Treating SUD via Telehealth During the Pandemic

We talk with Dr. Robert Sise and Dr. Ty Reidenbaugh, co-founders of nonprofit 406 Recovery, as well as Tammera Nauts from the Montana Primary Care Association about the use of telehealth services to increase access to substance use disorder (SUD) treatment and mental health services. With changes to telehealth prescribing practices approaching next year, we learn how 406 Recovery is meeting patients where they are in their recovery journey. 

Transcript

Dr. Robert Sise  0:00  

If you think about stressors that can drive substance use, a return to use or acceleration use, certainly isolation, unemployment or sub-employment, all of which really describe the collective COVID-19 experience. That's something that our patients faced, just as any of us saw in intimate ways.

Beth Brown  0:23  

Welcome to Breaking Barriers in Rural Health, a limited series podcast from Mountain Pacific. We are sharing what is working in rural mental health and health care and discussing ways to replicate these successes. We're also shining sunlight where it's needed by identifying breakdowns and gaps in care. Ultimately, we aim to improve the health and well being of our health care communities, and anyone listening in to this podcast. Now here's the latest episode in Breaking Barriers in Rural Health.

Amber Rogers  0:58  

Welcome, everybody to the next session of our podcast, Breaking Barriers in Rural Health. Today, we're going to feature the wonderful people from 406 Recovery, which is a new service that started in the last year or two. So I'm going to let everybody do their own introductions. So Dr. Sise, do you want to lead off 

Dr. Robert Sise  1:24  

Amber, thank you so much for having us here today. I'm Dr. Bob Sise. I'm a physician boarded in addiction psychiatry, addiction medicine, as well as general psychiatry, joined here today by our chief medical officer at 406 Recovery Dr. Ty Reidenbaugh, who's also triple boarded and Tammera Nauts, who is a very, very fundamental and incredibly active member of our board. A little bit about 406 Recovery, we are a Montana nonprofit dedicated to treating substance use disorders and co-occurring mental health issues. There are three of us serving as physicians, Dr. Reidenbaugh, Dr. Mentel, who is family medicine and addiction medicine boarded, myself and four nurse practitioners. We do serve patients across the state of Montana. And certainly one of the common concerns that we treat is opioid use disorder, as well as alcohol use disorder, stimulant use disorders and we treat a lot of co-occurring issues, as two thirds of patients with a substance use disorder have a non-substance use disorder mental health concern, be it depression, PTSD, anxiety, that's all well within the core set of issues we commonly see and treat. We're dedicated not only to providing quality services across the state, we really want to advance access. And one of the core ways we're doing this is recruiting licensed addiction counselors who can perform the initial assessments and help us advocate for the level of care that patients really need. And most recently, we've partnered with the Rimrock Foundation to care for many of their patients who require both substance use disorder and co-occurring disorder care.

Amber Rogers  3:08  

That is awesome. Awesome. Tammera, do you want to talk a little bit about some of the trainings that your organization that Montana Primary Care offers to also support this? 

Tammera Nauts  3:20  

Hey, Amber, good to be back. We had a great time on our last podcast. And I know we've got another one coming up, too in this series. So thanks for having me back. I'm the IBH special projects director for the Montana Primary Care Association. So I and my team do lots and lots of training on medications for opioid use disorder, anything regarding substance use disorders. And what else do we do? Gosh, just so many things. I encourage anybody who's listening to head to the Montana Primary Care website and check out our events calendar. We've got a lot of just amazing trainings coming up. So to your specific question, the MPCA works with all of the federally qualified health care centers in Montana, and some urban Indian centers as well. So we have 17 members total. And so we have worked very closely with all of our centers in making sure that substance use disorders, the screening for, the treatment of, the support for, is a part of mainstream medicine. In other words, we really are helping our our sites to pull SUD out of the silos and just make it a part of everyday care. So working a lot with helping folks understand this chronic illness, that of course requires lifelong management, understanding the language that we use and how it impacts people. We talk a lot about the explicit bias and how that affects health care outcomes, and really trying to tackle the stigma that's associated with people with substance use disorders. We keep busy, we're having a good time. 

Amber Rogers  4:54  

Yes, you do travel a lot across this great state. So thanks for all that you guys do. And Dr. Reidenbaugh, do you want to talk a little bit about, you know, your work and how you see substance use disorder across Montana.

