50:00

Methadone Clinic. And if you don't, well, that's a

50:02

different, that's a different episode that we're going to

50:04

do in the future. And I'm just putting it

50:06

out there on how to make new Methadone Clinics

50:08

happen. But you need to know who those

50:10

people are, which means you need to pick up the phone and

50:13

call and say, Hey, I'm a primary care doctor. I'm the medical

50:15

director of a local primary care site. And we want to meet

50:17

you. We want to know your policies and procedures. We want to

50:19

know your walk-in days. We want to know your take-home bottles. We

50:21

want to understand Methadone. Will you come give us a talk? Can

50:23

I pick up the phone at any point and talk to you?

50:26

We do that in primary care with all the

50:28

other specialties. You know, I have everybody's text number

50:30

on my cell phone, right? The GI doctor, the

50:33

OB, the nurse midwife, I have them all. And

50:35

I call them all the time when I have

50:37

a question. We should be able to

50:39

do that with our local OTP. It's critically important,

50:41

partly to get your patients in there, partly to

50:44

advocate for them. Because in a case that David's

50:46

describing, a primary care doctor calling and saying, look,

50:48

do you know how well this person is doing?

50:50

And I heard their bottles are being taken away.

50:52

And I just want to understand that more. I

50:54

wanted to understand what it is you're thinking, what

50:57

can I do to document or help support this

50:59

patient during this time as well, so that we

51:01

don't lose them to treatment and have them have

51:03

the risk of dying? We know that being on

51:05

80 or 100 milligrams of

51:08

Methadone is this threshold to really

51:10

prevent overdose death. And the

51:12

most important thing is that people have Methadone in their

51:14

bodies every single day. I don't care how it happens.

51:16

That's the most important thing. The other thing I'm going

51:18

to say to you is that in the final rule,

51:21

it allows primary care to do the screening

51:23

to say that David has an opiate use

51:26

disorder. I'm really worried about him. He's been

51:28

on Bup with me. It isn't working. He's

51:30

really struggling. I'm going to send

51:32

you my most recent physical. It does not have to

51:34

be a complicated physical. It just has to document some

51:36

vital signs and a couple of physical exam findings. And

51:40

your documentation as a primary care doctor

51:42

that this person has moderate to severe

51:44

opiate use disorder based on your evaluation

51:46

as a licensed clinician. Maybe there's

51:48

a drug screen there. Maybe there's a historical

51:51

drug screen if you want to send that. If you

51:53

have recent labs that will prevent David from having to

51:55

do the labs again, and you

51:57

can send it to the OTP, and that

51:59

is the entry point for them to start

52:01

on methadone. Now, it is the

52:04

licensed clinicians on site that determine the dose.

52:06

They screen, they read what you sent them,

52:08

and they say, wow, David really has opiate

52:10

use disorder. He needs care. I'm going to

52:12

make a decision based on the referral that

52:14

came from Carolyn on how I'm going to

52:17

dose him tomorrow and we'll check in with

52:19

him. The OTP system has to

52:21

do the physical within 14 days after that,

52:23

but it's a low barrier entry. Every primary

52:25

care doctor out there needs to know about

52:28

this because you may know it, ahead of

52:30

your local OTP. We'll

52:32

have things in the show notes that

52:34

help advocate for this process. Yeah.

52:37

I feel like it's really good to hear, even

52:40

though we silo methadone and treatment, it

52:42

is medical care and we should be integrating it

52:44

into our primary care as much as possible, instead

52:47

of just throwing it on a problem list and

52:49

never talking about it. I

52:52

think it's great to hear that, and I think this is

52:54

some news to me too about the final rule and how

52:56

much more of a role we

52:58

can play in lowering barriers to get into

53:00

the OTP, as long as we get to

53:02

know our local resources too. I'll say there

53:04

are other things that you can talk to

53:06

your OTP about too, to lower barriers like

53:08

I know one of the local OTPs we

53:10

work with, instead of taking government IDs, we'll

53:12

take medical records like with a picture and

53:14

their name and address as an alternative to

53:16

the government ID and a lot of Medicaid's

53:18

that offer transportation benefits. There's a lot of

53:20

things you can do to facilitate entry into

53:23

this methadone system and helping people continue on it

53:26

too. Totally. I think exactly

53:28

like you said, Ruth, you won't know how

53:30

you can help until you talk to your

53:32

local OTP, because there is a ton of

53:34

variability. I do want to touch

53:36

upon another challenge that we

53:38

face for patients who are on methadone,

53:41

or who maybe start methadone in the

53:43

hospital, who need to go to a

53:45

skilled nursing facility, maybe for prolonged antibiotics

53:48

or just for rehab, because they

53:50

had some injury where they would

53:52

benefit for more intensive physical therapy

53:54

because we see this issue all

53:56

the time where we hear that

53:59

short term. facilities won't take patients

54:01

on methadone. And

54:03

I'm curious, Ruth, from your

54:06

point of view, how do we sort of

54:08

troubleshoot this in terms of

54:10

helping patients access methadone and

54:12

skilled nursing facilities? Well,

54:15

I'm gonna say the first strong statement, which is it

54:17

is against the federal law to

54:20

deny access to methadone or buprenorphine at a skilled

54:22

nursing facility. So it is a violation of the

54:24

Americans with Disability Act and the Department of Justice

54:26

will come after you. So that's the first thing.

54:28

And it depends on who your Department of Justice

54:30

is, how aggressive they'll be. I'm in a part

54:32

of the country where my assistant

54:34

attorney goes after every single skilled nursing facility. And

54:36

yet we know that skilled nursing facilities will say,

54:38

oh, we didn't not take them because of the

54:40

methadone. We didn't take them for 12 other

54:43

reasons, most of which seemed bogus. So

54:45

that's the first thing. It's against the law, period.

54:48

And a lot of us work in nursing homes. I

54:50

mean, I worked in nursing homes forever as a primary

54:52

care doctor, and it was part of my gig. And

54:54

so if you're one of those primary care people out

54:56

there who also sees people at a skilled nursing facility,

54:59

you should be working from within to make

55:01

sure that that's changed. It's really just stigma.

55:04

It's that people don't want that type of

55:06

person in their facility. Well, you have all

55:08

people in your facility. And

55:10

how to advocate. So then

55:12

that's why you're best friends with your

55:14

OTP medical director, because you can do

55:16

chain of custody, meaning that the OTP

55:18

can deliver or a nurse or somebody,

55:21

anybody from the inside of the skilled

55:23

nursing facility can come pick up the

55:25

dose and bring it back to the

55:27

skilled nursing facility to administer it. Another

55:30

thing that came out in the new final

55:32

rule is something that's very clear, which is

55:34

that if you are a hospital, a long

55:36

term care facility or correctional facility who has

55:38

a DEA clinic or hospital license, which almost

55:41

all of us do, you actually don't need

55:43

to be an OTP to use methadone. You

55:45

can order methadone on your formulary from your

55:47

normal pharmacy, and you could dispense it to

55:49

patients. So if somebody

55:51

left the hospital on 120 milligrams and

55:53

you just knew this, you would just

55:56

continue them on their 120 milligrams without

55:58

ever interacting with an OTP system.