Intersection of Addiction Treatment and Behavioral Health

Intersection of Addiction Treatment and Behavioral Health

and it is a privilege to moderate uh this panel and of course this is a critical moment uh as we contemplate today the intersection of addiction treatment and behavioral health um it’s a pleasure to join you today we want to just introduce today’s discussion with some context next slide we have understood the opioid epidemic as having three main points of inflection beginning in the late 1990s with the increased advertising for prescription opioids uh and the emphasis on pain as the fifth vital sign that there was a wave of prescription opioid related uh misuse uh and over prescribing uh that that occurred at that time uh and so that was primarily responsible for the first wave of the opioid epidemic the second point of inflection was in the 2000s when we learned that a transition to heroin use was occurring across the country and we also uh all are aware of that seminal article that identified for the first time the american life expectancy uh was on the decline and we believed at that time that we had entered what is called the epidemic of hopelessness where more individuals were dying of behavioral health related needs addiction suicide or overdose and finally uh in 2013 uh we identified the fentanyl-related crisis uh that was associated with synthetic opioids uh and we know that especially in the district of columbia uh the last report i received is that we have had a 45 increase uh in opioid overdoses since last year and that over 95 of those are driven uh by synthetic opioid overdoses next slide and so uh we recall that in 2016 the u.s surgeon general issued a historic letter uh to two million providers across the country asking us to evaluate our practice when it comes to uh particularly uh pain management next slide uh we also know from the uh national institute of drug abuse uh that uh actually most individuals with pain syndromes uh do not misuse opioids in fact uh the numbers that they provided is that roughly 20 to 29 percent of patients who are prescribed opioids for pain misuse them they also found that an estimated eight to 12 percent of people who use opioids for pain go on to develop an opioid use disorder in addition uh an estimated uh four to six percent uh who misuse prescription opioids uh transition uh to heroin uh next slide uh we also uh are aware uh that racism uh has to be acknowledged when we think about uh how issues of pain uh and addiction are addressed uh sadly uh the association of american medical colleges has found that half of current uh medical trainees who are white still believe uh racist myths about biological inferiority of black people they still believe uh that black people are more immune to pain uh and in fact uh this is perpetuating some of the inequities uh in terms of how pain is addressed uh jama psychiatry uh also acknowledged that when we think about the intersection uh of opioid use disorder with this matter uh that in fact uh buprenorphine prescriptions are concentrated among people of privilege people who are white college educated and live in suburban areas uh in fact black patients are 77 percent uh lower odds of having an office visit that included a buprenorphine prescription so we have a vast problem uh right now when it comes to uh both assessing these issues and responding and treating them next slide uh and so the national institute of health as well as health and human services have identified key priorities for how to tackle this problem they have identified a need to improve access to services to promote the use of life-saving overdose reversing drugs we have to strengthen our understanding of the epidemic and specifically its impact on vulnerable communities we have to provide support for cutting-edge research on pain and addiction as well as advancing best practices next slide and so with that context today’s conversation is really about discussing current practice methods for addressing chronic pain opioid use and mental illness our panelists today will address risk factors in treatment options to discuss specifically the role that trauma plays in mental illness and what providers can do to mitigate trauma risk in their patients uh this auspicious panel will also further discuss creative solutions uh to the unique challenges facing caregivers uh as we understand we’re not only in a covet 19 pandemic we’re also in the midst of an opioid and a racism pandemic and all of those issues must be addressed and so we will hear today how communities of color are also disproportionately affected by pain opioid use uh and behavioral health uh disorders specifically the chronicity of of those disorders and together we will hope uh to shed some light on innovative strategies uh to achieve optimal patient care and outcomes and so with that i would like to transition to our first question i would like to begin with dr richards uh can you describe uh your contribution uh to the spectrum of care uh in regard uh to these issues thank you dr milan for such a uh an all-encompassing introduction because there’s so much to unpack um moving forward and when i think about specifically the role that i play now my contribution uh is in the bigger sense related to what we do to support people once they reach the level of inpatient admission and we’ll talk throughout the throughout the hour about dual diagnosis when we hear the dual diagnosis of course we’re talking about not only the substance use disorders but also mental health and and where is that that intersection and as a psychiatrist at sibley hospital then what we try to do is severalfold but most of the time we see people hit the hospital it’s because they’re in crisis and the crisis is several-fold one is a lot of times they are trying to start on the path perhaps for treatment but in order to move down that path for treatment we have to we have to look at different aspects and i like to say we look at four different things when we’re talking about the mental health of someone one of course is the diagnosis what are we talking about certainly substance use disorders are involved but also is there an underlying depression is there an underlying anxiety is there bipolar disorder and identifying that matters because we then have to talk about how we