WV Project ECHO Medication Assisted Treatment 5/13

great so Matt oh sorry go ahead do you want to click I get to do that yeah oh sure okay Thank You Caitlin okay so I wanted to talk about stigma today and the role it plays in our field because frankly I just don't think we can talk about enough I think the more that we talk about it the more we could become aware of it and help others become aware of it that's just consistently constantly helping our role in fighting it so that was why I just wanted to briefly touch on that today I get to be the only how's that go is it automates going to take me well so what is stigma stigma is an attitude behavior or condition that is socially discrediting oftentimes the major influence regarding stigma with addiction are the beliefs about the cause and controllability so it's our beliefs on what we believe caused the addiction and what controls the person or what control the person has over it the words we use have been shown by researchers to not only negatively influence our attitudes towards people in recovery and people who use substances but they also impact access to health care and recovery outcomes research shows that addiction is the most stigmatized condition worldwide and it's one of the few health conditions out there that some members of the public still consider just a moral or criminal issue clicking so stigma occurs at many levels the public level the private level in the personal level people fail to access or engage in treatment because of fear of what people might think they don't want to be considered a quote/unquote addict the medical profession often fails to treat patients appropriately like not using fda-approved medications mental health programs may exclude substance use disorder patients funding for substance use disorder treatment is insufficient to meet the demand substance use disorder patients are frequently sent to prison rather than treatment programs people in recovery are always under suspicion and if patients have a criminal history because of their drug use and this causes future stigma in terms of employment housing and educational loans so ultimately stigma be comes a barrier to acknowledging the program accessing help helping our patients remain in treatment just for some examples we want to take a look at our language I know for a lot of the folks that participate in this in this project here over the years you know you guys have all we've done a great job of over time trying to change out our language so for example where we used to use the term zit addict or abuser you try to use the term person in active addiction or person with a substance use disorder the old terminology clean and dirty urine is now replaced with positive or negative urine the term replacement therapy I will still hear from folks in the public and I'm always you know try to cook to be replaced that with medication assisted treatment drug habit used to be that's the term we used to call and now we stick with substance use disorder the war on drugs is also to me that was interesting that's the old terminology and now we really try to focus just on fusion harm reduction and treatment I'm sorry and then you know in the past we used to only hear folks introduce themselves as hello my name is John and I'm an addict and now we will often hear folks with it using different terminology for example how hello my name is John and I'm a person in recovery I teach a and into addictions course or the University and one of the members of the collegiate recovery program comes and does a little introduction to the class just to talk about the program and he specifically talks about the when he's out in public he likes to introduce himself as said and he'll say hello my name is John and I'm a person in recovery because it's his way of trying to help change that language in the general public but that for him personally when he still goes to a meetings or NA meetings for just his own recovery who likes to introduce himself as an addict so I like you know him sort of taking charge of what fits best for him in the moment in the moment I sure that I do people exactly you should yeah so is helping professionals we have the opportunity to help influence stigma and many different ways so we can do so with our patience by helping them to reduce guilt shame to the treatment process by offering moral support respecting confidentiality adopting a non-judgmental yet accountable stance from that very first time we need them treating the patient like any other patient with a chronic illness and I'll just take a second are there any other ways that you folks have learned over the years working with your patients to help reduce stigma with them we come we can come back to that afterwards and so it's helping professionals we have the opportunity to help influence stigma within our own coworker within our own selves and with our co-workers by educating colleagues about substance use disorder being a disease helping share stories of success and then we can include stigma with ourselves by being aware of our own biases changing our language and then finding support for transference issues that were generally going to face maybe I'll leave us some opportunity afterwards if there is any kind of open dialogue that folks want to have so we have the potential to be so much more effective with our patients if we talk to them with compassion and empathy early on an addiction treatment confrontation really used to be kind of the go-to model don't get me wrong I still confront my patients on the reality of the situation they're in by confronting them with force and aggression is really simply just a way to try to shame them into honesty and instead holding them accountable with respect that's a way