Optimizing Opioid Bridge Programs

Opioids remain a leading cause of death, but success at lowering these numbers is being found through the use of opioid bridge programs that connect individuals reporting to the ED for relief from an opioid addiction with next-day addiction recovery programs. 

Arianna Campbell and Dr. Loni Jay, two experts in the California Bridge Program share what successful bridge programs need in this month's episode of Caring As Communities. 

Transcript

Enrique Enguidanos:

Welcome to today's episode of Caring as Communities. I'm Dr. Enrique Enguidanos, and today we're talking about Opioid Bridge Programs. 

Opioid bridge programs which engage individuals during crisis moment, and facilitate immediate transition into effective long term care have begun to appear communities across our country. Today's two guests have been pioneers in this work, and we're so grateful to have you both here today, I'd like to introduce Arianna Campbell and Dr. Loni Jay. 

Arianna is director of the rural Bridge Program and co director of the substance use Navigator program for California bridge. She has over 20 years experience as a practicing physician assistant primarily in emergency departments in California, and her work with opioid bridge programs has been featured in The New York Times and several other publications. 

Dr Loni Jay is core faculty member of family medicine at Sutter Health, while starting her practice in family medicine. She was profoundly impacted by the volume of patients presenting with substance use disorders and pursued additional board certification in addiction medicine, eventually, starting the Marshall cures Addiction Medicine Clinic in Eldorado County, California. Ariana, Lani. Welcome and thanks so much for being with us.

Arianna Campbell:
Thank you.

Loni Jay:
Thank you.

EE:
So I want to hear a little bit more. We want to hear a little bit more about your backstories before we're going to question is kind of what led you into this work because that, as far as I know neither of you got into medicine thinking you were going to do this type of work. Arianna, how would you start maybe tell us a little bit about your story what triggered your work with opiod bridge, what was your experience prior to starting this type of work and kind of what motivated you to start up and how did you start?

AC:
Thank you for the introduction and, and yet really at the time I started doing this work I had worked in the emergency department for 17 years. And I felt that this was not an emergency department thing or even I worked in family practice initially this was this was sort of not my jam right, I really felt like this was this specialty gig, and if I just handed patients a list they should be able to go, secure treatment, where I landed, I actually started with, you know when, when was information about the opioid epidemic, you know they're the hospitals were tasked with what should we do, and I think a lot of hospitals start with opioid stewardship programs so I was asked to sit on a, you know, on a process improvement committee to discuss what we were going to do about opioids, and it felt incomplete we were talking about checking cures automating things, I was trying to create objectivity in it, I felt like, what happened is we were labeling patients like, oh, there's a, there's a CURES patient we'll check there.

EE:
And when you mentioned that sure is what what is CURES for someone that says that I'm California.

AC:
Oh sure, that's just the, that's a database where you can look at our trolled substances. So what we would, you know, there was patients that may have been, you know they let's check to see if they've been prescribed controlled substances recently. And really, if I can put in quotes, is this a patient who is "drug seeking," right, so there was a lot of labeling, there was a lot of judgment, and I was trying to take the approach of more objective information so we took, chief complaints, and then we. That's how we are going to check yours reports, automated so we weren't labeling somebody by the way they looked the way they talked, etc. 

So that's, I guess that's the very first project I did where I started realizing that there was these disparities in what we do in medicine. And what I can tell you is at the end of the project we may have been, we were better at identifying patients, but it started some conversations that were a little uncomfortable, and that I didn't sleep well at night, realizing we hadn't answered and one of them was okay so we identify somebody who potentially has opioid use disorder. What do we do, like, we're going to get better at identifying folks and and being more objective. But what do we do now, and is this really where it's at. 

So, I was invited to a meeting and it was a community health center actually said, we have an expired provider. We are having trouble getting folks in and that wasn't sitting well with them, they were people were having to wait to get treatment, there's an emergency department in at Yale who did this, who started folks on buprenorphine for opioid withdrawal and referred and this worked, and so I came into that meeting I said Well isn't that just substituting one opioid for another. And I was educated so you know I had some education in peep an orphan. And then I said well this is an emergency department thing. And I was presented evidence that my patients were already struggling with this, but didn't necessarily feel comfortable talking to me about it and I really wasn't providing adequate treatment. 

