to learn from everyone who practices day-to-day in the trenches. So after the presentation's over, attendees can raise their hand, and I will go ahead and unmute you. Our speaker today is very accomplished from an academic standpoint, but mostly I admire the work that she does in the trenches. She's very dedicated to improving the health and the lives of people in portions of Philadelphia that have suffered a heavy toll in our current opioid crisis. She's also very dedicated to ensuring that individuals in rural and remote regions of Pennsylvania have access to life-saving medication. She's very versatile. Shoshana Aronowitz is a family nurse practitioner, community-engaged health services research, and an assistant professor in the Department of Family and Community Health at the University of Pennsylvania School of Nursing. Her research examines innovative delivery models to promote equitable access to substance use treatment and harm reduction services, as well as racial disparities in pain management in the context of the opioid overdose crisis. She received her bachelor's degree from McGill University, her master's in nursing from the University of Vermont, her PhD from the University of Pennsylvania School of Nursing, her master's in health policy from the University of Pennsylvania School of Medicine, and she completed her postdoctoral fellowship at the National Clinician Scholars Program of the University of Pennsylvania. She provides substance use disorder treatment at Prevention Point Philadelphia and also Ophelia Health. In addition, she is a member of SOL Collective, a grassroots harm reduction organization located in Philadelphia. We are very fortunate to have her this evening, and I will turn it over to Dr. Aronowitz. Thanks so much, Dr. Lovely, and hi, everyone. Thanks. Thanks a lot for attending today. As Dr. Lovely said, my name is Shoshana Aronowitz, and I'll be talking this evening about expanding access to opioid use disorder care with low barrier approaches. So, as Dr. Lovely said, I'm an assistant professor at the Penn School of Nursing, an ex-waivered OUD treatment provider at two programs, and I provide both telehealth and in-person care, and I'm also a community organizer with a harm reduction group called SOL Collective in Philadelphia. Trying to get my slides, there we go. I have no disclosures or conflicts of interest. Okay. So, my objectives today, I want to introduce low barrier buprenorphine treatment approaches, identify some common barriers to receipt of OUD care with buprenorphine, and review some strategies to make care more accessible for people, and generally just increase comfort with providing OUD treatment to patients who have previously struggled to access care in traditional substance use disorder treatment settings. Okay. So, I know we are all aware of these staggering numbers. More than 100,000 people in the U.S. died of a drug overdose in the 12-month period ending in April 2021, and this was nearly a 30% increase from the year before, and drug overdose is one of the leading causes of injury-related death in the U.S. We also know, of course, that COVID-19 has only deepened and accelerated this crisis, so social isolation, of course, is a substance use trigger for many people. We know this. And in addition, the pandemic caused many treatment centers to close or scale back their services and led to further instability in the drug supply. So in that vein, I'm sure you all know about how the drug supply across the country is becoming increasingly contaminated with fentanyl, and in some places, including here in Philly where I am, much of the heroin is actually fentanyl, and heroin has really become almost impossible to find. And in addition, at least in Philly, much of the fentanyl actually has xylosine in it as well. So we all know that buprenorphine and methadone are amazing for how effective they are at reducing risk of overdose. A really great paper published recently by Wakeman and colleagues in JAMA found that methadone and buprenorphine were associated with a 76% reduction in overdose at three months and a 59% reduction at 12 months, and this is in contrast to other treatment methods which were associated with no reduction in overdose risk at three or 12 months. And they compared detoxification, inpatient treatment, IOP, and naltrexone. But unfortunately, as we also know, less than 20% of people with OUD actually receive buprenorphine or methadone. And although it's really wonderful to be able to offer counseling along with medication to patients who want it, there's lots of evidence that buprenorphine is effective at decreasing opioid use, even when it's not paired with any other interventions. So this graphic is from a study that I was actually a clinical trial nurse on in Vermont years ago, and it was published in the New England Journal. And we tested the effectiveness of providing buprenorphine alone with no counseling component to no treatment. And this was at a time when medications for opioid use disorder really were almost never given without any counseling or other intervention. So it was kind of seen as radical by many other people, but I now think of it as my first exposure to low barrier treatment. It's really wonderful to see how far we've come, but you can see here, of course, how effective buprenorphine