Emergency Care and SUD during COVID-19

In this edition of the Science Behind Addiction LIVE video series, Yale emergency care and addiction medicine physician, researcher, and advocate Dr. Gail D’Onofrio and NIDA Director Dr. Nora Volkow discuss COVID-19 and emergency room care.

Emergency Care and SUD during COVID-19

Video length: 38:24


[Dr. Volkow speaking]

It's a pleasure for me to have today as a guest, Doctor Gail D'Onofrio. So, Doctor D'Onofrio, thanks very much for being with us today. I know that you've been on the frontlines of emergency medicine, in addressing substance use disorder in patients. And as the chief of the emergency services at Yale New Haven Hospital. That has placed us in a position of tremendous responsibility, but also opportunity for innovation. Nor does it relate now just to your past work with substance use disorder, but now with the challenges that we have with COVID. 

And of course, you bring those together, and you speak about the challenges of the intersection between these two epidemics. So as your personal experience in the emergency department, what have you seen? What has changed in the emergency department since… In the last few months when we have been overcome by the COVID pandemic?

[Dr. Gail D’Onofrio speaking]

So, Nora, thanks for having me. You know, we all throughout the country, have really seen similar things in that our overall volume has decreased. In most places that's been as much as 40% less than what we generally see. It's really scary because we know that people aren't coming to the ED that have heart attacks, or strokes, or other symptoms, or even use disorder withdrawal, or seeking treatment. Because they're so afraid to come, they're paralysed that they may get COVID while they're there. 

On the other hand, we've seen really lots of patients, at least in my area, New England, and at Yale New Haven Hospital, we've seen an overwhelming amount of COVID. And at one point we had, oh, more than 450 patients in our hospital. And most of our patients in the ED were either there or people of interest, and that was overwhelming. 

Right now those numbers have gone significantly down. But it… In Yale New Haven, our numbers of pretty much all of our diseases or all of our presentations have really paralleled that decrease. And we're starting now to come up.

[Dr. Volkow speaking]

And now we know that vulnerable populations are… There are certain groups that are much more at risk, greater risk of developing COVID, and if they do get COVID they have much worse outcomes. Among them are people with substance use disorders. But also we have all become very sensitive about that overrepresentation of minority as it relates to very, very negative outcomes from COVID. So how is your team and you experiencing these big challenges, and what are you trying to do to address them?

[Dr. Gail D’Onofrio speaking]

So that's totally right. I think in general, the emergency department is there for everyone. You know, we're open 24 seven, 365. We're the only part of the health system that is open at any time for people to come to. We often have people who are disenfranchised. As long as all the people who just get access care. But we certainly are there for the entire population of people. 

What we're seeing now is that we're just having more, really more barriers of care for those people who are disenfranchised. So for example, in the group of substance use disorder, no matter what, we have many homeless populations. And it's really difficult to manage the homeless, obviously, in something like COVID. So in all EDs around the country, they've been grappling with this, and as we've moved on, we've been better at it. 

And recently, here in New Haven, they opened up a high school for, what we call, shelter one. They put patients in there who are COVID positive that were homeless. And we're working with that. But in a… On the other hand, we had difficulties in that our one real in patient, out… It's outpatient, but it was for the homeless and shelter for substance use disorder emptied out. And they would no longer take more patients.

So we were then trying to figure out what are we going to do with these. And we also know that people who are homeless, or people who are disenfranchised are not going to have the proper equipment to do Telemedicine. And with the closures of the… Of anywhere they might go, like the library, or any public facility that where they might be able to use the internet, or whatever, were also closed. So that added another level of barrier that you can't even imagine. 

And we'd done all kinds of innovative things regarding that. Our opiate treatment program for example. Even though for most of their patients, they're giving multiple doses. If someone needed to come in and see the doctor, or do a Telemedicine, they could come in and use their facility, and they would call the doctor. 

In fact, one of our doctors, Doctor Kim [inaudible] says to me, she's available at six o'clock in the morning. She might be at home in her bathrobe, but she's taking a call because a patient came in, and really needed help. And so the one nurse that was there was able to connect them together. And so we've done all different creative things like that. But it is really hard for people that don't have options for Telemedicine. 

