Leveraging Technology

Episode 4: Leveraging technology: Expanding Veteran access to harm reduction resources through vending machines 

Featuring:
Tessa Rife-Pennington, PharmD, BCGP
Harm Reduction Coordinator
Clinical Pharmacist Practitioner
San Francisco Veterans Affairs Health Care System
Volunteer Clinical Assistant Professor
University of California, San Francisco, School of Pharmacy

Andrew "Andie" Ruggles (he/they), LCSW
San Francisco Veterans Affairs Downtown Clinic

Hosted by:
Beth Dinges, PharmD
Harm Reduction Coordinator
Clinical Pharmacist Practitioner
VA Illiana Healthcare System

Episode four introduces harm reduction vending machines (HRVMs)! HRVMs are an evidence based and successful strategy to address many barriers Veterans face when seeking harm reduction strategies, including syringe services programs, overdose education, and naloxone. Presenters Andie Ruggles and Tessa Rife-Pennington, from the San Francisco Veterans Affairs Health Care System Harm Reduction Program, discuss how and why their program chose to implement HRVMs, how the machines work to increase Veteran access to resources, key implementation strategies and lessons learned, opportunities to include multidisciplinary team members and learners, and ongoing future research.  

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 dr. Beth dinges in conversation with dr. Tessa Rife- Pennington, and Andy Ruggles to discuss leveraging technology, expanding veteran access to harm reduction resources through vending machines. Our host: beth Dinge's PharmD, pronoun she, her, has been a clinical pharmacist at various Veterans Affairs facilities over the past 20 years. She currently works as a Harm Reduction Coordinator at Illiana Veterans Affairs Healthcare System in Danville, Illinois. Here, she piloted the VA's first syringe program in 2017, which was a shark tank winner and a model for many VA facilities. She is a 2024 Innovation Fellow with the mission to incorporate veterans with lived living experience into harm reduction programming. Overall, she is committed to creating a more engaging and less stigmatizing healthcare environment for people who use drugs. Tessa Rife Pennington, PharmD, BCGP, pronouns she, her, is a clinical pharmacist practitioner at the San Francisco Veterans Affairs Healthcare System and volunteer clinical assistant professor at the University of California, San Francisco School of Pharmacy. Since graduating from the West Virginia University School 2010, she has worked in a variety of roles within the Veterans Health Administration, including medication therapy management, academic detailing, and pain and opioid stewardship. She currently serves as the harm reduction coordinator and is passionate about expanding access to harm reduction resources for veterans with lived or living experience of homelessness and drug use. Her work is driven by and aims to reduce the increasing rates of Fentanyl involved overdose deaths among both veterans and community members in Northern California. Andy Ruggles, LCSW pronouns, he, they is a medical social worker at the San Francisco Veterans Affairs Healthcare System. Andy finds passion in working both clinically and administratively advocating for marginalized populations. A proud neurodivergent human with nearly 15 years of personal sobriety from opioid use, Andy is a current doctoral student that utilizes a trauma informed perspective to promote diversity and equity in their daily life. As a member of the Harm Reduction Committee, Andy works under Tessa Rife Pennington to provide education and support to staff acting as harm reduction advocates within each clinic of the healthcare system. The presenters reported nothing to disclose. Thanks for joining us, Beth, Tessa, and Andy.

Beth Dinges: 3:11

Thanks so much, Kina, and welcome to our listeners. So good to have everyone here today. My name is Beth and I'll be your moderator. Today we're talking all about harm reduction vending machines. What are they? What's the evidence? And how do we put at all into practice? Joining us today are two experts, Tessa and Andy, both with VA San Francisco, who will share their experiences. Let's get started.- So what are harm reduction vending machines? What do they do? Who are they for? What's in them?