can support someone in their role for treatment so so there’s there’s looking at the disease there’s looking at what i call someone’s life story what brought them here today what is happening did they lose their job are they are they arguing with family members are they desperate are they looking at kind of the racial injustice and trying to find an escape so there’s so many things to look at in terms of that life story piece then we have to address you know the behaviors in different ways one of which is actually talking about the substance use disorder and how we can talk about that and the fourth of course is the personality of the person how can we talk to them is it motivational interviewing how are we going to discuss what these next steps are so on the inpatient unit we try to assess people for all of these aspects because we know that the way they fit together is so important for addressing things moving forward you dr richards that was a great uh framework to get us started dr cartwright you have some experience in uh pediatric populations in regard to these issues can you share with us uh how you contribute to the spectrum of care so during the early parts of the day i i’m the medical director over at united medical center many times we see the larger number of folks who are coming to us are persons who are involuntarily admitted so these are persons where the behaviors are to to the extent where the authorities are involved and sometimes the person is doing so poorly their insight really is um impaired and so when they come to us they really are not in the best of places uh psychiatrically and so that when you see those persons at that point in an adult hospital you also have to recognize that some of them may have children at home and so i’m also a child psychiatrist and on an outpatient basis the children that we see when the parents have a substance use disorder it’s very difficult for those children to form attachments uh to the parents that are um secure and many times you may see concurrent psychiatric illness that sort of mirror the difficulty that the parent may be having and so particularly with the pandemic what we’ve seen is as the parents struggle the children too are in crisis and the question becomes how do you support those children but also help the parents because again remember a lot of the persons coming to us are persons who are involuntary so how do you get the parent to be able to move to a point where they begin to see that there is an issue that they need to address because they have people who are depending on them but they also have to figure out how do they take care of themselves and so when you see the intersection of financial struggles the pandemic having to manage children at home being stressed out and the stress of the pandemic affecting things like relationships marriages the education of the children you it really has put a lot of strain on the families and um even some of the little kids will say to me sometimes like i i just want to go to school i just want to see my friends and so when you look at the impact that that the opiate crisis in conjunction with the pandemic that that’s not on family and children it has really been quite significant absolutely and you have emphasized thank you dr cartwright the importance of having a team-based approach uh as we think about these issues and so i want to transition to dr petit who is currently practicing in a team-based model dr petit can you can you share with us how we address these issues dr richards has highlighted needs among adults dr cartwright has shared the needs with families so so how do we address these issues as a health care team right uh well basically as a the addiction medicine fellow like you mentioned i’m part of the team that involves peer recovery coaching psychiatry psychology as well as case management primarily through the urban health initiative so i see patients know from the emergency room to the inpatient detox unit and follow them to the to our outpatient treatment program and then from there i titrate medications for opiate use disorder or alcohol use disorder provide motivational interviewing and during that relationship building period we can get a better idea of your additional needs and connect them with like i mentioned case management primarily the urban health initiative has done a really really good job in helping patients stay into treatment if patients fall out of treatment they bring them in they call them and so forth if they listen to missed an appointment for a prescription they get a hold of me really quickly um a lot of times you learn from that the kind of just struggles that they’re having with child care and so forth so you get a really good picture of what’s going on and the challenges that may precipitate a relapse in these individuals so that’s really how the the care model kind of works we all work as a team and communicate consistently on patients so each patient has about i would say about four or five people that that’s around them to support them through their recovery thank you dr petit it sounds like a dynamic team approach that that you were using uh there at the howard university clinic dr manola uh you are the director of addiction services at the psychiatric institute of washington uh can you share how your team uh is contributing uh to the spectrum of care dr manola we we just need you to come off mute can you hear me now yes okay first of all good to see you again and good to see everyone else there um i think we are in a unique position we uh kind of combined what uh dr richards and dr cartwright said in piw so we have services that are voluntary and services that are court mandated at times in the combination of sometimes quote unquote pure substance use disorder although very rarely you would see them purely it’s most of the time co-occurring disorders and we care for the most disadvantaged and ignored population in the city um being the largest inpatient psychiatric facility we have larger numbers of patients and fortunately we have in the position to provide care for those individuals that probably most ignored in other systems which has been a pleasure personally for me um our patients are usually grateful and the way they express it makes our job although it’s very difficult uh highly enjoyable um