Harm Reduction in the Hospital

Episode 2: Harm Reduction in the Hospital: Meeting People Where They Are

Featuring:
Marlene Martin, MD
Associate Professor, University of California, San Francisco
Director of Addiction Care Team, San Francisco General Hospital
Director of Addiction Initiatives, Latinx Center of Excellence

Kimberly Sue, MD, PhD
Assistant Professor of Medicine (General Internal Medicine), Yale School of Medicine

Hosted by:
Amelia Goff, NP
Assistant Professor, Oregon Health & Science University, Portland Oregon. Improving Addiction Care Team (IMPACT), HRBR Clinic

Episode two highlights how hospitalization is a known opportunity to offer addiction services, including harm reduction. The philosophy of harm reduction and harm reduction supplies can be incorporated into healthcare settings. We describe two approaches to implementing harm reduction in a hospital setting, with a focus on obtaining support, implementation, challenges, and lessons learned. The two resources presenters wished to share with listeners can be found at: lawatlas.org & nextdistro.org . 

Find us online at amersa.org, and see our tweets at x.com/AMERSA_tweets.

Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Learn more about PCSS-MOUD at pcssnow.org.

Transcript

Kinna Thakarar: 0:13

I'm Keena Thakkar and welcome to the podcast series, Harm Reduction, Compassionate Care for People Who Use Drugs. Harm Reduction is a social justice movement started by and for people who use drugs, and it's a philosophy of care and practical set of strategies to optimize people's health, safety, and rights. We want to acknowledge and honor the long history of street medicine and healthcare developed by people with lived and living experience to keep one another alive and safe through community care. Whether you're a seasoned harm to the concept, we're glad you're here and hope you'll learn something new and are curious to explore seeing patient care through a harm reduction lens. This podcast series is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project, and AMERSA. This week, we welcome Amelia Goff in conversation with Dr. Marlene Martin and Dr. Kimberly Suh to discuss harm reduction in the hospital, meeting people where they are. Our host, Amelia Goff, NP, is an assistant professor of medicine at Oregon Health and Science University, where she works on the multidisciplinary hospital addiction consult service, improving addiction care team, and in the Low Barrier Addiction Medicine Clinic, Harm Reduction and Bridges to Care, serving patients across Oregon's rural and urban communities. Her particular interest is improving healthcare systems to increase access to evidence based addiction care, including integration of harm reduction and overdose prevention services. Marlene Martin, MD, is an Associate Professor at UCSF and Director of the Addiction Care Team, ACT, at San Francisco General Hospital. ACT is an interprofessional consult service that provides compassionate care focused on harm reduction, evidence based treatment, and linkage to care for people with substance use disorders. Drawn to medicine to address health inequities and social injustices, her interests lie in systems improvement and innovation with a focus on addiction, community partnerships, Latina health, and care transitions. Dr. Kimberly Hsu is an assistant professor of medicine with the Program in Addiction Medicine, Division of General Internal Medicine at Yale University School of Medicine. Currently, she serves as an attending physician Central Medical Unit, Abt Foundation, which provides primary care to patients receiving methadone and other substance use treatment services and supervises fellows and trainees within the Yale Addiction Medicine Fellowship Program. She is also an attending physician on the hospital based Yale Addiction Medicine Consult Service. Her current research interests include harm reduction, stigma, gender, women, and substance use, and overdose response strategies on local, state, and federal levels. The presenters reported nothing to disclose. Thanks for joining us, Amelia, Marlene, and Kim.

amelia-goff--she-her-_1_04-26-2024_101854: 2:55

Right. Thank you so much. Kina. Welcome listeners. It's great to have everyone here. I'm Amelia golf and I'm your host for today's episode. We have a great conversation planned. We're going to discuss harm reduction care in the hospital setting. I'm really excited to be here with our 2 brilliant guests. Marlene Martin and Dr. Kim Su, who both have expertise in integrating and delivering harm reduction care in hospitals. First to kick us off, I'm going to share our three learning objectives for today's episode. We're hoping that these will be important pearls that you can take away from our discussion. listening to the episode, listeners should feel confident describing strategies and steps to gain institutional support for harm reduction interventions. identifying potential challenges when implementing these interventions and ways to address these challenges, and discussing how integrating harm reduction into standard addictions care in the hospital impacts patients and staff experience and outcomes. Marlene, Kim, welcome. Thank you so much for being on the show. It's wonderful to have you both joined today. Would you mind introducing yourself to the audience? Tell us about your current roles and your hospital based addiction care practice.