And so I just shifted, very quickly in literally in a one hour meeting how I thought about this, and then also determined. I did not have adequate training knowledge in addiction, and yet, you know 28% of my patients screen positive for, for you know for substance use disorder. Why on earth do I not have more education so I it's available I went out and I did a Scholars Program through, through the, through CSAM which is the California Society of Addiction Medicine I applied to it. It was a physician program really for residents but I just decided to take a chance and I applied as a PA and was accepted and so that was my first educational experience in addiction medicine. It was just great because I learned so much and I really thought, wow, I really should have known this like 17 years ago, this could have made a difference. But in my defense, the X waiver at that time had just opened up to BS and I started a program to my emergency department, without money or grants or support or anything and our PA is nurse practitioners, got our x waivers and then he started the program and just started treating

EE:
Well, and, you know, I'll say let me qualify this question because you look like you're about 17 years old. So let me just ask when about was this because as you describe this, this concept of Well, that's, that's really not my role as an ER provider. I have felt that way, I bet you every single emergency provider has felt that way. And yet, things are changing and they're changing because we've begun to think in the ways that you just described, but I think I, my experience that's been probably over the last 10 years or so, would you say,

AC:
yeah, I really do. When I started in 1999—I was in school from 1997 to 1999—and it really was this, there was a lot of judgment too if I can just be honest it was, you know, pull yourself up by up by your bootstraps where, you know, why isn't this person strong enough to get over this and just stop using that's what people do, right, they just stop using, and I never looked at the evidence I never put it in the category of the other medical problems I was treating and actually looked at the evidence and really at that time there was even evidence then we just weren't necessarily adopting it here in the United States, there was the French field experiment where they, they really released buprenorphine without barriers to folks who were struggling with opioid use disorder because they had a lot of issues with increased HIV rates, and what happened, you know, deaths, decreased. So you know I really there was some evidence out there, it just wasn't really widely known and I believe that within our medical education system I mean I did a lot of rotations and an internship and when I started in the emergency department, it was 2002. This was just felt like this was a moral failure. People can pull themselves up by their bootstraps, it was kind of more in the AA model I would, I would say not to say anything against a that works for a lot of folks but I just think that that was more generalized for this is what how you should do this and not really taking into account the disease process the individuals, the the drug.

EE:
And just to be clear, now we've done a section on buprenorphine but for our listeners that might be new buprenorphine is a medication and opioid based medication that's new, relatively new last 10 years or so has become more available to us as providers, you mentioned the ex waiver. And can you give us a little one or two liner on what that is.

AC:
Yeah sure it's the data X waiver that allows physicians PA, nurse practitioners who are not addiction specialists to be able to prescribe a schedule three medication for the treatment of opioid withdrawal. For for patients and the only medication that fits into that category is buprenorphine methadone is a scheduled to medication, and therefore, that requires a lot more regulation and licensing etc but buprenorphine is able to be prescribed by generalists, who obtained the special waiver through the DEA. 

EE:
Thank you, that's, yeah, that's a nice, isn't that we're gonna get into some of that a little bit more but thank you for that background. Loni,  I'd love for you to have to have you share your story with our listeners kind of what was your experience getting into family practice. Suddenly, experiencing this addiction cohort and deciding you're going to become involved.

LJ:

Yeah.

So I, first off, thank you for having us. I love listening to Arianna speak it's part of that excitement and knowledge that she brings to the table that helped enroll me in this work and I found that over and over again with providers doing this work that there is this excitement and hopefulness that we often don't see in medicine so I'm happy to be here to share my perspective today. 

So I, I have not been practicing quite as long as Arianna so I actually graduated from residency five years ago, and I had my training was in family medicine I had excellent training and family medicine I learned to practice very broad Family Medicine, very evidence based. And in one of my third year my last year elective rotations, I spent two weeks working at a clinic in Sacramento that practiced very low barrier Buprenorphine Addiction Medicine care, and it was a unique clinic and a unique experience, that is, that was a little bit ahead of its time and starting to bring this work to Sacramento. 

