Insights from the Front Line

Episode 3: Insights from the Front Line: Harm Reduction Interventions in an Urban Hospital

Featuring:
Sophie Zhai
B.A. Public Health - University of California, Berkeley
Patient Navigator, Addiction Care Team at UCSF

Patricia “Patty” Moreno
B.S. Global Disease Biology - University of California, Davis
Patient Navigator, Addiction Care Team at UCSF

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

Episode three introduces San Francisco’s first ever hospital-based harm reduction program, led by Sophie and Patty with the Addiction Care Team at Zuckerberg San Francisco General Hospital. Together, they’ll reflect on the challenges they experienced with changing culture around addiction care in the hospital, and address strategies to combat stigma and staff burnout. They will share real-life impacts of patients who participated in their program, and explore exciting new projects for hospital-based harm reduction in the near future!

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 Kinna Thakarar 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 Lea Framel Wong in conversation with Patricia Moreno and Sophie Zai to discuss insights from the frontline, safer use supplies, and other harm reduction interventions in an urban hospital. Our host, Lea Framel Wong, is a former community health worker and graduating medical student at UCSF. She co authored a study on patient and staff perspectives on San Francisco General's Harm Reduction Services published this February in JAMA Network Open. Patty Moreno is from Stockton, California, and a first generation Mexican American college graduate from San Joaquin Delta College and UC Davis in global disease biology. Long term, she wants to become a physician, contribute to the addiction medicine community and address numerous barriers faced by marginalized people in the Central Valley. She is currently working as a patient navigator with the addiction care team at UCSF where she talks to patients about their substance use goals and provides guidance and support in the intricate healthcare system. Sophie Zai grew up in the Bay Area and obtained her degree in public health at UC Berkeley. She developed an early interest in community based care, working for several years on street medicine teams to provide health services directly at syringe exchanges and encampments for the homeless. Most recently, Sophie joined the Addiction care team at UCSF as a patient navigator, where she helps break down barriers to addiction services. She hopes to pursue a career in medicine and continue advocating for people who are most vulnerable in her community. The presenters reported nothing to disclose. Thanks for joining us, Leah, Patty, and Sophie.

Leah Fraimow-Wong: 2:34

Thank you so much, Dr. Thakkarar and listeners. so great to have everyone here. I am your host for this episode, Lea. Really excited today to talk about frontline insights on hospital based harm reduction. To kick us off, I'm going to list out our learning objectives for today. One, you know, just being able to describe what a hospital based harm reduction program might look like, being able to identify common challenges for implementing a hospital based harm reduction program and strategies to address them, and really being able to explain the significance of offering harm reduction to patients in a hospital setting. Over the next 30 to 40 minutes we're gonna get to hear from two amazing experts with us today. Patty Moreno and Sophie Zai who are substance use navigators at San Francisco General's Addiction Care team. It's so wonderful to have both of you here. Maybe just to, to start us off, tell us about your current role.

Sophie Zhai: 3:29

Thank you so much, Leia. So, Patty and I are actually patient navigators on the Addiction Care Team, or ACT, which is a multidisciplinary inpatient addiction medicine consult service at San Francisco General Hospital. ACT has been up and running for about seven years now. six years now. And just in this last year, Patty and I have touched about 600 patients primarily in the emergency department and in the med surg unit. But we also see folks in our psychiatric emergency services unit and also in our skilled nursing facility. And because we're working in a safety net hospital, we're primarily working with folks who are under resourced. So 60 percent of the folks that we see are unhoused. 50 percent are unhoused. are black or Latinx and most of them have public health insurance or don't have any insurance at all.

Leah Fraimow-Wong: 4:20

Yeah. It's so amazing to see how the addiction care team has grown over just these past six years. And I understand that more and more hospitals are kind of continuing that trend. But San Francisco General is one of only a handful that provides harm reduction services, even though that might kind of be in the ethos of a lot of addiction care teams. Tell me about some of the services that ACT provides.