alone is. So unfortunately, despite how effective methadone and buprenorphine are, we know there's so many barriers to access. So just some of these barriers can include high threshold, low tolerance programs. So these are programs maybe where complete abstinence from all substances is required to continue in the program. Maybe there's very frequent follow-up visits. People have trouble with that because of competing responsibilities like work and child care, for example. Some programs require counseling and groups. Patients sometimes live really far away from some of these programs or providers, or even if they don't live that far away, they still don't have a car or a way to get there. Patients still might not be aware of what's available. Some programs may be cost prohibitive or maybe travel to the programs would be cost prohibitive. Still lots of stigma, keeping people from getting treatment. We'll talk a little bit more later about fentanyl and how that's making it hard for people to get injected onto buprenorphine. And then, of course, we know methadone specifically has some really serious federal and state regulations that can be a barrier to many people. So this is where low-barrier treatment models come in, and they can help address some of these barriers. So there's a great paper by Jakubowski and Fox that was published in the Journal of Addiction Medicine that kind of outlined this whole framework for low-barrier treatment models. And so they pointed to a few things that were really important in thinking about how to make care more accessible. So they talked about same-day access to medication. And I remember when I worked as a methadone nurse years and years ago, we would have these long intakes of people, but people wouldn't get medication the same day. So they'd have to come again for another visit. And so they talk about how important it can be for people to get medication the first day, the day that they come for their first visit. Having flexible scheduling, so trying to figure out ways to make visits fit into patient schedules however possible. Not requiring abstinence from other substances or necessarily opioids. And meeting people where they are, and sometimes that really means literally. So we'll talk a little bit today about telehealth specifically, but also mobile models. And this here is a picture of a treatment van that I worked on that parked at a corner in Kensington in Philadelphia. And we had clinic inside the van, which the point of that was to not make patients necessarily come to our building if they didn't feel comfortable doing that, but we would come to them where they were. And we also see successful programs that are co-located with other things that folks need. So that sometimes syringe access programs or harm reduction services having buprenorphine programs co-located right with those services, or also a long care with HIV and hep C care, which can make both types of treatment more accessible for people if they can just get them all at once. So I just want to talk about some of these facets of low barrier care in a little more depth. And I'm just really going to talk about what I do in my practice, and I know Dr. Lovely and I have discussed this, and not all of these things are necessarily possible for every practice. But one thing that I found to be really helpful for one of my practices, at least, is certainly the same day access to medication when someone comes in for their first visit, but also having some flexible scheduling. And the reason for this, depending on your patient population, one of my clinics treats lots of folks who are experiencing unstable housing and don't always have phones that And setting a time for an appointment and saying, like, you have to come at 10 or something, people really struggle to do that. And what seems to be easier is having this range of time. So it's like my clinic is from 9am to one, and people can come and they might, they might know that they might have to wait if they come at a busy time, but if they come during those hours at any time, I will see them. And I think for some people, it's, you know, things that we don't always think about, but if you don't even know what time it is, like, how are you going to make it on time somewhere. So that's something that can make it a lot easier for people. And even if that's not possible, really making it as easy as possible to change or reschedule appointments, and not having a penalty for missed appointments whenever possible, it really can be hard, I know, in busy clinics to do things like this. But I think in my practice, at least it really has made a difference for some people. Moving on to the kind of harm reduction approach or no abstinence requirements. So this is something that comes up a lot, I think, for a lot of clinicians, because, you know, it's a real worry. I think one thing that I talk about a lot with new clinicians who I'm mentoring, we're just getting started with buprenorphine prescribing is remembering, of course, that buprenorphine is only treating opioid use disorder. And so lots of our patients use multiple substances, and buprenorphine is not going to treat, you know, the use of those substances. And some people also, some patients, their goal from the very beginning, if they feel comfortable to tell you, is not actually to