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Jamelia Hand, Part Five – Getting more doctors to provide MAT for opioid addiction.

Jamelia Hand MHS CADC CODP is the CEO of Vantage Clinical Consulting LLC. In a recent episode of The Rehab Podcast, I interviewed Jamelia on the topic of Medication-Assisted Treatment of opioid use disorder and how to make this proven treatment more accessible and standardized. The following is a transcript of our interview. You can listen to the entire interview here. Or, you can download it here. This is part five and the final segment of the transcript of this podcast episode.

Jamelia Hand: Oh yeah, that’s terrible. You know all physicians are not bad. I know, including yourself now, so many wonderful, wonderful physicians who are doing everything that they can to ensure their patients have a high quality experience and that they have access to what they need so they can plan for recovery.

Jamelia Hand: And I think about, as you were speaking, I was thinking about one physician in particular. I really liked him a lot. This was maybe about 15 years ago. He was a very gentle person. He really had everything that was needed to do a good professional clinical business. He had staff that appeared to support him, and we haven’t talked about that, but sometimes staff is not onboard with the type of work that you’re doing. And they can get in the way and sabotage the great work that you’re trying to do.

Jamelia Hand: But in this case he had a wonderful staff, everyone seemed to be okay with treating patients, I was able to get them trained on the disease, get everyone on the same page, create the protocols around the screening and the intake, I created a clinical pathway and map for every stage of the process from induction, through maintenance and medical withdrawal. So, I created policy and procedure for them.

Jamelia Hand: So, everyone had what they needed, they had a blueprint, they had: “this is what we do, right?” And the physician would not do urine-drug screening. Now he would send the patients out for labs, but he did not screen on site. And he did not screen for norbuprenorphine. So, he had no idea whether or not the patients were actually taking the medication. And my question to him is, well, how do we assess if what you’re doing is working?

Jamelia Hand: And he said to me, “Jamelia, I don’t want to police my patients. These are adults, and for the first time in their life I want to be the one person that treats them as such.” And this was his belief. But unfortunately, over time I wasn’t able to work with him anymore because, of course, there was abuse and diversion, which we know. We know this happens, it’s no secret. And I think that we should do a better job in discussing how and why medication is diverted.

Jamelia Hand: But he ended up getting into trouble. I don’t think he was a bad person, I think he really wanted to help people, but he had his own spiritual idea about how he wanted to treat patients. And unfortunately urine-drug screenings onsite was not part of his practice.

Mark Leeds: Yeah, and we still as doctors, we have to work within the community standards of what’s acceptable and… even if we can make a good argument for why something shouldn’t be done.

Jamelia Hand: Mm-hmm (affirmative). When you think about it, buprenorphine is not a drug of choice for most people, it’s a solution to a problem. And that problem is usually withdrawal and cravings. I believe there was a study, I think it was in the journal of Drug and Alcohol Dependence last year where they discussed diversion and why buprenorphine was diverted. And what they did was they surveyed adults who met the DSM-4 criteria for opioid use disorder and found that, I believe, it was about 80% of respondents prefer to obtain and use buprenorphine the right way.

Jamelia Hand: They wanted to go and get it from their doctor. But what was found was that they were diverting to prevent withdrawal most of the time, I think it was about 80% of the time and some were diverting to maintain their abstinence. So if you have someone who has left a residential treatment center where in that case their increased risk of overdose goes up about, I believe it’s about eight times and they want to continue to be stable but it could take them a month to get in to see a doctor.

Jamelia Hand: They may buy buprenorphine on the streets and I totally get that. But very few people in the study had shared that they were buying buprenorphine to get high. I believe it was less than 4%.

Mark Leeds: And that also brings up harm reduction. Of course now apparently the FDA is trying to fast track the approval of over-the-counter Narcan, or naloxone, as a rescue drug to make it available where you don’t even have to walk up to the pharmacy counter, you can buy it in the checkout lane at the supermarket.