to communicate I care about you enough to be honest with you so we want to have educate them on the fact that addiction is a disease the disease model of addiction shifts that national focus from blame to recovery and under a disease model addicts addicts are not amoral they're ill we want to educate them on the link between trauma and substance use disorder we want to show them why they deserve to let go of previous guilt or shame because those are some of the biggest relapse triggers for folks and then along the way we want to hold them accountable for their actions because we know that accountability great way to show respect I respect you enough to help you in this learning process I think I think Laura I'm not good with time frame I want to say it was in the last couple of months that she talked about stages of change but frankly in my brain the last couple of months could have been sometime in the last year if I'm gonna briefly touch base on stages of change just in the context of how I use it in my role as a helping professional but probably in the future we could it's really a good time to do another deck just on stages of change so when we're meeting a patient with an addiction it can be most helpful to first establish where they're at in terms of readiness to change so the stages of change model also called the transtheoretical model that's something i needa lies on a regular basis on a daily basis so I'm just gonna review stages here they go from there's the pre contemplation stage at this point the patient really has no intention on changing their behavior so maybe either they're in complete denial about having a problem or they're aware of it just not yet sort of willing to make any changes the next stage is the contemplation stage so at this point the patient is aware that a problem exists but just hasn't yet made a commitment to changing it oftentimes I see the most fear at this stage because the idea of change and idea of taking a risk is really terrifying at the preparation stage the patient has accepted there's a problem and is now willing to take action and start to make some changes at the action stage the patient is actively working on those issues getting into an attending treatment making changes within their life that support their goals etc at the maintenance stage the patient has made sustained changes in their life with new behaviors and is doing the work to maintain those changes and then at the relapse stage the patient is either falling back into old patterns of behavior or potentially on including actually using substances and so the so for me why I appreciate the stages have changed so much as it really helps me keep track of where the patients are at and where I need to be focusing my work on if I'm not careful maybe I'm meeting a patient at a pre contemplation stage and I'm trying to treat them as if they're in the in stage and if I'm not careful and accidentally shame them along the way because maybe my expectations aren't the same as theirs or my goals aren't the same as theirs and I'm trying to pull it over to my side as opposed to trying to meet them where they're at and so for me keeping stages of change is one way to help reduce that the shaming that can come from stigma and that was kind of why I wanted to present it here I think I think my last slide is just additional information on those stages of change so those those are my thoughts on stigma again I feel like it's something we can talk about on a regular basis because it's just a good reminder of what are we doing to combat it on a regular basis what are some accidental kind of old habits that we're falling into the stigma that we can help each other be aware of I don't know if you guys had any thoughts on you know what are things that you purposely go out of your way to do with your patients to help reduce stigma with them what do you do for your co-workers what do you do for yourself one of the largest groups of people is being stigmatized or people who are in long-term recovery on medication assisted treatment mm-hmm they're being taught by just about everybody that they're never supposed to say that in public they say they're on long term recovery they're doing great on recovery and everybody claps and is satisfied and happy and but if they mentioned that they're on effective evidence-based standard of care treatment everything goes downhill pretty quickly and I'm just mentioning that it's a problem I don't have a solution for it but it's I do have a few patients around here in Shepherdstown who are very proud of their recovery and are very proud of the fact that they have achieved that through a long-term suboxone but those people are few and far between yeah you you know thank you so much for sharing that we we hear that here as well for folks that are in the surrounding Morgantown areas that attend 12-step meetings around here some of them will say you know there's meetings that I go to and I can be really open and honest about being on medication assisted treatment and they're fine with it and they said or tit and and they don't really care either way and then some of our folks will say that they they sort of learn their lesson that when they explain to people that they were in long-term recovery and in a medication assisted treatment program that there was definitely some initial backlash that was one of the reasons that we started or we helped our patient populations start the butte group and it takes place at Chestnut Ridge and I'm jobless when I ask how old that meeting is I would say it's probably about three years old okay see I would have said here so I'm glad and it's specifically for people that are in a medication assisted treatment program and it's the 12-step philosophies so they