Dr. Tyler Reidenbaugh  5:10  

Amber, thank you very much for the opportunity to be here. It's always a pleasure to be able to talk about something that I'm so passionate about as well. So just as a brief matter of introduction, I'm an addiction psychiatrist boarded in general psychiatry, addiction psychiatry and addiction medicine as well. So I got to know Dr. Sise. We became friends and colleagues during our training in addiction psychiatry fellowship at the University of Washington. So following our graduation from that fellowship program, we each went in different directions, vocationally, as far as where we chose to work. We stayed in touch and reconnected and have come together as partners and co founders as 406 Recovery, working in the state of Montana. So I am a new provider here in the state of Montana. But looking forward to very much increasing my network of providers, getting to know and collaborate with other people who work on addiction issues in mental health care. And it's a robust community that we have here in Montana, have many opportunities to interact at local events, and even national events with providers very passionate about substance use and substance use disorder care in the state. And I'm privileged to be a part of it. 

Amber Rogers  6:37  

Thanks for all that. So one of the things that has really taken well taken off in a bad way, in some respects, is it seems that with COVID, and everything, people have really increased their use of alcohol and other substances. Have you noticed that change in your own practice, have things have people more people presented for treatment?

Dr. Robert Sise  7:04  

We certainly see it in the patients that we began to serve across our work. Prior to founding 406 Recovery. We founded 406 Recovery in July of 2022. We've been seeing patients now for about eight months. Reflecting on the COVID experience, and I can only immediately speak for myself, but I'm pretty confident that all of us who've been treating patients over the last few years have noticed this, those who had substance use disorders, often struggled. Struggled because their access to care became that much more fragmented. And if you think about stressors that can drive substance use, a return to use or acceleration of use, certainly isolation, unemployment or sub-employment, all of which really describe the collective COVID-19 experience. That's something that our patients faced, just as many of us saw in intimate ways. So certainly we did see this on the patient-focused individual level also, when we look at all of the epidemiologic data, opioid use disorder, alcohol use disorder, stimulant use disorder, all surged in COVID-19, and we're seeing the effects, the aftermath, now, in the at least supposedly post COVID era. 

Amber Rogers  8:19  

For sure. Yeah, I know that I personally too felt the impacts of having such a small social circle and not not getting out and doing the typical things that you usually do that helped relieve some of that stress. So I can't even imagine having a substance use disorder on top of that. 

Dr. Tyler Reidenbaugh  8:39  

Amber, if I may just add a little element of context. So not only during the isolation and the stress of COVID was use of all substances increased, but we're seeing the financial toll as well. When you hear about things like the great resignation, it's been a challenge for addiction treatment centers to recruit and retain personnel. So we're talking about a disease process for which we already have a dearth of providers and facilities to meet our needs, statewide and nationwide. But in addition to that, COVID created these other factors, and we're seeing treatment centers closed down, further limiting availability and access to a much needed treatment already.

Amber Rogers  9:33  

That is really sad, because we all need all the physicians and providers that that we can get, especially in Montana. One of the things that I think is so great about 406 Recovery and the other telehealth companies that are in Montana, is just the fact that you can reach people where they are that you have this ability to go to these small towns, not even physically go. But you're able to enter into people's homes and take care of people that perhaps would not have been able to seek care in a 100 mile radius. Have you noticed that you have more people from more rural areas of the state, or what are the population centers. 

Dr. Robert Sise  10:22  

Certainly. So I could certainly speak to the juxtaposition of having worked in an addiction treatment clinic at Billings Clinic pre-COVID. Flash forward to COVID and now, here in 2023, immediately, we're seeing many more patients coming from the Hi-Line far eastern Montana, and rural sites across the state that otherwise these patients would either not have access to service, or whatever access they would have would be highly fragmented. As the telehealth boom has brought in this incredible channel of access, it's really on us as an organization to make sure that we're doing it in a compelling way, in a way that's resilient to the ends of all of the exemptions we've seen thanks the public health emergency. And I know this is something we'll probably touch on more directly in just a moment, but as an organization, we've been really focused on ensuring we can continue to provide a high level of access across the state, in spite of the fact that for the treatment of some things like opioid use disorder, we're gonna need to see patients within the first 30 days of treatment in person.

Amber Rogers  11:29  

Yes, and as a person that grew up in Glasgow, Montana, along the Hi-Line, I really do appreciate the fact that those resources are pretty few and far between in some of our more rural areas of the state. So but let's touch on that public health emergency. So for those of you that may not be aware, the public health emergency allowed telehealth to really take off like a rocket ship. There were less restrictions on how you could use telehealth. And then there was also some prescribing patterns that were able to be changed, specifically around narcotics. So, Dr. Reidenbaugh, do you want to talk about that a little bit, about some of the changes that you're not only anticipating occurring, but then how you're going to address them? 