Jamelia Hand: Yes, and I hope and pray that it happens. And then there are many pharmacies where you can get it over-the-counter. And when I talk to healthcare professionals, that is actually what I tell them to do. And before I even go visit them I find out if there are local pharmacies in the area that has it over-the-counter and if they have it in stock I want to be able to tell them when I visit them, “These are your resources and this is where you can find this in your community.”

Jamelia Hand: I’d actually worked for the makers of Narcan nasal spray and I have the privilege of training close to 800 law enforcement professionals across the US on how to use it. And there were so many concerns, and fears, and stereotypical thoughts and questions. It was a lot of education, but I’m really grateful to have been on the frontlines of that launch and helping people to get educated and armed.

Mark Leeds: I know there’s also been stories, you know the media loves these sensational stories about law enforcement officers, sheriffs and people like that who are against the use of Narcan in the field and they don’t want their officers carrying Narcan. Or they believe that if a person has been revived with Narcan a certain number of times that they shouldn’t get a third or fourth chance, which is really a terrible thing because… and that brings us to…

Mark Leeds: Every human being is valuable. Everyone should have a chance and relapse happens and it can happen over and over again. But also, there’s people out there, there could that person on the street who in their eyes has no value and maybe they believe they should be just let go. You know, they did this to themselves. But that person could be someone who, if they come around and they finally get bet better, they finally go into recovery, they could be someone that helps a lot of people. They could maybe be someone’s sponsor. Maybe that person is a doctor. Maybe they’re a professor. Maybe they could educate other people and those people they help can help other people. They’re potentially very productive members of society that need help and maybe they need help more than one time.

Jamelia Hand: Yes, and it’s their obligation. If the patient had diabetes they wouldn’t withhold insulin. And I’d have to say that law enforcement has probably been the toughest nut to crack in my work because for the first time in history they have to be social service professionals. So now they’ve gone from law enforcement, serve and protect. Officers are not counselors by trade. They’re just not. They have a function, and they’re good at it, and they do what they do. But now they’re having to be a social service worker as well, which, if you really want to be a good law enforcement professional, you should have some of those therapeutic skills to be very good at your job. But I did a talk at a state police association conference.

Jamelia Hand: And, I’m talking about overdose, and I’m demonstrating how to perform rescue and one of the officers said that there was a patient or a person, I refer to everyone as patients so forgive me for that. But there was a person that he had given Narcan to twice that month. And he has one more unit and he had an opportunity to use that unit again on the same person, and he declined that opportunity. He said, “I’m not using it on him again. You know he’s going to do the same thing next week, I’m not using my last unit on him.”

Jamelia Hand: Now at the time, my heart was breaking. I had a father overdosed so I’m thinking, “Wow, if this was my dad and he was confronted with this officer, he probably wouldn’t make it.” But that is some of the thinking that is going on out there and it’s incumbent upon us to talk to people and share information and insight, but we first have to meet them where they are. So I had to put myself in his shoes. And even though I didn’t agree with what he was thinking, I had to figure out how to understand it so that we could start from a mutual place of understanding.

Mark Leeds: And that also brings up that we have to look at the liability for treatment programs that do have an obligation and maybe even law enforcement and doctors. They have an obligation to do something and they don’t. And there’s a case that was brought up by Dr. Bisaga on the podcast and was out there in the news that when, and I don’t know the full story, but when Prince overdosed and died, a week before, he had been in the hospital and there was the opportunity to start addiction treatment with him. MAT could have been started, but instead apparently they gave him more opioids and he died a week later. And apparently the family was, or maybe still is, taking legal action against the hospital for not providing adequate addiction treatment.

Mark Leeds: And that’s something that I think could spread everywhere. I mean, addiction treatment programs that are abstinence based and are against MAT for no good reason really, they just aren’t ready to accept it. That maybe a lot of these programs may start finding themselves liable when their patients leave and relapse and overdose and they didn’t offer scientifically proven medical treatment.