And so I had just a taste of that perspective of Addiction Medicine care. What I did find in my training that I didn't quite realize till later was that a lot of those same patients weren't quite making it into my residency primary care practice, and, and, which was interesting, and so I had this experience when I left residency and went out to practice on my own that I was suddenly practicing in a rural community, I work in, I worked in Placerville, which is an El Dorado County, it's a small town foothills town in California and that's where I met an encountered Arianna and the practice experience was different in some ways, the the rural part of it was different, and then also the lack of access, so there were a lot of patients that are on Medicare and MediCal are the Medicaid California Medicaid system that didn't have providers. 

The community have lost a few providers recently so I opened my primary care practice and really was flooded with patients needing care, and a lot of what I saw come in were people struggling with substance use disorder and people also that had all of the complex psychosocial situations that can go along with people struggling with substance use disorder, so I saw people struggling with difficulty finding the stable shelter stable housing, keeping their medical funding in place so they can see me and so just a lot of complexity to my practice. 

With this I had received my X waiver training during residency though I had not actually prescribe buprenorphine on my own for a patient. I sort of felt like I was in this rural community practicing in the wild west taking everything on and getting my feet wet as a new primary care provider, and just very surprised by the complexity due to substance use disorder, and so I started my first patient on buprenorphine when they did well I started the next patient. 

My partner started sending me their patients because they were not X wavered and these were their problem patients that they couldn't fix and. 

And what surprised me was how patients did well, but also I was, I felt like I was the only one doing this, and I met Ariana at a county opioid coalition meeting that we that was in the early stages of our counties coalition coming together starting to have conversations bringing our voices to the table. I followed her footsteps to go to the California Society of Addiction Medicine training workshop, and I did that a couple years in a row and so I just like Arianna started to more broadly, educate myself in what was evidence based what other people were doing, and it helped me realize that my experience of feeling like I was the only one doing this and I was unprepared for the volume and the need that I was experiencing in my practice, that, that this disease process needs more support and more providers and more care, and some of the the guidance the mentoring I was receiving as within the organization as I was building primary care practice. 

I was getting the advice of "oh you should really limit those patients, they're they're going to drag your practice down. "If they were late the front office staff would complain why are you still seeing this patient and so it just, it became complex, and after a couple years I actually
found a grant, and, and had a sort of transition point in my career where I had the opportunity to continue practicing as I was in primary care, or apply for some grant funding, organizational support to do something different. 

And at that point, area not on end, I started partnering more closely, and we built this clinic, focused on treating these patients and so we were part of two large grant systems, the California bridge grant system and then also the Hub and Spoke which was some large federal money that came through and and now Marshall is on their third year receiving that funding and they also have a fourth year coming and so they've gotten very good funding, we were able to get startup money to cover our staff spec primer, started doing just Addiction Medicine. 

One point I work on my off at a neighboring addiction medicine clinic to sort of understand a little more how to do that specific piece, how to work on a multidisciplinary team, and really just put together a training program for myself to meet the needs of the community and what we ended on was this clinic we called it the cares clinic, which I just to this day feel like is the perfect name, with the goal of meeting the needs of this community, providing low threshold care, meeting people where they're at, wherever they're at in the disease spectrum, there's a place for them in this clinic, and trying to establish this as a standard part of primary care or a needed part, and so it shows a need wasn't getting met before it came, and now I think— Arianna you'd agree—I can't imagine this not being there, I mean we can't unprovided this service which is so clearly needed. 

And the one thing that's been very interesting that I've learned is that it's, it's been common for primary care to not assume responsibility of patients struggling with substance use disorder that it is a clear disease process and. And yet, we, we understand our responsibility to treat diabetes we understand our responsibility to treat high blood pressure, but the disease process of addiction is really somebody else's problem. 

And therefore this problem ends up being an ER problem but they with an outpatient, primary care, solution, and so that's what's been so unique about the bridge program is bridging the way patients often present in crisis in the ER with the outpatient solution where it belongs. And so it's been a privilege.