Dr. Tyler Reidenbaugh  12:21  

Yes, absolutely. So a word that you will hear us use, we who work with this population and work with substance use disorders, you will hear us use this word barrier very frequently. And so it is high on our list of agenda to lower the barriers to care. Telehealth is certainly a very excellent platform in getting access to care to a person. And so to comment on those changes that you mentioned, during the public health emergency associated with the COVID-19 pandemic, we were able to prescribe controlled substances to patients without the required inpatient evaluation and encounter in person evaluation and encounter. And so those changes are coming to an end. So originally set to end on May 11. The Drug Enforcement Agency had a period where they received comments and they received over 38,000 comments on the potential of this public health emergency ending and reverting of these standards to the pre-COVID timeline. So if I have my facts, correct, that is the greatest number of comments that they've ever received on a national issue, such as that. So we are seeing changes and they have responded to all those number of comments. And so they have postponed changes to the public health emergency. And so now those changes are going to be occurring not may 11, but November 11. And there are some additional exceptions in there as well. So if we have begun delivering health care to a patient, formed that relationship, we're already prescribing controlled substances. And just to be more explicit, primarily in our practice, where we're talking about stimulant medication for ADHD, and suboxone or buprenorphine for opiate use disorder. So if we've established with these patients, we will be able to continue that prescriber-patient relationship through November 11 of 2024. That gives us a lot of breathing room in meeting the needs of our patients. In addition to that, we're a telehealth company, but we're already transitioning to be able to perform hybrid services and see patients in person presently at a Billings location and a Bozeman location but also very soon in Missoula in Great Falls as well. 

Amber Rogers  14:55  

Oh, that's awesome. That's a lot of travel for you guys.

Dr. Robert Sise  15:00  

Well thankfully our team really is a trans-Montana, in the geographic context we're all over the state, with people in Missoula, Great Falls, Bozeman as well as Billings. And we're leveraging that. In particular, we're looking this summer and into the fall that pop up clinics in eastern Montana, to the extent it's meaningful. Certainly there's not the same onus as there was prior to the extension of those telehealth exemptions under the public health emergency. Now we have until November. Also really compelling is Kalispell, as that is a big population base, and certainly a lot of folks that there need care and the transition coming in November is going to be significant.

Amber Rogers  15:44  

Yes, taking the conversation in a little bit different direction, more on kind of the the genesis, not the genesis, that's probably not the right word. But some of the cultural aspects of alcohol use, as well as other substances in Montana. One of the things that's always struck me is that in many of these small towns, you can't even find a restaurant that doesn't serve beer or alcohol. And we have a culture of having a beer garden at every event and the availability of that. Do you see some of those practices that we kind of take for granted in Montana, as, maybe not a precursor, but contributing to some of our addiction issues?

Tammera Nauts  16:36  

You know, certainly Montana has a high rate of drinking, and so does every other state. I mean, if you look at any group of people, on average, we're gonna know that 10% have an addiction that's engaged. Alcohol is part of our culture in America. And certainly there are states that have higher incidence than others. But yeah, I hear it everywhere. When I worked in Washington, I heard the same thing. I work in Montana, I heard the same thing. Worked down in New Mexico, I heard the same thing, so. 

Amber Rogers  17:07  

So it's everywhere. 

Tammera Nauts  17:09  

It's everywhere. 

Dr. Robert Sise  17:10  

What is remarkable is that we do suffer a disproportionate burden of alcohol-related deaths. I think we're fifth in the nation and you're left asking, what's driving that? Is our use pattern somehow different than the majority of other U.S. states? Is it a question of access to care? Is it that we're more isolated, geographically and somehow socially? Is it that social events tend to be more alcohol-associated in Montana in comparison to other states? We don't have clear and immediate answers. Certainly, we'll relate that time and time again, we're seeing in our patients who have alcohol use disorder, there's a narrative, one of I drink, and I'm lonely. I drink, and it's the only thing I can do with people when we get together. I need to redefine what I'm doing, and find healthier ways to spend time with people and be less alone. 

Amber Rogers  18:05  

Loneliness, that's probably the real epidemic, is loneliness. 

Tammera Nauts  18:10  

Well, and also to kind of piggyback on that Montana, as we know, is number one in the nation for completed suicides. And I think the latest stat that I saw is that 48% of those involve alcohol or other drugs at the time of the event.

Amber Rogers  18:25  

So we'd have just a few minutes left, do you guys have any other thoughts that you'd like to leave our audience with? 

Dr. Robert Sise  18:32  

So just a doubling back, if I may, Amber. In regards to one of the responses I made, I would emphasize that certainly in addition to Kalispell, most definitely looking at the Helena area to have some sort of brick and mortar presence to see patients certainly after November. 