Patricia Moreno: 4:45

Like Sophie mentioned earlier, we're a diverse team with unique skills and we all work really hard to prioritize patient's substance use goals and their recovery. And we advocate for more inclusive and supportive healthcare environment. And the addiction care team, we really capitalize off a, what we call reachable moment during a patient's hospitalization to start addiction treatment for those that didn't necessarily looked for care upon initial presentation. And it's really a continuum of care and a spectrum. And particularly what Sophie and I do, we provide linkage to services and that can look like outpatient resources, residential addiction treatment for substance use disorders. And we also talk to patients about harm reduction services and safer use supplies, which is going to be the focus of our podcast today.

Leah: 5:42

Oh, I'm so excited that you guys are here. Tell us more about the Safer Use Supplies Program.

Sophie Zhai: 5:50

So, what's really unique about our program is that we're actually the only ones in San Francisco who are distributing safer use supplies directly from the hospital setting. And this program has been running for about a couple years now. It was created by one of the patient navigators on ACT, and her name was Rachel Pereira. She was able to do this by partnering with. syringe exchange programs in the community. I actually just want to say that we are super, super lucky to be in San Francisco where we do have an abundance of community resources who are really there to guide and support this whole process of bringing harm reduction into the medical setting. Originally, these supplies were provided by the San Francisco AIDS Foundation, and now they're being currently provided by the Alliance Health Project at UCSF, and they include safer smoking supplies, safer injection supplies, fentanyl test strips, and we also get naloxone from the Department of Health Care Services.

Patricia Moreno: 6:48

To talk a little bit more about our harm reduction workflow, what Sophie and I do when we talk to patients about their substance use and their relationship towards those substances and their goals, we find that the patients are very ambivalent about their, their substance use. And harm reduction is for people who don't view cessation as an immediate or attainable goal. And Sophie and I, we really serve as a nexus. Like a central point where we serve as advocates for our patients and talk to them about harm reduction. To get into our workflow, what we do is once the patient requests a harm reduction kit, we talk to their bedside nurses and also their primary team, we have these brown paper bags with stickers with our ACT logo and the patient's name and their room number, we give it to the bedside nurses so they can safely store it in the medication cabinet. So we don't give it directly to patients for safety precautions. Once the patient discharges, they have their medications on hand, their discharge summary-- that's when the harm reduction kits get distributed.

Leah: 7:55

That's, that's so cool. I remember seeing so many of those brown bags across the hospital. And it always makes me smile. You know, for our listeners, why, why should we give out safer use supplies from the hospital?

Patricia Moreno: 8:10

Research shows that individuals who access syringe services programs known as SSPs, it can help patients reduce HIV and Hepatitis C virus by 50 percent by incidence. And the CDC also has showed us that these programs, patients are five times more likely to enter drug treatment and three times more likely to reduce injection frequency compared to individuals who don't access these kinds of services. We see infections all the time, Sophie and I, when we come in here and we look at the consult list for the addiction care team. People come in for endocarditis, cellulitis, even sometimes accidental fentanyl overdoses. So this is very common what we see in the hospital.

Sophie Zhai: 8:59

I would say It tends to be the majority of our patients who have some complication related to their substance use or just have this acute or chronic medical issue that's being made worse because of issues related to their substance use.

Leah: 9:14

I think it's really incredible the kind of shift to thinking about prevention and like, how do we get to some of the upstream of what we're seeing in the hospital every day? It's been a few years now with these services-- I would love to hear about how you all kind of introduce safer use supplies to patients. But before you answer. Maybe I'll ask listeners to just kind of take a moment and imagine you have a patient who you've talked to and they've communicated that their goal at the moment is to continue, continue using substances. How would you kind of open the conversation about harm reduction and safer use supplies? As you think about that maybe Sophie and Patty, you're really kind of experts at this point. And I know you each have your own style. How, how do you each approach this conversation?