marlene-martin_1_04-26-2024_101853: 4:16

Yes, thank you so much for having us here, Amelia. My name is Marlene Martin. I'm the Director of the Addiction Care Team at San Francisco General Hospital and I work for UCSF and I'm also a practicing hospitalist.

kimberly-sue_1_04-26-2024_131853: 4:29

I'm an assistant professor at Yale in the Yale Program in Addiction Medicine, and I see patients on the Yale Addiction Medicine consult service several times a year, and I also see patients in the outpatient setting doing primary care at an opioid treatment program.

amelia-goff--she-her-_1_04-26-2024_101854: 4:44

Terrific. Thank you so much for being here. start out, could you both describe the models you've used to integrate harm reduction in your hospitals?

marlene-martin_1_04-26-2024_101853: 4:56

I'm happy to get us started. A couple of years ago we were looking at whether providing harm reduction services in the hospital would be something that our patients would be interested in. We are based in San Francisco and there's a few different syringe service programs. That are embedded throughout the city and so we were wondering what the role would be for harm reduction services in the hospital setting. And so 1 of our patient navigators. Led a needs assessment with patients and ask them, like, if they would be interested in services, if so, what services would they be interested in and why? And we heard an overwhelming. Yes. From patients. Some people were not familiar with harm reduction and we're really interested in learning. Some people were new to San Francisco and not yet connected to community syringe service programs. Others talked about when they leave the hospital, getting to a syringe service program may not be their 1st priority amidst the many other things that they have to do when they leave. So, once we showed there was a clear need from patients, we then partnered with a community based organization, the San Francisco AIDS Foundation, which provides and 1 of the syringe service programs in San Francisco, and they were just so wonderful. They educated our whole team about harm reduction about supplies. About the education piece, and then they also said that they would be willing to provide the supplies that we needed. And so now, with the patient need and with a community partner in place, we then went to hospital leadership and we showed them the data we showed the evidence for harm reduction and we shared that we already had a community partner. And then we worked with the hospital leadership and our regulatory department to really create a workflow and we partner closely with nursing on this. Then we were able to pilot the harm reduction intervention that we planned after building a workflow on 2 of our medical surgery units. With lots of input again from nursing about, storage of the kids when to give them to patients. And once we did this in two units and we showed the evidence and the impact, we were able to broaden our effort throughout the hospital. And then one of our health network physicians, Dr. Joanna Eveland sort of spread this model throughout the city at the other health network clinics.

amelia-goff--she-her-_1_04-26-2024_101854: 7:15

Wow, that's an impressive amount of collaboration and strategic planning that was necessary to pilot and integrate the work. I really appreciate you sharing all those details. What about in your system,

kimberly-sue_1_04-26-2024_131853: 7:32

Yeah, I would say it's different than Marlene's. Actually, it's much more informal. We have most of the supplies come through the Yale Addiction Medicine console service, we wanted to build on those relationships similar to Marlene with existing syringe service programs. in New Haven. So we partnered with the community health van at Yale that does drug checking or syringe service programs, wound care in the community. So they are a very well established program. And we felt it was really important to establish that relationship, especially when someone's leaving the hospital and going into the community because of the chaos that can happen when you're discharged, there's so much activity and stress. And we wanted to ease that. And we wanted to really bring supplies to people like Marlene's program as well, knowing that similar to programs like meds to beds, that it's hard for people to get what they need. And, let's decrease barriers to that access. So we talk to people about harm reduction, we talk to people about educating them about safer use, and if they're interested, we give them supplies on discharge, and we want to see if they're enrolled as clients or participants in the syringe service program so that they can have ongoing longitudinal harm reduction care, because really, if they're going to continue to inject drugs or continue to use drugs in other ways, we want Then we really want them to have those touch points and build those relationships with syringe service programs. So, it also comes to us from different departments or different other consult services might consult us and we can carry our supplies, from, provided from the syringe service program.

amelia-goff--she-her-_1_04-26-2024_101854: 9:17

Fantastic. So there are some differences, but really both of your addiction consult services have built in this workflow to deliver full spectrum Addiction services, including safer use discussions and supplies. Kim, if you could tell us how harm reduction in the hospital setting can address some of the inequities that we see in addictions care.

