Rachel Palicte (She/her): Alright. Hello, everyone! Welcome to today's webinar. We'll go ahead and get started in just a few moments, but until then, if you'd love to share who you are and where you're coming from in the chat. That would be great. Rachel Palicte (She/her): All right. So good afternoon, everyone, and welcome to today's webinar titled, providing comprehensive care and opioid treatment programs. a policy and provider perspective hosted by the Providers. Clinical support system Rachel Palicte (She/her): in partnership with the National Council for mental well being. Thank you so much for joining us. My name is Rachel, and I am the project, Coordinator of Practice improvement here at National Council. Rachel Palicte (She/her): and I will be moderating today's event. Rachel Palicte (She/her): So before we begin, I'd like to cover a few housekeeping notes. Today's webinar is being recorded and all participants will be kept in. Listen. Only mode. Rachel Palicte (She/her): the recording and our slides will be available on the Pcss. Website within 2 weeks, and there will be an opportunity to ask any and all questions that you have that pop up throughout our webinar. Rachel Palicte (She/her): So we encourage you to do so by submitting your questions in our Q&A box which is located at the bottom of your screen. Rachel Palicte (She/her): All right. So I am pleased to introduce today's speakers. Today we have Mark Perino as well as Jennifer side with us. Rachel Palicte (She/her): So, starting off, Mr. Perino has been involved in the delivery of health, care and substance use treatment since 1,974. Rachel Palicte (She/her): Currently, Mr. Pino is the president of the American Association for the treatment of Opioid Dependence and Vice President of the World Federation for the treatment of opioid dependence. Rachel Palicte (She/her): and next, Miss Sive has been involved in behavioral health care for the past 20 years. Rachel Palicte (She/her): She is a license, mental health counselor and credentialed alcoholism and substance use counselor. She was directly involved with the startup of the opioid treatment program at best self and currently oversees the startup of the mobile medication unit at vessel as well. Rachel Palicte (She/her): It's Mark and Jennifer. We are super to have each of you here with us today. Rachel Palicte (She/her): So this is just a quick note to let everyone know that our speakers have nothing that they would like to disclose with our audience today Rachel Palicte (She/her): and our overarching goal within Pcs that is, to train healthcare professionals and evidence-based practices Rachel Palicte (She/her): for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well for the prevention and treatment of substance use disorders. Rachel Palicte (She/her): So at this time I would love to turn it over to Mark Perino, who will go ahead and review our educational objectives and begin his presentation. Mark Parrino: Thanks, Rachel, thanks very much. So. The objectives for today's webinar is to examine the current policy landscape for otps, which I will cover, discuss the value proposition of becoming an Otp. Identify strategies to provide comprehensive services in the node Tp. And to describe what services can be offered at the program itself. Mark Parrino: so Mark Parrino: as a prelude to these slides I'll be sharing Mark Parrino: I will cover the broad policy landscape. Mark Parrino: And and Jennifer is going to provide more of the sort of hands on clinical issues that go on in the program and the services that are provided. Mark Parrino: So our Association has been in existence since 1984. Mark Parrino: Clearly we have been Mark Parrino: witness to a critical number of changes in the evolution of how medications are used to treat opioid use disorder. I'm sure the audience is fully aware that no date passes without a mention of the Mark Parrino: Opioid use crisis that we're in. Mark Parrino: And from my point of view there are 2. One is the overdose crisis, mortality crisis, and then the opioid use crisis in and of itself one begets the other. Mark Parrino: But there is an interesting distinction. So if you're dealing with overdose steps and trying to reduce them and reverse them. Naloxone is critical, and their number of agencies that want to saturate the communities with Mark Parrino: Naloxone, and then, of course, train emergency responders and then get them to emergency rooms. In this case the emergency rooms that do need resources. If they determine that the patient needs will care, and that's an important issue. It's one thing to reverse Mark Parrino: the overdose. It's another thing to treat the individual. And then, of course. Mark Parrino: the tragic issue of how many people are using Fentanyl. Mark Parrino: since that is the leading cause of mortality. And that's where treatment expansion comes in. And the purpose of this webinar. Mark Parrino: I can also tell you that Mark Parrino: there is a need to expand access to care, and you'll hear me talk about mobile vans in my in my time with you. Mark Parrino: and I want to let you know that Samhsa and the Da. And the State authorities are extremely helpful to us. We consider them policy partners. And Mark Parrino: it is Mark Parrino: basically simple to set up and Otp as long as you know what you're doing. Mark Parrino: And you have to start with the State opioid treatment authority, and then go on to deal with Samhsa and the Dea, and you'll find them to be hopeful. Mark Parrino: So next, please. Mark Parrino: I'm showing you this because it's a reminder of where we got started. Mark Parrino: The current opioid crisis had its original incarnation in the misuse of painkillers. As physicians. Mark Parrino: practitioners Mark Parrino: provided a significant amount of painkillers in the United States, and the reality is that Mark Parrino: a significant majority were not following the impact it was having on the patient. And this, as most of the participants know, led recently to settlements to create the opioid Settlement Fund, which has been funded by pharmaceutical companies. Mark Parrino: basically Mark Parrino: large pharmacy Mark Parrino: distribution, and also the distribution houses themselves. Next. Mark Parrino: this would lead to the Pain Killers