Jamelia Hand: Right. And they’re ethically bound to do so. They should be morally bound but they’re definitely ethically bound to do so.

Mark Leeds: And that’s definitely a good place for education. I mean, the ERs. And that’s really where this should be started. One of the main places where buprenorphine treatment should be started is overdoses in the ER. Nobody should walk out of an ER without at least being offered it either educated about it. And there’s a couple of ER’s locally here. There’s JFK Medical Center in Palm Beach County, there’s now Memorial Hospital which is multiple hospitals in Hollywood which is just south of Fort Lauderdale.

Mark Leeds: And I know there’s other programs around the country where the ER is a place where they start medication assisted treatment. And then they make plans for continuing it. But there’s also a lot of hospitals that I think you just don’t know what you’re going to get. Even though the doctors are, they’re allowed to give a short-term prescription even if they’re not certified, I believe, they may just refuse to do it. Is that correct that they’re allowed to give a three day supply even if they’re not credentials in that area, or certified?

Jamelia Hand: Yes. Yes. That is correct. So it is a great opportunity, as you mentioned.

Mark Leeds: Is that true for all doctors or is that just the emergency room that they can give a short-term supply until they can get to a certified provider?

Jamelia Hand: It’s just in the emergency setting.

Mark Leeds: Okay. Yeah, but which is still good. I mean, hopefully almost everybody in the country is within reach of a hospital emergency department. That is an important thing if all ER doctors could be educated on that, that they can start treatment and at least give a person the chance to find a local doctor or even better if they could direct them to one or have a program in place for continuity of care.

Jamelia Hand: Absolutely. I agree with you, 15,000%. And honestly, I did a talk for a hospital in Chicago with about 40 residents. And the goal was to inspire them to consider getting certified to prescribe buprenorphine. And my talk was supposed to go one way, but after sitting with them within the first 10 minutes I learned that in some cases, in most cases, they had asked the questions, they have to ask about drug and alcohol use.

Jamelia Hand: But it’s a very surface conversation that they’re having with patients, because once they ask the question they have no idea what to do next. So, they keep it surface because they don’t know what to do. So instead of educating them about the process and how they should get involved, we literally sat around in a group and discussed what do you do when you have a patient who is with you that you suspect is addicted or dependent to opioids.

Jamelia Hand: We talked about the conversations that they can have. I left them with a list of questions that they can ask and then what to do if the answers to those questions are yes. And then I researched some of the resources within their community that they could use. One of the things that I do for all of my clients is, if they choose to purchase the service, because I do what I call a community matrix assessment, and I’ll build a profile.

Jamelia Hand: So, I’ll go around to treatment providers in their community that provide services that they don’t and I’ll vet them personally. I’ll go in, I’ll ask them what is your treatment model? If the physician is not available to you, what do you do? Where do you send them? How are you treating this issue within your organization? To see if they’re actually a good fit for the position, because a physician’s office, you can have a ton of resources, right? You can have an entire list of people that you refer to, but when was the last time you checked in with those people to make sure that your treatment thinking is aligned?

Jamelia Hand: They may be abstinence-based and you’re medication-assisted open. But they’re sending all of your patients to AA and NA and they’re providing therapeutic interventions that support an abstinence-based treatment model. But that’s in no way aligned with what you’re doing. But if you don’t check in with them at least at the most annually to see what their beliefs are, what they do in certain circumstances, you have no idea what they’re doing with your patient when the patient leaves your office and goes to theirs for some ancillary service or treatment.

Mark Leeds: There’s that danger everywhere that a doctor is treating a patient with buprenorphine and then wants to recommend therapy because it’s required. You really have to provide therapy, at least by referral to a patient. And you refer a patient to a psychologist and you’re taking the chance at that psychologist maybe against medication-assisted treatment and tell the patient, “This is not the right thing for you, we can work on this through therapy.” Actually that happened with a patient of mine. She said that the psychologist supported her decision that she should just come off the medication quickly within the first month.