Patricia Moreno: 10:08

The way I typically approach talking to a patient about their substance use, I leave it very open ended, non judgmental, and I ask a lot of broad questions regarding their substance use history. We really let the patient lead on the conversation, and once we start asking these open ended questions, we get a lot of answers. We start understanding what their social situation is like, in what environment are they using drugs, also what their relationship to those substances looks like. Many don't know what their goals are all of the time. Using motivational interviewing skills helps us really tease out the, the relationship that patients have with substances and what works, what doesn't, maybe what are some of the pros and cons when they're using these substances, and then we just go from there.

Sophie Zhai: 11:03

I think leading that way is super helpful for actually understanding where people are at with their drug use practices too, what they're using how they're using how much how often it gives us a really good picture of where people are at with their current harm reduction practices, we can answer some questions like are they using test doses? Are they carrying naloxone? And are they using with somebody nearby who could potentially call ems if there were to be an overdose that were to happen. How are they accessing supplies? Are there any issues with access? Are they sharing supplies when they are using? These are all questions that tend to come out when we're asking these like broad questions when we're understanding where people are at. I just want to recognize that most of our patients are actually teaching us about their harm reduction practices. A lot of them are doing a really great job of integrating harm reduction into their drug use. They're able to teach us when new things kind of come onto the market and we're able to understand what's going on in the community a little bit better when we meet them at the hospital and do these assessments. For those of you out there who are just starting out and taking a history and learning how to engage your patients in conversations about harm reduction, Patty and I actually came up with this really cool mnemonic that can help be a framework for when you're having those conversations. The mnemonic is called DOPE and it stands for Drugs, Objective, Paraphernalia, and Environment. These are the four key things to think about when you're asking your patients about their drug use.

Leah: 12:42

Wow. That's really helpful. Drugs, objectives, paraphernalia, and environment. I'm going to put that in my back pocket. Is there ever a situation where you hesitate to offer someone harm reduction supplies?

Patricia Moreno: 12:57

I'm really glad you asked that because sometimes it can be a very tricky situation depending on what the patient discloses. There are green lights, there are sometimes red lights or yellow lights and a green light to know when to offer harm reduction supplies to a patient is when they outright tell us, Hey, you know, my goal is to continue safely using, or I want to reduce use, but I want to continue using substances. I'm not ready to quit yet. That's not in my near or long term goals. That's when we typically tell them what we offer in our harm reduction closet. We even have this binder that really summarizes all the supplies we offer in the hospital. It was created by one of our LBNs. Her name is Xenia, we show this to patients. We also show this to staff just so they can know. What exactly we're offering and honor that transparency with our patients and also our colleagues. It's also very effective when patients say that they plan on self directing their discharge so they can go self medicate or leaving against medical advice.

Sophie Zhai: 14:04

I find it super, super helpful in those instances because we're When people are making that decision to self direct their discharge, they're quite literally telling us that they're going to go self medicate and use drugs. And this is an opportunity for us to reassure them and let them know like, hey, even though you're doing this, we still care about your safety. We still care about you and it's an opportunity to still build that relationship. It's a way to continue that trust if and when they come back.

Patricia Moreno: 14:35

Within our roles, Sophie and I, it's really important for us to establish that trust with a patient like you mentioned earlier and that's why we ask all All patients indiscriminately if they would like any of these safer use supplies because we understand that part of the recovery process, it's a chronic disease addiction and it's something that we can prepare for if they ever find that they need those supplies. If a person returns to use, they have those supplies in hand. And sometimes it's not only just for them-- they can share it with someone they know or someone else in the community. We leave it very open ended for them and make sure that they have that option available.

Sophie Zhai: 15:18

I think you bring up a good point, in that, you know, even though we might've just had this conversation about abstinence, and that might be where that patient is at, they're wanting to pursue abstinence, recognizing That return to use is part of addiction. It's something that we can prepare for. Not saying that that person will return to use, but it's something that we can prepare and offer and we put it out there for patients in case they do want to prepare for that.

Leah: 15:45

It sounds like what I'm hearing is it's really kind of leaving the options open and really being guided by kind of that relationship and rapport and trust building of what the patient's goals actually are and what they want to do after they leave the hospital. It makes me curious what have patients responses been like?

