Okay, good evening, everybody. Welcome to today's AOAAM webinar, The Evolution of Buprenorphine, Prescribing Practices, and Efforts to Increase MOUD Access, by Dr. Bradley Stein. My name is Julie Knick, and I'll be your moderator for this session. This is the next to the last webinar of this series, Hot Topics in the Treatment of Opioid Use Disorder and Stimulant Use Disorders. Dr. Bradley Stein graduated from the University of Pittsburgh School of Medicine in 1995 and went on to earn his MPH in 1997, followed by a PhD in Health Policy from Rand Graduate School in 2002. He's a practicing psychiatrist and a senior physician policy researcher at Rand Corporation. A health services and policy researcher and clinician experienced in working with individuals with substance use disorder, Dr. Stein's research activities focus on better understanding and improving the quality of care provided to individuals with mental health and substance use disorders being treated in community settings. In recent years, much of Dr. Stein's work has focused on the opioid crisis, serving as PI or co-PI on 12 federal and privately funded studies related to the opioid crisis. And he's currently the director of NIDA-funded Opioid Policy, Tools, and Information Center of Research Excellence. He has testified to Congress on issues related to the opioid crisis, as well as publishing multiple peer-reviewed articles in a range of journals, including the Journal of the American Medical Association, Health Affairs, the Milbank Quarterly, and Drug and Alcohol Dependents related to the crisis on topics including the treatment of opioid use disorders, the prescribing of opioid analgesics, and the effects of state and federal policies. So welcome, Dr. Stein. Julie, thank you so much. I'm very glad to be here. Let me get the slides back up. There we go. Are you seeing them? Yes. All right. Well, thank you so much. I'm so glad to be here with you all this evening or afternoon for those of you on the West Coast. Today, I'm going to be talking about sort of the evolution of buprenorphine prescribing practices and some of the policy efforts to increase access to medication treatment for opioid use disorder. I'm still, after several years, I'm not completely used to the Zoom sort of mechanism. I prefer much more talking with people than at them. So please, I encourage you, if you have questions, drop them in the questions. I'm happy to answer them as we're going along. So first of all, let me thank SAMHSA for the funding for the Opioid Response Network and express that the views expressed are my views and the research views and don't imply any endorsement by HHS or the U.S. government. I have no conflicts of interest. I don't believe Julie does either. Before diving in, while I have the pleasure of talking to you this evening, you know, the work I'm going to be sharing represents work from lots of colleagues, a number of whom are listed here, as well as a number of funders, including both NIDA, the NIH, and the Foundation for Opioid Response Efforts for. And so none of this work really could have been done without them. Again, they're not responsible for any of the content. That's the work of the researchers. So during today's talk, what I'd like to do is sort of cover a number of different areas. One, I sort of want to take a step back and talk about sort of a brief history of the policies related to buprenorphine and sort of what they were intended to achieve and accomplish, and then sort of share a little bit about sort of how buprenorphine prescribing has evolved over time, and also what we've learned about various aspects of buprenorphine prescribing practices that I think inform our understanding of sort of the impacts of the policies, but also may inform where we go from here. I'm going to, instead of focusing on one or two studies, really in many ways take you on a tour of a range of literature that sort of touches on many of these questions. So I expect I'm preaching to the choir here for many of you, but buprenorphine is an essential tool in the nation's response to the opioid crisis. It was approved in 2002, and it's effective in preventing opioid-related overdoses and other opioid use disorder-related harms. Buprenorphine and methadone appear to be sort of the gold standard and better than sort of non-pharmacologic treatment as well as injectable naltrexone. And so one of the advantages when buprenorphine was approved is it was viewed as an opportunity to expand access to individuals who are unwilling or unable, for a variety of reasons, to go to an opiate treatment program every day to receive methadone. And this could be people who live far from those programs, individuals who might be working multiple jobs, a range of issues. And so there was really optimism that buprenorphine would greatly expand access to effective medication treatment for opioid use disorder. Now, when it was first approved in the Data Act, it was prescribed, it required obtaining an ex-waiver by the prescribing clinician, which required for most clinicians eight hours of training, and there was also limits to the amount of prescribing a clinician could do. So you see here over time, what you see is sort of an evolution of federal efforts since that time to sort of remove some of the waiver-related barriers. So as I said, in 2002, approval and prescribing of buprenorphine for most individuals was limited to 30 patients concurrently being treated with buprenorphine for opioid use disorder. And then because of concerns that this was insufficient and to allow clinicians to treat more patients, in 2006, the patient limit was increased to 100 patients with the idea that this would allow many of the buprenorphine prescribing clinicians to treat far more patients. Stayed there for about a decade. And in 2016, again, because of concerns as the opioid crisis worsened and that the patient limit may be setting barriers to clinicians being able to effectively treat more patients, you saw an increase in the patient limit for a number of clinicians who had been prescribing buprenorphine to 275 patients concurrently. And also in separate legislation, they started expanding who could prescribe buprenorphine beyond physicians to physician assistants and nurse practitioners. And since that time, it's expanded even beyond that. Now, since then, there have been a couple other sort of relevant policy changes. In 2020, during the pandemic, buprenorphine was a medication, because of the Ryan Haydeck, that could not