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Jamelia Hand, Part Four – MAT: What Are The Links On The Chain?

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.

Jamelia Hand: I look at just medication-assisted treatment in general as a chain, and there are links on the chain. And each link represents a treatment team member. For example, you’re a link on the chain, the nurse or PA that supports you could be a link on the chain. The lab is a link on the chain, the pharmacy, the counselor, the patient, of course, is at the center of all of this. Their family, is housing and employment an issue or a consideration that needs to be addressed? That’s also a link on the chain. And the patient must be stable across this chain and if any of the links on the chain are broken or deficient, the patient is at risk of relapse or overdose.

Jamelia Hand: So, it’s really important that we make sure that these links are strong, and they’re intact, and that we’re communicating with each other in an effective and efficient manner so that the patient has everything that he or she needs.

Mark Leeds: There’s a topic I wanted to really get to talk about with you. And I had brought this up before with you through email. That there is this issue of maybe physician guilt about telling a patient, you know, when a patient asks, “How long am I going to be on this medication?” Opioid use disorder and addiction in general is a chronic illness. It’s like just like diabetes, high blood pressure. Nobody wants to call something permanent, but it’s kind of indefinite, it’s going to be with you, you may be able to treat it without medication at some stage to some degree, which is exactly like these other conditions. Blood pressure when we first start treating a person with blood pressure we give him a chance if it’s not too high, let’s try diet and exercise. Let’s try lifestyle changes.

Mark Leeds: Same thing with diabetes, let’s try lifestyle changes, more exercise, better diet, maybe we can get this under control. But it’s not going to cure the underlying disease. And same thing with addiction. And we know that a lot of these patients who come in for treatment of opioid use disorder they may need to be on this medication indefinitely.

Mark Leeds: But there’s so much pressure from the society, from the media, from what people around us are saying that we’re just trading one addiction for another, we’re treating a drug addiction with a drug. So, even for the doctors, I mean, for everybody involved, for the patients, the doctors, the families, we all feel this pressure of, “Am I doing the wrong thing keeping this patient on this medication long-term?”

Jamelia Hand: Right. Right and I really like the way that you state it, and I’m guessing that’s the approach that you use with all of your patients, you tell them about the “ifs” and the ” ands”. But in general it’s so much noise, it’s so much noise out there. It’s very easy for a clinician to be very confused about what to do, right? Everyone has an opinion about how opioid use disorder should be treated. And because we have intervention across the spectrum from the federal government will come in and make treatment recommendations even though that’s not their role, right? They’ll come in and sometimes make recommendations about how you should be doing your business, or what you should be doing in your business.

Jamelia Hand: We have local advocacy groups, nationwide task forces, congress bipartisan groups, there are so many cooks in the kitchen right now. And I think that you and your physician colleagues really have a wonderful opportunity here. You have an opportunity to press reset and design your practice in a way that works for your patients and your community.

Jamelia Hand: So, I really think that for a very long time, we’re just overthinking this. We’re overthinking this and then we’re imposing barriers on how we do business. When in reality, you have the opportunity to design your practice.

Jamelia Hand: So, one thing that I often say to people in your role is that this is your practice, act like it. These patients are your responsibility. Your license is on the line. How do you feel about this? What do you feel in your gut? As long as you’re not doing anything, for example, I’m not doing urine drug screenings when you know that you should be in an effort to gauge whether or not a patient is getting better. If you’re not doing very basic things like urine-drug screenings or consulting your state physician data monitoring program. There’s no reason why you can’t set things up the way that you want them to go.

Jamelia Hand: I mean, methadone has been around for what, 50 years now, buprenorphine for almost 20. So we know a lot about these medications, how they work and their efficacy. It’s been very well documented that they can curb the opioid crisis and reduce overdose. But we continue to self-impose barriers. And it’s actually getting in the way and making things more difficult than they have to be.

Mark Leeds: And just to go over that, now buprenorphine has been around for a really… probably even longer than that as a medication. And we know it’s safe. I mean, would you agree? I mean, a person can take it indefinitely and if they’re not having problems or side effects and it’s working there’s not really any need to one day out of the blue tell a patient I think you’ve been on this for too long, let’s start cutting back and take it away. That’s not needed really. It can be continued indefinitely.

Jamelia Hand: Right. I totally agree with you. But we go back to that discussion, how do you feel, if you feel healthy? And it amazes me that we don’t look at buprenorphine the same way we would any other psychotropic medication. It’s really important to allow the body to reset, to calm down so that someone can know what it feels like to function normally over time. And like any other medication, we never say you need to stop taking this medication within six months. We don’t impose limits or barriers.