as the gateway to Harold, which is reported in the New York times. Mark Parrino: and that would lead Mark Parrino: to Mark Parrino: Fentanyl. Now we have been conducting a study through 75 programs in our associations in 2,005, Mark Parrino: and after 4 years of gathering data. Mark Parrino: we found that 43% of new patients admissions were using prescription opioids what was not known at the time, but was reported in 2,009 was of that 43%, just over 30. We're injecting the prescription opioids. Hence the gateway to heroin. Mark Parrino: What we did not anticipate Mark Parrino: was that Fentanyl would become so popular. Mark Parrino: Next slide, please. Mark Parrino: This is the current map. It's the Samsung map of where all of the Otps are distributed in the United States. Mark Parrino: you you could see where the large States like California. New York, Florida, Georgia, Texas. Mark Parrino: have pro Ohio, have treatment programs in Pennsylvania. You'll also notice that Wyoming is the only state in the country that does not have an Otp Mark Parrino: to this day. I still do not understand that, because there's no shortage of people who would need access to care. Mark Parrino: But you also see the opportunity for growth. There are 2,019 programs in the country. That's about 300 more than existed Mark Parrino: just 4 to 5 years ago. So the opportunity to expand is real. And for those of you who are thinking about opening a program they certainly encourage. It Mark Parrino: may have the next slide, please. Mark Parrino: So A. Todd worked with NASA Dad, the NASA, the National Association of State Alcohol and drug abuse directors. and we published these findings in September 2,022. Mark Parrino: This provided the first real opportunity, not of an estimated census, but an accurate head count. And at that time, as of January, one of 2,021 Mark Parrino: we had about 1,800 programs. We had an 85% response rate or 15 1,547 programs. Mark Parrino: And we amassed a lot of data. We even learned not just the number of patients in treatment, which with that time was about 512,000. It's now 600,000. But the form of medication that the patient was taking. Mark Parrino: and for the most part the majority of patients and the Otps Mark Parrino: over 90% use methadone. And that's generated because most of the patients over 80% new admissions are using fentanyl. Mark Parrino: and as the patients are inducted and stabilized into treatment. Mark Parrino: it has found that methadone is the preferred medication for this particular patient population. Mark Parrino: This is not any way criticism of buprenorphine. It's just the clinical experience of the providers within the Otp system. Mark Parrino: This is on our website as well, and you'll see it at the end of the presentation. May I have the next slide? Mark Parrino: So these are the mobile units across the United States? There are 33 operating vehicles more opening on the way, and Jennifer will talk about her experience with that regard. But Mark Parrino: we are looking to see this expand, and the next several slides will give you an idea of why this expansion is critical. Mark Parrino: Basically, the vans are connected to the otps. Mark Parrino: and the vans really extend the reach of the otps into the rural and underserved areas of the country. Mark Parrino: Also, these fans can be used in delivering medication to correctional facilities, and there is a greater interest in having correctional facilities. Treat inmates with the federally approved medications. To treat opioid use. Disorder Mark Parrino: may have the next slide, please. Mark Parrino: This is a form. It's a Samsa form that otps can fill out. So in this case, if you are an existing Otp. Mark Parrino: and you want to have a mobile unit. This is where you get started Mark Parrino: after you talk to the State. Opioid treatment authority talking to the State authorities initially is extremely important. and the reason is that they will help Mark Parrino: provide funding for the purchase of the vans, and I'm going to get there in a minute next slide, please. Mark Parrino: So this is the Otp extranet help desk. So if you are interested in developing vans which would be directly affiliated with the Otps Mark Parrino: after you go through submitting the form dealing with the State authority and the Dea. Mark Parrino: If you need help, you'll get it through this. This desk Mark Parrino: and Sams of people are helpful and they are responsive next slide, please. Mark Parrino: So this gives you an idea of what these vans look like. This is courtesy of kodak in Providence, Rhode Island. Mark Parrino: This is the look of the van. may have the next slide, please. Mark Parrino: This is the general schematic. These vans, with these kinds of specialties, cost about $400,000, Mark Parrino: and if you have an interest and opening a van service within the Otp. Mark Parrino: you talk to the State authority and you and you talk to them about getting access to the funds. Samhsa funds can be used Mark Parrino: for by otps for the purpose of of opening these vans and given the expense. That's important. Mark Parrino: Also keep in mind that the vans are then owned by the otps directly. Mark Parrino: and if you are a publicly funded Otp. Mark Parrino: that you get a different grant from the State. If you're a privately financed Otp you, then you then set up a contract with the State opioid treatment, authority of the State, alcohol and driver Abuse Directive. Mark Parrino: But you see their compact units, and that's where they're costly. And also, you can see, because of their mobility. They do the outrage next slide, please. Mark Parrino: Also courtesy of kodak. This is the typical staffing, configuration Mark Parrino: driver, nurse. the provider, either on call or in person. Case manager and peer recovery support specialists. The services provided are listed which includes the storage of the medications. Mark Parrino: administration and objective on our track zone. Mark Parrino: behavioral health assessments. And what's the remaining issues on the on the list. Next slide, please. Mark Parrino: These are monthly maintenance costs for those of you who are interested. Again, you're going to get access to this information, as Rachel said in her introduction. Mark