so our role is to kind of see can we break the cycle of i would use that pejorative term but i think it is appropriate to use in this video uh treat them and treat them so it’s the recidivism is to a degree ex expected the risk reduction approach would be to reduce that but at least some people may or may not be able to uh sustain in the community so there’s some recent debate recidivism but in what way we could support our patients to reduce that recidivism and also to break that cycle of going in and out of the hospital which for example when they are using opiates and they are quote unquote complete with the detox and go back to the community if they use probably it would put them at higher risk for unintentional overdose the same amount that they were using at this point after five six seven ten days may actually be little by that time so the way we look at it at least our goal is to become a transitional point between when patients come and hopefully get them connected to programs like howard we do ask our patients to go to howard the buprenorphine maintenance program they have wonderful program that patients can walk in i think both of us have been part of that program at some point in our career and also to transition them from inpatient to some sort of structure environment the 28-day rehabilitation program and we are fortunate that we partner with a group medical group home that they have been very gracious when we have patients that are highly motivated they could actually leave with a prescription for example for subtext [Music] thank you dr manola you said something that is so critical that we are caring for some of the most marginalized populations in our society uh and i want us to tackle that point next uh this idea of structural vulnerability uh that often the uh threats to one’s health exist in the community uh in terms of economic resources trauma that has been experienced history uh etc and so i want our panelists to tackle this as we think about the history of marginalization uh specifically of trauma uh how does that impact this issue uh especially uh substance use i want to go to dr cartwright first uh and ask for her to share with us uh what is the impact of adverse childhood events uh as they relate to trauma and addiction well when you take a look at primary things let’s if you think about for example eric erickson and life cycle theory and you start to look at phases of life and experiences that kids will have from the time of birth as they get to their teenage years and then transition into adulthood when you don’t have stability if you don’t have strong attachments when you start to get into just day-to-day adversity whether it’s bullying at school if you’re a little kid a difficulty academically say if you’re trying to learn how to read if a parent is not available to be able to give you support and encouragement during those periods of time the child begins to then look for support elsewhere sometimes it’s not exactly in the most constructive of places and over time this can sort of chip away at the development of a young person also when you look at for example substance use and youth typically the emotional development of the child is going to stall around the time that they begin to abuse substances and so coping skills don’t continue to mature and so as they age their chronological age of course will continue but their developmental age is going to be underdeveloped and that makes it much more difficult for example when you go to a workplace and you feel as though it may be stressful how do you cope with that stress when you haven’t really had the coping skills from your youth and so the impact of substances and trauma on the la the life of a person from whether it’s an infant who has difficulty bonding with a parent or a young person who has difficulty in a marriage because of communication issues all of those things sort of come to a head and um the traumatic experiences make that even more so imperative that you have someone to be able to help guide you through how do i solve these problems for myself um but but the trauma we see that a lot um across the board for persons for example who come to us sometimes it’s very hard to even get the person engaged to go to a therapist because they feel whether it’s embarrassed about a history of molestation or rape uh it’s very hard to get somebody to say i have to face this in order to be able to improve the quality of my life and um so again i mean if this is a topic that can take weeks to be able to discuss really and truly sometimes you could spend hours just on the impact of trauma at one point in a person’s development but it is quite significant thank you dr cartwright for that excellent uh explanation i want to go to dr petit who works at a university that has been positioned to specifically address historical trauma among racial minorities as a historically black institution uh can can you speak to uh how your team thinks about trauma uh and perhaps even racial trauma as it relates to this issue right well recently we added a psychology psychologist to our inpatient detox unit for this because of this very uh issue um so my background is in internal medicine so when i think about trauma most of my patients that i come across you know i have suffered significant amount of uh trauma so i kind of did a deep dive into how is this um lead to uh substance use and so in disturbances and so forth and it seems like multiple articles out there that show that trauma either childhood experiences or adult experiences can lead to significant hypersensitivity in the hypothalamus pituitary access that makes it um more difficult for these individuals without assistance therapy and so forth to learn how to manage their their stress stressful situations from a regular day in and day out as well as they’re more prone to suffer from depression and it’s been shown that individuals with trauma that have depression have higher levels of cortisol versus individuals who just that suffer from depression so i think keeping that in mind kind of helps me understand a better picture of of the individual that i’m treating and understand that the behaviors that i’m coming across aren’t necessarily completely voluntary that this is a disorder like any other disorder that has to be managed you know really in a