introduce our featured presenters, Ben Miskell and Allison Lynch. Okay. Thanks, Jen. Yes, my name is Allison Lynch. I'm a psychiatrist, family physician, and addiction medicine specialist here at the University of Iowa. And with me is my colleague, Ben Miskell, who's a clinical psychiatric pharmacist also at the University of Iowa. And we work in the University of Iowa's Addiction and Recovery Collaborative. And one of the services that's part of that collaborative is our MAT Clinic, which we're going to tell you a little bit about today. So if we can go on to the next slide. I think the next slide is our disclosures, right? So neither of us have any financial conflicts of interest to disclose related to today's presentation. The target audience for today is in line with PCSS's overarching goal of training healthcare professionals and evidence-based practices for the prevention and treatment of opioid use disorders, particularly prescribing medications, as well as the prevention and treatment of substance use disorders in general. Our educational objectives today are that by the end of this presentation, we hope that you will be able to describe how healthcare professionals can work successfully together to coordinate and optimize care for patients with substance use disorders, which is going to be abbreviated as SUD throughout our presentation. We hope that you'll be able to examine the role of the pharmacist as a member of the interprofessional SUD team and the impact that that pharmacist can have on patient care outcomes. And finally, you'll be able to identify substance use disorder treatment settings where pharmacists can be integrated and the enhanced services that can be provided through the pharmacist. So we're going to start off today's presentation with a case. This is a 24-year-old patient who presented to your clinic two days ago requesting treatment for opioid use disorder. They'd been using fentanyl and they described smoking blue tablets, about 10 of them a day for the past nine months. And prior to switching over to fentanyl, they'd been smoking and then later injecting heroin for about two years. In the clinic, you recommended that they waited for between 18 and 24 hours after their last use of fentanyl and then start buprenorphine, the plain monoproduct, brand name is Subutex, at a dose of two milligrams, which is administered sublingually with a plan to repeat the dose every one to two hours as tolerated. You spent about 30 minutes providing education to the patient about how to take the medication, some common pitfalls, including precipitated withdrawal that can happen and how to manage that, how to monitor their own withdrawal symptoms as they're getting ready to start the medication, who to contact with questions if they come up along the way, and the importance of getting naloxone and how to use that in case there's an overdose, and finally the follow-up plan. Okay. And then in the past 48 hours, the patient is called six times to your clinic and left messages for you with a number of questions and concerns, and they include concern about the buprenorphine requiring a prior authorization in order for the insurance to cover it. The patient's pharmacy did not have buprenorphine in stock. The patient had questions about eating and drinking when taking buprenorphine. The patient had trouble waiting for the medication to arrive at the pharmacy, so they took some oxycodone tablets and then wasn't sure if they could still start the medication as planned. The patient noticed worse withdrawal symptoms within 20 minutes of taking the first dose of buprenorphine, and the patient didn't like the way the tablets tasted and dissolved, and they wanted to know if there were other options. So just discussion questions here, and I'd like to ask people to put their responses into the chat. How much time does buprenorphine initiation counseling take you when you see a new patient and you're planning to start them on buprenorphine? And how many of you have time in your clinical day to field multiple phone calls from individual patients? And finally, do you have others in your clinic that help with these tasks? So there's one that says 10 to 15 minutes. One says five to 20 minutes for initial counseling, maybe 15 minutes. So this is a sizable part of our day and certainly a sizable part of an encounter with the patient. And it looks like, yeah, people spend a sizable amount of time talking with people in preparation to get started. Yeah. There's 30 minutes, no help. And it depends on how much time they have. Sometimes help in the clinic, other times not. Some people have some nursing staff available. So you can keep putting comments in the chat if you want, and we're going to get back to that case. But I want to start by telling you a little bit about our MAT Clinic and how we got started. So we started our MAT Clinic in 2017, and it was a project that one of my psychiatry colleagues and I started together, and we each agreed to see patients one morning a week. So I did Tuesday morning and she did Thursday morning. Just to get it started, we really didn't have a great sense of what the demand was going to be, but that was a place to start. And we were able to get a little bit of time from one of the social workers in the clinic where we were working and who served as a case manager. So her main thing was that she helped triage referrals and then take calls from patients in between appointments, and we probably had like two or three hours of her time per week. We also worked with our hospital's emergency department and were able to get a number of the physicians, residents, physician assistants in the emergency department to get a buprenorphine waiver. And so in working with them, people were able to then start coming to our emergency department and get started on buprenorphine, and then follow up in our MAT Clinic. So that was one of the important sources of patient referrals. We were the only clinic at that time in our community that prescribed buprenorphine and accepted Medicaid, and so it was a new thing that all of a sudden patients in our community who had Medicaid could get access to buprenorphine in our community. Also at this time, all of the buprenorphine products required prior authorization from the Medicaid managed care organizations, and it typically took between three and seven days to get the prior authorization approved. And the typical amount of time that they would approve it was anywhere from 30 to 90 days, which meant that every 30 to 90 days we had to resubmit the prior authorization and get it approved again. And if we wanted to prescribe more than 16 milligrams a day, we had to do a peer-to-peer call with somebody from the MCO. And when we started the clinic, we only prescribed the sublingual formulations, and we were really lucky to have a good relationship with our hospital pharmacy. And what that meant was that they kept buprenorphine products in stock. We could call them and they could call us, and we had kind of a good working relationship so we could resolve problems on our end or on their end pretty quickly. And they also were really nice to our patients and treated them with respect, which many of our patients noticed and appreciated because that had not always been their experience in the pharmacy. Dr. Lynch, there