completely eliminate all opioid use. Sometimes it's to decrease, or at least decrease in the beginning, and then eventually stop. So that also might be a reason why people, you know, it might not really necessarily be a failure if they continue to use opioids, if their goal had been to use a lot less, and they are able to. Continued stimulant use, there's really relatively low risk with continued stimulant use. And again, you know, like if people, people might use stimulants occasionally, but they also might have a stimulant use disorder, and buprenorphine certainly is not going to treat that. And then continued sedative use, which has, of course, been a very big concern. More and more recently, and the FDA put out this announcement in 2017, you know, it's kind of being realized that the risk, although there is a risk, is outweighed by the benefit of decreasing risk of overdose from opioids for buprenorphine to be prescribed. So sometimes maybe that means like really trying to have very honest conversations with your patients and maybe following up more frequently. But I do remember a time when co-use of benzodiazepines was actually a reason why people could not get access to buprenorphine, and I'm sure in some cases, some practices, that's still the case. But, you know, that might be a really big barrier for many patients. And so given that it's quite possible, you know, that patients won't stop using opioids or other substances right away, I think it's really important to incorporate harm reduction practices into your care. So these include but are not limited to co-prescribing naloxone, which I always, always do, and providing education about safer use strategies, including like skin and wound care. And this is just a plug here for a really great program that some of your patients might benefit from. So Next Distro is a national organization that partners with local organizations to mail free naloxone, in some places, free fentanyl testing strips to anyone who requests. You can Google NextDistro to find out more information, but that's a great resource that I like to give to my patients too, because although I'm prescribing naloxone, they might wanna receive it by mail at any point, or maybe they wanna tell their friends, and I have found that this kind of secondary strategy of getting the word out about naloxone can be really helpful. So my patients will tell their friends, many of whom maybe are not actually in recovery or taking buprenorphine and really need the naloxone. So something I think it's important to pass along. So what about urine drug screening? We're talking about continued substance use. So of course, drug screening has traditionally been a mainstay in substance use disorder treatment, although not completely without controversy. When I worked at a methadone clinic, we did observe urine drug screens at every single visit. Of course, observed screens can be incredibly difficult for patients, especially patients with histories of sexual trauma, and more and more, I think, especially in office-based care, we're not doing observed screens, and there's lots of reasons why doing a urine drug screen can be a helpful tool, and some patients also actually find it's a tool. I think I found that the most useful way for me to use it is after having a conversation with patients about what we're actually looking for and why we're doing it, because I found that lots of patients who have been in programs that will kick them out or have kicked them out for maybe a positive THC get very nervous and feel like they're incentivized maybe to falsify a urine or say they can't pee because they're so worried about it. And I found that having this conversation saying, I just wanna see how you're doing, and I wanna make sure you're taking your buprenorphine okay and all that makes people feel a little more at ease. But I certainly have seen this come a long way in my own practice because when I started, like I said, in methadone, it was something, we expected complete abstinence from all substances. We watched people. If people couldn't pee, they had to wait for hours in the clinic and maybe wouldn't get their medication if they couldn't leave the urine. So I won't spend too much time talking about this because I know it was discussed at the previous meeting, but if you weren't there and you're interested in learning more about this, I wrote a piece with a colleague, Dr. Utsakotri, which was published in the Journal of Substance Abuse Treatment, kind of starting this conversation about urine drug screening, when and how we should use it and how we can make sure we're using it in a way that's not punitive, but is supportive of our patient's goals. So another facet of low barrier treatment is offering care in non-traditional spaces to meet people where they are, quite literally. So this can include, like I said, in harm reduction programs, like syringe access programs, in mobile units, like the one pictured here and via telehealth. So I'm gonna talk a little bit more about telehealth because I know that's really a hot topic in every field of healthcare right now, but certainly in substance use disorder treatment. So I'm sure all of you are familiar with this, but due to the Ryan Hite Act of 2008, clinicians were required to complete an in-person evaluation in almost all cases