Mark Leeds: And I told her that was not a good idea and she said, “Well, he’s an expert in addiction, he’s been doing this for a very long time.” And that patient relapsed came back again and finally came to the conclusion that MAT is what works, for her at least and didn’t really have to go through that whole process of relapsing and suffering and maybe going through a treatment program or two and then finally coming back. It was all unnecessary, but it was triggered by just, there’s a whole world out there of people that are working against us and we just have to keep educating our patients and educating as many people as possible that this is what works and please don’t tell our patients that they should quit their medication.

Mark Leeds: Would you agree that there’s a huge opportunity for doctors that want to get involved that… Like say for example, say there’s a doctor working in, maybe in an abusive work place or working for a hospital and they’re being overworked and the EMR is impossible to work with and they just want to get out of it. Maybe they even want to quit being a doctor it’s so stressful.

Mark Leeds: And then maybe they hear this podcast and they say, “Well, wait. Maybe there’s a possibility I could go into addiction treatment and help people.” Is it true that there’s potential, there’s opportunities across the country and huge areas where there’s no doctors, or very few doctors providing this treatment that if they’re willing to relocate maybe that they could set up a small clinic. You don’t need a lot to set up a… just a couple of rooms and rent a space or share a space with someone and open up a… You know, you can keep the overhead low and start seeing your 30 patients in the first year. I mean, I know it might be difficult but when the options are for the doctor maybe in some cases it’s actually suicide, there’s a serious problem with physician suicide.

Mark Leeds: Some doctors are very stressed out by the whole field of medicine that this is a way that they could drop out, but at the same time not totally drop out and provide a useful service and maybe save some lives just by helping out. Would you agree that there’s an opportunity for a lot more doctors to get involved in this?

Jamelia Hand: Absolutely. So, I think it’s a really wonderful opportunity and I think that’s what the government had in mind when OBOT, which is office-based opioid treatment was passed, giving physicians the privilege to be able to treat opiate addictions on an outpatient basis. What they hope was that physicians would screen, and diagnose, and treat within their own practices. So they get the certification and they take care of the patients who they identified in their practice were suffering.

Jamelia Hand: That was the hope, but it didn’t happen that way. You had a handful of physicians that jumped in right away and that has grown over time. At this point we have, in Illinois alone, we have about 800 physicians, but we have less than a third of those who are seeing the maximum amount of patients that they can. And again, it goes back to the treatment barriers, but what most physicians who are doing a really good job like you will share with their colleagues is that this is the most rewarding work that they’ve ever done. And this is why they got into medicine in the first place.

Jamelia Hand: There’s nothing better than someone coming into your office who has nothing, who has lost everything, who has burned all of the bridges in their families, who has nothing. But within a couple of weeks, this person has begun to take care of themselves. They’re showering again. They’re talking about what they think they might want to do in their lives. They’re saying that they feel normal for the first time in decades. Nothing replaces that and it’s a really good feeling. And I think that if more physicians knew this, more physicians would be treating on an outpatient basis for opioid addiction.

Mark Leeds: Yeah, the change is incredible. I often don’t even recognize the patients when they come back. I mean, they look like completely different people. Sometimes in a week, sometimes two and some difficult cases maybe a month, but usually earlier than that. And some ways it’s almost too effective. I mean, that’s sometimes a problem where a person feels like they’ve been cured because it’s just such a dramatic change in a short time.

Jamelia Hand: Yes, indeed.

Mark Leeds: But it’s really effective and the thing is, and it’s not replacing one thing with another. Technically, buprenorphine is a form of an opioid but it’s a very unique and complex medication the way it works. And a person’s thinking is clear, they don’t have addictive thoughts, they don’t have compulsions and obsessions and they’re not constantly thinking about drugs and they’re thinking isn’t clouded by drugs.