was one question in the chat, and it was just, are you including the reading and explanation of the written and informed consent probably into that time as well? Yes. Yeah. Yeah. We have a treatment agreement, and so spend time with that too. Yeah. Okay. So then over the next couple of years, our clinic grew. Like I said, we didn't really know what the demand was, but it turned out it was pretty big. There were not a lot of MAT clinics in our neighboring communities. And so we, over the next couple of years, we started offering our clinic four days a week. We expanded to two locations. We had five licensed independent practitioners, both physicians and nurse practitioners that were working in our clinic. And we started having residents rotate through our clinic, medical students also, and support students. And we got a couple of grants and were able to hire two case managers to help with the triage and assisting patients in between appointments and getting people scheduled and that kind of thing. And then we also just have, over time, developed more collaborations with other departments in our hospital, building on our relationship with the emergency department. We have had an addiction medicine consult service for about 20 years, but it's been staffed most of that time with a social worker. And so there was no capacity for prescribing MAT medications to patients on that consult service. But as our clinic was growing, we also were able to add a couple of physicians part-time and a couple of nurse practitioners part-time. So about four half days a week, we would have somebody that could prescribe MAT medications, buprenorphine in particular, who was on that service. So part-time prescribing access. And we also were able to start offering naltrexone long-acting injectable medication or Vivitrol to our clinic. And then after about two and a half years, we were able to hire a pharmacist, which was definitely a transformative experience for our clinic. And Dr. Lynch, one other question in the chat. So with a pharmacist, were you able to store buprenorphine on site and dispense slash administer to individual patients as needed? Yeah, so our clinic is in our hospital. And so we actually don't keep medications in our clinic, but we have several pharmacies in our hospital facility. And so what we did when we were having patients start the medication in the office, they could stop down in the pharmacy, pick up their medication, and then come back up to our clinic to where they could get started in the clinic. So we haven't been dispensing or administering medications directly in our clinic. We've just used our nearby pharmacy for that. Ben's going to talk a little bit now, sorry. That's okay. So I thought it just might be helpful a little bit due to some previous meetings and calls to talk about what is a psychiatric trained clinical pharmacist and what does that mean? What is their training? What is their experience? And kind of just go through some of that information a little bit. So psychiatric pharmacists, they receive specialized training in the treatment of patients with psychiatric disorders, which also includes substance use disorders. Typically, these psychiatric pharmacists are going to do a general PGY-1 residency program, which is usually kind of a mix of everything. This is diabetes management, it's hypertension, it's hyperlipidemia, it's inpatient care, it's acute care medicine, it's you name it, pretty much do just about everything. And that's really to make sure that pharmacists have a very wide range of training coming into their specialization year as well. And so then the second year is more of a focused direct residency program. So specifically, a psychiatric pharmacy residency includes a mix of inpatient and outpatient, residential long-term care rotations. Each of these programs is going to be a little bit different, but there are competency areas and goals and objectives and standards that are required through the American Society of Health Systems Pharmacists or ASHP, which is the credentialing body for the residency programs. So to give you a little bit of an example with this, so when I went through a psychiatric pharmacy residency program, I did both inpatient acute care psychiatric needs, I did more of a residential type facility and did a residential facility for patients with psychiatric disorders, but also patients that had substance use disorders as well specifically. We also are one of the only two credentialed programs, residency programs that actually require training in substance use disorders with the other one being pain management or palliative care at this point. And so not all residency programs actually require substance use disorder training, although I could see that very easily changing in the near future. There are board certifications for psychiatric pharmacists. So you'll see this with BCPP at the end of somebody's credentials. And the Board of Pharmacy Specialties recognizes these board certified psychiatric pharmacists as being able to design, implement, monitor, and modify treatment plans, educate patients, healthcare professionals, and other stakeholders, and also provide leadership in the health system and public policy as well to improve the care of those with mental illness. Hey Ben, there's a question in the chat here. Are clinical psychiatric pharmacists in every state? Pretty much. The programs are growing and there's probably a program in almost every single state to train psychiatric pharmacists. Some states are going to have more programs than others, but yes, there are psychiatric pharmacists all across the country and probably at least every state, especially if you include like Veterans Affairs facilities and things like that, which often have multiple psychiatric pharmacists in their locations as well. So just some kind of general guidelines of practice for clinical pharmacists in general. So what can the clinical pharmacist actually kind of do? It's really varied upon the different states and state laws. So I wanted to kind of give you an example of one, but most states include the ability to engage in a collaborative practice with a clinical pharmacist in some way, shape, or form. Most people on the call probably know this through the way of like immunizations or things like that, where we're able to give immunizations to patients that come into pharmacies. And again, laws may vary on the ways that that's done, but these collaborative practice agreements may allow somebody to manage some of these diabetes medications or things like that. And we'll get into more particulars with this here in just a minute. But just to give you one example, so California created a designation of advanced practice pharmacists. And what these licensed pharmacists may perform, they may perform the following. So they can perform patient assessments, order and interpret all drug therapy related tests, refer patients to other healthcare providers, and participate in the evaluation and management of diseases and health conditions in collaboration with other healthcare providers. So what clinical pharmacists are not allowed to do is to diagnose a patient. They cannot diagnose the disease state. So these still have to be in conjunction with a provider who is in agreement for that pharmacist to move forward and perform