EE:
I'm so glad that you know thanks for sharing. I'm so glad you ended on that line because as I mentioned in the intro, you know I was a fire fighter paramedic for years before going to medical school and in that environment, and then in the last 20 years in the emergency department. We've experienced the these cases and it's always been. Well, that's not what I do or I don't have the training or I don't have the resources and it's, it feels like folks within our medical system have floated out there and it's, it's the work of both of you folks stepping up and creating the system that works and and I, I applaud you, I'm so grateful for those of you that have led this charge to address this issue. 

LJ:
Yeah, it's not our problem whose problem is it? We don't hold a solution, who does?

EE:
And that's what I love about the folks we've been meeting and are caring for communities podcast is folks stepping up and creating the solutions that are needed. So as we do that as we start creating the solutions we encounter bumps along the road and I want to fast forward now a little bit. So I'm just curious from from either of you, whoever wants to start, as you start setting up programs are gonna use to help set up programs across the state of California. What are some of the common hurdles that you began encountering early on and then how did you address them and what are some of the new hurdles you started coming across.

AJ:
Well, there's a lot of myths out there about treating opioid use disorder in particular, and I'm actually doing a whole thing right now trying to mythbuster right so there's just the deeply ingrained, you know, treating opioid use disorder with buprenorphine is just substituting one opioid for net I hear that that that's where a lot of folks start and so again there's so much evidence out there that this is this, you know we double a patient's likelihood of being in treatment in a month by just starting the right medication at the right time in the emergency department and referring. So we really try to remember...

EE: 
The comment right there, you double the likelihood of successful treatment just by starting treatment in the emergency department?

AJ:
Yeah this study at Yale was published in JAMA in 2015. And so this evidence is there and it really we've seen this also we recreated this at multiple institutions in fact at Marshall at one point, our follow up rate was, and our retention and treatment was even higher than what was happening at Yale, which is a large academic institution with a lot of resources so we did this in a rural community, and we had at one point, Loni we had 97% Follow up rate and that based in the sort of low threshold there at.

If they're late. Okay, this is what we can do to, You know, it was really, it was really patient centered care, because the system has been built on a bunch of expectations that don't remove marginalized or at the most unstable point in their life. 

So when you shift your system, you can address that. Now that being said, to answer your question, what what is been the biggest obstacle has been sort of that set system. We don't do this. This is substituting one opioid for another. This is not an emergency medicine thing. 

There's a lot of, I know that you're addressing this in regard in terms of stigma, but a lot of folks don't even realize they have this lens that they're looking at patients with substance use disorders through, and that has been, I think the biggest obstacle. Really we tried to, so my, I'm a director on California Bridge Program, and I'm doing actually, we have started programs now. 

And 206 hospitals across the state, and we're doing a lot of national outreach and I'm actually helping start a lot of programs across my, my company as US acute care solution. So, we have 240 hospitals and trying to start programs and as many as, as we can right now, and that starting the just questioning these ingrained beliefs about what diction treatment is what it should look like and what we are able to do for patients, that's where I found it's effective, too, because that's, if I don't address that early, Then it's hard to get folks excited and engaged about the 200.

LJ:
I want to talk and I'm sitting here thinking about thinking about this whole process,
and I you know, early in my training I remember, you know my intern year seeing people in and out of the ER struggling with alcohol withdrawal or something like that and there's this feeling we get that those people, you know, they don't want to do something different, they're back here doing the same thing. And, and then I remember living through this experience of 97% of the patients Arianna my colleagues on the ER 97% actually came to establish with me, which just completely blows that idea out of the water that, that they actually all do want to do something different . 

EE:
I don't know that there's anything in medicine that gets 97 responses. 

