Jamelia Hand: Creating Solutions To The Opioid Crisis

Dr. Mark Leeds [00:09] Welcome to The Rehab on the Mental Health News Radio Network. I am Dr. Mark Leeds and I will be your host. Join me in exploring the world of addiction treatment. How can we improve the ways that we help individuals to overcome addiction? The goal of treatment is to save lives and help people to get back on track to a path towards success and happiness in life. Today on the Rehab Podcast, my guest is Jamelia Hand, and she is a Master of Health Science, has a certification in addiction counseling, co-occurring disorders, is working on her doctorate and is also a consultant for medication-assisted treatment and has been doing this for many years. She’s an author, a speaker, and has worked with many people in the field of addiction treatment and specifically in the field of medication-assisted treatment and has helped many people to get into this industry. I’d like to hear more about it. Welcome to the show, Jamelia.

Jamelia Hand [01:22] Thank you. Thank you so much for having me and inviting me. I appreciate it.

Dr. Mark Leeds [01:27] So, yeah, if you could tell us, you know, exactly what do you do currently in your consulting work? Are you working with individual doctors or treatment programs or both?

Jamelia Hand [01:39] Well, in a nutshell, I provide expert direction to health care organizations, physicians, and other professional firms on opioid addiction problems. So I’ve worked with physicians, substance use disorder treatment centers, and corporate organizations to reduce opioid problems in their communities.

Dr. Mark Leeds [02:00] We were introduced by Nick Jaworski, who’s a really interesting person. He has a great podcast also. And I had heard something really, really interesting at the end of one of his episodes, where the guest had mentioned how useful it would be for treatment programs to integrate methadone maintenance treatment, or at least methadone treatment into the programs, which almost seems like an unusual thing. You think of methadone as being a separate thing. They have methadone maintenance clinics, and then you have your regular kind of treatment programs that are usually abstinence-based, and some of them are now integrating buprenorphine treatment. But the reasoning was that with these new fentanyl analogs being found in heroin, and it turns out a lot of people are using this stuff, and in a lot of cases being unaware they’re using it’s very difficult to transition onto medication treatment, and that might be a useful thing to have methadone treatment in a treatment facility. Is that something you’ve dealt with advising people on that?

Jamelia Hand [02:54] You know what? Not so much with methadone. Even though I am able to do it, most of my work has been with buprenorphine. What I found is that physicians, especially once they’re trained to get their waiver or XDA, they have a really hard time transitioning from training to treatment. So I help them to build the skills, the systems, and the mindset to go from training to treating as quickly as possible.

Dr. Mark Leeds [03:22] I had that experience where I went to a course. It was after my original certification. I went for a number of years without doing much with that. And then I went to a refresher course, which a lot of the people were there for their first time doing their first their eight hour certification. Certification and I was just kind of sitting in on the same lectures to refresh and get updated. And they do give the impression that it’s a little bit easier to get into the field than it really is. You know, they talk about that you just kind of open your doors and you’re, you know, you’ll fill up right away with great patients and you just have to help them out and follow, you know, the direction that they give you during that short eight hour course. It turns out that you know getting patients at least where I am getting patients to even come in is not all that easy and getting the patients that are really gonna that are really motivated for success is not easy it’s not as easy as they make it sound in the course

Jamelia Hand [04:18] No not at all I like to say that the recipe has been add water and stir you know and it simply has not been an easy thing. Honestly, if a physician is providing a quality care service, it could take up to 17 steps from pre-screening to actually getting a patient to the maintenance phase in their treatment for opioid use disorder.

Dr. Mark Leeds [04:49] So now suppose that a doctor is opening a clinic and they want to get into this field. And so they go, they take the course, maybe they do the course online and they’re now certified and ready to go. And at that point, they have no idea what the next step is. All they know is that they’re allowed to prescribe buprenorphine in the form of Suboxone or Zubsolv or even Subutex. They know they’re allowed to prescribe it to patients for substance use disorder and they know little more than that. And there’s also that fear of the possibility of a DEA audit of their practice. And now they could contact you to help them to consult and help them get started? What would be the next step at that point?