Sophie Zhai: 16:07

I think most people have been pretty pleasantly surprised that a hospital would even offer safer use supplies. And I think most of our patients are coming from previous experiences where they've faced stigma while being in the medical setting. It's a chance for us as providers to build stronger relationships with our patients, letting them know that, we're here for you, that you have options. We're here to listen and support you. And we care about your safety. Most people have responded very positively to it.

Patricia Moreno: 16:41

Sophie and I have interacted with a diverse range of populations within our patients and I just wanted to share one of the monolingual Spanish speaking patients that I had that learned about harm reduction supplies and how they really appreciated us having these services available to them in the hospital. This patient that I talked to, they had migrated from Latin America and they had experienced an unintentional overdose from fentanyl. They were smoking methamphetamine every day to stay awake for the long work hours that they had, and they had no idea what naloxone was or the importance of not sharing any supplies with anyone and why it's important to own your own supplies and becoming aware about harm reduction therapy centers that exist in San Francisco. I remember this patient telling me, quote, no one I know ever told me these things existed in the city. I'm ashamed to discuss it with my family and friends because I fear they will look at me differently. I do want to quit eventually but I know that once I leave the hospital I might fall back into smoking meth. I'm grateful that you shared these resources with me and even made me a kit that I can take home. No other hospital I've been to has talked about my drug use in a compassionate way. That really stood out to me. It made an impact on me, it just made me excited and grateful to know that our team is doing, is working really hard in having patients feel heard and feel respected. That way we can support them in their recovery journey, however that may look like.

Leah: 18:23

Wow, that's a really powerful testimony, Patty. Thank you so much for sharing that. And also, I'm so grateful that you were able to have that interaction with that patient. It really resonates with what we found in the study. Last year we had the opportunity to do a qualitative study about the harm reduction services at San Francisco General, where we interviewed 20 patients who had received harm reduction services and 20 staff who had worked with patients receiving harm reduction services. What we heard from patients is exactly what both of you have been saying that people felt really seen and the offer of harm reduction supplies often was, kind of the first positive experience that they'd had in the healthcare setting. A kind of sense of rebuilding trust after really awful experiences often in prior hospital stays. Like you were saying about self directed discharges people told us over and over again that because of this positive experience, they would be much less likely to delay care in the future. The testimony that you gave from that patient, really highlights one of the surprising findings to us in the study, which was that many patients who are in San Francisco are actually really linked into harm reduction services. And as you said, Sophie, are the experts who are teaching us as providers and as staff. But there are also a lot of disparities in access to harm reduction. What we found was that among patients who reported learning new strategies, who had less exposure to harm reduction, who were learning about naloxone for the first time, learning about community resources really all of them were black or Latinx including some Spanish speakers. Offering these supplies in the hospital was really a moment of reaching people where they were at And being able to connect with some folks who maybe are not being reached by, by services out in the community and being that linkage point to help people get where they need to go. We've talked for a while now about patients but what have your experiences been with the response from staff?

Sophie Zhai: 20:39

It's definitely been mixed feelings from staff. We have a lot of people who are super on board with harm reduction. Maybe they've had some exposure to harm reduction in their formal training or through other professional or personal experiences in the past. We have some folks who are definitely very open minded with harm reduction, but they don't feel super prepared to engage their patients in conversations about harm reduction yet. They feel like it might be a little bit awkward. They're not really sure how to approach it. But they're super grateful for ACT services and for ACT support. Then we definitely have a few people who are skeptical about harm reduction. I think some of that comes from burnout, from seeing folks who are coming in over and over again who are using drugs. I think some of it is also just related to like personal biases against drug use.

Patricia Moreno: 21:34

Within those personal biases a lot of staff have shared with us that they feel like they're enabling drug use and they feel inadequate to address harm reduction. We do get a lot of questions from staff and they ask us if harm reduction is actually really effective. We tell them that harm reduction acknowledges how using drugs can be very risky. And there are evidence based ways of safer using. This started from the community. I want to acknowledge that because now we're applying this to hospital and clinical settings. So it's been evolving for some time now.