Parrino: So. and if you have questions you can certainly send them to me. Mark Parrino: Those we don't address during this afternoon Mark Parrino: may have the next slide, please. Mark Parrino: These are the considerations about where the vehicle is going to be parked. Mark Parrino: What may will the medications be taken off the vehicle at the end of the day. Mark Parrino: and then the vehicle type really depends on maintenance, size. Mark Parrino: space, and the services that you do anticipate meeting on the vehicle. Mark Parrino: And and then you you need to talk to the Dea because you have to have safe that especially fitted to these vans and some of our colleagues have said that Mark Parrino: you need to check with the Dea as soon as you get into the planning process Mark Parrino: next slide, please. Mark Parrino: So this is now courtesy of our colleagues in Maryland, and are Wendell County. This is a van that's just been put into service. Mark Parrino: This is a different design. Different manufacturer. But you'll see it's a compact nature next slide, please. Mark Parrino: next slide. Mark Parrino: And again showing examination areas. medication dispensing areas next slide. Please. Mark Parrino: Now, let's switch to correctional facilities. The graphics are not mine. This shows you how long we have been pursuing getting medication, assisted treatment Mark Parrino: into correctional settings. I wrote this article for American Jails Magazine 23 years ago. Mark Parrino: and it shows you that it's been a very slow uptake The Elvira, like graphics is the result of a creative editor. Mark Parrino: Not me. But it was reporting on the Rikers Island jail experience in New York City which was one of the earlier availability of treatment behind the walls, and it was obviously quite successful. Mark Parrino: And next slide, please. Mark Parrino: this is a good example of progress. This comes from the New York State Legislature, and during January of 2,021 Mark Parrino: they created a requirement that all correctional facilities throughout New York State would have to make medication assistant treatment available to their opioid using inmates. Mark Parrino: and they have done this Mark Parrino: One of the early successes is now that whenever a patient enters a correctional facility Mark Parrino: they will continue the method on dosage, they will not withdraw the patient, they will not lower the dosage. Mark Parrino: It may not seem like a big leap, but it's a major breakthrough Mark Parrino: for New York State, and most States do not have this. So we're working on this issue, and we will write a template for this. And once again Jennifer may talk about this as well. More on the local implementation may have the next slide, please. Mark Parrino: This is a bill in the United States Senate that would achieve the same things. Clearly, we're supporting this kind of bill because we'd like to replicate what's happening in New York State and then expand it, and one way to do that would be through Federal legislation. Mark Parrino: Next slide, please. Mark Parrino: So I've tried to cover a broad number of topics quickly. Mark Parrino: and again, the expansion of otps, I think, is a critical part Mark Parrino: of dealing with the opioid use crisis. Mark Parrino: I think that the otps are well positioned Mark Parrino: because they. They do provide Mark Parrino: services to treat the needs of patients, whether it's dealing with psychiatric disorders Mark Parrino: dealing with HIV infection, hepatitis B and C Mark Parrino: dealing with trauma, and just to conclude, it's, you know, a medication in and of itself, all being effective is not going to respond to the needs that patients present. Mark Parrino: And as I'm sure Jennifer will get into the reality is that we do need to be responsive to the patience needs. Mark Parrino: Otherwise you really can't define that as a treatment experience, and Mark Parrino: the the patients need very. you know, significant things. But I think also the clinic, the clinician needs to be well trained Mark Parrino: and compassionate. Mark Parrino: and also wanting to respond to the needs of the patients. I spent 18 years of my professional career working in a methadone treatment program in New York city. Mark Parrino: I enjoyed that experience. I learned a great deal from patients. Mark Parrino: and I think that the Otps are really a good example of responding to the needs of patients and the opioid treatment crisis throughout the country. So I'm going to encourage you to open otps, look for the State authority Mark Parrino: and then think about the mobile vans as well. So with that, my time with you is up. I'm happy to now refer you to Jennifer, who is going to give you a a more detailed and clinically focused presentation, since this was more of a national policy issue. So, Jennifer, thank you. It's up to you. Jennifer Seib: thank you, Mark. and Hello, everyone, I'm I'm very happy to be with you today. As as previously stated, my name is Jennifer S. I. I'm the Vice President of strategic initiatives and integration with best self behavioral health. Jennifer Seib: which is primarily located in Buffalo, New York, And I just wanna make mention that? when I go through kind of our experience as a as an organization. I am speaking specifically to New York State, where where I'm located. So obviously, some things may vary And again, mark with the great advice of reaching out to your State opioid authority, who will, you know, be able to help navigate those different things? Jennifer Seib: so just a little bit about best self. as I said, located in Buffalo, New York and we were we became an organization in 2,017, after a merger between 2 existing Jennifer Seib: or previously existing organizations like shore behavioral health and child and adolescent treatment services. at that time we also became a Ccbhc. Jennifer Seib: And I think that's something that's really unique. so 2,017. We're a Ccbhc. We then start our process of opening an Otp which we then opened in January of 2,019 and our Otp is co-located with our Ccbhc. site, one of our locations. Jennifer Seib: so again, we were part of the original demonstration project for Ccbhc, so I, you know, could speak to both the you know, the Ccbhc side and the Otp side, and