know they're going to be able to go there and not get judged for whether they've been in this program a year or ten years so I'm so glad you brought that up that that is a problem yeah and of course you're referring to it in 12-step meetings and in groups like that I'm really talking to it in public I'm talking about people getting in front of an audience talking about addiction and possible recovery and treatment much on another issue on of problems but the the people you're talking to an audience like that are people if you're talking to a 12-step group they pretty well know what's going on they're already in the level of recovery of some sort that's because they're in that meeting but trying to get people who really don't know where to go next or how to go next that's we're not I don't think we're doing that well yet I don't know how yeah yeah very good point anybody talks on when you share oh yes sorry go ahead one of the things that I like to do with patients who talk about stigma is to point out that there are some exceptional people and your figures in our culture who have had addiction but have been you know important people in society like George Bush the President had an alcohol use disorder and he's in recovery and Oprah Winfrey had a cocaine use disorder and she's in recovery and Rush Limbaugh had a opiate use disorder and he's in recovery so he's all you know notable people who achieved tremendous things and successfully live good lives you know productive wonderful lives despite the fact they have an addiction and I think that kind of refrains it that you know it doesn't have to have such a negative connotation yeah absolutely oh that's a great idea one of the activities that do with the group's here in our city and system bill will do a values-based exercise I'm paired him with guilt and shame and we'll have them identify values and also look at which values are present now recovery which weren't present for which one they're not acting on in active addiction and then where those values still there though and buried because without guilt and shame even though they're uncomfortable to feel they show us that those values we're still there that they weren't a bad person even during all of that just I love that that makes me think um one day down the road I could see it being useful maybe in one of these echo calls where we sort of all talk about like what's art what's your favorite group that Iran or you know what's the group that you feel like it's the most you know activity from your group members or even an individual therapy session I can see that been really helpful because I can tell you I'm probably gonna steal your group idea yeah feel free to how to use on just like a list book into the twenty act books without use I'm actually usually to the the card sort the values card sort and we'll get everybody a copy and they'll just start clearing out values will write it up on the board and thank you for sharing it I know one thing we've been using amongst our medical professionals is really contrasting substance use disorders the chronic medical diseases for example they might ask us well why is your patient still on suboxone even after two years and we would say well hey if I had a diabetic and they started them on metformin what I tell them to stop the metformin in two or three years and I think when we provide good medical examples like that to kind of get it that's been helpful for us that really you know I've only been here just not rich for nine years when I first came that was something that dr. berry really helped me with with that I don't want to give him credit because it makes there's mustache to make but he really helped me recognize that the you know sort of comparing it to so many other medical illnesses that people are more familiar with that that helps sort of give them a framework of comparison another along the lines of what you were saying about the language that's used so like instead of a cleaner dirty urine a positive or negative urine in the in the coat clinic groups I'll talk to patients about how I don't use clean or dirty and they're drug screens because they're not a dirty person if they use so I I like to say that to kind of say you know I think it's a bad connotation for use and talk about kind of their identity song because I think how they view themselves is kind of the key to the problem with stigma and so if you can change their identity it has a big health outcome dr. Hirschl er I am NOT making this up when I tell you I had a peacoat today and there's somebody in my AP code who I think was out at Lakewood and somebody else in the group had I was just doing that the check-ins for them just the beginning in the group and I was asking them how many days over they had and somebody said I had three days clean and one of your patients corrected them and said well dr. Hirschl or would say that you're not a dirty person you know and literally that just happened this afternoon so when you like that's a great example of when you share that with the patients to them everything we're just finishing up a topic on stigma oh I think I know another thing our group has been doing a lot is trying to get our patients to focus on what makes them them right because addiction is a disease it's not who you are and so we try to draw out or what is your family which is it like like what makes you a valuable member of society because it's really amazing when you first encounter our patients in the group they really think of themselves as no good and worthless and a total mess up and that's not the case they have a lot of value so I know for us in Charleston we've been they're really trying to work on self-esteem issues we ask you a question Katie so you were talking about the stages