Tessa Rife-Pennington: 3:39

Vending machines, they're just like regular vending machines that provide or dispense things like, chips, soda, candy bars. They have been repurposed in a really cool way to dispense supplies that support harm reduction. Things like sterile syringes for, reducing risk for HIV and hepatitis C, as well as naloxone or Narcan kits for opioid overdose reversal. They have been available in other countries for many years. Denmark had the first vending machine in 1987. So quite a while ago these machines have been available. Many programs in Europe have implemented harm reduction vending machines, but the U S has been a bit slower to catch on. We had the first program in Puerto Rico in 2009, but not until more recently in 2017, there was a vending machine program, with many machines in Nevada. It's a great evidence based practice and they help increase access to harm reduction supplies in a way that reduces stigma, increases anonymity, increases access in different geographic areas like rural areas, and promote access for people who may not be able to or ready to engage with syringe services programs because there's no interaction with a person, you're just interacting with a vending machine.

Beth Dinges: 5:04

How did you guys decide to pursue these vending machines? Could you describe a little bit of the pathway to get you to where you are today?

Tessa Rife-Pennington: 5:11

It's definitely been not an easy journey, but a very much loved journey. Starting in 2019, I did a pilot to distribute fentanyl test strips and teach veterans about risks of fentanyl involved overdose and get their feedback on the education and the test strips. That led to another project for creating and distributing harm reduction kits for safer injection, hygiene, wound care, resources for veterans who are in supportive housing facilities in the San Francisco Bay Area. That led to another project where we did telephone and in person outreach to veterans in supportive housing to get them connected to these resources. And through all this process I was kind of taking harm reduction supplies in plastic totes on the bus to housing sites, trying to get veterans resources. And it was really tough, carrying two large totes on the bus. I was trying to brainstorm how, how do I increase access based on veteran feedback? They wanted more supplies, like a wider range of options access more regularly than one person could support bringing to housing sites. That kind of led me to this idea of different types of dispensing pathways. And I found some community partners like the Las Vegas program and a program in Rhode Island that have been using vending machines for a couple of years now with great success. And so I joined a community group to learn from them. That really just seemed like a great fit for increasing our access in supportive housing and also in rural areas in Northern California, where hadn't really been able to increase our program reach.

Andie Ruggles: 7:04

Tessa, I love the image of you just carrying these large totes on a public bus system. When people think of California, they think of LA or San Francisco. And while I'm based in San Francisco, there are clinics going all the way up to Eureka, which is five and a half hours north with a lot of rural area in between. So this is so critical for those areas and providing care.

Beth Dinges: 7:27

So I'm curious, what exactly goes into these machines? We said it's not snacks or chips or soda, but what all goes into the machines?

Andie Ruggles: 7:36

I can take that one. The great thing about these machines is that they are so varied and offer so many different types of resources. So when we're talking about harm reduction, the predominant thing that we think of is individuals who use substances, but harm reduction is such a spectrum. And so we really tried to focus that when we were developing the idea of what to put in these machines. So all supplies are completely free. There are no copays. They do have to register for the process, which we can talk about in a bit, but the supplies access are also anonymous. The machines that we actually have currently is a pilot program, so it's looking to be updated as we find out more information and get better but we, as Tessa mentioned, have safer injection supplies. So we have sharps containers of various sizes, alcohol swabs, disposable tourniquets five different sizes of insulin syringes with more that we can order and then as well as cookers with cottons for more sterile use, we also have hygiene supplies. So we have toothbrushes, toothpaste, soap, washcloth, tablets, and combs, all in a single hygiene kit, as well as mouthwash, lotion, deodorant, sunscreen, and even hand sanitizer. And then beyond that, we also offer safe erectile use kits, sniffing and snorting kits, um, wound care kits, which include bandages, as well as medical tape and things to sterilize. We also offer sterile water. as well as safer sex supplies like condoms of various sizes and lubricant. And then a big ticket item that we offer is fentanyl and xylosine test strips, which also come with instructions and micro scoops. But beyond what's actually in the machines, we also keep some other things on site that due to policy require prescriptions. So something like plan B, or emergency contraceptive prescription naloxone, also called Narcan. Those are things that require provider prescriptions, provider intervention. But we do keep those on site. And if someone doesn't want to ask a provider or isn't linked with health care, they still have access to those supplies we can message Tessa who can provide that prescription for those things. It's really a broad variety of materials that we offer.