Amber Rogers  18:48  

That is awesome. I love the idea of the pop-up clinics to you know, you can hop in your little minivan and, and just go anywhere where there's a patient population that needs help. 

Dr. Robert Sise  19:02  

And certainly community partners, Eastern Montana Community Mental Health Center, it makes a big difference having a destination and having a community partner that can really work to identify the patients who are seeking care and can help organize a clinic day to have that pop-up clinic and host us. 

Amber Rogers  19:19  

Yeah. Other thoughts on any myths or stigma reduction that you'd like to share with the audience before we go? 

Tammera Nauts  19:29  

So thanks for bringing that up. You know, my training partner, Gina Pate-Terry and I go all over the state and we do training of all sorts and what we noticed in our kind of early days, 2018, 2019, is that we were encountering so much stigma, you know, with and against patients with substance use disorder, that we actually put a training together on language and stigma. Implicit, explicit bias, how that results in discrimination and poor health care outcomes, etc. So one of the things that we know is that as our health care system, and when I say our health care system, I'm including everyone; not just doctors, not just nurses, but CPS workers, Department of Corrections, we are all involved in our client or patient health care. And the more that they understand that this is a chronic illness and not an issue of a choice or moral failing and can develop a little more compassion, the greater our outcomes are going to be, as we can get our language corrected, and use first person language. So for example, instead of saying, Oh, they're an addict, or they're a junkie, and saying, oh, yeah, Bob's got, you know, an alcohol use disorder, and then I'll go talk to him. Awesome, that's great. He's doing great. As we can change our language our levels of burnout actually reduce. It's awesome. So we've done that training so often, you know, the last time we did it, we thought, are we gonna still do that? Gosh, we're so tired of doing this training. And then within two days, we have 26 more bookings, literally. So we're working very, very hard at reducing stigma around this population. And then of course, there are a lot of myths about medication for opioid use disorder, I think we should probably make that a separate podcast and really, maybe kind of drill down on what medications for opioid use disorders are, and what they aren't, how they work and talk about the myths. So let's get a date on the books for that, we'll do that. 

Amber Rogers  21:19  

We can do that. We can do that. Just so that everybody is aware if they would like to reach out, we did a previous podcast on in the emergency department, initiating treatment for medications for opioid use disorder in the emergency department. And for those that are interested in having their hospital also do that work, we have a complete training that's available to everyone we've recorded it. Plus, I am sure that Tammera and I and Dr. Sise would love to get on the road and and recreate that for an organization that is ready and willing to tackle that because that's exactly, it not only combats the stigma, but I think you're really starting treatment when people are needing it and not making them wait. 

Tammera Nauts  22:15  

Yeah, thanks for that. Amber. We're happy to come. We have a whole team, and we can come facilitate it any site implementation of emergency department work. It's exciting, really exciting. 

Amber Rogers  22:26  

Any other final thoughts for me, Dr. Reidenbaugh? 

Dr. Tyler Reidenbaugh  22:31  

Yes, yes, Amber, if I may add one final thought. We're talking about stigma very appropriately, from sort of the community perspective or their perspective at large. But it is certainly a challenge that we deal with on the individual level with those patients right in front of us as well. This is a chronic disease process. It has a relapsing and remitting course. And so it's a constant effort when talking to members of the community or with patients to align it and to align understandings of substance use disorder, along with other disease processes like diabetes, or hypertension, that are also chronic disease processes, that while they have no cure, they have successful management. And so a patient's perception of themselves when they have a relapse can be quite damaging. And there can be, over the long haul, a significant erosion in self esteem. And so the reaction the patient may have when they have a relapse on alcohol is totally different than what their reaction would be if their cancer relapsed. Totally different. The anger and the frustration will be focused on the cancer in that situation, but when we're talking about a substance use disorder, too frequently, that anger, that frustration and those feelings of failing, are focused inward. And so just in brief, my final thought it's one of my greatest joys in the work that I do to be able to give that individual a pat on the back for being there, when they're not able to provide that pat on the back for themselves.

Amber Rogers  24:23  

That is a wonderful sentiment to close today. Thank you guys so much. I always learn a ton from all of you. And I hope everybody that's listening to this podcast, also received some benefits of that. So thanks again.

Dr. Robert Sise  24:42  

Thank you so much for having us, Amber.

Beth Brown  24:51  

Thank you for listening. Be sure to subscribe to Breaking Barriers in Rural Health and learn more about Mountain Pacific at www.mpqhf.org.