be initiated via telehealth. I think there might be a technical difficulty here. Dr. Stein, are you still on? While we wait for him to get back on, let me just see if there's anything in the chat yet. No. I think he just had a bad connection, so he should be on in a second. You're still muted. Sorry about that. That's all right. Must have been a technical difficulty, so. Yeah, it looked like for whatever reason Zoom kicked out. Okay, let me go back. I apologize for that. All right. Can you both see my screen? And I'm assuming this is where I was. Yeah, you were talking about the right around 2020 to 2021 area. All right. Thank you. I apologize for that. So in 2020, during the pandemic, policies were changed to allow buprenorphine for the first time to be initiated via telehealth, to allow clinicians to be able to not have to see the patient in person for the first time. And then additionally, because of concerns about the training requirement preventing people from obtaining the X waiver, in 2021, there was actually a relaxation of that training requirement for individuals who only were seeking to prescribe buprenorphine up to 30 patients. So that you no longer actually had to do the training. You just had to sort of ask for permission to get the waiver. And at the end of 2022, federal legislation was passed that actually abolished the X waiver completely. So as you could see over time, there were efforts to try to remove barriers to allow clinicians to be able to prescribe buprenorphine more easily. Now, during this period, you do see that there was substantial growth in medication treatment for opiate use disorder. And as you can see here, it really was provided. Most of the growth did come from buprenorphine. While there was some growth in the delivery of methadone during that period, and a little bit of naltrexone, the vast majority was related to buprenorphine. Related to buprenorphine. And as this graph shows, you certainly see a tremendous growth in the number of clinicians attaining waivers to be able to prescribe buprenorphine. But if you look at the bottom line on the graph to the right, you'll see that the number of clinicians who were actively prescribing buprenorphine didn't increase nearly as rapidly. And so as a result, despite this growth, we still have the, in some ways we're sort of treading water. While we had growth in medication treatment for opiate use disorder, the percentage of individuals who need that treatment really did not grow that quickly. And so we've sort of been treading that water. The other thing that we do notice, that there's tremendous variation in the use of medication treatment across states, which may suggest that there may be some policy differences that may be contributing to some of these differences that we're observing. So what I'd like to do now is sort of take a step back. And so that sort of describes what we've seen at a 20,000 foot level related to medication treatment and buprenorphine growth for opiate use disorder. And I think the general story is we had a lot of growth, but probably never as much that we had hoped we would get. And so is it possible to take a step back and unpack this a little bit and understand why we really didn't get as much traction in increasing buprenorphine in terms of access and utilization as we initially hoped we might get when it was first approved? And do we have some understanding of the many barriers that are discussed to buprenorphine prescribing and how different efforts and policies might increase access to utilization and how this may inform some of our efforts sort of going forward with respect to increasing access to and use of medication treatment for opiate use disorder? So I think there are multiple parts to the story. So let me try to walk you through them. You know, I think one thing that we certainly know is that most clinicians never sought to obtain an X waiver. Now, I think an argument here is there are many specialties for which this is not relevant, but even the majority of primary care physicians in practice never sought to obtain an X waiver. And I think it's hard to argue that they're not a clinical group who's seeing people who have opiate use disorder. They're going to be in almost every primary care practice. Now, whether they're recognized or not is a separate issue. Now, one of the barriers that was sort of raised is that, you know, physicians are very, very busy and requiring an eight-hour training is a barrier to being able to obtain that waiver. But I think when we look at the data, at least, while this, I'm not going to say it's not a barrier, I think there's some data points that suggest that this may not have been as much of a factor as sort of some people may talk about. One thing is I had mentioned on the prior slides that we relaxed the training requirements to treat up to 30 patients. So suddenly you no longer had to go through that eight-hour training. Literally, all you had to do is send an email and say, listen, I want to start prescribing buprenorphine. But studies of what happened there really suggest that relaxing that training requirement didn't really, didn't result in any increase in individuals obtaining waivers. And I think the other thing that people have pointed out is that this eight-hour training, yes, it takes time, but in pretty much every single state, physicians need to obtain continuing medical education for relicensure. And this eight-hour training would contribute to that. So, for example, in Pennsylvania, I'm required to have 100 hours of training every two years to maintain my license. The eight hours of training that was required would only be a small piece of that and would contribute to that. So this is something that's certainly talked about. I think the data suggests that this may not have been as much of a barrier as often referred to. It's also fairly difficult to find, for many patients, buprenorphine prescribers who are accepting new patients. And this, I think, has been a challenge that many of us have heard our colleagues talk about. So one study of this was conducted by Stephen Patrick, and it was a secret shopper study where basically they had folks, females 25 to 30 years old, use SAMHSA-provided contact information to try to call around and obtain an appointment for medication treatment, either from opiate treatment programs for methadone or from buprenorphine prescribers. And I'm going to focus on the buprenorphine here. And so a couple of things that came out of that study were fairly important, I want to point out. One is that they only successfully reached, of the entire list of the SAMHSA-provided contacts, only 33% of the calls successfully reached a clinician who was prescribing buprenorphine. And people have raised questions about sort of the SAMHSA provider list before, but this does suggest that this is sort of what most of our patients would do. And it does suggest that that route to obtaining information is probably not going to be very effective for patients if they're using that list to try to find someone, to even find someone who's prescribing. Then even among those buprenorphine clinicians who were prescribing, less than 75% were able to get an appointment. About 75% of the sort of mock patients were able to get an appointment. 