kimberly-sue_1_04-26-2024_131853: 9:41

Yeah, I mean, I think providing this service and the education as well as the supplies can really directly address some of the inequities we see in addiction care. First of all, there are many people who are not on medication for opioid use disorder, and we really want to engage and care for those people just as much as we care for people who are on medications. We certainly want to start them on medications if possible, like methadone and buprenorphine. And we also want to provide it for people who are on medications who are using on top because we do know that that happens. And we know that we want to engage people in which they might have limited English proficiency, people who might have an uncertain sort of legal status in this country. know that it's a way to engage people who use stimulants primarily, as well as people who lack access to those structural determinants of health, like things they need to exist and live on a daily basis, like housing, transportation, and phones. The more we can create that therapeutic relationship with a harm reduction mentality and harm reduction supplies, see as ways to address directly inequities that are present in access to harm reduction and access to addiction treatment.

amelia-goff--she-her-_1_04-26-2024_101854: 10:59

Thanks, Kim, for highlighting how we really need to protect the dignity and health of all people who use all substances and the hospital is an opportunity to be thoughtful about equal access to those resources and treatment for minoritized, marginalized groups, including harm reduction. And Marlene, this is making me jump to and think about the equity piece your recent study that you conducted with your team. I'm wondering if you could share what you learned when you interviewed staff and patients about their experience with harm reduction practices integrated into hospital based addictions care, and what the main results and takeaways were.

marlene-martin_1_04-26-2024_101853: 11:45

Yes many of the things that we find that harm reduction does in community settings In terms of equity we found similar results in the hospital. In our patients, we found that it increased access to both education and supplies. I want to highlight the education piece because many people practice in different settings. Right? In some settings where they may not be able to give supplies, but really the education and the philosophy of harm reduction is something that we can all incorporate in our practice patients who identified as Black and Latine particularly found that they had not had a lot of the education and exposure to harm reduction practices in the past. And then people who identified as primarily using cocaine and methamphetamine also shared that they learned new harm reduction practices. The second thing that we learned from the study was that the harm reduction intervention in the hospital rebuilt trust and improved the care experience for patients. People said that, they really couldn't believe that we were offering harm reduction and that we acknowledged their goals, right, which if it included return to use, if it included perhaps not necessarily starting medication for opioid use disorder, but that they felt seen when we offered them harm reduction supplies. And then we found that it catalyzed culture change and destigmatization and even, when people express like, ongoing stigma, the people who did express that shared that what they had learned through the harm reduction intervention was that it just made sense that the data was there. And of course, we should be doing this. We did face some challenges with implementing this. Some of those included the hesitancy about the legality of this, and it was so good that we had run this by many different leaders across the hospital and had them on board, had regulatory on board. And then as we were discussing this with staff, people just shared that they wanted more education about substance use. So that was kind of a surprising result that came out of, you know, we're talking about harm reduction here and then, the staff that we're chatting with are identifying actually, we have this big need and desire for education. I guess it's not surprising because none of us really who trained earlier on had been exposed to addiction education, but that the culture was shifting such that people were now demanding this. I think that was a surprising piece for me the remaining stigmas I discussed and then patients who shared, there was one patient who participated in the study whose goal was actually to not return to use, and they had a kit delivered unintentionally. And so they woke up and saw the kit there, and they were wondering, like, why was this kit delivered to me? This is triggering. And so just being really careful in assessing patient goals as we're performing this intervention.

amelia-goff--she-her-_1_04-26-2024_101854: 14:38

Karleen, this is such impressive work, and I think the opportunity to think about harm reduction is not one size fits all. And that final example is so important that patients are seen as individuals and what's important to them and make sure that we're centering their priorities and appreciate you highlighting the need for education and that kind of exciting finding that it was something that staff regardless of discipline were interested in. I'd love to just highlight, you know, Folks checking out that publication since I think it's so important in helping to highlight that harm reduction needs to be a standard of care in hospitals. Speaking of standard of care and what else we can be doing, Kim, could you give us some advice about how hospitals and healthcare workers who are motivated to offer these services and care, but practicing in states where harm reduction supplies to patients might be challenging to give? For example, if they're in a state with limited paraphernalia laws, could you talk a little bit about that?