Beth Dinges: 9:53

Amazing array. I have to be honest. I was thinking that it was mostly just syringes, but it's a whole spectrum in there.

Andie Ruggles: 10:00

It is absolutely.

Tessa Rife-Pennington: 10:01

it's been really cool to see you like the highest uptake items and also surprising the hygiene and wound care kits are the most popular by far. Then condoms, both sizes of condoms and lubricant are kind of next most commonly dispensed. So really supporting people and staying safe and and then of the safer use supplies, the 31 gauge syringes and the safer sniffing snorting kits are the most commonly accessed.

Beth Dinges: 10:30

No, those are great things to know as I try and replicate your guys's pilot at my site. If I'm a veteran, I come across 1 of these vending machines and I want to use it. How do I get started?

Andie Ruggles: 10:41

It takes very little time. It's actually a five minute or less registration process. And the registration only takes one time. After that, it's free and open access. So we have points of contact at each site, and, or Tessa, who is available by phone, is our amazing program manager. With that the process itself is very simple. The point of contact, or Tessa, would be Ask the veteran some very basic questions that our funding requires. Asking things like have they experienced any unhoused nights in the last six months? Have they experienced or witnessed an overdose in the last six months? And are they interested in education or access to Narcan, to sterile syringe programs? As well as to sexual infection disease testing and or treatment. So once we get that information, we provide them with a laminated wallet card that has a barcode on it. They can access multiple resources per day. There's a very high limit to many of these resources. The thing about this is that questionnaire that we provide also allows us to link them to community based services that we partner with. So community based sterile syringe programs, substance use disorder treatment programs HIV, HCV, STI testing and treatment, housing resources. So when we're asking for that registration, we're also able to link them to all of these other holistic and surrounding, encompassing programming, which is really fantastic. The important thing to remember when we're registering veterans is that any eligibility status can register. It's very low barrier. They are not required to be enrolled in healthcare. They're not required to have a doctor. Obviously the point of ongoing healthcare is we want to get some options available if they wish to pursue healthcare. Which is great that we have these in our outpatient clinics. It's also important to remember that when we're registering veterans. It's not just social workers and clinicians that are registering. We have a multidisciplinary team. So our front desk staff sometimes assists with registering. We have licensed vocational nurses, registered nurses, PCPs, both MD and nurse practitioners, as well as a physician's assistant. We have social workers ranging from mental health social work to medical social work to housing social work. We have psychologists and even a psychiatrist that are willing to step in and have these conversations. It's a very broad multidisciplinary team that's allowing this very simple five minute registration that allows the veterans to access this moving onward.

tessa-rife-pennington---she-her-_1_04-15-2024_111139: 13:20

Veteran comes in to a clinic, we have phone numbers on the machine. If they want to call me or one of the onsite points of contact to register over the phone, or they can register in person at the clinic and meet with one of the points of contact. And I do in person outreach to six supportive housing sites where we have a vending machine in the housing site where veterans live. So I go once a month and work with the social workers and case managers on site to get all of the veterans registered who might be interested in resources. We have lot of different team members across disciplines helping veterans get access which has really just been helpful to have all of the different options. We have telephone in person. We also have a referral process in the electronic medical record where any person can refer a veteran to get signed up for the vending machines. We try to make it as low barrier easy access as possible.

Beth Dinges: 14:25

I think two things stand out to me. One, I love that you're taking advantage of a integrated healthcare system, all the different disciplines that are under one roof. But I also like that you guys are a bridge to what else is in the community. It's not all what's available in this VA bubble.

Andie Ruggles: 14:43

Beth, that's so critical. In order for us to provide true harm reduction, we have to be integrative and collaborative. There are so many amazing grassroots organizations that are just doing on the ground work that we really need to tap into because they're the ones that are seeing these humans every single day.

Beth Dinges: 15:03

Such a good point and they're the ones that have been doing it for decades, right? Whereas I feel it's something relatively newer to health care. Where did you get the money to support this program?