25% of these clinicians who were prescribing had no appointments available. Then I think another barrier, which I think is critically important, is these patients were sort of randomized to where they either had, these mock patients were randomized to where they either had commercial insurance or Medicaid. So they brought some type of insurance to this call with the clinician. 40% of the women were asked to pay cash to be able to obtain an appointment. The clinicians were not accepting either of the insurance. And the average out-of-pocket payment for that initial appointment for the clinicians, for the buprenorphine prescribers was $250. So I think you could see a whole variety of barriers here to individuals being able to find clinicians who are prescribing, who accept insurance. And even if you're willing to pay out-of-pocket for so many, like $250 is going to be out of range for tremendous number of patients seeking to obtain treatment for opioid use disorder. So I think as we're looking at these numbers of like, okay, do we have prescribers out there? While they may be out there, I think this raises sort of important questions about the accessibility that's truly there. So I think as we look at the data, one of the other things that we see that is sort of related to this, and this is a study we published in JAMA a number of years ago, is that of those clinicians who are actively prescribing, the majority of them treat relatively few patients. Like 70% treat less than 30 patients. With more than one in five, only treating one to three patients a month. So again, we sort of have this barrier of even if you have clinicians prescribing, you don't have clinicians treating lots of patients. And so this creates a tremendous skew in sort of being able to get access. So I think the way to think about this is about half of all the patients being treated by buprenorphine prescribers in this country are treated by about 5% of active buprenorphine prescribers. And if you go up to about 10% of prescribers, you're now talking about 80% of all patients being treated are being treated by a fairly small number of prescribers. And so we're going to refer to these, I'm going to refer to these questions as we go on as sort of high volume prescribers. Although I want folks to keep in mind, as I say that term, that in some cases, high volume may only be 30 patients a month. So you may actually be talking literally prescribing to one or two patients a day. So one of the questions we got is, okay, well, is this because like over time, clinicians are slow to start and they're sort of ramping up. So we looked at this a different way. We used IQVIA data, which is pharmacy claims data for about 90% of retail pharmacies in the country. And we identified clinicians who we saw the first observed sort of dispensed buprenorphine prescription being filled. And then we sort of followed those clinicians and say, okay, what does their buprenorphine prescribing look like over time? And so I think we were shocked. I don't know what people would sort of expect if you didn't know this study, but we were shocked. If you look at the bottom blue line, you'll see that 90% of clinicians after that first buprenorphine prescription prescribe very little. And it's only 10% the green and the red lines of prescribing clinicians who go on to average more than 10 patients a month over the six years. If you break this out even further, so this is a breakout of that low prescribing graph or that low prescribing line. And again, I want to draw your attention to that red line at the bottom here. And so you'll see that of that low of all buprenorphine prescribers, 75% are what we called in a low extinguishing group, which meant that after that first prescription, within a year, they had basically stopped prescribing buprenorphine and never restarted it. So it's not that most clinicians are sort of ramping up. In fact, we're sort of seeing the opposite in terms of patterns of prescribing for buprenorphine prescribers. That you're seeing the vast majority of individuals who do prescribe actually cease prescribing. And the reason why relatively few are prescribing to so many of our few are prescribing to so many of our patients is relatively few ever break out into some of the sort of high volumes of prescribing where they're moderate or high volume prescribers. Now, the high volume prescribers are a little bit different than prescribers overall. You can see here, compared to all active buprenorphine prescribers, the high volume prescribers are more likely to be primary care physicians, more likely to be psychiatrists, more likely to be pain specialists, and clearly more likely to be addiction psychiatrists, although addiction specialists, which includes addiction psychiatrists and addiction medicine specialists. And while they're clearly more likely to be addiction medicine specialists, you'll see that they still represent a relatively small number of the high volume prescribers. Now, the one caveat I want to give on this slide is this was drawing on data from 2019 and 2020. And so the advanced practice prescribers, the physicians, assistants, and nurse practitioners may, for many of them, they still may have been in that period of ramping up. And I suspect that as we look over time, and particularly with the abolition of the X waiver, that over time, you're going to see them playing a larger role. But at least when we looked for data in 2019 and 2020, at that point, they were playing a fairly small role. So I'm going through lots of information here. Certainly, I don't know if there are any questions coming in, Julie, if you want to interrupt or I will keep going. But certainly feel free to ask questions, because I