of change the transtheoretical model and you and of course in group therapy you have people in different stages especially in the weekly groups you know or early recovery groups where someone might be kind of further along and abstinent for a while on someone else you know maybe pre contemplative but getting the medication for to reduce third is to use heroin or whatever or sell their suboxone to use something else or and so if you're targeting one person in the action stage and someone else in the pre contemplative stage though I just wondered you said that that you shame them by by talking about action when they're really in a pre contemplative stage do you think that affects them that way if you're talking to a different person in the group so question you know I have often so I often try to teach my especially that's a really good plan especially if there's a group where they are sort of all over that model it's not you know 95 percent of armor in one stage and maybe one person is another stage if there's a group where they're they start all fit in that model then to me that's a great time to teach them the stages of change model and how we use that as a way to kind of help them objectively look at their group just the group dynamics in there and help them understand on an objective level that people are in different places and that when were you know talking about solutions or solution thinking for every person that it doesn't have to be for them if that's not fitting for them but I also think if you know font out let's say doctor Zhang's and on stage and I'm talking with him about ideas I'm not singling out Lawrence if he's not in that stage but he may be hearing some things that I'm sharing that's gonna be planting some seeds for him that's my hope as opposed to temp in Lawrence well Lawrence you're not what dr. Zhang is so do what you can to get there as soon as possible if that makes sense okay thanks dr. Diane Lawrence for filling in for my group you mentioned something about the war on drugs which and of course then we have the business of trying to treat patients while they're in imprisoned or in jail and it's kind of a double stigma isn't it that they have two stigmas one they're people with addiction and two they're people who are felons are in prison and the people who are controlling their their future who they are what's happening to them isn't us it's not well-meaning clinical providers and so a lot of a lot of bad stuff is happening there and I hope maybe somewhere we can we can start getting the jails and the prisons to start treating these people like they have a disease they of course like to use the word choice they made a choice and that's about as far as it goes yeah did I just see in the news last week or two weeks ago that I don't know which state it was but that a judge ruled that that they had to be provided medication assisted medications in jail was that anybody else yes it was methadone yes that's right it was only one person but it made it a class ruling so we'll see what happens with it yeah the idea of course one of the processes in jail is of course the diversion in jail is what it is on the street 100 times over mm-hmm and so the the price of suboxone strip in jail is several times higher than it is out on the street and so direct observed therapy is obviously a better way to do things so to speak and but but still it's would be very good to be able to start these people in the humane treatment protocol and have them experience that while they're a captive audience so to speak and by the time they leave they've experienced recovery on a level that would be great yeah absolutely any other thoughts or one other thing I'm gonna be the devil's advocate here so I don't think stigma is all bad okay I I think that stigma makes people with mental illness and addictions want to be healthy and if there wasn't a negative connotation to the behaviors and to the pathologies that people have there would be less incentive to be well so I'm not sure how you frame that exactly you follow what I'm saying I think I think so tell us a little bit more about that well so y'all patient is using methamphetamine and their family says they're the black sheep of the family and they're an outcast and so one person may respond to that stigma and never grow out of it and never improve whereas someone else will say you know I don't want to be excluded from my family and so they're motivated to get treatment and turn their lives around because of the stigma sure I've heard of that yeah yeah justice bill in Charleston well I think one of the differences is though is looking at the behavior of the behaviors as being bad versus the person being bad done a bad thing but I'm not a bad person you know I think that that helps you know that's the issue of accountability that she was talking about earlier or at least that's the way that I've tried to frame that you know that and it goes all along with the the notion of shame versus versus guilt you know if I've done a bad thing I can change that if I I'm a bad thing there's no there's no change so you know that goes along also with doctor what doctor though was talking about with the self-esteem it's really not about who they are it's something that they have and it's also not the entirety of who they are it's only a part of who they are they have a disease they aren't a disease as well yeah oh thanks for sharing that bill I like that yeah anybody else it's just one minor points so much of this discussion of stigma about half the time we're talking about the person feeling stigmatized and you know other half of the time we're talking about the community the people the surroundings stigmatize the person that is hold a stigma against that person and of