Sophie Zhai: 22:14

Definitely a lot of the staff responses that I've seen, they have questions like, is this really working? Is there data behind it? Some people feel like, Oh, I don't know. I feel weird giving it out. I'm not sure if I'm doing the right thing. I made this oath to do no harm, is that what I'm doing? We definitely have a lot of questions when we do engage our staff about harm reduction and safer use supplies. What you said, Patty, wanting to acknowledge that drug use can come with a lot of risks but there are safer ways of using drugs-- that's really what we're trying to hone in on.

Leah: 22:48

That completely resonates with what we found in the study talking to staff. I feel like the overwhelming feeling from the vast majority of staff was profound sense of gratitude for ACT and for the harm reduction feel like, wow, this is one of the most challenging parts of my job and I finally have some support and someone telling me what I should be doing and giving a framework. What I thought was really interesting were the staff who were maybe a little bit more skeptical or we heard from a number of staff who were initially skeptical and their views kind of changed over time with exposure to harm reduction. I feel like so much of that came from all of the really incredible and challenging work that, that you both are doing every day and that prior substance use navigators have been doing as well, as well as all members of the ACT team. There's a lot of fruit, I think, in some of those conversations that have been had. Maybe for our listeners to just take a moment to reflect, if you noticed a staff member who you were working with who seemed uncomfortable around harm reduction, or some of the services we've been talking about, how would you approach them? How would you engage them in a conversation? Holding that in the back of your mind, Patty and Sophie, you guys are really experts at this now. I've learned so much from you about how you engage staff. What do you do when you work with staff? What are some that you might have?

Sophie Zhai: 24:21

Responding to providers who might be a little bit more skeptical about harm reduction, I like to understand where that's coming from. I find that most providers actually just want to keep their patients safe. They always, just want to make sure that my patient is safe. I want to make sure I'm doing the right thing and doing everything I can keep them safe while they're in the hospital. What we find from patients is that they want to feel safe when they're in the hospital. We actually have this shared goal of safety. I think there is a way to kind of bridge what the provider's goals are with what the patient's goals are. I think something important to keep in mind is that traditionally in medicine, addiction treatment was on an abstinence based model. We were looking for this benchmark of abstinence. You know, when somebody came in with a substance use disorder, we would just counsel people on their drug use and then tell them to stop using. But as we know, that's not very effective. It doesn't really work. As providers, even though we tell people to stop using drugs, that doesn't often happen. Kind of reframing how we think about addiction treatment and what we're really looking for. Some of that could just be like reducing a person's risk of overdose or reducing their risk of infection. These could actually be benchmarks that we're looking for and it can help us reframe, what are these positive changes that we can make with our patients that don't necessarily have to be abstinence based. Once we kind of reframe that for providers, they can really improve their work experience and that in turn really improves the care experience of our patients.

Patricia Moreno: 25:57

I wanted to mention a little bit more of the teachings that Sophie and I have been doing. So we've been engaging with staff in the intense care unit, with nurses, also third year medical students, internal medicine residents, we have done this 45 minute training on harm reduction where we go over a case study and we go over harm reduction philosophy and principles and we're measuring some core competencies from the people who participate in this training to see if they can take a thorough substance use history, if they know how safer use supplies function and also to see if they know of some resources that they can link patients to for harm reduction. Our research showed that after the training, these staff and students were a lot more comfortable with these competencies. We asked a pre and post survey, and we were able to see a huge difference, and we also noticed how the staff and students were able to develop clinical skills and to better treat patients with addiction upon leaving this training. That's helping with the culture change around harm reduction in the hospital. Even though we're leaning into the discomfort, and we know it can be really hard to talk about we're doing a lot of the work in order for this to become more normalized, in order for us to move forward.

Sophie Zhai: 27:24

Definitely, not only did staff feel more confident in talking to patients about harm reduction and about their substance use, but folks who we noticed were a little bit more skeptical in the beginning, they were shaking their head, they weren't really sure about harm reduction-- at the end they were a little bit more engaged. They were taking pictures of our slides, of our supplies, and they had a little bit more interest and more buy in. I think even from a comfort level of being more open minded towards this I think the trainings that we did made a huge difference.