and hope to kind of share with you how those work really well together. as, as Mark had mentioned as well, we are in the process of bringing online a mobile medication unit or a mobile mobile service as part of our brick and mortar services as well. Jennifer Seib: So next slide. So I just wanted to share a little bit. What what does it take to open up an Otp? And and I had the the privilege Jennifer Seib: to be a part of all of that start up? So it was started in 2,017 through 2,019, when we opened the doors. really, we just Jennifer Seib: all all the as Mark mentioned, the Sams of the Da, the State opioid authority, and working with all those folks very, very helpful indeed. So again, there's a lot of a application process. So you have to have a a location that is approved by the Dea lots of Jennifer Seib: things that they're looking for, around, making sure you're not that you're controlling diversion, and that you have a safe space, that it's accommodating for folks all of those kinds of things. Jennifer Seib: and and another thing that some people may not be aware of, and and is that once we became our we received our Otp and we opened. We had one year to become accredited. So the accreditation process is a pretty lengthy process. I won't go into all of the details, but Jennifer Seib: we at itself have the Council on accreditation. Co. A. Is who we're accredited by. And not only did we decide as an organization to go for Otp to be accredited, but we did our our entire service delivery system. So our entire organization became Co. A accredited was a a big up Jennifer Seib: take, but it also was very beneficial, and I think, shows that we're providing high quality care to. People ensures that we're doing that Jennifer Seib: next slide. Jennifer Seib: So I just wanted to speak a little bit about us, the the Otp and the Ccbhc being co-located. So these and just kind of give you the lay of the land of what that looks like. So we have one building. actually, our Otp is located in a southern suburb of Buffalo. So it's kind of unusual. Most of most of our otps are located in the city. So, being outside of the city and in a suburb area is a little unique. Jennifer Seib: and so that's kind of a a cool little difference, but one of the great things about the the layout. We have one entrance that's for the dispensary, where people enter in Jennifer Seib: and get their medication, and can meet with their doctor with their primary counselor all of those things in that location. But then, within the same building, they can easily move over to our Ccdhc services. So for those that aren't familiar, Ccbhc offers many other additional things like a targeted case manager a psychiatric rehabilitation specialist to focus on vocational goals or educational goals. Jennifer Seib: we. We have peer services within all of our all of our areas and and they also have access to a psychiatric prescriber to get medication for their cell or for mental health concerns. So there's all of these ease of access between all of these services, and I think one of the great highlights is Jennifer Seib: And Mark spoke to this, you know, in an Otp otps are very well positioned to work with people with opioid use disorder, you know. That's kind of the specialist in this area. That's our our peers, our counselors, and our our providers. But it's also great that the complexity of people that they get to stay connected to that while also accessing these additional services that help support Jennifer Seib: their vocational and educational goals, help support their care around their mental health concerns without necessarily having to have a a second counselor, or you know all you know, it doesn't parcel out these services in a way that makes it Jennifer Seib: cumbersome for patients to to access. Jennifer Seib: I think another thing that's really interesting about this, too, is, if we have people who want to transition off of a traditional Methadone dispensing type of schedule, and, let's say, would like to move to injectable buprenorphine. Jennifer Seib: they can do that within the Ccbhc site. So again, it's a very easy transition. It's connecting to a lot of different a lot of different people at the same time. likewise, in our Ccd, we have lots of groups available for many different types of Jennifer Seib: concerns, things that people want to focus on. So again, they're here at our Otp, but they could attend a group on a very different type of topic that's in line with their treatment and recovery goals Jennifer Seib: next slide. So you know why otps, right? So it was like, but that's kind of what we're here for, so like from a patient perspective. You know what's what's great about that. So you know, we're able to dispense it in in an Otp. We dispense Methadone and people, and we're Jennifer Seib: the way that I look at that. And why that's so important is for some people Methadone is the Jennifer Seib: the most appropriate medication. And again, Mark kind of talked about that knowing, especially people with fetin all use and and that so here's this great, you know, we have this place. This is the right medication. Jennifer Seib: Now we know that people can also access buprenorphine oftentimes in a in a more traditional outpatient setting, and get a prescription. But for some people that might be the best medication, but maybe that's not the best modality of services or treatment for them. So for those that buprenorphine is the right medication, they can still come into the Otp. They get all of those specialized and supportive services from our Jennifer Seib: nursing staff peers and counselors, and and have support in managing their medication and making sure that they're they're safe and their medication is safe. So I think it's really key to think about. you know where. Historically, we've talked about places as methadone clinics. And now we talk about them as opioid treatment programs, because it's not just about Methadone. It's not just about Jennifer Seib: you know, handing this this one particular medication out on a daily basis, it's much more comprehensive. And really we can help support people it with opioid use disorder in many different ways. Jennifer Seib: other things that we focus on in our in our clinic, you know, I think it's like, said specialized