Jamelia Hand: But we do this in addiction treatments across the board. We put these barriers and these time constraints. You know, it’s okay to put a time constrain on a goal so that we can measure how far we’ve come in obtaining that goal, but why in the world do we treat addiction different than any other mental illness? It’s ridiculous. Taking medication daily is not the same as addiction. And we need to talk about dependence versus addiction and why those things are different so that patients can understand that this is a long road or it can be a long road.

Mark Leeds: That’s a good point. And not just mental health conditions but also just medical conditions in general, I remember a patient of mine recently… well, maybe in the last couple of years he went into the hospital with high blood sugar. He felt really sick, went to the hospital, they checked his blood sugar and it was really high and he didn’t… had never had a problem with diabetes before but suddenly he was given a diagnosis of diabetes. And they gave him some insulin, stabilized him and he was discharged. And he came into my office and he said, “I had high blood sugar in the hospital, they treated it, it’s back to normal so I’m done with that now. They basically solved the problem.”

Mark Leeds: And I had to have that conversation with him, “Well, no they didn’t. They got it under control for that time period but this is something we’re going to have to deal with on an ongoing basis.” And of course, I didn’t want to tell him forever, but this is going to be a long-term thing. And it took a while for him to really, for that to really sink in that this is something he’s going to have to deal with, and learn about medication, and how to use medication, and how to do things besides medication to treat the condition.

Mark Leeds: There are elements of… what do you call it? Of not wanting to, what do you call it when you don’t believe you have something?

Jamelia Hand: Denial.

Mark Leeds: Yeah, denial. Right, yeah denial. Exactly yeah, denial is there with all medical conditions. You know, when someone finds out they have something permanent right away they’re going to be in denial like, “No, I don’t. I’ll get past this.”

Jamelia Hand: Of course. Of course. I mean, we all do this. This is not limited to patients with medical issues or mental health issues. I mean, we do this daily. I recently stopped drinking Pepsi. Pepsi was my drug of choice, right? And I made a pact with my son, like people do. You know, they make a pact with their family that they’re going to stop doing something that is harmful, or that could be harmful. So, the same week that I told my son that I was going to stop drinking Pepsi, and I made the promise to stop doing so, I went to a week-long conference.

Jamelia Hand: So, I was in Kentucky and I’m at the conference, and you know, the day was going well, I had just got up, I had a cup of tea. I felt really good about my decision to have the tea, the tea smelled wonderful. I’m walking down my hallway with my fancy cup, with my name on it. And I’m drinking the tea.

Jamelia Hand: We go into the general session which lasted for about an hour and a half. And then we got a break. The moment I stepped outside of the room, there are Pepsi products everywhere. And the cans are assembled in this diamond shape, and there is sweat running off the Pepsi cans. I mean, it looked like a commercial. And I had to have a Pepsi.

Jamelia Hand: As a matter of fact, I took two or three of them and I put them in my bag so that I could take them up to my room and have them for later. Now, this is just a Pepsi. Just a Pepsi. I made a commitment to my son and I made a commitment to myself that I was going to stop drinking Pepsi. But the first opportunity that I had, and as soon as those cravings set in, next thing you know I had a Pepsi in my hand.

Jamelia Hand: So is it that easy for me to relapse on my promise? And then I felt guilty about it. I can only imagine what people who are dependent and/or addicted to opioids are going through on a daily basis.

Mark Leeds: You know those cravings are… I mean, they really, I think, represented addiction really well in the movie Finding Nemo when they had the shark meetings. The sharks said they were not going to eat fish anymore. And they said fish are your friends not food, and then the one shark, he finally decided, “I’m having fish for dinner.”

Jamelia Hand: Right. Oh gosh. It is something, you know. And I wouldn’t dare minimize what your patients are experiencing with my little Pepsi situation, but it does help me to understand what they’re going through. And right now, and to go back to what you were talking about a little bit before about denial. And this happens to your physician colleagues as well. They don’t want to believe. I hate to repeat this, but I will because I think it’s important. I remember once asking one of your physician colleagues, “Why won’t more of your colleagues get involved with this? Anyone who is prescribing opioids within their practice have patients who are opioid-dependent that’s just the name of the game. So, why are they not getting involved?”

Jamelia Hand: And he said, “Jamelia, we can’t be the problem and the solution.” And that was really impactful for me because it helped me to understand that they were also having their own internal struggle about what patients were experiencing. And they felt the sense of, “Did I contribute to this? Am I actually part of the problem? And I’m not sure what to do next. If I do something am I admitting that I am part of the problem?”