team effort that’s where psychology the peer recovery coaches uh i mentioned played a really big role my patients tell me all the time that when they’re having a crisis they call their peer recovery coach and really helps them kind of talk through the situation and step away from it and once that happens they’re able to actually learn from that experience and learn how to deal with stress instead of seeking substances as a way of managing their stress thank you dr petit and i noted that you highlighted the role of peers and we we should underscore that today the role of individuals with lived experience to help other individuals who may have or be living through trauma i want to go to dr manola and then dr richards to conclude our thoughts specifically as it relates to trauma and substance use i think dr cartwright is very right trauma has a significant part in substance use disorder actually it is an independent risk factor for substance use trauma is an independent risk factor for future traumatization and substance use disorder so it may be too at the order of for example genetics uh it’s an independent risk factor for uh uh individuals to be uh in a situation that they may use substances and may get significant social problems that’s compounded by the fact that once they are using substances it puts them at higher risk for trauma when they are traumatized it is by itself a risk factor for future traumatization now they are using substances and it puts them in a vulnerable position it creates a herbaceous cycle or a further traumatization if we think about it you know kessler in his epidemiological studies at least in one of the um very interesting papers say about 70 70.4 of people at some point would experience trauma and about almost 40 percent of those who are in sexual uh traumatized in some ways sexually usually in uh female gender but it could be in male males as well um they develop ptsd and ptsd puts them at risk for further traumatization substance use and this continuation of a basis cycle so if we look at it from that perspective hopefully our treatments not only address the possibility of them getting off the substances hopefully our treatment would be a little bit more holistic to consider the original sin that for some people results in patients using substances addressed hopefully we would have psychologists on our team peer supports on our team and address the trauma and also can we fix some of the automatic thinking that may not be so healthy uh for example fixing the relationships that can never be fixed we go to the same traumatic relationship one after the other theoretically we try to fix the thing we couldn’t fix last time if a psychology or some sort of therapeutic uh psychotherapeutic approaches are employed probably we could decrease that uh events and also the interesting part about trauma is that most people do experience substantial relief after treatment with the exception being war trauma tend to last much longer most other traumas including the sexual abuse they do receive substantial improvement after a treatment even within the first year um of course they remain vulnerable down the road so uh not only understanding that trauma can predispose our patients to uh substance use it may act actually help us when we address it to reduce future traumatization and decrease the recurrence of uh the recidivism and pattern of inpatient hospitalization repeatedly dr manlock may i just piggyback on what dr manola just said i think his example is a beautiful one because when you think of what we are talking about it seems so heavy and hopeless but the point that he just made for example when you were able to assist someone and address these problems let’s let’s use a specific example if you have a mother and the mother is depressed 50 of those children including babies end up with a similar diagnosis the solution is to treat the mother because the children will mother will mirror what the mother does and so in terms of being healed able to help the parents you actually sort support the children within that family and that will be able to help them to avoid becoming collateral damage to a traumatic experience that may have been uh may have taken place with an older person or an adult inside the family so there’s a lot of benefit in being able to seek treatment absolutely and i i see a lot of nods and amends coming from dr richards so dr richards uh jump in and tell us what you would add to this this conversation even before i do that i have to pick you back now off of what dr cartwright has said because it’s so important and it’s so it’s almost um if we take things back i mean certainly this is you know we’re talking about patients and and and what happens in our world but this has been traced back to different animal models and everything else with when we know if we treat mom’s anxiety the offspring actually improve and so that is it’s almost easier sometimes in other models humans have a harder time of figuring that out but that is one of the key issues um and you know dr petit has mentioned race and the role that race plays in this and i would take it a step farther further to even say there’s so many other examples we’re still in this pandemic and the cdc has published that either 13 of people have noted that either there’s increased use of substances or they started using substances during the pandemic and so it really is our ability to help people cope with adversity and and traumas of course have to be addressed and there’s so many other issues that people are facing that with the right coping skills with the right information we may be able to steer them on a different path away from the substance use and so that’s one of the most important things that we have to identify is what is the background what’s causing what what’s causing what’s contributing to this trauma and understanding that then allows us to move forward but a lot of times people get stuck in trying to say i don’t have the trauma you have to be able to understand that but i also wanted to highlight the fact that we’ve talked a lot about different traumas but we also have to again talk about treatment and how we address that and what comes to mind when we talk about this is even sickle cell crisis i mean we’ll hear time and time again from patients that are having