treatment with that patient. And we'll actually give you an example of our collaborative practice later on and talk about a little bit more about that. I see one thing in the chat, somebody has their hand raised. We could definitely unmute if somebody wants to ask a question. All right, let me see here. Joshua, if you have a question, I have asked you to unmute if you would like to send us a question. We'll try again. Well, I'll go ahead and move forward here. But some of the things we want to talk about are just things we've done in our clinic that a clinical pharmacist can do and things that we did. We created some developed patient education, either through the use of me creating these things or some of my pharmacy students that I work with as well, have created some of these things which also allows them the opportunity to build on some of those skills with patient education as well. But one of those examples is kind of our constipation handout. So, obviously most people on this call are pretty aware that patients on buprenorphine oftentimes still have constipation as a general side effect. And so we actually developed a constipation prevent and treat handout. So we talk about what is constipation? How do we treat this? And talking about the different options. And then on the back of that same form, so one page handout, we actually talk through some of the different treatment options for patients with constipation. And obviously, we'll go through and maybe hand them this and say, hey, this is what we would want you to take, but here's how it typically works. Here's how quickly it's going to kick in for you. But just more of this kind of general patient education and try to help with some of that timing in clinic appointments. So you don't have to spend as much time maybe covering this. Instead, hey, I have this great handout. Feel free to take this home. And we highlighted this particular medication we want you to take. And if you can't find it in the pharmacy, feel free to show this to the pharmacist and ask them, hey, where can I find this as well? Other things that we've created. So how to manage medications. This is something that we've kind of had to do quite a bit. And we spend a lot of time going through very, very little things, but things that can be very important as well. So things like how to plan for a refill. In our state specifically, not every pharmacy, and I know this is across the US, but not every pharmacy carries buprenorphine or stocks it all the time. So, hey, before you run out a couple of days before, go ahead and call your pharmacy and ask them if they can refill it. If you have no refills left, we have our case managers. So they can call our case managers and we can get that new prescription for them. Also, they should know their pharmacy's hours because from somebody who used to work in a community pharmacy setting, those hours where pharmacists need to eat lunch, they can close down. And so if that's the only time the patient can go in, maybe it might be better to find another pharmacy or figure out another way that they can get in at a different time. Check to see how much medication you have left before a weekend or holiday. This is where a lot of our questions tend to come from is around holidays or vacations or trips or things like that. And also just if your pharmacy doesn't have all of it, they may be able to fill part of it. So if they fill part of it, that's something you can let us know. And then that way we know that we may need to send a new prescription for you moving forward. Also things like what to do if you don't have access to your medication. So for us, it's call your case manager, tell your provider, those sorts of things. And then also just things about safeguarding your medication. So oftentimes specific insurance companies will say, if your medication is stolen, do you have a police report? And do you have that police report number where you can provide it to them? And so there's a lot of different things about that. And so just some of these general handouts that can really help patients kind of manage their medications a little bit more effectively. Another thing that we wanted to create is understanding insurance coverage. I have found that a lot of patients, no matter what the disease state, patients don't understand how insurance works. And oftentimes we also don't understand fully how insurance works at times. And so some of those things again, so insurance reminders, just sometimes insurance will not cover the cost. There may be an out-of-pocket cost. Not all forms of medication are covered by each insurance plan. So it may require that we try one formulation before we try another. Knowing that your insurance can lapse. So keeping track of those letters in the mail that you need to return and sign to make sure you continue to have insurance information as well. Keep track of your prior authorization dates. So we actually ask our patients to do this for us. And sometimes they'll reach out and say, hey, I know that my prior authorization is coming up and due. And that just helps us to be able to get it done quickly. So that way there is no lapse in coverage. Other frequently asked questions. So what is a prior authorization? Actually defining that. How do I get a prior authorization? So we kind of go through that process of what a prior authorization is. And then basically talk to them about that, once this is approved, it almost always has an end date. So again, kind of watching that for us and try to refill the medication before that prior authorization ends, if we can, and then let us know. And so that way we can go ahead and fill out the next one for them. So some discussion here. Are there education tools you could create to help make your clinic more efficient? And what other education tools do you think would be useful in a medications for addiction treatment clinic? And I see one question here. So I can answer this one. What kind of additional training would you recommend for a pharmacist who is residency trained, but does not have a site PGY-2 or BCPP? I think this is where I love where PCSS comes into play. Take the waiver training. It is very, very helpful. It's very effective. It's easy to do. And I've actually given some of those trainings with Dr. Lynch as well. And so we do those together. And I just can't say enough. PCSS trainings are honestly one of the best tools that I always point people to when they wanna learn more about treating substance use disorders. Otherwise, SAMHSA also has a lot of great education tools and information available. The other thing you can do is you could always reach out to me as well. I'm more than happy to field some of those things and say, hey, here are some programs in your state specifically. But there's usually some programs within the state. So we offer a lot of training and education events within our hospital. We have our own addiction medicine didactic series as well. And so we can open that up to a lot of different people. Oftentimes there's things going on at your own site that maybe a lot of people aren't even aware of. Dr. Lynch, do you have anything else to maybe add to that as well? Yeah, and actually somebody put it in the chat that the American Academy of, or Association of Addiction Psychiatrists, or AAAP also has a lot of