kimberly-sue_1_04-26-2024_131853: 15:41

I'm really happy to. One way to address this and answer any questions and make sure that what you're doing is ethical and also in line with regulations and rules within your state is to talk to the Network for Public Health Law. They're a great nonprofit legal organization they focus exclusively on understanding local, state, and federal laws, especially regarding increasing access to harm reduction is a main priority of them. So feel free to. Reach out to them, tell them that, you heard this amazing podcast and they can work with you and advise your legal counsel, or just advise you on what the laws are in your state. There's also a law atlas online, and we can probably share the link with you and some notes where you can look at syringe policies and laws syringes considered something, it's paraphernalia, for example and, better understand that for yourself. I think the goal for us as clinicians is really to develop relationships with our harm reduction agencies. If you have them in your state and really trying to build out those relationships will strengthen the clinical care and the advocacy that we can do. If they're not there, there is a national online harm reduction group called next distro dot org and they can send supplies to your patients, you can offer them that information and they're a mail based syringe service program with a bunch of supplies as well as amazing education. Another thing that I do in Connecticut that, you have to check with network for public health law or others around you is if you can't necessarily distribute supplies directly to think about how else can I partner with other types of professionals who can get people what they need. So can I work with pharmacies? Can I work with pharmacists? Can people buy them at pharmacies? Can I prescribe syringes? For some of my patients I do regulate prescribed syringes with the ICD 10 code Z 20. 6 or, contact with or suspected exposure to HIV. And unfortunately in New Haven, we've had clusters of HIV, including last summer. So this is a very real situation trying to provide people with, what they need to stay safe.

amelia-goff--she-her-_1_04-26-2024_101854: 18:04

Kim, these are all great ideas. I think center around being creative and doing what we can as individuals in our different circumstances in different states. I'm just going to encourage listeners to explore these. figure out what might be best for your environment and your practice, then we can share these resources and ideas on the podcast page of the MRSA website. In a similar space, Marlene, can you discuss how we can apply a harm reduction lens in other aspects of hospital based addictions care?

marlene-martin_1_04-26-2024_101853: 18:40

I think we can provide a harm reduction lens really in all the work that we do in health care, whether it's addiction focused or not. And when we talk about hospital based addictions care, Really thinking about providing dignified and compassionate care to the people that we're taking care of one area of interest of mine is how the policies that we have in hospital settings and how we respond to patients is affected. Right? By written or non written policies, but by bias treatment. So really thinking about, for example, urine toxicology practices. Some hospitals have consent practices around getting urine toxicology tests. Others do not. For example, in our family birth center, Some of the individuals working there found that grand toxicologies were being primarily performed in pregnant people who identified as black and Latina, and this has huge implications, for child protective services later on. And so they change practices to now having a standard uniform practice that they find decreases inequities and how we're responding to different individuals. Other ways that we can think about harm reduction in hospital settings is, person 1st language, making sure that we're educating healthcare workers about using person 1st language and how they're interacting with patients and also documentation, especially now that many people have the ability to read their charts. Thinking about the meds we are offering. Or when people want to self discharge, what do we do? if somebody is on intravenous antibiotics, are we offering oral antibiotics? Do we have them ready when we know that somebody is sort of going back and forth in their mind? Am I going to leave? Am I not going to leave? That decision often comes right after people sign out. And if you don't have those medications ready for them, they're not going to be able to get them. So you can practice harm reduction by having that oral antibiotic ready for people by having their buprenorphine, buprenorphine ready for them in case they're, thinking about self discharging. This area of interest of mine, which is in hospital drug use I know this is something that's happening across hospitals. I was at a national meeting of hospitalists recently discussing in hospital substance use and best practices with Dr. Ana Maria South. And we asked everyone in the audience, have you ever responded to somebody using drugs in the hospital and every single person raised their hands. And then, when we asked if somebody had had a patient overdose in the hospital, nearly everyone again raised their hands. So I think this is something that's very, very common. And it's something that we looked at it in our own hospital, because we found that we actually did have an in hospital substance use policy and the original policy didn't provide a lot of guidance around what to do, but 1 of the options was interpreted as a 1st line response was calling security when somebody used substances in the hospital or was suspected of substance use. In the matter of 2 or 3 months, we had a couple of people who security was called for, and our security is provided by the local sheriff's department. That was really harmful very punitive response to patients. We also learned that when sheriffs respond, they are sort of subject to their own, regulations and practices. The priority and health get superseded by this, more punitive response, and then really thinking about the context that many of our patients with substance use disorders may have been criminalized for their substance use, especially black and Latina individuals. This got us to really take a harm reduction or approach to our in hospital substance use policy. And when we did that, we gathered the interprofessional group that was subject matter experts. And that was involved in responding to in hospital substance use. We did an analysis of the most recent cases of in hospital substance use. And we really changed our response to be able to really take this harm reduction approach and think about why are people using substances in the hospital, they're often using because their pain and their withdrawal is being under treated. They are bored and they are triggered in the setting of something that feels like potentially a carceral setting to individuals. So. If we offer addiction services, if we offer opioid withdrawal and pain control that accounts for high opioid tolerances, people are going to be less likely to use if we are really treating people with dignity and respect from the minute they walk in, perhaps they're not going to be afraid to disclose that they use whatever they're using and that we can partner and come up with an adequate treatment plan and their share when their dose is too low, because if we don't, people will come prepared to take care of themselves, and potentially use drugs in the hospital. Or what we find is that people call friends or their friends come to visit their friends, see them suffering and then give them drugs. Then those drugs may not be the same. supplier they're getting the drugs from in the community. They may have riskier use in the hospital, right? They go into the bathroom. So things that make them at higher risk for overdose. Working with the hospital system and the legal department, right? To craft a policy that really decreases harm, centers the patient and offers aggressive addiction services.