attention. And there's a lot of those frequent touch points when people are coming in daily or close to daily. You know, they have a lot of connection. They build camaraderie. They they know they have a a place of support. and I think that's really key, and Jennifer Seib: and also being able to be in that space and decrease stigma. You know we I know Mark kind of talked about that in in some degree, and and how people need to have a place of where they're treated with dignity respects. That's really You know, we have this opportunity to let people know we're here to support you, and we don't judge you. And we, you know, we want to welcome you and and help reinforce that throughout. Jennifer Seib: Other key. Things that we can do is looking at more holistic care. We make sure we're doing blood work. we're doing hepatitis, testing and treatment for hepatitis C, working with pregnant and parenting women, helping support women who are either pregnant or maybe have young children, and making sure that we're through our targeted case management, they have access to Jennifer Seib: transportation and or child care so that they can continue to get their health care taken care of. obviously trauma and co-occurring mental health, as I spoke to in particular, being co-located with our Ccbhc really allows us to provide robust services in that space. Jennifer Seib: And I did want to. Just before I I move away from this slide. I had Jennifer Seib: colleague from our our Otp. Share a really nice story with us. that I just wanted to share. Why, you know why it's so important. that we do this. And and there was a a a woman who came to our services, who at the time was pregnant Jennifer Seib: was homeless, and also had just had a recent loss in her. From her partner who had had died of an overdose. Jennifer Seib: And this so clearly that just not just opioid use disorder, but lots of other. You know, complexities going on in this person's life. And from through this work and through working with our Otp staff connecting with our Ccbhc services, working on vocational and educational goals. This person's been in recovery, for is is in long term recovery with Jennifer Seib: you know. Now we working, supporting herself, taking care of of of her young child. So being able to really pull all these things together. We're not just addressing the opioid use. But we're really helping to support all of these all these areas. Jennifer Seib: the next slide, please. So mark also mentioned about jail-based services and correctional based services. So that's something that we Jennifer Seib: really, you know, spend a lot of time with as well. So for us at best self. We work with 2 county jails, which is the Erie Erie County jail and and Buffalo is located within Erie County, and then Niagara County jail is a Niagara county is an adjacent county Jennifer Seib: In those spaces we have our own counseling peer case management and discharge planners that work with the incarcerated individuals on site. So they're doing individual and group counseling treatment, planning all of those things Jennifer Seib: in addition for those that become incarcerated when they are and and they are on Methadone. At that time they connect with our Otp. We have a system in which we work with the correctional staff to get the Methadone to the jail, and then they get that to the patient and then we quickly. We don't part of our discharge planning is to make sure that Jennifer Seib: there's no lapses in care, so that when people are discharged, when they go back to their own homes and maybe their their home otps that we're able to get them right back into our services with where it makes sense for them. Jennifer Seib: in addition to that through the New York State Department of Corrections. There's one State correctional facility that's Jennifer Seib: relatively near to where our brick and mortar Otp is and we've been doing a lot of collaboration with them as well. It was really unique about that. That program is sometimes those incarcerated individuals are people that may not be getting out ever. There are people that may not ever be released, and yet we're still working with them, and we're not able to see them. So it's a lot of collaboration between our medical providers Jennifer Seib: and the The correctional health staff to, because the correctional health staff is seeing the patient and then reporting back. And then there's a lot of collaboration. that needs to happen. And then, of course, we work with them all the logistics on how to get the medication to them. all that kind of stuff. But this is something that is a lot of work. and it's It's challenging in the sense that it's relatively new. Jennifer Seib: but it is amazing, and it is just I can't speak enough about how important it is for this work to happen. Jennifer Seib: because Jennifer Seib: before this we unfortunately saw so many, we lost so many patients. who would be incarcerated sometimes even for a short period of time. Jennifer Seib: be released, return to use, and then die of an overdose. So this is critical work to make sure that people are able to stay on their medication throughout their process. you know, obviously to decrease the risk of overdose and also to Jennifer Seib: help them not be sick while they're in jail and go through all of the you know all those kinds of uncomfortable things. So this is, you know, more to, I'm sure more and more will come on this as as it gets further down the line, and we get more experience in this. But it's great work. next slide. Jennifer Seib: So so, as I mentioned, we are working on currently our mobile medication unit Jennifer Seib: and we for us, we were awarded funding through the State of New York to to do a a startup of a unit. So we. So we have some funds to get the unit and to do some startups. so, or with the startup funding for that. Jennifer Seib: So I think Mark kind of spoke to this. But obviously here, like some of the key reasons that a mobile unit was great. It is, helps us to extend the reach of our services so that we can extend more into rural areas. And folks that probably are able to get to us in our our traditional locations. Jennifer Seib: for us, we, our staffing requirements, are we have to have an Md. And Rn. And 2 nurses and then counseling and peer