Tessa Rife-Pennington: 15:13

It's not a one answer question. It's been a journey with finding funding and sourcing all of the different pieces to make the program work. This started out as my side hustle, not a full time job, but I just really wanted to make this happen within our healthcare system. I was working on it on the side-- was able to get funding through the National VA Office of Pain Management, Opioid Safety, and Prescription Drug Monitoring Program, or PMOP. They funded the vending machines, which cost about 11, 000 each. They also funded the initial purchase of all the supplies that go in the machines. And then going forward, it's been kind of a mix of funding from PMOP, funding from the National VA Office of Mental Health and Suicide Prevention, funding from our local San Francisco Veterans Affairs healthcare systems. That's been kind of a mix. In terms of staffing, it's really excited that we have some full time staffing now. My position is a full time harm reduction coordinator, so I get to do this every day. And then we have another full time staff member, a logistic service supply technician, who I'm really grateful to have because he receives all of our supplies, unpackages and repackages them, maintains the inventory, and is now in charge of restocking the vending machines. Which was really hard to manage 15 machines across Northern California as one person. So, and as a side hustle. Two full time staff now and we're funded by the mental health and suicide prevention office.

Andie Ruggles: 17:05

Then in addition to the staffing, we have currently, we're still out rolling this program, but we have 21 points of contact from all those multidisciplinary aspects that we talked about. So in addition to, and Tessa, I don't know how you did 15 machines, across going all the way up to five and a half hours North and two hours South. That was huge, but now we have 21 amazing volunteers who are adding this into their day to day work and other positions.

Tessa Rife-Pennington: 17:32

Ideally we have a few or several people around each vending machine location that support the veteran experience piece. If there are any issues with the machines, I know every now and then an issue crops up and I learned how to manage another technical aspect of vending machines. So it helps to have many team members who can support. A lot of our staff are volunteering their time, it's not part of their work duties like Andy. Just really appreciate people's interest in volunteering with the program.

Beth Dinges: 18:07

What do you think your biggest wins have been? Along the same note, what are the biggest challenges? I'm sure there's a very long list for each of those, but let's start off with the positive part. What have been some of your wins along the way?

Tessa Rife-Pennington: 18:23

I'm really excited to share. We have about 300 veterans already signed up for the vending machines. So we launched the machines from August to September of 2023 and already have 300 veterans using the machines. It's not just one machine. They have access to all machines, so some of the veterans are using three different vending machine locations, which just really gets that kind of the access in housing and access in VA locations. So wherever they are, they can get what they need. One big win, I think for for us as a harm reduction and syringe services program, we have really increased our syringe access-- pre vending machines we had lower rates of syringe access and now we've kind of taken out the provider driven approach and we just let veterans get them as they need them. There are a lot more people accessing syringes now that it's anonymous and there's no health care provider as an in between. Our previous process was for me to prescribe them and that requires interaction with a health care provider. We know that people who use drugs face so much stigma and discrimination in the community and health care by health care providers. So I think seeing increased syringe access is huge. I think one thing that I love is hearing stories from veterans while I'm working on the vending machines, like in the housing sites and at the clinics. Veterans will come by and tell me stories of using their Narcan to save people. It's just, so incredible to hear stories of veterans saving lives. Other veterans use the sharps containers and the machines to pick up syringes in the community. They get syringes to hand them out to other people who need them. It's been a really cool experience seeing how veterans become peer distributors and peer educators and like taking the conversations we have to help save other people. Those are some of the most rewarding experiences, just hearing how many other people we can help just by having one vending machine.

Andie Ruggles: 20:38

The biggest part of the wins here are seeing the community come together. As someone with lived experience and nearly 15 years of sobriety, it's still a daily aspect and to see staff who have living experience and veterans who are living with substance use and mental health concerns providing their own feedback, saying what they want and getting it out of this program as we adapt and shift to really focus on what they need in the moment. And I think that's really fantastic. I also think that reduction is a culture shift. And so as we are providing opportunities for learners through the residents, both in pharmacy as well as public health, as well as a social work intern that I'm taking on this upcoming year well as providing education and ongoing support for our multidisciplinary team. Really providing ongoing education, community support, opportunities for individuals to support each other, especially as we have harder conversations, which is one of the challenges that we can talk about. All of that really provides fuel for your soul to know that you are making a difference in the day to day lives of these veterans that we're serving and the staff that are wanting to support them.