Jamelia Hand: There’s a whole thing that goes on internally and maybe you can speak to that a little bit more based on your own experience. But I was really, I felt really bad for him when he, well, him and his colleagues when he shared that with me.

Mark Leeds: I can see that as being an issue and I would agree with that on some level if it’s a pain management clinic, one of these clinics where most of what they do, even all of what they do is prescribe opioids for pain. There is a place for pain management and I’m definitely in favor of it for patients that benefit from it. Not everybody is addicted to opioids. There’s people that take them responsibly for chronic pain, but I would agree that maybe a pain management clinic where everybody in the waiting room is sitting there waiting to see a doctor to refill their prescription for opioids, that it might not be the best place for a person to go to get their prescription for Suboxone.

Mark Leeds: And ,especially if that person coming in for suboxone has had an issue with pain clinics in the past, or maybe that was their source of opioids at some point. It’s kind of like going to an AA meeting in a bar. Not exactly the same.

Jamelia Hand: Right.

Mark Leeds: So yeah, but one thing I see as a problem, I went to a meeting, it was a round table discussion where they were doing a marketing study for a new drug with a couple of other doctors who were working in the field of addiction. One of them was board certified in addiction and someone who, I had never met this doctor before but knew of the name for many years because I had worked in pain management in that area and had looked up what doctors are available, so I had actually referred patients to this doctor over the years. And, at the round table discussion they asked us, “what is the most difficult part of working with addiction patients?”

Mark Leeds: And this particular doctor who’s board certified in addiction, that’s their entire practice, responded, “My biggest problem is the lying. I can’t deal with the liars, or the lies are really difficult for me.” And I thought, “Well, how strange.” You specialize in something where that’s one of the main symptoms. Addiction causes people to tell lies. I mean, it’s just one of those behaviors.

Mark Leeds: And I thought, of all things, I mean, you just, that’s something you have to accept and work with. And I think that that could be possibly an issue for a lot of doctors that they just, there’s the stigma of addiction, you know? Doctors want patients to be straightforward and honest with them and they know that this is a condition where people steal, they lie, they try to get away with things when they’re in active addiction. And maybe they don’t see the potential that if you treat the patient, and you get them past that, once a person is clean for a period of time a lot of that just clears up on its own with time.

Mark Leeds: Therapy can help also, but I think that that could be a barrier for a lot of doctors. They just don’t want to deal with patients with addiction because of the stigma. They don’t see it maybe as a mental illness but they see it as a moral failing, which it’s not.

Jamelia Hand: Right. Oh my gosh. That one is actually one of the things that I address in my service. I don’t call it a service, but one of the things that I know for sure is that physicians and other treatment providers, this is not limited to physicians, this could also be a healthcare provider, an employer, they just simply haven’t been trying to understand the disease of addiction and what those symptoms look like and what resources they have to help manage or combat those symptoms, right?

Jamelia Hand: And unfortunately lying is a symptom. Also, even though a physician may have completed the modules and gone to the live trainings necessary to complete the requirements for their waiver, they still don’t know what it’s actually like to treat patients in their office. They have no idea what that looks like, what it feels like. So, one of the things that I do very early on in my agreement with them is I’ll bring in a patient. I talk across the country with a young woman who has been stable on buprenorphine for almost three years.

Jamelia Hand: And, what I do is I talk to her in front of a group of people and she shares her experience. She had done many, many things in her addiction. Eventually, she ended up losing her arm because of the damage that had been done to her body as a result of her trying not to be sick. So, her and I we have tag where I’ll sometimes bring her in for really tough customers. And they’re able to actually have a conversation with her so that they can see what it looks like from someone who was really, really sick and the process that it took for her to get better.

Jamelia Hand: And it’s important to install hope very, very early. Because like patients, it’s easy to get distracted and say, “This doesn’t work,” or, “This can’t work,” and decide not to do anything further about it.

Mark Leeds: And the thing about lying being a symptom. And sometimes I’ve caught patients in lies and a lot of times it’s almost funny that the lie was, it was something harmless or almost pointless and I’m wondering, “What was your motivation in even doing that?” A guy came in and he said, “I’ve never tried Suboxone. I’ve never been prescribed it. This is my first time.” And I walked out of the room and I came back and I said, “Well, actually according to the PDMP, you were in a doctor’s office last month getting Suboxone and a few months before that.”