LJ:
Wow, I know, and so if you can make it as easy as, hey, right now you're here feeling terrible let's get you out of withdrawal, and then go right there tomorrow just right there a block away. There's an appointment at night, but honestly whenever you wake up, they'll see you go right there 97% of them did actually show up, and we, we did not have an expectation of people being well before they, they got here of, or being well before they've received standard of care treatment so if they couldn't show up at nine o'clock or nine o'clock visit we would see them whenever they showed up that day, or we would see him a week later when they walked in because the chaos that comes with people's lives when they are struggling with substance use, is, is a symptom of the disease that is not a moral failing, it is not that they obviously don't want treatment if they can't show up for the appointment we gave them it is the way people often live their life, their life is chaos and they are struggling with this disease process and so accepting that and rolling with that and allowing them away in the services that understands that, that then we can help them stabilize showing up for a clinic visit on time as a product of stabilization is not an expectation at the start and so that is one of the most important pieces that however people present in the ER, allowing them a route that they can meet the expectation or they can live with for showing up, that 97% of them will, if it can be that low barrier and that really is key. 

EE: 
I just was thinking about how important that point is.

Well, like I said, I can't think of anything that gets a 97% response and and you both touch it, I'm going to just throw it right out there. And as you alluded to Ariana next month, our podcast is going to be focused on stigmas that complex care individuals patients have to suffer through have to navigate. You both must encounter stigmas not only for your patients, but amongst providers and, you know, there are three of us providers here in this talk and I think all three of us at some point realized or thought of while this is not my job and yet we realized we have to step up. Can you speak to me a little bit about the stigmas stigmas your patients experience, the stigmas amongst the providers and how you might have navigated some of those hurdles?

AC:
Yeah, you know, I, I'll tell a personal story because this, this one is personal to me, but my sister died from the effects of substance use disorder from stimulant use disorder she had a stroke at the age of 42.

EE:
I'm sorry,

AC:
and my phone call to the hospital to the to the ICU that you know that day when I was trying to make some, some decisions and, you know to weigh in on what we should do. I remember having to talk to the nurse, and to explain to the nurse that my sister was a really good human being, even though she looked at a certain way. I knew her urine drug screen was positive for methamphetamine, but I felt the need to explain to her that she's, you know that her family's really nice, and that, you know, she didn't start out this way. 

And when I, after all of that happened. I remember reflecting on that and thinking, why on earth did I feel like I had to tell you know this nurse and I advocate for her and say hey, where she comes from it's really nice family. My parents are great and I really have felt I had to do this, and it's because I'd worked in the system for so long for you know, 15, 16 years at that point that I knew how the lens that the nurse was seeing my patient through. And that is something that also really drives me to change medicine because I know that we all see this lens and that's natural, we all have this lens, but for folks with substance use disorder, the lens was that she was lesser than less deserving, maybe didn't need the, you know, the highest quality care, wasn't even transferred to a stroke center yet and had this massive stroke at the age of 42. 

This blaming on substance use disorder so you know not the same evidence based treatment. So I had to sort of vouch for my sister. And what I have done since then, and my emergency department. I've worked in my emergency department forever. I'm a fixture, but my, the nurses, I work with the folks I work with. When sort of resetting with certain patients. I would just say that could be my sister, you know, And I think that has made a difference because it just humanizes the person in front of us and helps us see through a little different lens. 

And I have said that multiple times, and I think you're addressing stigma within my nursing staff, addressing stigma within registration, like sort of resetting everything and providing that education. This is the model of care. You know addiction is not a moral failing, it is a chronic brain disease that is treatable. These are the things that we say all the time to sort of do a reset. Because as it turns out, treating patients as a moral failure or with stigma, really doesn't help them and in fact I really feel it's responsible, and I think there's some evidence out there that it is responsible for increased mortality.

EE:
I can't agree enough I've. And I find I have to train myself constantly, even those of us who, who are in this medical field have to constantly revisit this issue. Thanks so much for sharing that personal story, Arianna. 

Loni, would you, would you add anything, I'm really curious how, how your partner providers have have engaged with you on this, on this topic.

LJ:
Yeah, you know, the first thing I would say is actually this has been really a story of personal growth that as I've grown in my practice and grown as a provider, it's been an opportunity for me to look inward and think about how I meet people in every part of my human life interaction I need them where they're at, without judgment and accepting that we are all human with flaws and we all do the things that make us feel better, whether it's a substance or whether it's you know the different parts of our lives. 