Jamelia Hand [05:26] Well, we have basically three areas of the service that we provide, and we can work with a physician in any one of these areas, or we can work with them and work simultaneously across the areas. So the first thing we have to do, if they’re brand new, is we would need to go through what it takes to establish a buprenorphine practice. The first thing that I do is what’s called a practice readiness assessment. And I think it’s important to understand where people are and why they do what they do. That will set the tone for how patients will be treated and how successful they’ll be in treating patients. So during that establishment of a practice, we talk about developing a treatment framework. We talk about addiction treatment considerations. Even before the practice readiness assessment, and I can tell you more about what’s involved in that, I do what I call a secret shopper. Have you heard of a secret shopper? Do you know what that is?

Dr. Mark Leeds [06:29] I can kind of imagine. I think I’ve seen ads for that, like you go to Macy’s and pretend you’re a customer.

Jamelia Hand [06:35] Yes. So what I’ll normally do is I’ll have, you know, an intern or, you know, maybe a counselor colleague to give the office a call and simply ask about their services. What does it take to become a patient? And the goal is to really find out how they’re setting the tone for patients to arrive. You’d mentioned previously that you had an appointment of your own, a medical appointment. I’m not sure what it took to get that appointment. I have the type of healthcare professional, my physician. Their office usually calls me. They’re proactive. They’ll call and say, hey, you know, it’s time to do this screening. You know, have you made an appointment? They’ve gone so far as to send me text messages, and I feel, you know, really cared for. However, other organizations don’t always do those things to make you feel as though you’re a part of their practice family. So if you were to give an office a call, in many cases, you’d be put on hold immediately. So consider this. A patient is calling in. They may be in mild or moderate to withdrawal. They’ve heard about buprenorphine or Suboxone for medication-assisted treatment. Someone gave them the number of your colleague. They’re making the call. Now, mind you, they may have made 10 calls already to other providers that were full. They didn’t have appointments until August or, you know, they don’t accept their form of insurance. But they have gone through all of these steps with all of these other people. They’re now in withdrawal and they’re calling your office. And the first thing that you do is to put them on hold. What does that say? That says that maybe you’re not that important to me. Now, it doesn’t mean that’s the case. It doesn’t mean that the phones are not ringing off the hook. It doesn’t mean that office staff are not on other lines trying to get prior authorizations approved. It doesn’t mean that the physician isn’t taking care of someone else in your same condition. But as a patient who needs help right away, right now, today, if they call in and the first thing they’re asked is what type of insurance you have or they’re put on hold, the message that they receive is that maybe this practice does not care about me. So the secret shopper calls to uncover if a patient will have that experience within that initial phone call.

Dr. Mark Leeds [09:10] Now that you mention it, I feel like I’ve had some of those calls myself. I don’t know who’s arranged for the secret shopper to call me.

Jamelia Hand [09:17] It wasn’t me.

Dr. Mark Leeds [09:20] That’s great because it’s true, though, that I think a lot of really great doctors don’t realize that their own staff is sabotaging their practices by treating patients that way when they come in or when they call.

Jamelia Hand [09:31] Absolutely. And what I attempt to do, I’ve actually taken physicians out of their office. So if it’s possible, if we have a meeting set up and I know that I have an hour of their time, if there’s someplace quiet that we can go outside of the office, maybe a cafeteria close by or, you know, some other quiet space, I’ll say, come with me. And I’ll make that call in front of the physician to their office so that they can actually hear. But what I tell them before is that this is a training opportunity. We are not doing this to be punitive. We’re making this call so that you can see how you might be losing patients. Because I get those calls as well. Well, Jamelia, my phones are not ringing. Or my phones used to ring off the hook and now I’m not getting as many calls as I used to get. So can you figure out what’s happening here? In some cases, it is that initial phone call. Someone may be saying, oh, we’re booked. But the scheduler has not communicated with the receptionist or the medical assistant that a few slots just opened up because a couple of patients were discharged from the program. So we have a communication issue, and we also have a lack of knowledge that could prevent patients from coming in to get the treatment that you want to provide for them.