course the solution of those is two different things yes the person's sense of being stigmatized has to be addressed but also the community has to get addressed too and that's a different different subject altogether I was just thinking of that in the context of the transtheoretical model though it seems that maybe we have communities of pre contemplates and you know and you have different pre contemplate errs you have reluctant pre contemplate errs you have resistive pre contemplate errs you have ignorant pre contemplatives or uninformed pre contemplate errs and you know that's part of the issue I think with the community is just you know trying to catch all those different people and and that there's going to be resistance in different ways so one of the things I think that we haven't done is maybe educate the community about the nature of you know the the the suboxone and subutex and so forth don't don't really change level of conscious for in a bad way you don't you don't get the intoxication so the big immunity stages of change model I know dr. berry I mean and I think probably some folks on this call as well have participated in some town halls over the years as new treatment centers or treatment providers were opening up treatment centers in their community to kind of talk about some of those you know some of those misconceptions about what that treatment center was going to do for the community and I think it sounds like sometimes it's been really helpful and sometimes it's it's been borderline helpful all right awesome everybody thank you so much Katie oh yeah thank you if you guys have any more questions or comments you're welcome to throw them out there I just wanted to take some time if anybody had anything they wanted to talk about we don't have a case plan for today so if you guys have questions or want to impromptu ly submit a case or discuss a case I have a general question about approach to pregnant patients you know I think that's a special population where harm reduction takes a greater emphasis and perhaps in someone some other patients and I just wondered in general how you guys are approaching pregnant patients and I know we have a special clinic for that population but some of them don't end up attending that or they wind up in AP codes or so I just thought it'd be a worthwhile discussion about pregnant patients and the approach to that do we want to let other sites sort of talk about how they handle that first era nhoa city we just basically put them in a separate group we don't have enough patience like to be here to do group pregnant patients but the whoa what I've gotten over the years with presenting all my pregnant patients the sort of a protectionist plan is that we don't throw them out for it almost anything and except for if they get really out of control with recurrent benzo years as the only thing and even then it would just it would be a you have to go to w the ear thing it's how I handle it so we we just escalate the penalties the same way we would with a non pregnant patient to intensive Matt or daily they made daily visits if they're breaking all the rules and we just give them priority in and and priority to not discharge them is the only sort of special things we're doing with pregnant women of course see by the new hall you have to also say that you offered them same sex counsel it would be good sometime a future session we have a new detox crisis stabilization clinic facility whatever it's called opened up here seven plus days movie treatment end quote and we also are opening in the process of opening a long-term rehab 21 28-day program I'm not a big fan of either of those with moderate or severe opiate addiction I don't think they play a huge role but they're here they're required to offer have available make part of I'm not sure what the phrases have Matt medication assisted treatment to be part of their program and both programs are struggling with that because they're not an outpatient clinic we know how to do that in an outpatient clinic they're also not a hospital but the long-term rehab is going to have 48 in patients with nursing staff giving their regular medications every day just like nurses do on the words and real hospitals and I have no idea how that's supposed to work and I've talked with them and it's pretty it's pretty challenging it might be good to have somebody or a couple of people who are running a crisis detox center and I know I know of one good one there in Clarksburg to have them explain how that's done in the context of setting them over to Matt as soon as they're discharged or starting Matt while there while they're there the same thing for the long-term rehab the effectively run the properly run the the oh flack approved programs just to see to get us some wider experience for how we're supposed to do that maybe we're we're strictly coached and we're strictly outpatient based mat programs and maybe we can think of it wider because these programs or other programs are supposed to be using that as part of the program yeah we can definitely speak to that either at a later time that for saying I don't know if you have any thoughts on that for this program let me ask you dr. artists this is this is this a 21-day a residential program or what kind of program uses okay it's two different programs one of them as a 28-day inpatient program and the second one is a seven days eight for whatever ten day detox crisis okay we have a city we have a very similar treatment residential program here is a 3.5 residential treatment program 20 days then we attach through same building we have a detox unit we just open it here in Morgantown it's more for people it's three seven three point seven a level facility but for we we send people there mainly we