amelia-goff--she-her-_1_04-26-2024_101854: 23:52

Marlene, this is such an important space to think about all the ways that we can integrate and change from a system level, individual level. I really appreciated you talking about from modeling person, first language for trainees all the way to a larger undertaking like your hospital did of reviewing, updating the hospital policies that were punitive and harmful to people who are using drugs. And then I think you're doing that and then publishing it. Creates a best practice roadmap for other institutions who are considering doing it themselves and really also appreciate your call out that it's so common and it's something that we really need to address to make the hospital environment less stigmatizing, less traumatizing, less of a space that feels like incarceration for the patients we care for. So thank you to you and Kim for the type of advocacy and systems change work that you're both doing. I am gonna just take a pause recommend that listeners consider how you can incorporate with all these different examples, a harm reduction philosophy and care in your own workplaces, then what you can do in your day to day interactions with staff and patients to have this lens in mind. We've covered quite a bit, and I was hoping to kind of pull together All of these themes and discussions with a case, Kim, would you be able to describe a case that helps our listeners better understand harm reduction in the hospital setting?

kimberly-sue_1_04-26-2024_131853: 25:38

I'm happy too. So the case that I have is a 30 year old female who injects drugs and she injects about Two bundles of fentanyl a day. So heavy sort of use she presents with fevers, rigors, and she gets worked up for endocarditis and is found to have tricuspid valve endocarditis. The Yale addiction medicine council service comes to see her and really tries to, the first and foremost thing is provide aggressive withdrawal management for opioids, nicotine, and anything else that she is experiencing withdrawal from. The patient elected to start methadone. So we titrated methadone pretty quickly up in a patient with high opioid tolerance and significant Health issues that needed to be addressed, including numerous echoes, both TTEs TEEs, and then sort of CT surgery evaluation for a replacement valve. We worked with the patient patient was able to get mitral valve replacement, able to stay again, very important in that aspect is to get significant amounts of additional. phylogenous opioids on top of the methadone, short acting hydromorphone it's often what we turn to and making sure that pain is really well addressed both before and after that surgery, trying to make sure that patient is on a pretty good dose a therapeutic dose of methadone on discharge. at that time the patient's been in the hospital for a long time and we do often go back. One of the fellows or a resident can go back and really do a very specific harm reduction checklist and just talk to the patient about their circumstances that they're going to be going home to. Circumstances in which they were injecting before, educating patients on safer injection practices, talking to them about why they think they got it this time and where they procure their supplies. In this instance, She had gotten some from a bodega and she didn't share with anybody, but she did reuse her own syringes and she really didn't clean her skin and had some ways that we could try to improve her injection practices to make them sterile and if she had enough supplies to not reuse them. So on discharge, it was a great success story she was able to access syringes in the outpatient community by working with our Yale community health care van on discharge. We actually have a van that can deliver supplies to people, which is pretty amazing. And she became involved in the syringe service program and was able to volunteer and be a part of creating that community change at the syringe service program, she was able to get her. Hep C treated and other issues addressed related to injection drug use, as well as just general health and well being. That's an example of a case which we've been able to utilize harm reduction supplies and education to really, help people be healthy and, be educated. And from programs like that, we actually made a website specifically around endocarditis called safersubstanceuse. org, where we interviewed people with endocarditis from injection drug use and we pulled together the information that they said that they wish they had had. They didn't know you could get it from this. You didn't know that he had it from this. Didn't know you could get it from sharing a cooker. so we pulled together a lot of that information on this website, and we made a little video that explains endocarditis and how to have a harm reduction philosophy to that with some of us in addiction medicine, some of the hospitalists, and some of the cardiologists and the cardiac surgeons, which is really cool.