crisis and either it’s sent to one it’s treating that pain has become an issue and so collectively again talking with years talking with people who have addressed that there’s a need for even the providers to really understand not only the traumas but what has created people in the moment that we’re seeing them and do we talk about substance use disorders do we talk about i know we’ll get into this do we talk about pain and how we’re going to help someone manage pain but all of those things actually fit in together and are important in moving forward and addressing the reason for the substance use disorder thank you dr richards for getting us there with which is exactly uh where we’re going next is treatment how do we provide the life-saving treatment that is needed uh for individuals who are are dealing with the legacy that we acknowledged in our introduction that the trust for medical providers has been eroded because of historical decisions as we know historically there was a war on individuals with substance use disorder and now we are transitioning into models of treatment and engagement but many communities have been harmed who historically also needed to be rescued uh and treated and so understanding that legacy and how it impacts uh those in in greatest need we we know someone in the chat is asking uh what do we know about the demographics of those affected in dc uh we know that they are predominantly african-american uh in spite of the fact african americans are only 47 of dc’s population uh we we see the same inequities when we see those affected by cobit 19. um and so i i want our panelists uh to just share with us how do we engage communities specifically of color uh those who are in greatest need uh with with treatment and let me go first uh to dr petit okay um well what we’ve been doing here is just really providing a lot of education when they come into my office the first question they asked me you know why are you giving me one drug for another drug you know this is just a way for you to you know make money for the uh for the man if you will and so with that question it opens up an opportunity to for them to understand you know what the whole idea is behind uh methadone or suboxone and so that they can understand appreciate the future of not having to wait on the street corner to buy something that they don’t know where it’s from um and only four or six hours later they have to be out again to do the exact same thing that uh methadone or suboxone would help them normalize their life that something that they’ve never experienced for quite a long time and allow them to spend most of their day doing other endeavors so that’s what most i say half of my time during the clinical appointment is education and i know we’ve got some outreach programs um that how university is doing we’ve been talking about putting together a bus as well to go out into the community so basically it’s all about outreach and education thank you dr petit dr carl wright what would you add to that especially with your lens uh thinking about the whole family i will tell you some of the best outcomes i see in terms of outpatient is being able to have a position where you feel as though the person is relatable sometimes when we sit in the office it’s just to sit down and have coffee and to chat about what has your experience been with your spouse what have you all argued about just last week and so it may seem simplistic but if you were able to get support and learn how to communicate better with that person because your mood is under control because the antidepressant is working it gives everybody a boost of encouragement one of the things that i hear a lot is i don’t want to be stuck on your pills for the rest of my life and my response with all sincerity is i am happy to kick you out of our office when you are feeling better once you stay on your medication and you are doing well we are happy to see you go what i mean when i say that is i try to educate them for example on the guidelines regarding the treatment and how long the duration of time for example would be for the treatment of depression if it’s the first time the person is being treated what the statistics will look like 90 chance you don’t have to come back here but we always tell them we enjoy being invited to nice parties and weddings if ever you want us to celebrate with you and so i think when people feel as though the physician is cheering for them that the physician understands their perspective and it’s not coming from a position of judgment because i have a conversation with you that your urine talk screen is positive does not mean that i’m being judgmental i’m trying to at least figure out where is the start point for us and what do we have to do to get you to a place where you feel is so you can tolerate the stresses that you have and directly address the issues that you feel are contributing to those stressors or contributing to the behavior that you see that’s negatively impacting your life i will say though for us what we see at united medical center is unusual in that right now and i did not see this before the pandemic but right now about a third to a half of the person’s coming into our hospital we have a positive urine drug screen for pcp and so opiates are there but for our population it’s it’s unusual but we see that about 30 to 50 percent of the time with admissions and um and so being able to have a conversation that’s not positioned from judgment but let’s look at what the options are and what will be some of the barriers for you to be able to address this when you leave how can we help you i think that people begin to realize like look they really are trying to help me get my life back on track and it may not be in the best place but at least i can see that there’s a step-by-step route that i can take to improve the quality of my life and i always tell them it may take a while but it’s worth it it’s worth it to be able to invest in yourself and see that things can get better and you may have some bumps in the road but our philosophy over at united medical center is every day is not going to be perfect and it’s okay if today is bad but we can work toward tomorrow being a little bit easier and that sort of normalizes expectations in terms of how long this process of getting better may take thank