are pretty sure we're very selective we know those people do not have complicated withdrawal complicated detox so those people I get basically they're pretty young healthy and they're very short admin table or maybe just Seva see what you got paper taping protocol so those people what we do is like we send them to this detox unit it helps them a lot because because they can be transitioned into 2020 they program very easily so I don't know because your programs like a 21 day inpatient program so I guess it's kind of a little bit different but it's it's 28-day I believe it's going to be 28-day but it was originally designed without Matt involved and Matt got sort of stuck on because of the new rules in West Virginia so and and they're there are different programs ones on one side of the town the others – the outside of town it's not even in Martinsburg I see because we want you know that well the situation I see a lot because uh didi you do diagnosis you know we have 12 beds and we have a lot of readmissions because we understand like a statistical admit for the whole country only 10% people seeking help and actually 70% of people we see every day in our daily practice a relapsing patients so so when I see on didi you we have a lot of readmissions some all times because it's very hard to get them to a long-term rehab program so it's it's because they have to go after detox even if we put them on these and maybe suboxone I'm eighty the problem is like if they go back immediately immediately to the same living environment so the problem is like they you know basically they they're either offered or they you know they they just you know they they stay with people using accurately using all the time so the long times I think this 28-day program since we started this 28-day program I have seen some definitely some changes because a lot of people go can be transitioned we are lucky enough because those people because we take people a lot of 20 they programs that you know I don't want to tell people and maybe that's a big stigma and we can you know very much related to what we just discussed so now we have this 28-day program we have 30 you have 30 baths and open for those patients from ddu and most impatient that refer from didi you then they they they just go it you know directly to this 28 days then they're doing these 20 days we have a lot of you know we have we have time to arm them with with a lot of tools to help them with relapse but in the meantime we do have time to develop a good plan for their you know sober living or different kind of living situation changed so I think I think this program could be very very helpful that's what I think at least you know for this population who are kind of frequently relapsing and a lot of readmissions to to detox unit so I think I think it's very hopeful even not 21 days could could be could make a big difference I hope it does we need something here please take a minute I was in Charleston a couple weeks ago and I ran into an old box that runs a 20-day male facility and they are now going suboxone with Northwood and wheeling and they are not comfortable storing it on-site for obvious reasons so they have made a partnership with a pharmacy in town where they drive the guys down in their band every single day and do daily dosing the guys pay a little bit more because the co-pays are more but they have agreed to do that so they're taken down to the pharmacy every single day a lot so it's a it's a lot of work especially when you have a sub you have a methadone clinic patient that's that's a lot more work because you have to work with a methadone clinic OTP but one last thing we have learned is we take people with with sobota mhe however before because we you know we send patients there and give them 28 April a 28-day prescription of suboxone because we because nobody nobody there with prescribe suboxone so there we we learn a lesson because of because what we have some patients left after two or three days a may so just two or three days but they left with 25 days prescription so that that was a big problem so we noticed that luckily those patients came those three patients actually left AMA and early stage they came back to emergence room and the way we just got them you know into treatment quickly but so what we are doing now is we give them one week prescription man we just renew it so they leave with seven days prescription it takes the seven days prescription to the residential place man we just we just renewed if they're still there otherwise they don't get a prescription they don't get a lot of films you know with them to leave a may so that something probably could be helpful yeah for this new place Thank You Jepsen so just real quick going back to the subject of pregnant patients in the Koch clinic oh yeah so in morgantown of course we have a clinic just for pregnant patients men that group things are done a little bit differently there's a little different rules regulations and things like that such as we allow those patients to count OB appointments as a recovery meeting it kind of get them motivated to get to those appointments what what else yeah that's been mean I think they just try to keep their OB team very can their OB treatment very connected to their addiction team in the in their work they're doing here so yeah so any kind of visits over there account for what some of their requirements are here there may be a little bit more they try to be more flexible with scheduling their individual therapy sessions to make sure that it happens at one point they offered at one point we had we get volunteers from the nursing program that would come over and help offer childcare in those groups education is also a big factor in those groups too they bring