Dr. Mark Leeds [10:59] And for the patients, when they go to a program and they get started, I guess there’s not a lot of standardization across the industry of how doctors do their treatment. You know, there’s, you know, maybe doctors that have the idea that I know there’s one local doctor that I’ve I’ve read his his writings online and some patients have told me that his theory is that no one should be on buprenorphine for more than I think I think it’s six weeks. That beyond that, it becomes very difficult to come off of it, which is completely against what I believe that the current thinking is that it’s probably people should plan on somewhere around a year and a half at least and maybe longer.

Jamelia Hand [11:37] Right, absolutely. We need time to, you know, stabilize a patient so that we can actually support them in the treatment goals that they have. I think as clinicians, it’s really important. I’ll share with you the first physician that I ever worked with. He had been treating, and this was maybe back in 2003, 2004. So this was, you know, still very early, you know, after the launch of Suboxone. And I came to his office very early in the morning. He was one of the few physicians that did both methadone and buprenorphine, and he did them within the same setting. And he actually did a very good job at being able to provide those in one setting. But anyways, I was there. It was very early in the morning. I was sitting in the waiting room. His office staff had not arrived. He had a patient in an exam room and the door was open. So he didn’t know that I could hear. And of course, that’s a HIPAA violation, but I was really excited about the opportunity to hear a little bit about the patient experience and what type of things happened in that appointment. So one of the things that I heard him say that stuck with me throughout my work, he’d asked the patient, how do you feel when you feel healthy? And that question resonated with me. It told me that he had no intention of setting the treatment goals for the patient, that he wanted the patient to take control of their own recovery. He wanted them to do their recovery planning. He wanted them to do the work. He wanted them to ask themselves those questions so that he could know where to start. So they said, well, Doc, I don’t understand. It’s been a long time since I felt good about anything. And he said, well, tell me about a time where there were things happening in your life that you felt good about. And the patient started to reflect. He reflected on a time when he was in college. He reflected on a time where his marriage was intact. He reflected on a time where he was able to spend quality time with his children. So what I was able to take from that is that maybe his treatment goals are to reconnect his family. Maybe he wants to go back to school. You know, maybe he wants to repair his marriage or even find a relationship that he can feel good about. But those were his goals. The doctor did not impose his goals onto his patient. And that really stood out to me.

Dr. Mark Leeds [14:25] That’s a good point. This sort of treatment, medication-assisted treatment for opioid use disorder, it should be patient-directed. The patient, you know, where the patient’s at and what their goals are should determine where treatment is going. If a patient is not ready to start tapering or reducing their medication, it’s not really the doctor’s place to say, today’s the day, you know, this is the day of your plan that I’ve set for you that you will be reducing by this much. You know, so that’s, you know, but if the, on the other hand, if the patient really, really wants to start tapering, and they have a specific goal, you know, we can work with them. I mean, I can still advise them, well, you know, if you get to a point where you have cravings all the time, or you feel sick all the time, you know, maybe it’s not the right thing, you know, we should, maybe we should rethink it, and we should look at what you’re doing besides taking medication? Are you know, getting the proper support? You know, and of course, if a patient comes in and says, my goal is to be off of this in two weeks or four weeks, you know, then we should kind of step in and say, well, your goals may be unrealistic. Let’s talk about it more. And I mean, there may be those situations where a patient comes in and says, you know, I’ve been clean in Narcotics Anonymous for 20 years and everything was great. I have a sponsor, I have a great support network, and I just want to get off of this heroin. I had a slip and I want to get back to my program. And as you probably know, Narcotics Anonymous is not really MAT friendly. They disapprove, as official policy, they disapprove of the use of what they call replacement medications, methadone and buprenorphine. So maybe that patient really does want to quickly get back to where they were and to be clean in the eyes of their sponsor and their support network. And it still might be a bad idea. But maybe in those cases you work with him, you say, well, maybe we can plan for three months or six months or something like that instead of keeping you on medication indefinitely or for more than that time.

Jamelia Hand [16:22] Absolutely. And that’s what you are to do. You’re morally and professionally obligated to have those conversations, you know, to educate your patients, tell them, you know, what their options might be, tell them about the science and the evidence to support, you know, the recommendations that you’re making of them. I look at, you know, 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, your 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. If housing and employment is 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. 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.