tessa-rife-pennington---she-her-_1_04-15-2024_111139: 22:00

I'll just kind of piggyback on what you said, Andy, about having learners involved. I think this has been such a cool opportunity to engage with learners from different disciplines in harm reduction work-- from pharmacy students and interns to other, I have a public health intern from a local university and just getting more learner involvement. This work is not necessarily part of our curriculum training in school. I know in pharmacy school, I didn't really have a learning experience in harm reduction. I think Increasing those opportunities for learners across disciplines is really important because the earlier we start integrating these concepts, the more normal it will be and the more people will incorporate these concepts in their practice.

Andie Ruggles: 22:54

Absolutely. I would also say that we've had some challenges with this program. And I would say specifically the stigma and discrimination that you mentioned. Part of that we're turning into that win is, as I mentioned, community space. So providing ongoing meetings with our point of contacts and with full time staff who are involved to provide a chance to counteract that stigma with affection and with ongoing education and support for each other. We have daily stories that are shared in that chat of people thanking staff for providing those resources for them. I would also say the fact that this is not a no barrier program. It is low barrier. We try to make it as low barrier as possible, but we also work in a healthcare system and only service veterans. The fact is, is that not anyone can come in off the street and access these vending machines program, which would truly be ideal that they could just come in, press a button and get what they need. But that is a challenge that it is low barrier, and we do encourage our veterans to take materials and hand them out to friends who are not veterans and to provide those resources to all of those involved that need them. But there are some limitations there.

Tessa Rife-Pennington: 24:07

In Addition to those challenges, I definitely would say that space has been a huge challenge. Having 15 vending machines requires quite a large amount of space to receive all of the supplies because while the vending machines are spread out all the supplies that go in the machines come to the main hospital. So we receive, many many boxes of items unpackage them some of the items need packaged in a way that they will dispense out of the machine, which has been a learning curve. I thought initially that we could just put items in the machine and they would properly dispense. But they, some of them needed bagged or packaged, which takes time. Getting the items from the hospital to all of the other locations. We're fortunate enough to get a large Connex shipping container, like a literal shipping container for all of our inventory. It takes up quite a bit of space for 15 machines. Our logistics technician spends a lot of time packaging and getting all the items ready. So ideally, we would have additional team members to support the amount of work that's needed to support all the machines. Other things that didn't anticipate, like some of the machines didn't fit in the locations we had planned for them to go because they, while they fit in the destination, they didn't fit through the entryway. We had to reconfigure some plans for where we wanted them to go. We also had we had an, a complaint at one of the locations in regards to seeing syringes where some of the residents have children and they were concerned about children seeing syringes in the housing building. So two of our machines were moved out of the front lobby area to one is in a parking garage and one is in a bicycle room which while those areas may afford more privacy, it's also kind of like putting a machine in another area, which may not be as desirable or accessible. So there have been definitely some challenges regarding stigma. But again, every time I'm at the machines, so many people come by and thank us for what we're doing. It's not an overnight culture change. It's a, gradual, gradual change that we're hoping to steadily see in the right direction, which I think we are.

Beth Dinges: 26:37

I empathize with that a lot. Just the amount of"no's" and obstacles along the way and really hanging on to the little snippets and feedback that you get from the veterans, like those little moments that keep you going. Where do you see this program going? Any plans for expansion? And how do you determine if it's working? Any metrics that you're holding yourself to? How do you evaluate progress

Andie Ruggles: 27:02

Oh, that's such a good question. I would say my primary focus is going to be expansion of points of contact and staff and education. Just continuing to reach out and get that multidisciplinary team and bring in as many different disciplines as possible. So that way we can learn from each other and really bring in veterans every single step of the way to make sure we're hearing from those with living experience to actually serve the needs that they have.