am throwing a lot of information out here. No questions so far submitted. Okay. All right. Now, so we've been trying to understand what's going on with the high-volume prescribers more. And what we're actually seeing is that there has been growth in high-volume prescribers. And so the number of high-volume prescribers is growing more quickly than buprenorphine prescribers overall. And the total amount of buprenorphine prescribing that is provided by these high-volume prescribers has also been growing. So we'll see what happens after the abolition of the X waiver, but at least prior to that, it seems that we're moving... The pattern of buprenorphine prescribing that we're providing in the country is really around this high-volume prescriber model. And again, oftentimes when I say that, people are like, well, yeah, they're going to be our addiction specialists, but they aren't necessarily. Now we don't know if the primary care physicians we are observing may be practicing in specialty settings. That's not something we can tell from the data. But I do think this idea that our high-volume are really right now the majority PCPs with addiction specialists and psychiatrists having the greatest percentage of those specialties being high-volume prescribers. The other thing that we're starting to observe is there's tremendous variability in where these high-volume prescribers are located. Not surprisingly, they're located predominantly in more urban communities rather than rural communities. But you even see sort of regional variation with much of the central United States, even in the more urban areas, having a lower penetration of these high volume prescribers. The New England state's probably having the greatest penetration of high volume prescribers. All right, so that's sort of where we've gotten to at this point. Yes, Julie? Yeah, we had a comment or so, I think. And it's that there was never a concerted effort to get PCPs to start to deal with people with addiction in their offices. Also, the stigma and blind spots still in the area of addiction has not been nationally addressed either. Oh, I think that's absolutely right. And so, you know, I think we've, how would I say this? And I will get more into this, but I think much of our efforts to date have been about sort of, well, we have these barriers, let's remove them. If you think back to that policy slide, so many of those things are like, well, we think this is a barrier, let's take it away. We think, oh, well, that may not be the barrier, let's take away this different barrier. And I think whoever made that comment is sort of alluding to the same thing. Maybe we need to be reconsidering some of the other options. So let's actually talk about some of those other options. And a couple I'm gonna wanna touch on include Medicaid expansion, some of the education efforts. And also, I think it's hard to talk about buprenorphine right now as we're moving to a different stage of the pandemic without talking about telehealth, particularly since this is a topic that currently DEA is taking comments on, and there's going to be some new regulations coming down at some point. And also sort of the role of non-physicians in prescribing. So there have been a number of studies that have shown as states expand Medicaid, it increases buprenorphine use among Medicaid populations. However, I think one of the things that we're increasingly learning is while increasing that is helpful in those states and certainly is probably allowing people to have buprenorphine paid for by insurance rather than potentially paying out of pocket. As you look overall at the amount of buprenorphine being prescribed, it really doesn't seem to be changing that much in non-expansion states versus expansion states. So it seems what Medicaid expansion is doing is sort of shifting the payer much more than sort of increasing the overall amount of buprenorphine. But then I think something else I wanna draw your attention to, and this is a slide I'm gonna have to walk you through a little bit more slowly. So one of the things we wanted to see is, okay, Medicaid expansion does seem to be increasing buprenorphine prescribing to those individuals. Is it doing it equitably, right? Because one of the things that we've known historically is individuals of color, black individuals, Hispanic individuals and individuals living in those communities where there are greater percentage of residents of color have been more likely to get buprenorphine, have been less likely to get buprenorphine, right? And so here what we have is a slide on the left are non-expansion states, on the right are the expansion states. And we're looking at them in three periods, sort of pre-Medicaid expansion, sort of a three-year period that sort of covers sort of going into Medicaid expansion immediately before, and in 2015 to 2017, which was after most states who were going to expand Medicaid did so. And we looked at sort of the difference by county in terms of the percentage of non-white residents, okay? And so what you're seeing here is quintiles one through four from the left to the right, with quintile five being the county with the greatest percent of white residents being the referent or not shown, okay? On the non-expansion states, and you look in the pre-period, you see that there wasn't much buprenorphine, there really is not much difference based on the nature of the county, the residents in the county in terms of race ethnicity. As you start to move later, you see buprenorphine growth increases, but you also see that compared to the counties with the most white residents, which is sort of the comparison line, counties with greater percentage of residents of individuals of color or non-white residents have lower rates of buprenorphine, but they're not statistically significantly different. However, when we move to the Medicaid expansion states, I'll draw your attention to a couple of things. One, overall, it looks like even prior to Medicaid expansion, they were probably doing a better job in terms of prescribing buprenorphine. And this is using ARCOS, so National Data of Buprenorphine being distributed to pharmacies. You do see that even prior to Medicaid expansion, that states with more individuals of color had lower rates of buprenorphine per capita. But then in the period after Medicaid expansion, you see that those disparities actually increased. And so one of the things that I think is important to keep in mind about is we're talking about policy