Mark Leeds: Buprenorphine is a very powerful drug in the way that it blocks cravings. People tell me that they feel almost like as if they’d never been addicted ever. Like they feel like they went back to how they were before they got addicted. And they don’t think about the drug, they’re not obsessed or craving it, but because of the fact that it’s not clouding their thinking like a normal opioid, it almost feels like it’s not doing anything but it’s really doing a lot.

Jamelia Hand: Yes, indeed. Yes, indeed. Absolutely. It’s amazing. It really is an amazing thing to watch. So, outside of the business opportunity, which is what I hope your colleagues were, because when they call me I always ask, “Why? Why do you want to get into this?” And preferably they will say, “I want to get into this because I want to help people,” or maybe they’ve been touched in their personal lives or someone in their family has been impacted by the devastation of this illness.

Jamelia Hand: Hopefully they say that to me. But some people want to get into it for the business of addiction. And I don’t say “no” to them either and I’ll tell you why. One of my first clients, he said he wants more patients. He wants to treat addiction, he wants to grow his practice. He wants more patients. And he saw this as a way of doing it.

Jamelia Hand: And I’m not a bad person. I didn’t judge him completely. There was a little bit of judgment at first because of course the heart-focused person that I am, I want everyone to be soft and warm and gooey and do it for the right reasons and save all the parents and the kids, that’s just who I am, naturally, innately. But there was something that stood out to me about him. I thought he was very good at what he did. He had a very good understanding of how addiction works and he also had a good way of explaining things.

Jamelia Hand: So, I thought the patients who would come into his office and be under his care could learn a lot from him. So, with that, I decided to work with him and I’ll tell you within six months, this guy became one of the biggest advocates for outpatient-based opioid treatment.

Jamelia Hand: I mean, he wanted to tell everybody. He had fallen in love with his work. He was so excited for patients and their families. I’d go in there sometimes and there’d be an entire family in there. And you know they’d have gifts, and treats, and they loved him. They adored him because he had given them their relative back.

Jamelia Hand: So, someone once said to me, “You can do the right thing for the wrong reason and then still be okay.” And now I believe that based on that experience that I had.

Mark Leeds: Yeah. Reminds me, there was a meeting that I had with a doctor at a convention, I think it was 2011. And we were talking outside of the convention. We walked out together and we were talking. And he has a practice in Miami where he only does MAT. He only provides buprenorphine treatment to patients. And we talked at length and he explained how he practiced. And at the time I was employed by somebody but I wasn’t happy, but it scared me at first because he drove a junky car. And he told me, “You don’t make a lot of money doing this but it’s a really great thing to be independent and to help people and all that.”

Mark Leeds: It took me a few more years to get to that point to realize how much I hated my job and that kind of thing. And then I realized it’s true. I mean, feeling fulfilled in your work and realizing that you’re really helping people and doing a good thing. And seeing how these people transform and recover is worth way more than having a fancy car or… It’s definitely is worth it.

Mark Leeds: And also this kind of work does give you the opportunity to maybe be independent and drop out from being employed and open, and start your own practice and just really dedicate yourself to helping people.

Jamelia Hand: Right. I love it. I love when they come to that point and to see that fire in their eyes where initially they were just, burnt out. So for them to be, to go from being burnt out to excited about the work that they do again, it’s so fulfilling and gratifying for me. And it’s why I love what I do.

Mark Leeds: So, tell me how can people reach you if they’re interested in your service like for speaking engagements or for consultation, how can they reach you?

Jamelia Hand: Sure. You can find me at vantageclinicalconsulting.com. And if you visit my website, I do have a free e-book for you called, “Black & Aging During An Opioid Crisis”, where I share my perspective on the opioid epidemic and treatment considerations for the aging minority client.

Mark Leeds: Jamalia Hand, thank you very much. Thank you for joining me on the show today. This has been an incredible talk and I know we’re going to help a lot of people with this, so thank you.

Jamelia Hand: Thank you for what you’re doing. And I think you’re incredible. So keep doing good things.

Mark Leeds: Thank you for joining us today on The Rehab on The Mental Health News Radio Network.

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