before prescribing a controlled substance. So this changed pretty abruptly in March, 2020, when the DEA loosened restrictions and allowed for telehealth for buprenorphine induction and maintenance. So researchers are kind of scrambling now to publish evidence to help guide our practices in this area, because there really isn't a lot of evidence about how actually to do it. But the future of telehealth for opioid use disorder treatment is still really uncertain and may end up varying actually from state to state, depending on the regulations. There's a few great reports out there about this. This is a JAMA Health Forum piece that kind of talks actually about different regulations state by state. And there is a really great episode of the Trade-Offs podcast, which covered this issue and kind of talked a little bit about the future. And I really highly recommend listening to that. So many of you might provide telehealth already. I've been doing it since the very beginning of COVID-19. And these are just a few things that I've been thinking about since I started providing it and concerns that I had certainly at the beginning. And I think the first question for most clinicians is really which patients are considered eligible. So there's so many things that could go into this. I think one of the most kind of tangible things is does the patient have a stable phone or internet connection? Because that can be really hard, especially if you wanna, there are clinicians who do audio only visits, but if you wanna be seeing your patient, just because someone's phone works to talk, I have found even if they have an internet, Zoom or whatever platform you decide to use can be really hard and that can become really frustrating. Of course, if patients have other illnesses that are not currently being treated, that might influence how comfortable you feel, especially if it's like hard to do any sort of testing via telehealth. If they have other substance use disorders, specifically benzodiazepine and or alcohol use disorders, if they're pregnant, I'm not saying these are reasons people would be ineligible, they're just things that maybe would impact a clinician's willingness to offer telehealth. But I really think one of the most important things that we kind of have to consider going forward is will the patient, if they're not eligible for telehealth, will they have access to any in-person care? Because I think a lot of times patients, it's easy for us to say like, this patient requires a higher level of care, I think they should see someone in person, but what can be hard for a lot of patients is maybe there really isn't any good option for them besides telehealth. And that's where it really gets sticky because you wanna be practicing safely, but we know that people are at such high risk without medication and we wanna make sure that when we say you need to go somewhere in person that there really is somewhere that that person can actually go. And in providing telehealth since the beginning of COVID, I've really found that the visits are very similar, I'm doing all the same things that I was doing in person. I do think the most important piece is education about telehealth treatment, making sure that patients know how often you're following up and how you're doing these follow-ups. Urine drug screening comes up a lot and I think different clinicians can use different models and decide what they're comfortable with. One thing that one of the programs I work at does is actually offers mailed screens, so sends cups in the mail to patients and then patients do urine testing unobserved, of course, in their own bathroom, the clinician waits outside on the computer and then the patient shows the urine cup in the camera. And that seems to be another option, of course, is using a saliva test that you could actually watch the person do in the camera. But I do feel like there's probably ways that we can get around these issues and I would hope that testing wouldn't be a reason that we wouldn't move forward with offering telehealth. So this is one thing I wanted to briefly touch on, Dr. Lovely and I talked about, it's a really important part of low barrier care and buprenorphine induction these days in general. And as everyone knows, induction can be incredibly difficult for some patients, especially those using fentanyl, so this is where microdosing might be useful. So this was first described, I believe, in an article in 2016. And really just the general premise for any of those not familiar is that very, very small doses of buprenorphine are taken while full agonist use is continued, slowly built up, much more slowly than traditional induction while the full agonist use is slowly decreased. And if done correctly, hopefully it does not precipitate severe withdrawal and the buprenorphine actually very slowly replaces the full agonist at the receptor. So this is a screenshot of the dosing protocol that's from that original article. And you can see here, of course, like lots of people, it's very hard to determine actually how much someone is using, would you know this specifically, but the idea is for people to just slowly on their own be decreasing their full agonist use while slowly increasing their buprenorphine use. And this is a more recent protocol that was developed by colleagues of mine at