interventions. As well, Medicaid expansion in those states was associated with significantly greater dispensation of buprenorphine. It actually exacerbated some of the disparities in those states that existed with respect to buprenorphine being dispensed in counties with more residents, non-white residents. All right, Julie, another question, comment? Yeah, let's see here. There was a question that said, did I understand that right, that the PCPs are the most common high-volume prescribers? If so, are they doing this as part of their everyday office visits, or have they split off to specialize? Yeah, he comments that he doesn't see many. He goes on to comment that he doesn't see other PCPs doing much, if anything, in substance use disorder treatment. Okay, so I think the way to think about this is the percentage of PCPs who are buprenorphine prescribers remains relatively modest. The percentage of PCPs who prescribe buprenorphine, who become high-volume prescribers, is also a pretty low percentage. It's less than one in 10. I think it's probably less than one in 20. But because there are so many PCPs, they are still the ones who are prescribing. The numbers of PCPs who are high-volume are still more than psychiatrists or addiction specialists. But I think the point is well made, that you look around and you see very few PCPs prescribing, and even those who are prescribing, very few of them are doing high-volume. We can't tell from our data if this is in their routine practice, or if they've opened up another clinic, or if they're moonlighting on a substance abuse treatment center. Can't tell. It's one of the things that we've actually are trying to get some data to better understand right now. It's a great question. Somebody else had a question about a barrier of the large chain pharmacies to accept patients there to have the medications for opioid use disorder, and wondering why that is. So you broke up a little bit. So pharmacies basically not stocking or not accepting, providing buprenorphine? Yeah, and then I think there's some others. This wasn't mentioned, but sometimes some pharmacists will say they have an allotment, or the number of prescriptions of buprenorphine they can give is limited. So this is an important and emerging issue. It's something that I know from conversations today that policymakers are trying to understand. So it's pretty clear that lots of pharmacies have decided just not to stock buprenorphine. And there are many reasons that are put forward. I'm not sure they're gonna put forward, they're not gonna say stigma, but that's immediately the one that comes to my mind. And I don't think we can have that conversation without that. Now, the other thing is the FDA monitors overall how many opioids are going to particular pharmacies, or the DA does. And they do that, and some of this monitoring grew because of some of the issues you saw very early in the opioid crisis with some pharmacies, say in West Virginia and some other states dispensing tremendous amounts of opioids. What hasn't happened yet is buprenorphine is still sort of included in with all opioids. And so while there's supposed to be, and I think there is some flexibility around this, if you're a risk-averse pharmacist, sometimes people are going, I'm just not gonna deal with this at all. I do know that there are policy conversations currently underway to specifically try to address this either through legislation or through rulemaking. But certainly the issues of pharmacies stocking buprenorphine, while I'm focusing mainly on prescribers here, where I think our data is a bit more robust, the pharmacy issues are there and we're learning more about them. I don't think at this point we have a good handle on them enough to say, okay, here are some of the solutions that are likely to work, but you heard at least some of the things people are thinking about. No, thank you, that's it for right now. Okay. All right. So we've talked about sort of Medicaid expansion, which certainly people have talked about. And I think there are probably tremendous number of benefits but maybe not some of the benefits related to buprenorphine that people talk about. I think one of the other areas that I think is increasingly important, this goes back to the question and the comment or the comment in my response earlier, is I do think there's sort of a lot of promise in sort of thinking about education. And I think there are a number of different ways of thinking about this. So certainly Project ECHO, distance learning approaches. And when I talk about education, let me be clear, I think we're increasingly learning that this isn't necessarily education to teach someone, it's not the education required to get your waiver. And it's probably not limited to education about here's how you can prescribe buprenorphine. And here I sort of lumping education in many ways sort of ongoing technical assistance or consultation to allow people not only to learn how to prescribe but how to become more confident in doing so. And so I think you see Project ECHO and a variety of sort of distance learning approaches taking this approach. And some of the preliminary data from them is actually fairly positive. Another study we did recently actually suggested that efforts in states that just required continuing medical education around substance use disorder more broadly were also associated with increased use of buprenorphine in those states. Now, we don't have, our study didn't allow us to sort of identify a mechanism for this. We're thinking some of this may be that it facilitates greater identification by some clinicians. It also facilitates some clinicians understanding that even if they're not a buprenorphine prescriber that this is a medication that's effective. Because some studies suggested that at least some primary care physicians that was not a belief they held. And third, maybe by this education you're starting some people down that road who previously would not have been a buprenorphine prescriber and start to prescribe. And again, if you take just a couple of those people and get them going and they go on to become high volume prescribers, you can move the needle some. But this was sort of just general training related to sort of the identification and treatment of substance use disorders. The other thing we did find is that in a number of states they've put in place policies that actually require additional training of buprenorphine prescribers that went beyond the initial sort of training