resources. And of course, conferences, and a lot of the American Society for Addiction Medicine has conferences. But I think going to a live conference and meeting with people that are doing this work can also be really helpful. Then you have peers to talk with. Yeah, and for the pharmacists on the call, there is the American Association of Psychiatric Pharmacists which also has a lot of education, a lot of toolkits on how to manage different substance use disorders as well. And they also have, they do have an annual meeting as well in April every year. Typically it's in April every year. The weeks kind of differ, but it's a very, very good event that people can go to as well. Okay, there's just another question in the chat that I'm gonna respond to, which is tips about making the financial argument to the hospital for hiring a psychiatric pharmacist. And we are gonna get to that. We do have a slide or two about that. There's also a question about pharmacy services being billable, and we'll talk about that when we get to the financial piece, making the financial case, so. Okay, so the next thing I kind of wanna go through are these collaborative practice agreements that we talked a little bit about, but going into them a lot more specifically here. So the definition of a collaborative practice agreement is a formal agreement in which a licensed provider makes a diagnosis, supervises patient care, and refers patients to a pharmacist under a protocol that allows the pharmacist to perform specific patient care functions. There's a lot of examples out there, but I wanted to highlight a couple of them There's a lot of examples out there, but I wanted to give you some examples of some that people probably know very well, but then others that people may not be as familiar with. So some examples of this, diabetes, hyperlipidemia, hypertension, anticoagulation management, especially managing the DOACs and warfarin and things like that. Another one that people probably don't think of very much is like vancomycin dosing in the hospital and other antibiotics, chronic obstructive pulmonary disease, HIV, hep C. Basically, if there's a specialty and if the state allows, you can create a collaborative practice agreement in just about anything that you would like to. But for us, we're going to focus on the medications for addiction treatment and kind of what that looks like here at the University of Iowa between myself and Dr. Lynch. And we'll talk about, you know, what the requirements are moving forward. So usual requirements for a collaborative practice agreement, they have to have a purpose and a goal and they have to have the providers authorized. So in this case, it's any of our attending physicians in our MAT clinic can refer patients to the collaborative practice with the pharmacist. And I'll pull up specifically, I have a picture on our next slide about what that looks like for us with the purpose and the goals. There needs to be a medical director, supervising physician, the responsibilities, so the pharmacist scope of practice on there and referring provider responsibilities as well. It's not one of those where you refer the patient and I'm done with them. There's still some collaboration that definitely needs to occur. Documentation and communication, how is that going to be documented? When do you need to communicate with the provider specifically in certain instances and cases? Quality assurance, oops, sorry, I accidentally hit my mouse. Quality assurance, so how do we know that high-level care is being performed? Who's going to oversee that? Who is going to make sure that good quality care is being performed with every single patient coming in? What does that need to look like? Whether that's a random spot check, whether that's a once a year check, that can vary depending on how the collaborative practice is written. Pharmacist training and ongoing competencies. So you don't necessarily want somebody coming in who has no experience in addiction treatment to come in and maybe start doing this right off the bat. There needs to be some training ahead of time. It's just like, you wouldn't want me going in necessarily and managing somebody's infectious disease clinic because that's not my specialty. My specialty is psychiatry. And so that training should be in conjunction with what the collaborative practice agreement is. And then also, as always, what references are we using to support this? Could that be guidelines? Could that be very specific references? But having those references are also required. So this is actually cut and pasted directly from our collaborative practice agreement. And we're more than happy to kind of share any of our documents as well. And there might be a way that we can coordinate that a little bit, but we're more than happy to share these things. So just to give you an example, the purpose for our collaborative practice agreement and the protocol is to ensure continuity of care and improve patient access to medications for addiction treatment in our addiction medicine clinic. Some goals, and these are going to sound very familiar to what you are doing day in and day out with your patients, but optimize medication management for patients with substance use disorders, enhance shared decision-making for treatment of substance use disorders. And through that, by making sure patients fully understand risks, benefits, and all alternatives, monitor for adverse drug effects, improve patient adherence to prescribed treatment regimens, improve knowledge of and adherence to laboratory monitoring, and also improve patient caregiver understanding of medications for addiction treatment, complications, and different medication therapies. So these goals need to be pretty well-defined, but if you think about it in the terms of you are doing this day in and day out, and if you have a pharmacist in your clinic, they are also going to be assuring that if somebody is having an adverse effect that we're talking about this and we're thinking about this. And so all of these things are things we would normally be doing, but it gives that clinical pharmacist some direction on what their goals are within that clinic and within the protocol. Some other things, and I kind of summarize this because this is a pretty long section in our collaborative practice, but so providers authorized, attending physicians may refer patients. Pharmacists in the MAT clinic may provide care. Now, so if I have residents that are with me on rotation, they can actually utilize this as well, or if there's another pharmacist that we hire in the future, then they could also come in and be added to this protocol also. Responsibilities, so just to give you some examples of what the responsibilities are for the clinical pharmacist via the collaborative practice. Medication therapy management for nicotine use disorder, opioid use disorder, opioid withdrawal, alcohol use disorder, alcohol withdrawal. Patient education, of course, is a big thing that pharmacists do. And so making sure that that is one of the responsibilities is key. Laboratory monitoring, if there's any monitoring that's needed, that can be done with the collaborative practice and pharmacists could then order those laboratory tests and also assess the outcomes of those results. Patient assessment or physical assessment. So