Also, people don't want to use their phones and the minutes that they have on them to do all this, because that's all they have to communicate with their families and other things. So that's another barrier. But we've tried, you know, as the weeks went on, we have tried all these innovative processes. And with the regulations now being really lightening in terms of that we can and have inductions for people [inaudible], for example, over the phone. 

And Telemedicine, this is great, we've done that. If patients come to the ED, they don't have to show up at the clinic. They will call them if they can negotiate that and do it over the phone. So that's great. My friends in Philadelphia, Dr. Jean Marie Perrone

have actually… Was able to get a pregnant woman inducted right on the phone, and she's been following her routinely, and doing great. Where she would never have been able to get to a place to get that medication in the past.

So, there is sight of a silver lining in many respects, in that we're able to get a lot of people the care that they couldn't get before. And a lot of people, who because of COVID can't… Have no public transportation or anything, because most of those are closed. They could take homes of their methadone. So, there was some kind of a silver lining for many in being able to do that. And of course, we're seeing really both ends of the spectrum. We're seeing people that flourish with all of this, and are doing great, and are hoping it never goes back to the old way. 

And then we see people who are really hurting, because they needed that human connection. And they’re not doing as well. So pretty much it's on both ends. It doesn't seem to be in the middle either. It's working really well, or it's not working so well. And those patients that need a little bit extra now, we're able to be opened up a little bit more and getting them into the system, and to see a human.

[Dr. Volkow speaking]

It's interesting what you're saying, and I basically, to a certain extent, resonates with what we have heard from other investigators that are working with the healthcare system, and specifically emergency departments. And one of the points that has been brought up quite consistently, is that they have seen a decrease in the number of patients that end up with an overdose in the emergency department. Has that been your experience, and if so, what are your thoughts of what's going on?

[Dr. Gail D’Onofrio speaking]

Well, it's different… I understand it's different, really, all over the country. We are seeing a decrease in everything, really, that just sort of mirrors our decrease in overall by [inaudible]. But other places, like Ohio, have seen an increase in overdoses. And we've certainly seen some alerts come out from health departments, Indiana, and Ohio. And at a few… there were a few more that were seeing massively more overdoses since… That they reported in the early parts of May than they've seen before. 

It's a problem in some places because maybe they cannot get into treatments. And not every place, like New Haven, we have a lot of treatment. There are so many places that don't. In a centre in Ohio that we're working with, with one of our implementation science programs. They are giving out one case, almost a month's worth of buprenorphine because they were not able to get people into treatment. Or people couldn't come back and get refills of buprenorphine. So, there are some highlighted places that can do that. 

But in other areas of the country, we're seeing it. Tennessee, Ohio, Milwaukee have all reported massive increases in… I don't know if I should say massive, but large, significant increases in overdose. And they're putting that out there. We have actually surveyed the EMS Directors Fellowship directors to try to see what was going on there. And overall, most of them said they were using less, they were getting less calls. That the calls for overdose were less. 

And that was sort of mirroring their less use of NARCAN, or naloxone. Others showed that there was an increase in calls in a few. And we were really concerned, because we didn't know if people were not using Naloxone. So, there was this big fear because there was one state that came out and said they didn't want their prehospital providers using the NARCAN version, the internasal. Because it was aerosolised, and therefore was a greater risk of transmitting COVID. 

And so, our EMS partners that can would give NARCAN IM, or they would give NARCAN even intravenously. But of course, those prehospital providers like police or fire, they wouldn't have those options. So, the question is, are they resuscitating people in the field or not? Because there's been a lot of consideration with not resuscitating people. 

And there's been a lot of not… States that maybe not even doing autopsies on people, because of afraid, and not having the protective gear to do that for potential COVID. So, there's all these things in the background, and it's not the same everywhere. There are just people suffering more in certain communities. And because the overdose rates are always delayed, we can't see them now. 

I can tell you in Connecticut, we've had an increase in overdoses in January, February, and March. And the April, we haven't been able to really get the data quite yet, because they're still looking at cases. So well, you know, we'll see that. But it's probably not going to be for another six months.