And so it's just been, it's been interesting personally to reflect as I learn more about this disease process. I'll share a personal story from this week actually in practice. 

So now I work in another neighboring rural county I work with the Sutter Health System now and I'm new faculty in the residency program so have an opportunity to train residents to do something differently, which is very exciting. I'm building a new practice with a similar experience of a rural practice, and we have a brand new baby bridge program, so we got a substance use Navigator just about a month ago and we are starting to recreate the same handoff and my substance use Navigator sent me a message saying hey all the primary care is booked out a couple months but this patient was just in the hospital with alcohol use disorder we got him through alcohol it's really stable he's really motivated, he doesn't want to drink again. Can you see him sooner? 

And my, My next new patient visit is three months away, but that was not going to work for this patient and so we double booked and fit him in and, and it was one of the best patient encounters of my week it was very wonderful to be able to provide care to this patient, and so he's struggling with alcohol use disorder and as I look through his chart I see ER visit after a year visit I see fragmented care. He has Medicare so he has insurance to get in and see a provider but I don't see significant outpatient stabilization for him. He's sitting in front of me, very motivated, it's been a week since he's had his last drink and he's so grateful I'm able to see him. 

And in the decades that he has been struggling with alcohol use disorder, not once has he been offered standard of care, medical treatment, he's never been offered naltrexone, which actually has good evidence it has the same number needed to treat as antidepressants do for depression. So, the confidence with which we see someone that's depressed in front of us and we offer them an anti depression as well as the counseling piece, and we know we feel good that we can stabilize them we can fix this. 

We should have that same confidence when we see someone in front of us struggling with debilitating alcohol use disorder that we can start now trek zone, and we can help we can help with your craving we can help with your desire to drink, we can help stabilize this process. 

It's not quite as effective as buprenorphine is for opioid use disorder but it is still a pretty good tool. And in his decades, no one has offered him this. Instead they left him on his own to stabilize on his own. They've expected him to be his own medical provider, rather than when he's encountered medical care have been offered a standard of care treatment. 

And so the biggest thing that I've learned about about stigma and stigma within the medical community stigma within myself and my times that I've practiced, is that I am committed to providing excellent care to patients that I see, and it just should not be any different, no matter what the medical problem in front of me is, and so that's the biggest stigma is that that disparity, or the, the discrepancy, we offer the the difference in level of care and standard of care and level of care that we offer people in front of us. 

And so and and I think again about these very busy hospital follow up visits where somebody has gone through alcohol withdrawal and they just had hepatitis or pancreatitis and also they haven't had care, so their diabetes is out of control my blood pressure is out of control. And I used to use that visit where they came in after the hospitalization and made sure their blood pressure was stabilized and they were on diabetes medication. And now I don't do any of that. 

Now I look at what is, what is the thing that is making you sickest, why is the reason your blood pressure is not controlled, or your diabetes is not controlled? What is the thing that gives you the highest chance of actually showing up for our next visit in a week. 

Let's address your use disorder, which is often the thing that makes them the sickest and the underlying cause and so seeing substance use, that is the biggest place where their judgment and stigma is that we don't see substance use, we choose to not see it we choose to see the things that we can easily fix. I know how to start a med for high blood pressure. And so I see how a lot of this judgment stigma just comes from a place of insecurity and providers a lack of training lack of, you can own this problem you can make a difference, just having a conversation with the patient and offering them, you know, and setting close follow up let me see you in a week like can be very therapeutic that can be very effective. 

EE:
So, well, you know, I love that putting in that first encounter what is the patient's greatest need and putting that foremost as an aside, I have encountered in our engagement of complex care patients that's been such a successful approach just putting everything aside and saying what in your world needs to be addressed first and foremost and I hope more of us can begin to do that. And I think a lot of it is having individuals that are preaching the gospel of proper care as the two of you are doing and and I know that that communities everywhere have folks that want to do the right thing. 