services. also. I I think I mentioned it on the next slide, but we have other some other specialty staff that we'll need as well. Jennifer Seib: one of the things that Samhsa does allow, and I think is really important is the mid level practitioner waiver. So I'm not sure if people are familiar with that. But what that does in in traditional services, an Md has to be the person who does our initial evaluation and initiates the person on medication. Jennifer Seib: But if you have the mid-level waiver through Samhsa and you and you get that awarded. You are able to then use some of your M. The Mps or Pas can then do those services, and that's that's really key, because that helps us expand. our ability to employ people and have them do this work. in New York State we do have to. Jennifer Seib: I'm sorry I lost my trade off for a second in New York State. Jennifer Seib: It's required of us on our medication unit that we have to do those initial emails on the unit itself. It cannot like. It cannot be done. Telehealth. So we have to be able to have a Md. And Ppa who has the waiver on the unit to see people to do those initial evaluations. Jennifer Seib: That is great for patient care, and as you may think, it could be a a a cost factor for people as well, because that's a some expensive staff that you have to, you know, travel and be part of of this unit. So just some considerations. But Jennifer Seib: great stuff there. we also have to be able to conduct the your analysis on the site. you know. So that means you have to have have a bathroom and ability to store all of those things. So I think Mark did a really nice job of of showing, and and thanks to the the program in Rhode Island that shared their their information, because I think it gave a good layout of what the units can look like. Jennifer Seib: next slide up. Jennifer Seib: So yeah, so other staffing requirements. There's a lot of security requirements. we need to make sure that the unit is GPS tracks. It has to be connected to alarm company. So there's like all these other considerations. and then the the unit itself Jennifer Seib: it can. Jennifer Seib: It must be stored either indoors or in a gated area for the for the regulations. So where I live in Buffalo gets very, very cold. I don't know if you know about buffalo, but it gets very cold and it gets very snowy. so we need to make sure that we have an indoor space to store the unit. Jennifer Seib: and Jennifer Seib: that also needs to be approved by the Dea, so not only does your unit need to be approved and and all the Dea requirements, but even where you're storing it needs to be and no medication can be stored on the unit itself. So it is. All the the medications always stored at the brick and mortar site. But even even with all of that, we need to make sure that we have all those all those pieces in place. Jennifer Seib: So the next slide? Jennifer Seib: so just some particular challenges. I kind of spoke to these already, but you know the staffing needs and travel. Time is something that we have to consider when we're talking about going into rural areas. And when you think about it, the further I kind of put out you go The more cost is associated with travel, and then it decreases the amount of time you have to provide services because your staff is working their day. I mean, if they're Jennifer Seib: driving for the majority of it, then that means the less amount of time that they're able to to provide services. So these are all factors that we're looking into. Jennifer Seib: So if you go to the next slide, I think is where I kind of yeah. So I just kind of did this little breakout. So you know we're talking about, how do we want to staff our unit? How do we? Where do we want to go? And these are all things that as a team we're still discussing. But if you can see kind of this breakdown, if we have a 8 h day for staff, who start at 6 Am. Jennifer Seib: And and debt to. They start their day with our brick and mortar location, where they need to get the medication and load it onto the Mmu to the unit and then travel to the location where they're going to park and and work for the day. Jennifer Seib: So then they maybe have 5 h and 45 min total to to meet with people with this and then they have to close down the unit. Then they have to drive back to the brick and mortar. They have to then put the medication Jennifer Seib: back into the main inventory of the brick and mortar, and then, you know, Park, the vehicle where it needs to be parked? And so for us, the location that we're looking at using is 30 min away from our current brick and mortar. So if it was an hour away, you know, you can do the math that would change that. So there's a lot to consider when you're thinking about expanding. Jennifer Seib: where is the greatest need? And then what's a reasonable distance that we can travel each day? What is those you know, what are those costs? Look like all that kind of stuff. So I just wanted to share that and and share a little bit about our journey and the things we're seeing and talking about is, you know, that may happen for other folks, is there could taking this route as well Jennifer Seib: next slide. so that you know, I this is my last slide, and I really just wanted to. Jennifer Seib: again. I I kind of spoke to this already. And just why otps, why do we? What you know, Otps, really make a huge difference. I think you know, Mark said he did this work, and for him absolutely loved it, you know, in a clinic. For 18 years I have not met a person that I that has worked in an Otp that doesn't love it like. It's just one of those places that because Jennifer Seib: it makes such a difference for for the people that come in every day, so people being able to receive that, that whole wrap around care Jennifer Seib: from people that understand their challenges, their unique challenges that understand the impact of especially severe opioid use disorder in a way that many traditional outpatient services just may not understand and then, being able to really work with those specialty populations, the pregnant women, the incarcerated individuals, and and advocating for them, and and and working on it, being Jennifer Seib: a place where people feel good and they feel non-judged and and working on getting rid of