a lot of people probably don't know this, but pretty much all pharmacists going through pharmacy school do get trained on physical assessment, whether it be listening to cardiac sounds or lung sounds or things like that. But these other things that I typically think of are blood pressure assessment, heart rate, those types of things, physical assessment. That could also help in a clinic, especially if you're the only person in that clinic and running that clinic. There's all sorts of different responsibilities that can fall under this. And so that's kind of why I leave it a little open-ended at the end, because you can really make this whatever you want it to be as long as you and the pharmacist working with this collaborative practice both agree. Just to give you an example, so medications that can be used in this collaborative practice. And this is something that most pharmacy therapeutic committees, P&T committees want to see when they go through and approve a collaborative practice agreement in their institution, is they want to know what medications are being managed, what medications can be ordered by that pharmacist working in that clinic. So you can see standard options of care there for opioid use disorder. You can see standard options of care for alcohol use disorder, as well as nicotine use disorder as well. And obviously, I didn't put everything on here. Again, it's very long, but to give you an example of how this is spelled out exactly. So looking at maximum doses, usual starting doses, frequency, basically it needs to state the name of the medication, the maximum dose allowed via the collaborative practice agreement, usual starting doses, and again, that dosing frequency. Now, it doesn't necessarily mean that you couldn't change those maximum dose allowed, but typically if we're kind of getting into that realm of things, we probably need to be having communication with our provider anyway to discuss the patient case. Now, if somebody has been doing really well on 16 milligrams of buprenorphine daily for months and months and months, that's not something that necessarily you need to reach out about every single time and say, hey, is this okay? But via the collaborative practice, the clinical pharmacist could actually order these medications and send them to the pharmacy for the patient. And so that also may assist with those refill requests and the burden that the physician gets on refill requests and other patient messages as well. Okay, so I'm just gonna talk about our collaborative practice agreement from the clinician perspective. And I've noticed in the chat that a couple of people have been interested in seeing a complete collaborative practice agreement. So we'd be happy to share ours as well. And we can talk at the end about how exactly we can get that out to people. But we do have in our agreement, we spell out the responsibilities of our referring clinicians. And so the referring provider is responsible for general supervision of the patient's care and has to maintain a relationship with the patient. And so in our clinic, we say that the patient has to see the referring provider directly at least once a year in order for them to continue to be part of this collaborative practice and have visits with the pharmacist. The referring physician or provider has to be available to the pharmacist if any questions come up. And if that provider is not available, then the medical director, which we'll talk about at the very end of this slide, would be the person that would be contacted to just address any questions about the patient's clinical care while the pharmacist is seeing them. And the referring provider can take a patient back, basically say, we're not gonna have this patient be a part of the agreement for now. I'm gonna follow them directly. And so they have that option. And the last bullet item in the first section, that fourth one that says the MAT clinic referring provider must retain a list of patients. We still want our referring providers to maintain a list, but it also refers to the patient panel size limit. And so back when there was a waiver required in order to prescribe buprenorphine, if I had a patient that was being seen by our pharmacist as part of our collaborative practice, even if I didn't see them for that visit, they were still on my patient panel, but that got rid of that. So that's really not, we need to update our collaborative practice agreement just to say that the referring provider needs to keep track of which of their patients are actually seeing the pharmacist for part of their care. And then as the medical director, my responsibilities are to really oversee the pharmacist and as far as his practice and how he's operating with the protocol and make sure that he's adhering to the protocol and agreement as we have set up. And I also have to be available to him for consultation on an as needed basis, which I am. Okay, so a couple of discussion questions and I'm going to point out Ben, there are a couple of questions in the chat also that you might want to address. But so if you could just put in the chat any thoughts about these prompts, do any of you currently have a collaborative practice agreement with a clinical pharmacist? And I know that somebody in the chat did offer to share their CPA. And so I know at least one person here has that, but I'm not sure how many already have that. And that could include with other disease states, not only opioid use disorder. And then for the case presented at the beginning of the presentation, would a collaborative practice model help with any of the challenges that the patient and the provider are facing? And we are going to address that a little bit more later. The answer really is yes. And we'll talk more about how the pharmacist can help with that. And there was one comment recently, but yes, but does not include controlled substances. And that is dependent upon each state. So the state of Iowa, for example, says that pharmacists can work under a collaborative practice with any provider, but they do not allow for C2 prescriptions from the collaborative practice. So that is one thing that the state of Iowa is very specific on. Not all states are that way, but I will say a lot of states have quite a bit of gray area in the way that the collaborative practice kind of rules are written. And so one of those things that was pretty helpful when I first started in my position was actually reaching out to the board of pharmacy in my state and saying, hey, this is something we want to do. This is something we want to move forward with. What are your recommendations? What problems do you see? And they were extremely helpful for kind of addressing that. And they said, no, we think this is great. Please move forward. And so I think that was really helpful early on, though, to kind of reach out. And I did see one, Dr. Lynch, and I kind of wonder about your thoughts on this. No, they don't have a clinical pharmacist, but maybe too small to establish an agreement. What are your thoughts from kind of where we started to where we are now? And I know we'll talk about that more, but. Well, you know, by adding a pharmacist for our clinic, that has really allowed us to expand. And so I think it really depends on whether the demand is there. If you envision that there's more