Leah: 27:57

That is just so powerful. I think that the work that you both are doing is really inspiring because based on this and based on what came out in the staff interviews, what we heard was just that for so many people, this was a huge frame shift in how they even thought about substance use, like you mentioned Sophie, even a different framework besides an abstinence only model. That goes on to impact every interaction that they have with patients who have a substance use disorder, not even the ones just involving harm reduction supplies. What came out in the interviews was a number of people mentioned how this went from something that was one of the hardest and most challenging parts of their job, that felt like it contributed to burnout because they were telling patients to stop and it felt like they were failing all the time, to a model that's a lot more humanistic actually felt aligned with their values of meeting the person where they were and figuring out how to best support them and best support their health. It ended up being something that was really fulfilling. I think the change that you both have been a part of is so incredible and it also highlights how much more work there is to do and that this is a constant struggle. It's a whole huge culture change. Where do you see all of this going? What are some of the things you envision for the future?

Sophie Zhai: 29:21

I think expanding the harm reduction workshops that we've been doing for staff. Seeing if we can equip more providers with these skills to engage patients in these conversations and effectively offer interventions that are harm reduction based. So what happens when more providers are using harm reduction in their standard of care? And does that impact patient satisfaction? Does that impact patient experience? Maybe having some surveys on that and seeing if there is some kind of tangible impact that we can see. I think the other thing is wanting to refine the curriculum a little bit more. I know Patty and I have some things in the works.

Patricia Moreno: 30:03

I would also love to see addiction care services expand to other areas. I know Sophie mentioned earlier how in San Francisco we're so lucky how we are rich with a lot of resources for harm reduction and support services for this, but I would also love to see more satellite programs in maybe rural areas, in other cities, maybe even more in my hometown where I'm from. I know that there are gaps still for awareness for harm reduction services. I would really love to work towards raising awareness for this and even the legal aspect. Continuing to do work in policy advocacy and also activism around harm reduction is so vital. There's a lot of work to be done there still, but I know that this takes a multidisciplinary effort in order for us to continue doing valuable and important work around harm reduction.

Leah: 31:00

We're in the middle of a national overdose crisis and we know these services work. They need to be out there and be accessible. I feel like as we're talking I'm just struck by how much expertise you both have at this point for others who might want to do just that and start a similar program or integrate harm reduction into their practice what advice would you give? Any lessons learned?

Patricia Moreno: 31:27

We know that addiction care treatment is a continuum and addiction is also complex and can exist across all levels like spiritual, humanistic, cultural, and social, and so much more. My dream is to see all of us, medical staff, non medical staff, community members, involve stakeholders even to work together to pave the way to recovery. I'm really excited to see how harm reduction will continue to evolve over the next years.

Sophie Zhai: 32:00

Like Patty said, this is a group effort. We need buy in from, from nurses, from providers, from everybody. It really is this movement that we're all trying to get on board with together. Asking a lot of questions, understanding where people are coming from, meeting patients where they're at, meeting providers where they're at and their education and their knowledge. Also understanding that this work is challenging. Making changes anywhere is super, super hard. So, but it's super super hard, but really, really important. Props to anyone out there who is doing this work.

Patricia Moreno: 32:36

We appreciate you.

Leah: 32:38

I appreciate the both of you. I think that's a perfect way to end it. Thank you so much for having this conversation today. I feel like I've learned a lot, it's always just a joy to chat with both of you.

Sophie Zhai: 32:53

Thanks, Leah.

Patricia Moreno: 32:53

Thanks, Leah.

Kinna Thakarar: 32:56

That was Patti Moreno, Sophie Zhai, and Lea Fremont Wong in conversation on harm reduction compassionate care for people who use drugs. Be sure to tune in next time when we welcome Dr. Tessa Rife Pennington, Andy Ruggles, and Dr. Beth Dinges to the series to discuss leveraging technology, expanding veteran access to harm reduction resources through vending machines. 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.