that stigma associated with the disorder and the treatment, modality and medication. Jennifer Seib: So With that, I I think I'm d with my piece, and I I appreciate your time. Thank you Rachel Palicte (She/her): alright. Well, thank you so much to Mark and Jennifer for such a comprehensive and informative presentation. With that we are now ready to take questions from the audience. So Rachel Palicte (She/her): our first question that we have is, Why are Alaska and Hawaii left out of Otp work? And what's the status for them in that regard. Mark Parrino: Alaska and Hawaii do have treatment programs. In fact, I think Alaska has increasing the programs in the last several years. So all of the States Mark Parrino: have otps, with the exception of Wyoming. Mark Parrino: Obviously, when you look at the map, you have some States with many treatment providers and some with less than 5 or 6. But Alaskan Hawaii definitely have otps. Rachel Palicte (She/her): All right. Well, thank you so much. Rachel Palicte (She/her): Another question for you, Mark, is, can you talk about otps as a value? Add to address Co morbid conditions like hepatitis. C. Mark Parrino: Yes, Programs have increasingly Mark Parrino: provided access to care for hepatitis C, both in testing and treatment. Mark Parrino: And we've advocated for that. We would like all of the programs, all of the 2,019 programs to be involved in this. Many are, but some are not. Mark Parrino: and we think that's a vital service for the Otp to provide, in addition Mark Parrino: to hepatitis B, Mark Parrino: and also to HIV infection. The whole argument Mark Parrino: in support of treatment services is to respond to the needs of the patients. And so that's why we encourage that. And for the programs that are not doing that, we really ask them to reconsider work with their colleagues and the State Opia treatment authorities. Rachel Palicte (She/her): Thank you. let's see. So can you say more about statements? That method? Don't that about the statement. It looks like that, methadone is better than view you can have in for FET and all users. Rachel Palicte (She/her): so literature seems not so definitive and lower relapse rates need to be bounced with high overdose rates. Might we still not be at a place where individual, patient choice is best. Mark Parrino: Well, I'll start and then ask Jennifer as well. Mark Parrino: The issue here is the pharmacology, the medication and brain chemistry. So buprenorphine Mark Parrino: is a very helpful medication. It has a very good safety profile, but it does have a dosage ceiling effect. Mark Parrino: and most people don't understand that Mark Parrino: Methadone is a pure agonist. It does not have a dosage ceiling effect. Mark Parrino: So with Buprenorphine, it once you get to a certain point. Mark Parrino: and the endorphins are saturated with buprenorphine. You Mark Parrino: it doesn't it, that you can't add to that effect. It's a dosage ceiling. Mark Parrino: since Fentanyl is so powerful, 50 times more powerful than Mark Parrino: Then morphine. Mark Parrino: You need for most of those people. most of those patients a full agonist because it doesn't have a dosage ceiling effect Mark Parrino: so you can increase Methad. In fact, as Ot. Piece admitted, bidding so many Fentanyl patients, the programs have had to adjust their induction dosage upward quickly Mark Parrino: in order to retain the patient and treatment. So typically a therapeutic dose of methadone might be between 80 to 120 milligrams in a 24 h period Mark Parrino: for fentanyl, using patients that has to go up generally to about 180 milligrams per patient per day of methadone. So this really is a matter of brain chemistry. Mark Parrino: And I Mark Parrino: now, in fairness, you don't have definitive research, fine things, and we know that neither is working on that and various researchers. Mark Parrino: But the clinical Mark Parrino: issues are clear in this regard. And that's when you have patients in otps. You know, it's sometimes buprenorphine will not hold the patient, and the patient will not get sufficient relief. That's that's just the issue of the pharmacology of the medications. Mark Parrino: Jennifer, if you you may want to add some of that. Given your clinical experience. Yeah, I don't know that I have much to add to that, that, you know. Jennifer Seib: I think, really captured it. And I and I agree. It's you know, things we're seeing in clinical practice, things that I hear from our providers, from our counselors and from our patients. You know, we have the being that we have Ccbt services. We have a lot of patients on Buprenorphine in that clinic setting. And oftentimes, if someone's really still struggling. They they may say, I want to, you know, start here in this modality with this medication. Jennifer Seib: and then find it's not very effective. And then the conversation is, what about maybe Otp as a different different route? Jennifer Seib: And some people will really just they. They'll make that if they give it a try and make that transition people report, feeling more relief of their cravings and symptoms associated with. So you know, like like Mark, I think you know, just from a. Jennifer Seib: you know, listening to patients and listening to our provider experiences. it just seems to be more helpful for those that have that have fentanyl and or long term opioid use disorder. People have been maybe using opioids for an extended period of time in their life. Rachel Palicte (She/her): All right. let's see. So Rachel Palicte (She/her): somebody says that they are working to help provide training and ta to providers at Otp practices. Where can they find the best resources for this. Mark Parrino: I'd say that the you know, there are 2 sources. The American Academy of Addiction Psychiatry. Mark Parrino: has a number of resources actually very helpful videos, and they have amassed us through their opioid response network, but also the Pcs network, which is also Mark Parrino: under the ages of the American Academy of Addiction Psychiatry. Also the American Society of Addiction Medicine has trainings, and also excellent resources, too, and the American Osteopathic Academy of of Addiction Medicine. So you, if you go to their websites. And and Sams also Mark Parrino: works with all