people in to educate the patients on several different topics so we have that program any patient that we have pregnant and the code program we offer them to be able to go to those groups now if those patients deny that and they stay in the code program then we treat them exactly the same as we do every other patient and the regular code program so they follow the same rules same regulations they'll get dismissed from the code program just as easily as any other patient in that program but also we try to encourage prenatal visits I think one prenatal visits cut can be counted as a meeting something like that right yep so that's and the pregnancy clinic um if they can't they can count those in the pregnant funny but it there in the coat program they have to go to the same amount of recovery meeting sometimes any questions about any of that to play that answered dog there's that question where Tyler in a bed actually I have a question about that so do you have two full separate groups of pregnant patients one is like pregnant patients and one is noncom pregnant patients know so so we have a code group just for pregnant patients we actually have two weekly groups um that just consists of pregnant patients but then we also have pregnant patients that are intertwined with the rest of our program so a patient in my weekly group who gets pregnant while they are already established in that group sometimes they don't want to move over to be to our pregnancy clinic because they they know their group they like their group they know their doctor their therapist they would just rather stay there you know just because we have a pregnant patient in the coat clinic we don't require them they go to the pregnancy clinic but we offer that so they don't go to the pregnancy clinic then we hold them accountable for the exact same rules regulations and so forth that we do all the other code patients but if they go to the pregnancy clinic then there's different things that's offered to them in that clinic does that make sense yes I'm curious about the big difference in what would lead you to be discharged from the special pregnancy clinic or what protections do you have there you're giving up to stay in the regular code clinic as a pregnant woman that's a great question some of this what I might do is is talk with Laurel Lander who she runs the pregnancy clinic so I may run this by her afterwards that I can kind of email you maybe what some of her specific answers would be for that you asked you asked a very good question sort of one of the what does it take to get dismissed from my clinic I think it's a lot you know I think they really tried to sort of give folks chances and get them involved in additional treatment if they're struggling before they would refer them outside of that group just because they're able in that pregnant I mean it's pregnancy specific so they're able to focus more on the patient's recovery and also the pregnancy where in the regular coke group pretty much the only thing we're really able to focus on is their recovery so they're able to focus on a lot more different things than that program I think the big areas that I'm not sure where to go on pregnant women is strongly suspected diversion and confidentiality breaches it's one of the reasons I like keeping them separate so that when to worry about a confidentiality breach because this I historically in order to try to protect myself from CFR have warned patients that breaching other patients confidentiality can I can't kind of thing in my group program anymore they're out of the clinic yeah yeah yeah I'm not sure that's that kind of rule I'm not sure that's a rule that we have different in any of our clinics because that's a really important value for all of the clinics to hold on to yeah I'm not sure that's one that the pregnancy clinic folks really would treat differently I'm looking at Douglas as I say that because I I'm not sure I'm a hundred percent with that answer right I feel pretty confident about it good do you remember have we ever dismissed any patients from pregnancy group so from the pregnancy group I'm sure that they have I mean I can't confirm or give a specific time that happen because I don't case manage the pregnancy group but I can almost guarantee you that they have dismissed patients from that group now they're not going to dismiss them what the tapirs correct there's you know out to the streets or anything like that they're gonna refer them or at least try to refer them to a higher level of care such as our advanced for base Nariko clinic or a daily check-in clinic or something like that they're not just going to give them a taper strip and let them go maybe it'd be helpful to have Laurel and their email all of us kind of the philosophy and you know approach to pregnant patients in the suboxone program yeah absolutely I will make myself a note on that that might be um you know should be able to answer some specific questions and there might be a good idea for a didactic in the very near future yeah we'll get that planned I'll make sure we send that out to everybody great guys do you guys have any other questions or anything you guys need to talk about in about ten minutes left I think it's been a great discussion for not having the case alright well thanks for your time thank you awesome everybody let's see our next session is on actually no no it's cancelled our next session is scheduled for Memorial Day so we will not be having it on the 27th so I'll email you guys that reminder of course if you guys do need anything in that time feel free to send it in and we'll we'll continue to get to it though we have a wonderful day thank you thank you so these people are interest

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