Mark Leeds: And he felt really terribly sorry. You know, “I’m really sorry. You’re right, I lied and I’ve tried this before and it didn’t work. And I just didn’t want to tell you because I didn’t want you to think of me as someone who’s failed and didn’t… wasn’t able to get this.” I said, “Well, that’s okay.” And I said, “Don’t even worry about, I mean, be honest with me. It’s a safe place. We can be honest together but don’t feel bad about what you just did. I mean, it’s okay. I mean, it is just a normal thing.” But of course, we have to be, we have to do what we have to do to catch those things. You know, like you said, the urine drug screens and just being aware and listening, checking the PDMP.

Jamelia Hand: Right. And you know, they really are doing the best that they can do. And thank goodness they have someone like you who understands the symptoms and can be compassionate towards them. I often, when working with clients, I’ll tell them to check the PDMP before the patient comes in. And if they see that the patient has gone elsewhere for medication again, just as we did under the secret shopper, this is a great opportunity, great opportunity, as a teacher and as a student who will be arriving at your practice to learn more about their illness from you. They can arm themselves with the information to help them to overcome some of the symptoms.

Jamelia Hand: So, let’s say you check the PDMP before the patient comes in and you know that they’ve gone to one other doctor to obtain suboxone or an opioid. And they come to you and they say that they’re ready to quit. One of the things that you might start with them and just put it out there early is to say, “I checked the PDMP and I understand that you’ve gone to other physicians for A, B and C or you’ve gone somewhere else to get A. And I just want to tell you that I really want to work with you. And for us to work together, we have to be honest with each other. Which means that this has to stop today. You can no longer go and get what you need from someone else.”

Jamelia Hand: “You come to me and we talk about it and we be honest with each other. If you agree to that, then we can work together, but you cannot do things that are illegal because you can’t get well if you’re in jail or unless the jail has a treatment program. But the best thing you want to do is to be out and be with your family, you do not want to be locked up and what you’re doing is against the law. So, if we can agree to that today, we can get started. And if we need to come back and have this conversation in a week or so, we will, but understand that starting today we need to be honest with each other.”

Jamelia Hand: And they actually appreciate it. And if you think about the best teacher that you had, it was the teacher that challenged you, it was the teacher that held you accountable, it was the teacher that you knew cared about you but they were a little bit tougher on you than other people had been. So, with that approach you earn their respect very earlier on and it can set the tone for a high quality experience.

Mark Leeds: That’s a really good way of putting it. That’s a really great way to explain it to the patient. That’s really good. And I would also add that we should definitely not always assume that a patient is lying or that the patient is wrong in a lot of situations. I had a situation years ago where a patient called me and told me that she went to the pharmacy and her prescription wasn’t there because somebody had come in and bought it ahead of her.

Mark Leeds: And at the time I was working for someone, and I went to my employer and I explained the story. And my boss told me right away, “Your patient’s lying. Your patient is a drug addict. They’re diverting, they’re just trying to get another prescription out of you.” It turned out that the patient was not lying at all. It turned out that there was actually somebody in the office who was going and paying cash for prescriptions. Calling in prescriptions for themselves. There was a whole thing going on in the office. But the first and immediate reaction was to say my patient is lying and patient’s diverting drugs and trying to get me to write more prescriptions. Even though it’s always a possibility, I think we have to believe that, we have to know that our patients are not always lying and be their advocate also.

Jamelia Hand: Absolutely. It’s so important, and thank you for sharing that. That’s huge. That’s huge. But understanding the disease of addiction and being able to recognize the true signs and the symptoms is part of the education that you pursue on a daily basis. I mean, opioid dependence, addiction, treatment admissions are going up. They’re going up. There are more and more patients who are struggling and seeking medical care.

Jamelia Hand: And opioid dependence can be managed in a medical setting. And we have a lot of tools to help us to accomplish that. But we need to be proactive at screening. We need to have a very good understanding of the signs and the symptoms and what to look for. And we also need to remove some of the self-imposed barriers.

Jamelia Hand: Now granted there are some systemic barriers including federal laws, guidelines, medication access, issues like prior authorization, even medication delivery. If we can’t get a medication delivered to the office that we’re working out of, that’s a barrier. You’ll begin to question your capacity to be able to provide a quality service based on some of these systemic barriers. And this is alongside the self-imposed barriers.

Jamelia Hand: The physicians that we spoke about earlier who might be in denial. “I don’t have those patients here”, or “I don’t have the appropriate staff to address these issues”, or “my practice isn’t set up for that”. These are all things that get in the way and prevent the patients from getting the type of care that they deserve.

Mark Leeds: Another barrier is, there’s the media and then if you look at some of the media articles you see things, articles about rogue doctors and the new pill epidemic being the Suboxone clinics. They’re really working against the solution here, I think.

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.

Please stay tuned for the continuation of this transcript of an incredible interview.

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