I'm wondering, the next question as as a program as a community wants to start a program, what are some of the other kind of required tools, you know, the does everyone need to know how to use medical assisted treatment right away, does there need to be available, electronic medical record right away, do they need to be a lot of patient outpatient providers that that know what I have handled substance use disorder, what would you say to someone that's wanting to start a program in their community. Arianna?

AC:
Yeah, I was just, you know, there's, there's this feeling that you have to build this entire system to do treat which is really not the case. 

I have to say I started my first patient ever on buprenorphine, and there was all these questions that I had at the time, there was no support this was back in 2017. So there was not the same level of support that there is now out there, and I always said well "what if I started somebody?" 

I didn't have my X waiver at the time because you don't need your X waiver to just start a patient on buprenorphine in the emergency department, you only needed to prescribe, so I didn't have it yet but I just decided, I got it on formulary, and I was going to give it, because I had a pregnant patient who is in withdrawal, who is asking for help. 

So I gave it to her, and first of all, there's a lot of languages, everything is what's called an X waiver so I thought, X that seems like it's forbidden that seems really scary. So I thought this was going to be scary. It's also called the you know, I call it "starting medication" because we were calling it an induction, and I had a 24 week pregnant patient in front of me that I was inducing on a holiday weekend in a rural county with no higher level of care for free, really, we don't have a NICU, so I thought that all sounded bad so I'm just going to start medication on this pregnant patient who needed help. 

And I, the follow up, you know, we just started getting some follow up, it wasn't really clear yet but I just gave her the right medication at the right time when she was in withdrawal, and she got better. So I literally sat there and watched her thinking that because it's called an induction, and there's this next wave where you need to prescribe it so I just stared at her uncomfortably. And she, she just got better and she educated me I also listened to her, and she told me I didn't give her enough medication. 

The first day I gave her more. There was just a very, there's a relationship that developed between the two of us because there's a 72 hour rule where you can treat for up to 72 hours in your emergency department, without an X waiver, so it's Memorial Day weekend in 2017 So I saw her every day for three days. and she like Monday Memorial Day Monday she said, this time I think he got it right. So I gave her the right amount of medication, and I was like oh good. So and then I got the follow up that she had followed up with her follow-up clinic, and that she was doing great and she was very grateful, and that piece, so without any funding, without an X waiver. I did have a follow up clinic. So I think that's important. 

That was, and I had some leadership support meaning the nursing director of our ER and I, we just wrote up, we wrote up a protocol of how to do this, But it wasn't this huge hospital wide thing we just decided to give, just like other medications give the right medication at the right time. And then we built on that. Then we decided, Well okay, we could do better here by getting feedback from the clinic and the clinic kept saying, You're not giving high enough doses, our patients are in withdrawal. 

The next day, you know, etc etc so we we really refined it and then that's when we founded the California bridge program, we, we, you know there's a group of us who came together with a lot of learnings and we tried to, we're still trying to disseminate that information so so folks can start from a place of, you know more advanced than where we started, but I, the reason I make that point is that you don't need a perfect system first. You just need to start giving the right medication at the right time to the right patient, and have a place that they can, they can land you know.

Loni's practice wasn't up and running at the time, so we had an FQHC family practice. You know docs in the community who were actually a nurse practitioner who started the program with me from this FQHC, and that's where we started and then we were trying to build an entire system to address the needs of the patients but so that if anything I could say is just, you know, is the first time in my career, if 17 years in that I actually talked to a clinic, just to say hey can you see my patients next day who I'm starting on Buprenorphine.

I said we will start them in the emergency department so we will do the initiation of treatment because that part was a little more difficult, and timing etc for the clinics, but really easy for us, because just show up when you're in withdrawal and we'll we'll treat you. And then I just said hey if you just have a standing appointment time. 

The following day, and we built the system entirely if that was that simple and so we just went one appointment time to keep it really simple for a unit, our unit clerks, and we just would fax over some information tele patient is to go in there at nine o'clock is as Lonnie referenced 10 o'clock the next day, and we built two different clinics that that are still holding that appointment time every day now for four years. So, that has not been a burden.