to achieve the waiver. And this additional training was also associated with increased buprenorphine prescribing. And so now as a physician, I'm always wary of saying here are people doing things and we should be requiring more training of them. So I think this takes a lot of thought but in terms of things that did move the needle, this seemed to move the needle in terms of buprenorphine prescribing. So I think these are things that at least we need to be sort of considering and thinking about. And as I alluded to before, when we looked at this, we really didn't see much of an effect of sort of Medicaid expansion overall or Medicaid coverage of buprenorphine. I suspect that what we're seeing there is that while those things probably have lots of other benefits, in terms of buprenorphine itself, it's probably replacing people who may have had buprenorphine either being paid for by out-of-pocket or other state funding mechanisms. So the states have gotten state response grants, other things that in those states where you don't have Medicaid expansion, maybe states are using some of that money to buy buprenorphine. And so overall what Medicaid expansion is sort of moving the pots of money without expanding things overall. We do have some comments that came in in the interim here. When was back on that Medicaid expansion state slide, was the baseline so high that it magnified the disparities? Was there more room for difference? So the states that already have the Medicaid expansion, you'd mentioned that they were doing better to begin with. They were doing better to begin with, but that by itself shouldn't have caused the difference. They started at a different point. So when we followed that out, the difference was still significant because it was sort of in relation to what that starting point was. So it's not the magnitude overall. That's a good question. Somebody had mentioned about the PCP. I agree with the PCP comment. As a PCP, I have too much to do already. And the only way to treat substance use disorders properly would be to specialize in this area only. There are only so many hours in a day and they keep adding to the PCP burden every day. Yeah, I think one of the recent studies said for PCP to do everything that they're supposed to be doing in sort of the guidelines would only take about like 70 minutes per patient. It's some ridiculous number that we know can't be done. So I do think that's important. And I think different people approach it differently. I think it's critically important for most PCPs we've talked to that if they're not in a specialty setting, at least they have greater support around them to be able to address the many other challenges that individuals who have opioid use disorder have. We know many of them are using other substances that do not respond to medication treatment. We know the rates of comorbid mental health disorders and insufficiently treated mental health disorders are very high. It's a very complicated population. It's a very complicated population. And I think it's a good question. For the high volume PCP prescribers, we do not yet know where they are prescribing. That's one of the things that we're starting to look at in data hopefully next year. Another comment came in saying, in Ohio, our OBOT rules are such that the prescriber can only prescribe and as a result has to see the patient certain amounts of the medication at once to the patient two weeks for the first three months then monthly for the first year. Our PCPs are already overwhelmed. So we'd love some suggestions on how to improve this. So I think one of the things we've started to do, and if whoever that is wants to follow up with me after I can send him some stuff, but we've started to look at a variety of state policies related to sort of buprenorphine prescribing to try and beyond those I'm talking about today that we haven't yet looked at empirically. And one of the things that's pretty clear is there are a number of states, and I'm pretty sure Ohio is one of them, that I would think the way to think about it is they put in place these policies that in some ways treat buprenorphine prescribing sort of like methadone. They're putting in place all of these restrictions that sort of provide far more control in the same way that sort of methadone does, that you have to see people more frequently. And we've got a pretty strong suspicion that in general in those states, and it's interesting, oftentimes in those states it's not just one policy. You'll see several policies, and it's probably about 10 states, and I think Ohio is one of them. I think one of the things that we're trying to help people do through some of this research we're looking at is look at states who have these buckets of policies and say, you know, if you're doing this, it's likely not increasing the ability to prescribe buprenorphine. And if you're serious about treating the opioid use disorder problem, and you certainly hear the politicians and the policymakers in Ohio talk about that because Ohio is a terribly impacted state, you do see policymakers start to look at what seems to be working on other policies. It's one of our things that our center does a lot of, is actually try to use what we're learning from one state or state policies that are working and sharing that information with policymakers so that they may be able to make more informed decisions going forward. Okay, thank you. And then somebody had just basically agreed, saying that docs need somebody to talk to, basically the mentorship when they're prescribing, and I think we're good. And the nice thing is, like, to the extent I can tell in the conversations we've been having, you know, policy moves slowly, but some of these things do seem to resonate with policymakers. We've seen some legislation introduced in a number of states that sort of addresses some of these things after we've been able to share some of these data with policymakers. So I do think in many cases, the policymakers, if you present them with information that like, you know, these things seem to be working better than these things, it resonates. There's certainly some it resonates with. I'm not going to say it resonates with everyone. But you know, if you can find some champions, it does seem to be moving the needle forward. All right, let me talk a little bit about telehealth, because I think telehealth is something that we certainly hear a lot about now, post pandemic. And I think there's viewed, some people view telehealth