Dr. Mark Leeds [17:54] There’s a topic I wanted to really get to talk about with you and I brought this up before with you through email that there’s this issue of maybe physician guilt about you know telling a patient you know when a patient asks how long am I going to be on this medication and you know addiction opioid use disorder and addiction in general is a chronic illness it’s like just like diabetes, high blood pressure. It kind of is. I mean, nobody wants to call something permanent, but it’s kind of indefinite. It’s going to be with you may be able to treat it without medication at some stage to some degree. And which is exactly like those other conditions, you know, blood pressure. When we first start treating a person with blood pressure, we give them a chance if it’s not too high. You know, let’s try diet and exercise. Let’s try lifestyle changes. Same thing with diabetes. Let’s try lifestyle changes. Is 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 disorder, they may need to be on this medication indefinitely. But there’s so much pressure from society, from the media, from what people around us are saying, that we’re just treating one addiction for another. We’re treating a drug addiction with a drug. So it’s 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 [19:26] 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 disorders should be treated. And because we have intervention across the spectrum from the federal government, that the DEA 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. 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. So I really think that for a very long time, you know, we’re just overthinking this. You know, 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. So one thing that I often say to people in your role is that this is your practice. Act like it. You know, 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, 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, you know, there’s no reason why you can’t set things up the way that you want them to go. 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.

Dr. Mark Leeds [22:12] And just to go over that, now buprenorphine has been around for probably even longer than that as a medication. I mean, we know it’s safe. I mean, so, I mean, would you agree? I mean, a person can take it indefinitely, and if they’re not having problems with 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 on it. Let’s take it away. That’s not needed, really. It can be continued indefinitely.

Jamelia Hand [22:40] Right. I totally agree with you. But we go back to that discussion. You know, 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, you know, psychotropic medication. It’s really important to allow the body to reset, you know, to calm down so that someone can know what it feels like to function normally over time. You know, 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. But we do this in addiction treatment across the board. We put these barriers and these time constraints. You know, it’s okay to put a time constraint on a goal, you know, 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.

Dr. Mark Leeds [24:03] 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 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. He came into my office, and he said, I had high blood sugar in the hospital. They treated it’s back to normal. So I’m done with that now they basically solved the problem and I had to have that conversation with them 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 don’t want to tell him forever but this is going to be a long term thing and it took a while 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. So there’s that element 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 [25:28] Denial. Yeah, denial.

Dr. Mark Leeds [25:30] 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 [25:43] Of course. Of course. I mean, we all do this is not limited to, you know, 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. 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 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. So I was in Kentucky, and I’m at the conference, and, you know, the day was going well. I got up, had a cup of tea. I felt really good about my decision to have the tea. The tea smelled wonderful. I’m walking down the hallway with my fancy cup with my name on it, and I’m drinking the tea. We go into the general session, which lasted for about an hour and a half, and then we got a break. The moment I step outside of the room, there are Pepsi products everywhere, and the cans are assembled in this diamond shape, and there is, you know, sweat running off the Pepsi cans. I mean, it looked like a commercial, and I had to have a Pepsi. 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. And so if it’s that easy, you know, for me to, you know, relapse on my promise, and then I felt guilty about it. You know, I can only imagine what people who are dependent and or addicted to opioids are going through on a daily basis.

Dr. Mark Leeds [28:07] 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. You know, the sharks that are not going to eat fish anymore. You know, fish are friends, not food. And then the one shark, he finally just said, I’m having fish for dinner.

Jamelia Hand [28:26] Right. Oh, gosh. It is something, you know. And I wouldn’t dare, you know, minimize what, you know, what your patients are experiencing with my little, you know, 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 opiate dependent. That’s just the name of the game. So why are they not getting involved? 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, you know, did I contribute to this? You know, 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’m part of the problem? You know, there’s a whole thing, you know, 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.