Penn Medicine. And so you can see the first day, very small amount, 0.5 milligrams, just once, that's it, with continued full agonist, slowly building up to day seven where a patient's taking 12 milligrams split into two doses, and that's the day they're stopping full agonist opioids. I think that doesn't work for every patient and I'd love to have a conversation if people want to about their experiences with it, but it seems to be one tool in the toolbox for patients who are really struggling to stop fentanyl use and start buprenorphine. So I'd like to wrap up so that we can have discussion, but I just wanted to address an additional barrier that you likely encounter if you prescribe buprenorphine, another thing I'd love to talk about, which is pharmacy level barriers. So recent research and my own experience suggests that pharmacists can be really wary of dispensing buprenorphine prescriptions. And this study that was just published a few months ago found that one in five pharmacies nationally actually don't carry buprenorphine. This was a secret shopper study. So this was based on what the pharmacist said. Some of my qualitative research suggests that pharmacists, if they don't want new buprenorphine patients, will say they don't carry it, even if they do carry it. So it's unclear whether truly one in five don't or one in five are not willing to say that they do to new patients. Either way, it doesn't matter. It's a barrier, obviously. And those that do carry buprenorphine may be picky with regards to co-occurring benzodiazepine or other controlled substance use or prescriptions that obviously they can see in the PDMP. Distance from pharmacy to patient or clinician, which becomes an issue when we're talking about telehealth because you might be treating patients who live far away from you. And how might that look to a pharmacist if you live very far away from a patient? That has been suggested as a red flag by a pharmacist to me about why they don't wanna dispense. Doses actually above 16 milligrams, which lots of patients, especially patients who are using fentanyl are on higher doses, but some pharmacists don't feel comfortable. And of course, filling early as well, which I'm sure many of us have encountered. So I think this is a really important thing to think about because for many patients, even if they can finally get to you, everything's set up. If there's one pharmacy in their town or close to them and their pharmacist will not dispense a buprenorphine, it doesn't matter that you prescribed it, they won't get it. And I've had some patients lost to follow up for this reason. They finally come back and it's like, oh, I tried, I went to the pharmacy. Either they wouldn't give it to me or I really didn't like the way they talked to me. And I felt like, what's the point? I'm not gonna do this anymore. So I'd love to hear from everybody if that's something that's come up for you. It's something I've not really experienced. Well, I've experienced a little bit in Philadelphia, but more in rural Pennsylvania. So anyway, in conclusion, thank you all so much for your attention. Main takeaways are that many patients with opioid use disorder lack access to evidence-based treatment with medications and low barrier approaches can help expand buprenorphine treatment. Many patients, especially those who are marginalized or who have struggled to engage with traditional approaches. I welcome any questions and here are my references. Thank you so much. Thank you, that was great. Hey, before we stop the recording, we had one question in the chat. Early on, you talked about this compound that's found in the fentanyl. Oh, xylosine. Xylosine, yeah. Yeah, it's a veterinary tranquilizer. And so it can mimic in lots of cases an opioid overdose, although it does decrease, it causes hypotension as well, but will not be impacted by naloxone. So that is a scary thing that a lot of people in Philadelphia are experiencing. Patients will tell me that what they feel, especially if they don't overdose, is they kind of black out for long periods of time. So they find themselves in a place that they don't remember going to. So they're not nodding off and falling down and sleeping. They're walking around, but they don't remember any of it. The really big, I mean, there's many concerns with xylosine, but one big concern here as well is it is leading to these really complex skin and soft tissue infections. So we're seeing wounds that we were not seeing before because of how damaging it is to tissues. So there's a few articles I'm happy to share about a few case reports about xylosine in the drug supply here. Yeah, I believe it's spelled X-Y-L-A-Z-I-N-E. The street name, they call it Trank. Is that right? And I'm not a toxicologist. I believe it works on alpha receptors in some way. It's like a central acting alpha agent, and that can cause some vasoconstriction or arterial constriction. That might be why we have such challenging wounds around injection of this substance. Well, that whole presentation was great. I just wanted to address that question since it was part of the content. I think we're able to go ahead and stop the recording and then we can move on to our discussion portion.

Low Barrier Approaches

Equitable Access

Substance Use Treatment

Harm Reduction Services

Buprenorphine

Methadone