as okay, this is going to solve our problems. I'm a little bit more sanguine about it. I do think there's a lot of data to suggest that individuals who engage and go on to receive ongoing treatment through telehealth, there's some advantages. They do seem to stay in treatment longer. And being in treatment longer for those individuals does seem to be associated with some improved outcomes from some of the emerging data. But we're also seeing the clinicians appear less likely to initiate buprenorphine treatment via telehealth, even when it's allowed. So you sort of have this seesaw. And overall, it's unclear that there's more treatment being provided. Some patients are receiving longer treatment, but there are fewer patients sort of entering the pipeline, so to speak. Their thing is, while we talk about telehealth, and for some individuals, it's great, data suggests that if you look at places that allow pretty flexible telehealth, the commercial, the insured populations, both there's study in commercial populations and Medicaid and Medicare, the minority in all those groups received their OUD treatment for buprenorphine via telehealth. They were still being seen in person. And likewise, when you look at treatment initiation, it looks like less than 10% of new episodes in some populations were initiated via telehealth. I do think telehealth is here to stay. I think there are lots of benefits. But I think we need to think about those benefits and who is getting those benefits. And here, I'll go back to the equity issue. I think we need to be very careful if we are moving people to telehealth to make sure that we're not leaving populations behind who have less access or are even less able to get the care they need. So I mentioned nurse practitioners and physician's assistants. This is something where the data we have is still sort of growing. But in some of the data we are seeing, this seems to be in terms of a group that's most rapidly growing in terms of providing buprenorphine treatment. And they seem to be particularly important in serving some of the populations who previously have been less well served. Individuals residing in rural communities, Medicaid enrollees in places that had less access. And so I anticipate that at least now and over time as more data comes in, we're going to see them playing an important role. Here too, we do talk about the role of state policies. And there are both general nurse scope of practice policies that can limit their prescribing. But some states have actually implemented sort of buprenorphine-specific nurse practitioner and physician assistant policies that greatly restrict their ability to prescribe. And not surprisingly, in some of those states, you see almost none of this. So this again is another opportunity to communicate to state policymakers and decision makers about some opportunities that most states haven't put in place. These are barriers that probably do make sense to revisit removing. Then again, someone brought up pharmacies previously. I do think this is something that is sort of critically important to talk about. So here they did another secret shopper study. This was a different group. And of the over 5,000 pharmacies they called, slightly more than half had buprenorphine, had Suboxone in stock. The chains were more likely than independent pharmacies to report having it in stock. Some of this we speculate is probably due to some of the reporting requirements that sort of large chains like Walmart or Rite Aid or CVS may be better prepared to sort of deal with. There was also tremendous state variation in buprenorphine availability across states. Again, suggesting that while this may be a national issue, there may be things in place in terms of specific state policies or other issues that may be very important. And again, what I mentioned earlier, there were both federal regulations and in some states state regulations that may contribute to this lack of access by sort of creating a disincentive for pharmacies to stock buprenorphine. So putting it all together, where do we go from here? And I think I've touched on a number of these points, but let me sort of revisit some of them. A lot of our conversations to date have been how can we sort of put in place policies to increase the total number of clinicians wavered to prescribe buprenorphine? And I think some of that conversation our data suggests may probably shift to not can we get more people to sort of prescribe at all, but for the people who are willing to prescribe, how can we help them and support them in treating more patients? And it sounds like some of those questions raised some of the things that like both the data suggests and clinicians suggest. And so I think these are things that we need to help sort of states move toward. And again, less attention to removing barriers and more sort of proactively supporting prescribers. There's a shift in mindset here. I do think increasing education at all levels in terms of training and practice and ongoing consultation probably plays an important role. The one I didn't talk about is sort of training of residents and other individuals in training, training of pharmacists in training about how they may be able to play a role. We know, certainly the drug companies know that oftentimes prescribing practices and behaviors are set very early on in medical school and residency. And I think it's pretty clear that for many years, the education that physicians at least received related to substance use disorder treatment was inadequate. There have been efforts to improve it. I would suggest that while those efforts are great, they are still probably inadequate and not where we need to be. And so we need to think about sort of education across the board. And again, our thing you sort of heard me allude to is that this isn't an issue just of specialists or primary care or specialty treatment or pharmacies. It's a broader issue across all of healthcare and honestly beyond that. And so I think if we're going to be increasing access to buprenorphine and medication treatment for opioid use disorder, we really need to be considering it broadly from a holistic system perspective. Thank you very much. Thank you so much. That was great. We do have a couple more comments in here in the chat. And if you do have some questions, just put them in the question and answer session. Somebody had mentioned about when you were talking about telemedicine, the DEA's attempt to regulate this now that that's