of these different groups, trainings are available, and A, and we always recommend that people be trained. Because if you have an undertrained provider, even at the Otp, that's problematic, and that gets in the way of effective patient care. And that's and also Samsa has provided. Mark Parrino: treatment, improvement protocols Mark Parrino: call tips, which really have been helpful. And I was the consensus panel chair for the first treatment protocol that Sams to use and published in 1,993, and that's been subsequently updated. So there are these resources. But I'd say the Pcss. Is a very good resource, too, in addition to as Sam, and in addition to Samsung Rachel Palicte (She/her): alright, and this will be our last question. But the question is with someone with a masters in clinical psychology and certification, an addiction and recovery counseling, be able to work at an Otp. And in what capacity as a therapist. Jennifer Seib: Jennifer, why don't you take that one? Yeah, I mean as hearing that. And again, you know, my UN unlike Mark, has the scope, the national scope. You know my scope is as much more limited to New York State and and practicing in New York State. But when I hear that question, my my original thought goes to that that person would be eligible to work as a therapist or a counseling position within the within the practice Rachel Palicte (She/her): awesome, and that was a quick answer, so I will throw in one more here, so do any otps serve folks that are under the age of 18. Mark Parrino: Generally speaking, no, but there is more of that. There is current interest. Mark Parrino: There used to be adolescent treatment programs in New York City, but they subsequently closed. Mark Parrino: What we did learn is that adolescent patients prefer to be Mark Parrino: in their own sector. They did not like mixing with the adult patients. Also, we found, is the in the adolescent patients. The first several months of treatment is critical also in supporting the needs that they have. So it it's it is a different population, even though the problem is the same. Mark Parrino: but they do need much more in the way of treatment services, and and more quickly because they have to establish trust. And for a lot of the adolescent patients that were in treatment. The real question was, how long do I need to remain in treatment? Mark Parrino: And that's a legitimate question. But there are now more patients Mark Parrino: under 18 that are now applying for treatment. we're not. I wouldn't say that we're seeing Mark Parrino: a huge increase, but we are seeing increased interest, and I know that some of the Federal agencies are looking at this as well, including Samsung. Rachel Palicte (She/her): Okay? Because we have so many questions. Let me squeeze in another here. But how much does a Mmu. Typically cost? Mark Parrino: Well. Jennifer Seib: Jennifer, what did you just pay for yours? That's just gonna say I have an invoice here on my, on my screen. Yeah. So the for us, it was right around 300,000 to to get the unit Mark Parrino: and depending on the length of the unit. Mark Parrino: basically special features that are added. It can go up to 400,000, which was the cost of that large unit from Providence, Rhode Island that Kodak had purchased. Jennifer Seib: Yeah. And I was, gonna say, ours is definitely on the shorter side. And that doesn't account for the cost of make it well, it it is having built in the security features that it needs to have But obviously there's just going to be some additional, you know, cost of the GPS, and you know other things that will be added to it. But the the unit ordering it, having it. having it made was 300,000. Mark Parrino: Also keep in mind that, aside from the purchase price, Rachel, you need reimbursement for the services provider and Samsa issued a letter during the early part of 2,021, which delineated the services that could be provided through the unit. Mark Parrino: and that prompted Cms. Medicare to set up a reimbursement rate for the mobile units as they are providing services through their facilities Mark Parrino: Cms. Medicaid and State Medicaid Directors lag behind that Cms. Medicare got out first once that Sam so let it was distributed. So, but for Mark Parrino: that's where the Mark Parrino: providers, like Jennifer work with the State authorities Mark Parrino: in order to work with the State Medicaid authorities that and that until all of this is these phone vans expand. That's a critical need. And we've certainly communicated that with our Federal counterparts. Rachel Palicte (She/her): All right. Well, that is all the time that we do have for questions today, however, I will plug that Mark has graciously offered, that if you do have additional questions that did not get answered in our Q. A. That he would love to answer any of those in his own personal email, which you can see on the screen here. Rachel Palicte (She/her): so we have a quick few logistical slides I will run through. But again, I would love to thank Mark and Jennifer for presenting today. We so appreciate. Appreciate your willingness to share your knowledge and your expertise with everybody. and I will say as a reminder, the recording and our slides will be posted on the Pcss website 2 weeks from today. Rachel Palicte (She/her): So a couple of things here. This is regarding our Pcss mentoring program, which is designed to offer general information to clinicians about evidence-based practices. So you can learn more about this mentoring program at the website listed on the screen. If you're interested in. Rachel Palicte (She/her): and if you have a clinical question, you're welcome to ask a colleague through the link that is listed on the screen. Rachel Palicte (She/her): this is provided by Pcss. And it's a great way to directly receive the answer questions that are related to medications for opioid use disorder. Rachel Palicte (She/her): This is just a quick shout out to all of our collaborative partners that we work with here at Pcss. Rachel Palicte (She/her): And last, these are all the ways that you are able to connect with Pcss. So that concludes our presentation today. Thank you so much for joining, and I hope that everyone has a wonderful rest of your day.

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