Dr. Mark Leeds [30:16] I can see that as being an issue and I would kind of agree with that on some level if it’s a pain management clinic you know one of these clinics where most of what they do or even all 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 kind of 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 and sit to get their prescription for Suboxone. And, you know, especially if that person coming in for Suboxone has had an issue with pain clinics in the past of maybe that was their source of opioids at some point. You know, it’s kind of like going to an AA meeting in a bar. Not exactly the same. So, yeah, but one thing I see as a problem, I went to a meeting, it was like a roundtable discussion where they were doing a marketing study for a new drug with a couple of other doctors who work in the field of addiction. One of them was 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 roundtable discussion, they asked us, what is the most difficult part of working with addiction patients? And this particular doctor, who is board-certified in addiction, that’s their entire practice, responded, my biggest problem is the lying. I can’t deal with the lies or the lies are really difficult for me. And I thought, 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. And I thought, of all things, that’s something you kind of have to accept and work with. And I think that could be possibly an issue for a lot of doctors. There’s a stigma of addiction. Doctors want patients to be straightforward and honest with them and they know that this is a condition where people steal, they lie, and 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. Therapy can help also, but I think that could be a barrier for a lot of doctors that 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 [33:10] 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 trained 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? And unfortunately, lying is a symptom. Also, even though a physician may have completed the modules and gone to the live training 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. And what I do is, as 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. You know, so her and I, we have a talk while 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. 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 decide not to do anything further about it

Dr. Mark Leeds [35:42] And the thing about lying being a symptom I mean you know and sometimes you know I’ve caught patients in lies and a lot of times a lot of times it’s almost funny that the lie was, you know, it was something kind of harmless or almost pointless. And I’m wondering, what was your motivation in doing that? You know, like 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 know, you were in a doctor’s office last month getting Suboxone. And, you know, a few months before that. And he felt really terribly. So, 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 wasn’t able to get this. And I said, well, that’s OK. And I said, don’t even worry about, you know, I mean, be honest with me. It’s a safe place. We can be honest together. But, you know, don’t feel bad about what you just did. I mean, it’s OK. I mean, it is just a normal thing. But, of course, we have to do what we have to do to catch those things. You know, like you said, the urine drug screens and, you know, just being aware and listening, checking the PDMP.

Jamelia Hand [36:51] 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, you know, 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 in 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. So let’s say you check the PDMP before the patient comes in and you know that they’ve gone to, you know, one other doctor to obtain, you know, Suboxone or an opioid. And they come to you and they say that they’re ready to quit. But one of the things that you might start with them and, you know, just put it out there early is to say, you know, 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, you know, 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. 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. Well, unless the jail has a treatment program. But, you know, 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, you know, in a week or so, we will. But understand that starting today, we need to be honest with each other. And they actually appreciate it. And if you think about the best teacher that you had, odds are it was the teacher that challenged you it was the teacher that held you accountable it was a 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 early on and it can set the tone for a high quality experience

Dr. Mark Leeds [39:41] That’s a really good way of putting it with you know that’s a really great way to explain it to the patient and that’s 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. 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 my patient’s diverting drugs and trying to get me to write more prescriptions. Even though, you know, it’s always a possibility, I think we have to believe that, you know, we have to know that our patients are not always lying and be their advocate also.

Jamelia Hand [40:57] Absolutely. It’s so important. And thank you for sharing that’s huge. That’s huge. But understanding the disease of addiction and, you know, being able to recognize the true signs and the symptoms is part of the, you know, the education that you pursue on a daily basis. I mean, opiate dependence, addiction, you know, treatment admissions are going up. They’re going up. There are more and more patients who are struggling and seeking medical care. And opiate 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. Now, granted, there are some systemic barriers, including federal laws, guidelines, you know, medication access, issues like prior authorization, you know, 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 know, 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 and barriers. 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.

Dr. Mark Leeds [42:56] Another barrier is there’s the media, and then if you look at some of the media articles, you see articles about rogue doctors and the new pill mill epidemic being the Suboxone clinics. I mean, they’re really working against the solution here, I think.

Jamelia Hand [43:12] Oh, yeah, that’s terrible. You know, all physicians, you know, are not bad. I mean, I know, including yourself now, so many wonderful, wonderful physicians who are doing everything that they can to ensure that patients have a high-quality experience and that they have access to what they need so they can plan for recovery. 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 you know staff is not on board with the type of work that you’re doing and they can get in the way and you know sabotage the great work that you’re trying to do but in this case we 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 you know, 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. 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 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? And he said to me, Jamelia, I don’t want to police my patients. You know, these are adults. And for the first time in their lives, I want to be the one person that treat them as such. And this was his belief. But unfortunately, over time, I wasn’t able to work with him anymore. Anymore because, of course, there was abuse and diversion, which we know. You 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. 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 on site was not part of his practice.