patients that can be served by adding a pharmacist, I think that's really allowed us to increase our capacity. And I'll talk more about that specifically in some of the upcoming slides. Okay, so these are just some of the roles that the clinical pharmacist is able to fulfill in our clinic. So our pharmacist provides a lot of education. And some of that education is to patients, specifically about their treatment, their medications, troubleshooting stuff. But our pharmacist is also a huge resource for our medical students and our pharmacy students that rotate through our clinic. And we feel really proud about the fact that we are having an impact on future healthcare providers by getting as many students and learners exposed to addiction treatment and compassionate care for people that have a substance use disorder. And Ben is a really important part of that. Also nursing. So as we've expanded our MAT injection clinic, we started off with long-acting injectable naltrexone. We have since added long-acting injectable buprenorphine. And when we rolled that out, Ben played a huge role in educating our nurses in our psychiatry clinic who had a lot of experience with injectable antipsychotics but had not done an injectable controlled substance that treated opioid use disorder. So that's been a really important role. And then as our clinic has grown and interest in our clinic has grown, we now have residents and fellows rotating through our clinic. And Ben is a resource for them as well. Our pharmacist can provide some direct patient care at initial evaluations. He's one of the people that meets our new patients and can talk with them specifically about medications and how they're taken and initiation. He also can meet with people and assess how things are going at a follow-up appointment, ask them about how they're taking the medication, do medication reconciliation and help us identify if there's potential medication interactions or side effects going on and certainly can answer questions about medications. He's also been really helpful with our interaction with other departments. As a pharmacist, he's got relationships with pharmacists in lots of other clinics and on other clinical services. And that's just really greased the wheels for us when we have a patient who has a need in the pain realm or in the palliative realm or in the hepatology realm or primary care, just to have him as a contact who can very easily reach out to members of other teams. That's been really helpful. He returns pages. He can help facilitate referrals for patients. That's pretty complicated. And like I said, he's been a really important person as far as our ability to be able to do long-acting injectable medications. Super helpful. I imagine everybody can feel our pain around prior authorizations. This can be a big sink of time and a real frustration for helping people get access to medication that they need. And having Ben to be able to help with that and get those approved is very helpful. And sometimes our patients don't know how much something's going to cost. And I often don't know either. And Ben can help troubleshoot that and get more information. Not only that, he's been really helpful in getting people signed up for pharmacy benefit programs and coupons and things like that to help defray costs. And then our case managers actually take a lot of our refill requests from patients in between appointments. They're not licensed practitioners, and so they don't have access to our prescription drug monitoring program. But Ben does as a pharmacist, and so he can check and see when the patient last got their medication or just help use the PMP as a tool when we're making decisions about refill requests. And I think our patients are pretty complicated and often have a lot of needs, both related to substance use disorder. But many of them have not been getting regular primary care or dental care. And many of them have other social needs. We help a lot of people find stable housing. We help a lot of people find a job. We help a lot of people access resources for clothing and food and stuff. And so having a multidisciplinary team really sets us up to better meet the comprehensive needs of our patients. And certainly having a pharmacist is an important piece of that. And I noticed in the chat, somebody talked about top of their license. And definitely, having Ben on our team has allowed many of us to really practice at the top of our license and helped him to also practice at the top of his license. And so just by having multiple skills, multiple areas of expertise, I think we're able to provide better care than we did initially when it was just a small number of us trying to do everything. And yes, good communication is always just critical. And so Ben and I communicate a lot. We talk about patients a lot. We do a lot of texting, emails, and I think that communication really allows us to work together pretty well and to be able to provide better care to our patients. Okay, so there's been a lot in the chat about this. And people want to know, how do we pay for this? And so our pharmacist can, by taking care of some of the things that he can do, that I could do, but instead, if he's helping with issues with patients, and it's freeing me up so I can see more patients. And so that's one way that we have been able to justify having a pharmacist on our team is it's taken our team and it increased our capacity to see patients. And I can bill for services and do that for our team, and that just allows us to see more patients. Our pharmacist can do some billing. And I know some of that varies from state to state. In our state, our pharmacist can bill for the facility fee. That's going to be limited to insurance companies that pay that and also in-person visits, but it is revenue generation and also helps us justify from a financial standpoint, why having a pharmacist is allowing us to, from a financial case, be solvent. He also, if you're working in a system where meeting certain outcomes or performing certain tasks or something, or having a certain number of patients, a minimum number of patients be compliant with certain things, having a pharmacist allows us to monitor that. So Ben and his students check every single time a patient comes in. We know before they get there, whether they have a current prescription of Naloxone, whether they've been tested for hepatitis C and HIV, they can help with like medication reconciliation and stuff, but they help us do our practice better and also make sure that we are actually achieving some of the goals that we have for our patients on a consistent basis. I've talked a little bit about MAT injections and having a pharmacist has made that a lot easier. Buprenorphine is a medication that's covered by 340B plans, and our hospital does make a little bit of money every time they fill one of those prescriptions. And so having Ben has helped us see more patients who are getting buprenorphine, helps us keep more people on buprenorphine because he can troubleshoot a lot of issues and that ultimately generates some more revenue. I think a big thing for us has been our collaboration with our College of Pharmacy, and our College of Pharmacy actually does support part of Ben's time. And in exchange for that, we have pharmacy students. So he does teaching while