amelia-goff--she-her-_1_04-26-2024_101854: 29:27

Amazing. I have so many thoughts, Kim, but first I want to say, I feel like this really highlights you as a physician anthropologist, just the way you told that story and shared that experience for this patient, which is impressive. And I think. In addition to the resources and education that you described, sort of the expansiveness of harm reduction. So from the beginning, when she came into the hospital, aggressive withdrawal pain treatment, and then all the way through to when she was leaving the hospital and becoming a part of the social movement herself and working in the SSP, which is really exciting. And I can attest to you, this website is a great resource for trainees for and for patients as well. It's a great example. Thank you, Marlene and Kim. This has been really enlightening and rich conversation. I've learned a lot. I'm sure our listeners have learned a lot. I would say you both Really are questioning the status quo, creating productive solutions and systems level change, and really appreciate you sharing the lessons learned with us about what we can do to create this important culture shift. Is there anything that you feel like are overarching takeaways that you want to highlight for listeners today?

marlene-martin_1_04-26-2024_101853: 30:52

A couple of the things that we can do include feeling empowered to create positive culture change, modeling best practices in addiction care and taking the best care we can have patients training others to do so, and then when possible, creating systems change so that the care that we provide individuals can be taken to a larger scale and everyone can receive best practice addiction care.

amelia-goff--she-her-_1_04-26-2024_101854: 31:16

Amazing, anything you want to add, Kim?

kimberly-sue_1_04-26-2024_131853: 31:19

I would just add if you're interested in learning more about the history of the harm reduction movement that there's a great recent history called Undoing Drugs by Maya Solovitz, and it can provide some of the background to the social movement behind harm reduction and how it's been fought for by people who use drugs and people who do sex work and really how we can plug ourselves in as clinicians how we can better treat pain and substance use disorders, which we really hope that you feel empowered to do after listening to this podcast.

marlene-martin_1_04-26-2024_101853: 31:53

I think the other thing that I would also plug is one, something that I provide to many of my patients who are requesting harm reduction education. And even when I'm just Taking care of patients on medicine is the Never Use Alone Lifeline, there was a recent episode on This American Life called The Call that really nicely highlights what this amazing group does, and so I encourage you all to listen.

amelia-goff--she-her-_1_04-26-2024_101854: 32:19

I imagine there are going to be a lot of listeners checking out both that book and that particular episode of that podcast. I hope overall that this episode empowers and galvanizes listeners to start integrating harm reduction approaches in their own personal practices and that you're walking away with some understanding of the opportunities and challenges for integrating this type of work in hospital systems and how important it is. Thank you both so much for your time and for being here today.

Kinna Thakarar: 32:52

Dr. Marlene Martin, Dr. Kimberly Su, and Amelia Goff in conversation on harm reduction, compassionate care for people who use drugs. you to tune in next time when we welcome Patty Moreno, Sophie and Leia Freymill Wong to the series to discuss insights from the frontline, safer use supplies, and other harm reduction interventions in an urban hospital.​Please take a moment to complete SAMHSA's post event evaluation survey on the AMERSA podcast page at www. dot AMERSA dot. Org forward slash harm reduction podcast. We welcome any comments, questions, or other feedback for presenters. You can send those directly to AMERSA through the contact us form at AMERSA. org. To learn more about the provider's clinical support system, Medication for Opioid Use Disorder Project, and AMERSA please visit our websites at PCSSMOUD. org and AMERSA org. Funding for this initiative was made possible by Cooperative Agreement No. 1 H 79 TI 086 770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U. S. government. Thank you for listening.