you dr cartwright dr manola what would you say to the question of how we engage vulnerable communities in treatment i think the my colleagues addressed some of them but one major part is uh on our part the systemic challenges we have in our educational system um i think both of us have similar experience of when i was at howard university sometimes i would force i would we hadn’t we will educate our students uh that for example schizophrenia is over diagnosed in my in minorities but once they are forced to make a choice between an affective disorder and a primary psychotic disorder it was my observation that our teaching did not have the desired outcome when the students are forced to choose they would pick up psychotic disorders more often for people of color compared to non-hispanic white population so that there are a few times that patients would be almost identical if you had covered the ethnicity the presentation would be very similar i think we should do a good job on our part to teach ourselves and our colleagues i would give a very heartbreaking a personal example i worked in a facility and i was called for a consult to talk to a 21 year old boy who attempted suicide by overdose on opiates and as i’m walking in the emergency room the emergency physician is leaving the room and he is in front of this kid who literally barely cheated death in front of the kid tells me talk to this idiot one of these days he will die so i think we should do a little bit better job and also have a way to measure do our interventions actually make a difference when it comes to systemic problems we have um also recognizing that what are our specific challenges in a specific environment for example there’s literature showing that different wars of new york have different challenges like dr cartwright mentioned that pcp is very prevalent drug in dc it’s in somehow since it is a drug that unfortunately african-americans use automatically we sometimes assume those patients are probably the worst patient you see um if you cross the river to virginia you don’t see pcp that much it doesn’t mean that the patients who are in dc they are worse off than the patients who are in virginia so we should customize our treatment approaches in a way that addresses the challenges we have as as a system as well as addresses the challenges that we have as localities thank you dr manola uh dr richards uh what what would you say uh in terms of recommendations for for engaging individuals in treatment right so so at sibley there are key changes that happened last year one being we did introduce the role of the peer recovery specialist and that has made a difference because the most important thing is as has been said letting people know that they’re supported that they’re not being judged but that there’s hope and that we can lead them in the direction which we recommend right starting them on medication assisted treatment is important telling them nope it’s not only while you’re here this is your next stop let me explain to you the roadmap for what’s coming next so that’s important and i think it’s simply one of the important things that we’ve seen this work we’ve seen people really engage um with others that they think they have a common bond with now of course that can be appear that also in last year in 2020 with some colleagues from um hopkins we published the fact that minorities are underrepresented in psychiatry and it’s across the board it’s in it says providing psychiatric care it’s providing therapy and so there are a couple things sure there’s a push um because a lot of times people do want to have a bond a lot of times what they’re seeing is the first things that you look at race gender identity cultural those sorts of things but when that’s not there and it’s not always going to be there the other thing we can do to support them is learn is understand is ask well why is that important to you what is the barrier why can’t you get to that clinic what happened when you took that medication and then being able to say okay i think i get it let’s try this but really engaging the person in as part of the treatment team and one of the first things i say is look you’re part of this team i can’t tell you you have to do x or y or z let’s talk about this plan ask me the questions and let’s see how we can move forward together thank you uh panelist and we we want to transition and acknowledge uh the excellent questions in our chat dr richards i’m actually going to go to you first because you mentioned something uh that is actually in in the chat uh one one individual has asked what do we do about the shortage of providers uh specifically uh those who who can engage uh and as you mentioned often individuals are looking for concordance uh between their providers and themselves um and so what what is the panel’s outlook uh on the shortage of providers and how do we address the shortage i think we need we need to sound the alarm it’s really important that we pull people into this field to in dr petit’s case we see that specifically when we talk about addiction medicine fellowships that again and even in that realm underrepresented minorities are not going into these fields so there’s twofold there’s a there’s a shortage of providers across the board and there’s there’s a lack of ongoing gender which is improving and and race concordance um and so one of the things that we need to do is find ways that we can pull people back into this field and it starts early it starts in high school with with different programs it starts in medical school a lot of times the medical schools had options to say well can you join this group that’s talking about psychiatry that’s talking about substance use disorders and so we have to get more vocal about why this is an important field and then find ways right there are ways there are grants there are other options to encourage specialists both medical specialists therapists who can provide additional support to encourage them to really join us in this role and one thing i would add to that is we have a need that is quite significant i think that we may have to appeal to congress to perhaps expand the number of residency spots for medical students to be able to enter into psychiatric training because this this area is very very important it’s i think it’s a beautiful thing