in the clinical setting. And that's just a win-win because like I said, we really feel like it's very important that part of what we do is teach future healthcare providers how to provide high quality, compassionate care to people who have opioid use disorder and other substance use disorders. So that's been actually really helpful. And then hospital pharmacy, we are not actually getting any funding from hospital pharmacy right now for Ben's role, but because Ben and pharmacists can help also expand specialty pharmacy medications, and that can be revenue generating, partnering with hospital pharmacy is another place to consider in your setting, maybe if you're looking for ways to justify from a financial standpoint, why you need a pharmacist on your team. Okay, so and I'll actually answer this question now, since I got to this slide, but we're going to talk a little bit about enhancing treatment, and expanding access to care, and then also reducing workload for other team members as well. But the question was, what settings have pharmacy students rotated through outpatient and patient? And the answer to that is both, as well as our addiction medicine consult service, and then also this clinic. So our medications for addiction treatment, that's our walk in clinic. So along with Dr. Lynch, and one of our other attending providers as well, we started this this walk in clinic, it's a low barrier access clinic, kind of an urgent care style clinic where patients can come in no matter what stage they are in in terms of engagement and treatment, they could be in pre contemplation stage, and just wanting to talk about what the options are moving forward, they could be, we could be talking about harm reduction, we could be talking about, okay, let's start medications. So, but between the three of us, we started this clinic. And so I am actually one of the people I'm there every single week, I see patients as they come in. On average, I'm seeing just myself, I'm probably seeing three or four patients each week. And then our other attending physician who is out there is usually seeing, you know, the other half of the patients, whatever that may be. And so again, you know, it does expand the number of patients that we can see by both of us seeing patients, which is very helpful. But it's also a site that we've gotten a lot of patients initiated on treatment to be able to allow them to then get engaged with our clinic and actually start receiving treatment services in our clinic as well. So just one example of kind of after how when I started here, how we kind of move forward and expanded and opened up these other services. And we're actually in talks currently to maybe even consider expanding and adding another location for this as well. So just enhancing treatment, kind of want to talk about, you know, things that that pharmacists do, but on the local level. So for example, here, integration on our Mac consult service, where we can initiate treatment, we can do withdrawal management, we can do complex pain management for patients with comorbid substance use disorders as well. Dr. Lynch and I have seen patients who are currently pregnant. And so we can talk through a lot of that risk benefit discussion with other healthcare teams, the patient, and, you know, just also managing precipitated withdrawal and some of the complexities of precipitated withdrawal treatment. Organizational level, I would say I do a lot with updating policies on buprenorphine and methadone, especially with the recent changes to the buprenorphine policies. Grand rounds educations, I do a lot of grand rounds I do in services for nursing. We've done pain management, psychiatry, pretty much you name it anything in that realm. And then also just expansion of grants for for SUD care by adding a clinical pharmacist on to some of our grants and, and making certain things to where we are going to outreach and train other pharmacists around the state. We feel like that's been received pretty well whenever we are submitting some of those grants to. On a state level in enhancing treatment. So speaking at conferences across the state on substance use disorders, I actually did one of these last month. And that led to multiple other people reaching out from different counties about, hey, we want to expand treatment access in our county, our very rural area, how do we do that? And so connecting them and helping them kind of fill that gap will also help our patients just dramatically, especially for our patients that drive hours to come, come to our clinic or see us. Involvement with pharmacy associations and Board of Pharmacy for regular regulatory practice changes. I've worked a lot with our pharmacy association here. I've done stigma talks, especially, and things like that, that oftentimes, you know, pharmacists get a lot of education on medication management, but not necessarily on some of those other things. So being able to talk about all of those other things, incorporating them fully into care. Creating continuing education to better assist pharmacists with education on substance use disorders. And then also one of my current projects right now is increasing naloxone access, but in different settings, but making sure that patients have access to naloxone. On a national level. So interdisciplinary publications, we write a lot of our publications as a team. And so we publish a lot on substance use disorders, stigma, et cetera. But then also that organization of involvement, and we've already mentioned it a little bit, but with the American Association of Psychiatric Pharmacists, I do work on our substance use disorder committee with that organization. And so there's a lot, a lot, a lot of organization involvement that can occur on a national level as well. And that's also just helpful for bringing in some of those new ideas and new things and reaching out to what other pharmacists are doing or, Hey, we noticed we, we started this treatment and we noticed this weird thing that we haven't seen before. Has anybody else noticed this? And if so, that can kind of help us kind of manage whatever the case was. I do want to talk a little bit about research on enhancing treatment. One example of this is metal at all. So basically patients with opioid use disorder and on buprenorphine, they were randomized to either a physician only group or a multi multidisciplinary team group. And the primary primary outcome in this study was retention and treatment over one year, and then also opioid return to use rates treatment retention in this study really remained consistent, but there was and there was significantly less return to use and the multidisciplinary groups. So decreased overall substance use in the multidisciplinary team. And then also buprenorphine adherence rates were higher in the multidisciplinary team than with the physician alone. And then this other study by air hard at all. So addition of a clinical pharmacist to the inpatient addiction triage team, this was a retrospective study to compare initiation rates of medications for alcohol and opioid use disorder. And the primary outcomes were to compare the initiation rates 12 months prior to implementation of the clinical pharmacist and then 12 months post. And basically what they found was prior to that implementation, they had about 7.4% initiation