Dr. Mark Leeds [46:26] 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 [46:39] When you think about it, buprenorphine is not a drug of choice for most people. It’s a solution to a problem, you know, 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-IV criteria for opioid use disorder and found that I believe it was about 80% of respondents preferred to obtain and use buprenorphine the right way. 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, you know, 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, they may buy buprenorphine on the street. 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%.

Dr. Mark Leeds [48:09] 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 [48:28] Yes, and I hope and pray that, you know, that it happens. And there are many pharmacies where you can get it over the counter. And when I talk to health care 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. I’d actually worked for the makers of Narcan nasal spray, and I had the privilege of training close to 800 law enforcement professionals across the U.S. 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 front lines of that launch and helping people to get educated and armed.

Dr. Mark Leeds [49:29] And 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 kind of brings us to you know I mean every human being is valuable I mean everyone should have a chance and relapse happens and it can happen over and over again but also I mean there’s people out there that there could be that person on the street who in their eyes has no value and they maybe they believe they should be just let let go you know they did this to themselves but that person could be someone who if you know if they come around and they finally get better they finally go into recovery they could be someone that helps a lot of people. They could maybe be a sponsor. Maybe they could be a 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. And just, I mean, those could be very, I mean, they’re potentially very productive members of society that need help, and maybe they need help, you know, more than one time.

Jamelia Hand [50:42] Yes, and it’s their obligation. If the patient had diabetes, they wouldn’t withhold insulin. And I’d have to say that, you know, 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, you know, law enforcement, serve and protect. You know, 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, you know, to be very, very good at your job. But I did a talk at a state police association conference, 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. Now, at the time, you know, my heart was breaking. I had a father overdose. So I’m thinking, wow, you know, 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, you know, 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.

Dr. Mark Leeds [53:04] 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 who 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 it 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, they’re taking legal action against the hospital for not providing adequate addiction treatment. 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 [54:14] Right. And they’re ethically bound to do so. They should be morally bound, but they’re definitely ethically bound to do so.

Dr. Mark Leeds [54:27] 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 ERs. Nobody should walk out of an ER without at least being offered it or educated about it. And there’s a couple of ERs 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. And I know that 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 allowed to give a short-term prescription, even if they’re not certified, I believe that 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 credentialed in that area or certified?

Jamelia Hand [55:25] Yes. Yes, that is correct. So it is a great opportunity, as you mentioned.

Dr. Mark Leeds [55:30] 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 [55:39] It’s just in the emergency setting.

Dr. Mark Leeds [55:42] Okay. Yeah, but which is still good. I mean, hopefully almost everybody in the country is within reach of a hospital emergency department. And, you know, but yeah, that is an important thing. If all ER doctors could be educated on that they can start treatment and at least give a person a 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 [56:10] Absolutely. I agree with you. 15,000, you know, percent. And, you know, 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 have to ask the questions. They have to ask about drug and alcohol use. But it’s a very surface conversation that they’re having with patients because once they ask that 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, you know, what do you do when you have a patient who is with you that you suspect is addicted or dependent to opioids? 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 is yes. And then I research some of the resources within their community that they could use. One of the things that I do for all of my clients if they choose to purchase a service is I do a community, what I call a community matrix assessment, and I’ll build a profile. 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, you know, what is your treatment model? You know, if the physician is not available to you, what do you do? Where do you send them? You know, how are you treating this issue within your organization? To see if they’re actually a good fit for the physician. Because a physician’s office, you know, 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? You know, 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, you know, 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, you know, what they do in certain circumstances, you have no idea what they’re doing with your patient when the patient leaves your office and go to theirs for some ancillary service or treatment.