to have a psychiatrist available if your child is in a difficult situation and to know that they are in well-trained hands and so if i think mike to my understanding there were very few maybe four residency spots that were unmatched this year but when you take a look at the impact that the pandemic has had on the population i have had people get very very frustrated like well dr carter why can’t we get another appointment and our office is working seven days a week some days until 9 00 pm and so it’s not that we are not trying there’s a need and i think that in order to be able to truly address that we have to have a bit additional physicians trained so the number of residency spots i would suggest that they need to be expanded it’s really really important for the health of the country as a whole and i would agree with this long-term they could easily give loan forgiveness as well i mean there are ways to pull people into these fields and we just need to activate them but just to piggyback on what dr cartwright said i think it would be a very wise advice to increase the residency spot we usually go for the low hanging fruit and not always it pays off what we want them for example nowadays i don’t mean in a demeaning way i appreciate the opportunity for some of our nursing colleagues to become nurse practitioners but sometimes the disadvantaged people who don’t have uh whose care is complicated already and then you provide them with someone who has less than adequate experience and expertise to care for them one their care is complicated and then the person who provides care um i don’t i’m trying not to sound in any ways pessimistic or demeaning to anyone but you provide them with an expertise that is less than adequate so i would agree with dr cartwright probably instead of kind of cutting corners and going for short cut and low hanging fruits let’s invest as a society to increase the number of residency spots increase number of training for example addiction medicine fellowship if it is incentivized i’m pretty sure more internist and primary care providers would jump on it for example if the salary is a little bit high provided some incentive that could make it a little bit more appealing why would they spend one year more in training providing care that no one likes those people i’m seeing those people in quotation so that people who struggle with addiction as a general i think it may be a little bit of a fact that most clinicians don’t like working with them can we remove that stigma from there to see if more people could jump on board and more uh people would be available to provide competent care meanwhile it is a good idea to continue with nurse practitioner but i would absolutely wholeheartedly support dr cartwright’s call that we need more resident thank you dr manola and want to also share with our guests today that during the pandemic we also learned that we can also do the work a little differently we learned that we could provide care uh through phone calls we learned that we can do this without uh standard office visits and uh and many providers uh are pushing and advocating uh that that these mandates that happened at a federal level with the dea would remain even after the pandemic and so we have to think about what we learned throughout 2020 i know myself as an addiction medicine a provider even caring for individuals experiencing homelessness it was amazing to see how our system uh just evolved uh to care for individuals uh who only had a phone um and and and that was incredible uh to see so we are we are advocating for a lot of those changes to remain i want to go to another question in the chat this also has something to do with provider capacity the question is very rarely do i see individuals who are prescribed a substance use disorder treatment linked to a therapist isn’t this counterproductive i want to go to you dr cartwright to tackle that question what is the role of a therapist in care how can we improve their integration in the care team i think therapists are very very important in therapy in general is very important for anybody who is also receiving substance abuse care um or substance abuse treatment medications but right now in the pandemic there is a large shortage of therapists just because so many people are stressed by the experience of the pandemic one of the things that we try to do in the outpatient practice is to even if we can’t assign the person to a therapist we can still have brief sessions during the period of time that we meet if the session goes for 30 minutes for example we can still touch on their medications make sure they’re doing okay and just talk about how are you how are you doing what are you planning to do to get past the fact that you’ve been stuck in your house for a week and you were lonely do you plan to go on dates you’d be surprised like these things seem very simplistic but for a person for example in their mid 30s who is interested in meeting someone who wants to start a family like this uh pandemic has really been it’s been terrible for different people for different reasons and so you can still provide brief supportive therapy sessions during the period of time that you also check on medication and then of course when we finish up with one patient we always try to place another patient on for therapy i do think that therapy in terms of being able to process why am i turning to this particular substance what am i getting from this what progress have i seen for myself being able to put those things in the forefront of your mind reminds you that you’re making progress it may not be perfect and i think that that’s a part of the role of the therapist in conjunction with medication again it may not be ideal the way it was prior to the pandemic when the the demand was not as high but we can still accommodate those persons and i think that many places really are doing their best trying to be as flexible as they can with scheduling thank you uh dr cartwright uh one want to pose this question next uh someone has asked uh let’s contextualize this specifically to the district of columbia uh and of course i did share uh my understanding of the latest demographics but they want to know specifically uh what are the unique differences uh in terms of demographics or treatment challenges uh when we look at dc who