[Dr. Volkow speaking]

And there are two things that are going in what you are describing. One of them is, of course, have the cases of overdose increased? And what we have actually gotten reports of is that, yes, overall there appears to be across the United States, in most states, an increase in people overdosing. But what they are reporting, is that those people that are overdosing, are less likely to end up in the emergency department. For some of the reasons that you are describing. 

But the other aspect about it, that is too very concerning, is for you to have an impact to administer Naloxone. Someone has to observe you. So, with social distancing, that becomes much less likely. So, the ability to revert someone from a overdose is much lower. And to what you were commenting has also influenced what happens to someone after a reversal, we always emphasize importance to link them with treatment. And emergency department was a great place to do that. But people are afraid. 

So… And I know that you're coming up with a commentary where you're bringing up your own experiences and recommendations. As we're living the COVID alongside the opioid crisis. So, what are challenges and opportunities?

[Dr. Gail D’Onofrio speaking]

Okay, so really we have… There's lots of challenges. But as you said, we have an opportunity to initiate treatment. And so, the most important thing, because there's always this disconnect, should you have to transport a patient that’s overdosed in the community to the ED. You know, will they be okay? Well they might not need another dose of Naloxone, but they certainly need the opportunity to access treatment. So, we're still going after that. We want people to do treatment. 

And we're still public messaging about this isolation. That we're hoping that people are with somebody when they're using. We've done, you know, simple things, like telling people, just call someone and tell them that you are using and have them call you back in a few minutes or in a couple of minutes or whatever, and make sure that you're okay. So, all different types of harm reduction methods. So, you're not going to be alone when you do overdose, and not have that potential.

And, you know, in terms of the emergency departments, you know, it really is on us to make sure that people do get into treatment. And as I've said to you before, it's not optional, right? It is not… At best, it's not optional to see a patient that has such a life-threatening illness, see them, and then let them go. Not everyone will accept treatment. But you can have a conversation with them, express your concern. Tell them that you're ready to help them start treatment today. 

But if not, where they could go if they needed that treatment, or even to come back. And to keep doing that. And, you know, we've talked about that before. There is nothing that is so life threatening than opiate use disorder, for example, than anything else that we see. And such life, you know, threatening in often a young population.

So, we talk about the quality issues here, and how important it is for emergency medicine to step forward, and to say, these are real quality and CMS quality measures. This has to be it. We do a lot of things for the other major, probably the largest thing we see is chest pain in an emergency department. And people that have acute myocardial infarctions have not much more of a mortality rate at one year, it's almost a little less than 6%, five point something. 

And yet, in that we have all these quality measures that we do. All these time sensitive quality measures that we measure, and we measure, and we measure. The time to get to the CAP lab, the time to get the medication if your CAP lab isn't open. The time to transport people. It's on, yada, yada, yada. On and on and on. And we probably have somewhere, we're a huge hospital, so we might have 20 or 30 a month. Most places probably have ten a month. 

And yet you to have that many people with substance use disorder a day that you see. And yet we have no specific guidelines that are required that we should do. And that is just not acceptable. It just isn't. We need to move on, we need to have better reforms, and better quality. Just like we do in any other aspect of emergency medicine. Whether it's sepsis, or it's MIs, or whatever, diabetes. We have protocols. 

So we need to make sure that these protocols are in place and that we're following them. And we need to really have good quality control. And some of [overtalking]…

[Dr. Volkow speaking]

Another thing…

[Dr. Gail D’Onofrio speaking]

Go ahead.

[Dr. Volkow speaking]

No, I resonate honestly with that recommendation that you have, that we need to have protocols with high quality control. And I think that as you highlight, more than 5% of people with an opioid use disorder that visited an emergency department will die. 

[Dr. Gail D’Onofrio speaking]


[Dr. Volkow speaking]

And so you had them in the emergency department, did not do anything and the person die. And you are discussing about where we don't tolerate that for a myocardial infarction, so we have a protocol and we hospitalise. We have a protocol and we hospitalise. Here people are thrown out on the streets when there are medications that can protect them from overdose with a large effect size. 