Dr. Mark Leeds [59:17] Yeah, and there’s that danger everywhere that a doctor is treating a patient with buprenorphine and then wants to recommend therapy because it’s required really. You really have to provide therapy at least by referral to a patient. Then you refer a patient to a psychologist, and you’re taking the chance that psychologist may be against medication-assisted treatment and tell the patient, you know, that this is not the right thing for you. We can work on this through therapy. And 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. 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. So I’m like, well, 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. You know it was all unnecessary but it was triggered by by just you know 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 people as many people as possible that this is what works and it’s you know please don’t tell our patients that they should quit their medication would you agree that there’s a huge opportunity for doctors that want to get involved that like say for example say there’s there’s a doctor working in maybe in an abusive workplace 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. They want to get out. Maybe they even want to quit being a doctor. It’s so stressful. And then, you know, 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 in 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 kind of set up a small clinic. You don’t need a lot to set up, just a couple of rooms, and rent a space or share a space with someone, and 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 a suicide. There’s a serious problem with physician suicide. Some doctors are very stressed out by the whole field of medicine, that this is a way that they could kind of drop out, but at the same time not totally drop out and provide a useful service and maybe save some lives, you know, just by helping out. I mean, would you agree that there’s an opportunity for a lot more doctors to get involved in this?

Jamelia Hand [1:02:12] 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 addiction on an outpatient basis. What they hoped was that physicians would screen and diagnose and treat within their own practices. So they get this certification and they take care of the patients who they identified in their practice were suffering. 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. 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, you know, this person has begun to take care of themselves. You know, 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 you know for the first time in decades you know 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 opiate addiction

Dr. Mark Leeds [1:04:20] Yeah the change is incredible I mean I and I’ve said I often don’t sometimes I don’t even recognize the patients when they come back. I mean, they look like completely different people. You know, sometimes in a week, sometimes two, you know, in some difficult cases, maybe a month, but usually earlier than that. And in 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. You know, but it’s really effective. And the thing is, it’s, and it’s not replacing one thing with another. I mean, it’s not like, I mean, technically buprenorphine is a form of an opioid, but it’s a very unique and complex medication in 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 their thinking isn’t clouded by drugs. Buprenorphine is a very powerful drug in the way that it blocks cravings. You know, the people tell me that they feel almost like as if they’d never been addicted ever. Like they feel like they kind of 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 [1:05:38] Yes, indeed. Yes, indeed. Absolutely. It’s amazing. It really is an amazing thing to watch. So, you know, outside of the business opportunity, which is, you know, which is what I help your colleagues with. Because when they call me, I always ask why. You know, why do you want to get into this? And preferably, they will say, you know, 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, you know, impacted by the devastation of this illness. 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, you know, 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. And, you know, not a bad person. I didn’t judge him, you know, 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, you know, soft and warm and gooey and do it for the right reasons and save all the parents and the kids. You know, that’s just who I am naturally and, you know, 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 worked. And he also had a good way of explaining things. So I thought that 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. I mean, he wanted to tell everybody. He had fallen in love with his work again. 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. You know, they adored him because he had given them their relative back. You know, so someone once said to me, you can do the right thing for the wrong reason and it’s still be okay. And now I believe that based on that experience that I had.

Dr. Mark Leeds [1:08:21] Yeah. Actually, there was a motive. It 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 kind of scared me at first because he kind of drove a junky car and he told me, you know, 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. And 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, you know, 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, you know, I mean, it definitely is worth it. And also, this kind of work does give you the opportunity to maybe be independent and kind of drop out from being employed and open and start your own practice and just really dedicate yourself to helping people.

Jamelia Hand [1:09:44] Right. Well, I love it. I love when they come to that point and to see that, you know, fire in their eyes where initially they were just, I mean, burnt out. So for them 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.

Dr. Mark Leeds [1:10:11] 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 [1:10:23] Sure. Well, you can find me at VantageClinicalConsulting.com. And if you visit my website, I do have a free e-book for you called Black and Aging During an Opioid Crisis, where I share my perspective on the opioid epidemic and treatment considerations for the aging minority client.

Dr. Mark Leeds [1:10:45] Jamelia Hand, thank you very much. Thank you for joining me on the show today. And 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 [1:10:54] Thank you for what you’re doing, and I think you’re incredible. So keep doing good things.

Dr. Mark Leeds [1:11:00] Thank you for joining us today on The Rehab on the Mental Health News Radio Network. I hope that you have found this show to be interesting and useful. If so, please subscribe to The Rehab Podcast and share on social media. I appreciate your taking the time to listen to The Rehab. Thank you.