going to go into effect in November of 2023. What do you think about those policies? And do you think there's going to be any change to that from what you know? So I believe, and I haven't, I believe the DEA is still, those conversations are still ongoing, right? The DEA issued sort of one set of proposed rules and received so much pushback that they've backed away from it. And now they've reissued something else, which I think gets rid of some of those things they suggested that were particularly problematic. But there's still lots of things in the proposed rules that I think are likely problematic. And I think DEA is hearing it. And I have a fairly strong belief that a number of these questions are still open to conversation. So I don't think we've sort of ended that story there. I think like the DEA is a drug enforcement agency. It's a police agency. It's not a healthcare agency at the same time. And I've had an opportunity to talk to administrator Milgram. She recognizes that law enforcement isn't getting us out of this. We need treatment. And so there's a balance there that I do think they are still open to comment, probably aren't going to end up at a place where I or many of us would like them to be. But I do think you're going to see continued sort of conversation and shifting from some of the rules that have currently been introduced. There's a comment here that says, not a question. In Vermont, Medicaid will pay salaries of administrators and nursing staff to providers who will prescribe buprenorphine. That's one approach. And so I would, I'd be very curious because Vermont clearly was one of the first movers with hub and spoke, but it sounds like what this person is describing actually goes beyond that in some ways. I don't know if it's the same legislation or not, but it, but it does sound and I, we need to experiment. Like we need to experiment with different things, but I think the general directions we need to move are becoming clearer. When one person also had a question about like, how can we get more patients on buprenorphine, mobile vans or serving patients to identify what would help them and saying that many are scared of going into withdrawal from fentanyl at this point. Yeah, I, I think certainly mobile vans and greater access is part of the solution, but I still think we sort of have a supply constraint. Like it's a workforce issue, right? And the workforce issue is no longer limited by the X waiver, but if other clinicians don't start prescribing, that is an issue. That said, I think we need to understand that, you know, in communities, and these are lots of communities where individuals are exposed to fentanyl, the nature of the conversation is different and we need to sort of respect that and be aware and sort of have those conversations with patients. And, you know, here I don't do clinical research. My research is at sort of the 20,000 foot level, but I know there are certainly a number of groups, and Julie's saying they're nodding her head because I think you work with some of these colleagues who are trying to sort of understand, okay, clinically, how, how do we need to be approaching individuals who have been using fentanyl differently than individuals who have not been using the synthetic? So I think all these pieces need to come together. Somebody had also commented to me that somebody had also commented to, thank you for this fast changing topic. My psychiatry residents are so comfortable and current in their practice, so that psychiatrists like myself in practice for 35 years need to just embrace these treatments. So I guess the younger generation is moving us forward. That's what, what she's saying here. Yeah. Somebody had asked the DEA has always been very strict with controlled drugs. So why are they being so relaxed with telehealth? So I, I think the relaxations for the DEA with telehealth around Ryan hate were specifically due to the COVID pandemic. Like you, you would not have seen them without them. And so I think we're now in the situation where I don't think you can, I don't think DEA can shut that Pandora's box, but DEA is also not comfortable with just the world we've been in this being as wide open as it has been. And so I think a lot of the conversations right now is DEA sort of trying to recalibrate and saying, okay, we don't want, we're not going, we, we can't get rid of telehealth because it clearly is a benefit, but for restricted substances, we're very not comfortable with where it is. And I think they're trying to find a way to a middle ground that they can live with and that the clinical community can live with. And I suspect we're going to get there. I suspect when we get there, no one's going to be happy. That may be one of the indications that we get there. Like I, there are going to be people in the DEA that aren't going to be happy. And many of us were going to be like, wish we could go further. But I don't think we're going back to a world where it's going to be as restrictive as it was before COVID. And I don't think we would have seen that change without COVID. Okay. We had somebody who said great talk and great information. Thank you. And somebody had just reminded me to mention that there is a mentorship program through PCSS, PCSSnow.org, and you can get a mentor there. There are also discussion forums and chats. And so there's lots of resources on PCSSnow.org if you're new to prescribing. And I guess we're, I just want to edging in on that six o'clock hour. So I think what we'll do, let me just make sure. Yeah. No more questions. So I'd like to thank you, Dr. Stein for a great talk today and all the work that you're doing on policy. And I just want to remind everybody that our last webinar is going to be next week, September 27th at five o'clock. And we're going to have Dr. Chelsea Shover speaking on update on the U.S. overdose crisis, which drugs, who is dying and how do we save lives. So thank you so much to the ORN for being our partner and for SAMHSA for funding this initiative. And I'd like to thank everybody for participating. Please be sure to go onto the website to get your CME at the end of this webinar. Thank you. Thank you so much for the opportunity. Thanks so much for participating and folks, my email is there with, you have other questions, feel free to follow up with me. Bye-bye. Bye all.

webinar

buprenorphine prescribing practices

opioid use disorder

X-waiver

access to buprenorphine

clinicians

telehealth

education and training

holistic approach