Tessa Rife-Pennington: 27:28

In addition to that, we have a couple of different projects going. I have a research funded project through the University of California, San Francisco to evaluate feedback from veterans who live in supportive housing where a vending machine is located as well as the staff who work there. So we're going to be evaluating feedback on the machines, the items within the machines, impact on quality of life and health outcomes. We're hoping to use that feedback to improve what we have in the machines as well as other services that we're offering. As Andy mentioned, this is the pilot and we're hoping to continue learning from our veterans and our staff so we can keep making improvements. Some things that I've heard so far, people are interested in access to COVID 19 tests. We're looking at point of care or oral testing for HIV, hepatitis C, and sexually transmitted infections, and how we can either have that in the machine or as a resource that we offer. We also have a quality improvement project where we're serving staff who work at the outpatient clinics where we have the vending machines to get feedback on what type of harm reduction training they're interested in and better understand their competencies and perspectives around harm reduction so that we can offer training to our staff to really help increase awareness and support for this initiative. Down the line would love to expand our team to include a peer and a social worker full time in addition to Andy's support full time social worker and another prescriber like a nurse practitioner would be amazing so that we could have HIV prep, medication for opioid use disorder like buprenorphine, really make it low barrier and easy to access.

Andie Ruggles: 29:29

I would also love to add into that team, a mental health provider like our contingency management team just providing that all around holistic care. If we're going to dream big, I want to dream to the max that we can.

Beth Dinges: 29:41

I'm starting on the journey of purchasing a vending machine for our facility. And I'm finding it all a bit overwhelming and daunting. I know many other sites are looking to get started too. If you could break it down a little bit, like what advice would you offer to someone who's just getting started in a very like pragmatic sense where it's actually approachable.

Tessa Rife-Pennington: 30:02

I would say similar to other harm reduction work, people in the community have been doing this work for a while. We have so much to learn from them. They're the experts. Joining the community roundtable webinar group that meets to talk about how to get started with vending machines, that's where I got started. They have a wealth of implementers across the United States who have, who work in different states. There's like all the different regions of the United States. So you can see what companies people work with in different regions, what works well, what challenges have come up across all these different programs. It's a really great place to get started. When I was getting started, I met with several implementers in the community to just like Q and a, like, how did you do this? What challenges came up, asking specific questions that I didn't have time to ask on the big group call. And that was really helpful for getting an overall sense of how these work and where do I get started? What companies are out there? From there, you can find out what vending machine companies exist, and then just contacting them, meeting with their representatives to find out how the machines work, how much do they cost asking questions about how they would fit into a specific setting, like within the Veterans Health Administration, we have veteran privacy, we have to make sure that we're taking precautions for and like how are they going to connect to Wi Fi and electricity, all of those things just like really figuring out how they work.

Andie Ruggles: 31:47

There's a phrase in the community of know your people. I would say that's really critical as you are building a program, know that you are going to get kickback and know that you are going to get some negative feedback and really surround yourself with people who believe in this mission that you're working to implement at your site. Because those are the people that are going to continue to push you forward and provide you the support and validation knowing that you are working to make a difference in the lives of so many. So really know your people and work with them to better the lives of everyone.

Tessa Rife-Pennington: 32:19

I love that Andy and just to add I think knowing your people and knowing what they need. As a health care provider, we can't always assume that we know what our people need. We have to ask them, what do you need to be safe and healthy and alive? I think that's been something that we've tried to do along the whole journey is incorporate feedback from veterans and from our staff about what the machines will look like and what supplies are in the machines. Having involvement from your participants the entire way is really critical to making sure that the program actually is well informed and meets the needs of participants.

Andie Ruggles: 33:02

And be willing to accept that even though we have decades of research in harm reduction, we are still learning every single day. And every single day, we're going to learn more and more about what's needed and what's not needed, what hasn't worked. if we think that it's valid and there's data to show that it's significant and relevant. It may not be at your site or in your community. Recognizing that we really have to bring in those with active living experience into this every single step

Kinna Thakarar: 33:32

That was Dr. Tessa Reif Pennington, Andy Ruggles, and Dr. Beth Dinges in conversation on harm reduction, compassionate care for people who use drugs. Thank you for listening. 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.