would like to tackle that one i will okay so again on our side over at united medical center i’ll tell you some of what we see the use of the poly substance use has gone up since the pandemic um sometimes for example we will see at least marijuana pcp in conjunction with something else and that has increased drastically to the point where i was really struck by it because as the pandemic has has continued i see it more frequently we have a large number of african-american persons who come through our doors at united medical center and also the trends that we notice when we offer substance abuse programs when it’s time for um the person to be discharged or get in preparation for that many persons have similar concerns i can’t take time off work because i’ve had to miss so much work because of the impact that the pandemic had on finances for my family prior to uh prior to being able to get back to work um and so they are worried about how am i going to maintain myself financially if i go to a substance abuse program then some of the programs had restrictions on the number of persons they would be able to take because you were trying to make sure you don’t expose people to coronavirus and so logistically that also played a part in how how many people would be able to receive care on an inpatient basis one final thing that i noticed but i find that this tends to be unspoken is there’s a there’s dignity and pride at stake as well where there’s there tends to be a lot of embarrassment sometimes people will be in complete denial and say no i didn’t use any substances and the question is at the time when you know we only have a limited number of days in the hospital how do i approach that conversation with you so that you see it’s not about judgment we are trying to get you to a place where you can address this and feel like your life has more stability how do we do that in a gracious way because all of us have pride that we want people to respect and all of us have a sense of dignity that we want other people to acknowledge in terms of how they treat us and so we have to be able to choose our words carefully so that folks who already have had difficulty even coming into the hospital because the police had to bring you or your mind was not clear and you didn’t have your clothes on and now you just feel completely embarrassed and vulnerable how do we still acknowledge the humanity of that person treat them well and say look that’s water under the bridge we have to get past that and try to make sure that we figure out how to make tomorrow better um so so that those are the trends that we see in terms of use and some of the barriers that we see that people are thinking about when they try to figure out what their next steps will be when they’re discharged from us if i could pick it back on that for a second if i could figure back on that for a second i think we should look at the specific population specific challenges and specific opportunities uh when we work in the district of columbia a few years ago we looked at our patient populations over 10 years one of our colleagues dr lawson had provided suboxone and we look at their the patients that have been adherent and we define adherence as 80 compliance um what would be predictor of adherence in our patient population uh some of the things are surprising like we were surprised that nothing is nothing was uh significantly uh associated with adherence except for alcohol and cocaine use later on we looked at another uh problem that was emerging at that time the k2 used is there anything that can be helpful identifying who is at risk for qt is it doesn’t seem like there’s any particular thing that would put a person at risk for kt is we thought probably since k2 is quote unquote similar to marijuana marijuana use would predict what k to use predict who might use the synthetic cannabinoids the most commonly known uh substance is k2 which is not really a substance a whole bunch of substances so i think uh dr putin and the people and education uh component of the district of columbia can play a role to find what are our specific challenges and that would open up a window for us what would be our specific intervention that could address the needs of our population and district of columbia a perfect example would be as dr carter said pcpus pcp is very common in our region but not in for example i don’t know other localities but not in virginia thank you thank you dr manola we are unfortunately out of time uh and i want to thank everyone for participating today want to also acknowledge the critical comment in the chat you are absolutely correct correct uh miss lightfoot that uh in in the context of the many needs that exist we can absolutely use peer providers uh to fill in the gap thank you for that reminder we all have a work to do uh in the spectrum of care uh and so uh let’s keep at it uh we’ve talked about reforms today that are needed in the system we’ve talked about uh how we can engage patients i liked how we started uh framing it from a person’s life story with dr richards and her perspective and so thank you panelists for your participation today and now i want to transition to miss cunningham to close us out thank you thank you so much dr medlock and thank you to all of our panelists your expertise is just so helpful for us to have these conversations and make sure that the important topics that we discussed today do not go overlooked when we’re trying to treat sud patients and behavioral health patients so i really appreciate you taking the time to speak with us today

The panel discusses current practice methods for addressing chronic pain, opioid use, and mental illness when co-occurring. Panelists address risk factors and treatment options and discuss the role trauma plays in mental illness and what providers can do to mitigate trauma risk in their patients. The panel further address creative solutions to the unique challenges facing caregivers, as well as how COVID-19 has affected and exacerbated chronic pain, substance use, and behavioral health needs. Panelists also share how communities of color are disproportionately affected by chronic pain, opioid use and behavioral health disorders. Together, the expertise shared by panelists shed light on innovative strategies to achieve optimal patient care and outcomes.