of medications for opioid or alcohol use disorders. But post initiation of that clinical pharmacist had actually increased to just over 26%. So again, more patients were kind of being offered and started on medications compared to before adding in that clinical pharmacist. One of the biggest things is reducing workload burden, though. And this is really where the clinical pharmacist, a lot of the information has come out about why clinical pharmacists should be added into basically any clinic. So things that I'll work on or do with my community pharmacies. So I'll do refill management, prior authorizations, insurance appeal letters, answering questions, building rapport with those community pharmacies and establishing good relationships with them. On an organizational level, providing education, updating training materials, updating policies, procedures, answering questions. But this study by Hag et al basically showed that it helped providers effectively manage their panel of patients. It improved overall medication use. It helped patients meet health goals and quality measures, reduced workload by working directly with patients and non-provider staff, and then more time to focus on professionally fulfilling aspects of work. And specifically, the most common thing here was that providers found greater meaning in their work through the presence of a clinical pharmacist. And 91% of the providers surveyed in this were extremely satisfied with their clinical pharmacy service. And I know we're starting to run a little bit short on time, but some things to maybe think about. Are there any specific workplace opportunities a clinical pharmacist could assist with within your practice, your current practice? And what might be some of the barriers for implementation of a similar program in your workplace setting? So these might be things to kind of think through, but I'm going to go ahead and move on to the next slide just due to time. So just real quick, our MAT Clinic has continued to grow. We are now operating four days a week. We have three locations, seven LIPs. We have a clinical operations manager who's trained as a nurse. We have two peer recovery coaches, and we're hiring at least one more. And we have five case managers. We also have more learners rotating through our clinic. We've been getting, you know, applying for grants to support our case managers as well as our peer recovery support specialists or recovery coaches. We continue to build on our collaborations with other departments. Our addiction medicine consult service now has an addiction-trained physician every day, full-time, rather than the kind of hodgepodge plan we had initially. We have MAT injections of both long-acting injectable naltrexone and long-acting injectable buprenorphine. And as we talked about a little bit earlier, we have our walk-in clinic. So back to the case. So I'm just going to recap kind of where we were at 48 hours. The patient had called six times, left messages, had a number of questions and concerns about prior authorization, about whether the buprenorphine wasn't in stock, questions about eating and drinking, questions about, you know, they couldn't wait because they couldn't get the medication, so they took some oxycodone. And then now what? It sounds like they had a little bit of precipitated withdrawal after the first dose, and they didn't like the way the tablets tasted and dissolved. And so, you know, our pharmacist was able to help with all of these things, right? The pharmacist can get the prior authorization and follow that through while I go on to see another patient. The pharmacist can call around and troubleshoot with the pharmacy around getting buprenorphine in stock and find another pharmacy in the community that actually had it so the patient could pick it up that day, can talk with the patient about recommendations for eating and drinking around when they're dosing just to optimize the absorption of the medication and reduce side effects, and talk to them about adjusting the plan to start buprenorphine since they took some oxycodone tablets and kind of reset the clock a little bit, right? And can also help with management of a plan for addressing precipitated withdrawal when that happens, and also talk with them about the option of maybe switching to a different brand of buprenorphine or trying the sublingual films. So, I think the next slide, I think, is our last one. Yeah, so just kind of just the wrap-up for our case, our clinical pharmacist who has training in substance use disorder treatment can help with a lot of the different things that come up along the way when we try to take care of our patients. I'll mention here, because we didn't talk about it earlier, the pharmacist can also help with withdrawal assessment, and we use some of the smartphone apps so that patients can do some of their own withdrawal monitoring, and so our pharmacists can help teach them how to use those, help us develop a treatment plan for precipitated withdrawal, because that does come up sometimes, and also plan for alternative initiation strategies, such as like low-dose or microtitrations, and that's been really helpful to have him with that, coming up with that plan for some of our patients. We recently transitioned a patient from methadone to buprenorphine who was pregnant and who was incarcerated, and having our pharmacist helped us come up with a very complicated, kind of, or drawn-out process, and that patient had no withdrawal symptoms while going from methadone to buprenorphine, so having our pharmacist help with that was super helpful. So, just key takeaways. Collaboration of healthcare professionals can optimize care of patients with substance use disorders, no question there. Addition of a pharmacist to our substance use disorder treatment team can reduce the workload burden, enhance treatment, and expand access to care, and that's definitely been our experience, and clinical pharmacists with substance use disorder training can assist in a wide variety of settings, which include consult services, telehealth, outpatient, and inpatient services. So, these are our references, and I just want to do a shout-out for the PCSS mentoring program, which is available to everybody, right, and can be a great way to connect with other clinicians who are dealing with some of the same challenges that we all are, to get some advice from someone who might have experience solving a problem that you're dealing with right now. It's free. There's also the Listserv, the question bank. Want to go to the next slide? Yeah, there we go. The discussion forum, that's what it's called, yeah, where you can post questions and get advice from other clinicians, like I said, who might have already solved that problem that you're faced with today, and then just PCSS in general. Oh, yeah, the lots of collaborations here, and then PCSS in general has been just, it's a great source of information. Their website is awesome. You can email them, and we just want to thank them for inviting us to speak today, and thank you all for attending.

clinical pharmacists

substance use disorders

Addiction and Recovery Collaborative

University of Iowa

Medications for Addiction Treatment (MAT) Clinic

patient care outcomes

pharmacist's role

collaborative practice agreements

interdisciplinary care