So, I think that that's why, very much, I mean in terms of where we are right now with this emergency with COVID and opioid epidemic is the opportunity to create those guidelines. So, what are the next steps? What would you like to happen? And how to make it happen?

[Dr. Gail D’Onofrio speaking]

Okay, so one is really clear. We need to have certain regulations made. One of the biggest things that we've seen during COVID that's been another silver lining is that we're now allowed to give the waiver courses over Zoom, which we couldn't do before. So, we have had these X Waivers in and my colleagues here, Doctor Hawk, myself, and Doctor Herring, we've done three now, and probably have trained over 200 emergency physicians, or providers in just the last month. 

And I have… There's other emergency physicians doing this same similar thing. And that's a four month… A four-hour course. We really don't need that X Waiver as we've seen a lot of people talk about in the recent paper as well. You know, we need to axe the X Waiver, right? It's an incredible barrier that doesn't need to exist. Education does need to exist. And I would argue that that four hours was well used. 

But in addition to that, they have to take four more hours. And then they have to be able to know how to navigate the whole system where you put all this information in. You send it along to, you know, the DA then you get your number back. It's just way too much. We find that we have to have a research assistant almost all the time walking through doctors, how they do that. They said I did the training, but I never got my X Waiver. And they said, well, did you do this, did you do this? Oh no, I didn't know I had to do that. 

So it's taking time and time and energy. And we just don't need that. First of all, emergency physicians should be able to give out three days' worth without a problem, no matter what. We can give out 150 prescriptions for Oxycodone, we have an unlimited armitarium of medications, narcotics we can give out. So why can't we give this life-threatening medication? 

And as I said, we do need education, but we don't need this long educational block. And we don't need all these regulations. But it does need to be incorporated into medical schools, in all residencies in education. Maybe a CME that people have to take. And that's one thing that needs to just go away.

[Dr. Volkow speaking]

So, one question, and I… It was intended actually in my prior question to you. Which was a notion is, is there need of more evidence, or based on the data that we currently have that shows such a large effect of medications like, Epinephrine [?], Methadone, Naltrexone. Is there anything else that is needed to document how powerful these treatments are? Specifically, in an emergency department setting.

[Dr. Gail D’Onofrio speaking]

In my opinion, no. But you often say that I quote you all the time when you say, okay, maybe 50% of our treatment at, you know, six months. But without it, only 5% are, right? So, what do you need to know? We already know that if you're not in treatment, you die. Right? We already know 5% are going to die in one year. We already know a huge amount are going to die within a month leaving a facility of some kind of controlled environment. Whether that's rehab or jail. We already have all that data. 

We have the data that it works. I mean in terms of the ED, that's a venue where we're using it. But there's enough information opiate agonist treatment works. We don't need to replace that. So that's why I think we don't need to do anymore ED studies, except feasibility studies and implementation, how we implement it. Nothings easy to implement. But we don't need to know that it works. We know that it works. 

I don't need to tell people that opiate agonist treatment works, because I just can give them a litany of proper reviews. I just need to tell them that, yes, you could do it, right. It's possible. I'll help you through it. Because even when people are waivered, they tend not to do it. You know, we published a study recently from one of our night at CTN baselines that is, that when we started doing our implementation and foresights, 80% of the emergency providers said they didn't feel comfortable doing it, they didn't feel ready to do it. And only 3% were waivered. 

So we, hopefully, have fixed that because we certainly know that more people are waivered. We know that more people are getting education. But once they get waivered, they have this, they're not quite sure what to do. And they sometimes just need a champion. So we just say we're… Just call up somebody now. Everyone… And in emergency medicine, we're open 24 seven. So, I tell everyone, I used to give my phone number to everyone. 

But now I just say, all of my doctors at Yale New Haven Hospital have a waiver. You can call up our ED 24 hours a day and get a doctor who knows what they're doing. And they'll just help you. So, you don't, you know, it doesn't have to be one or two of us anymore. There's lots of people. In every single city there's people. So, we're used to calling people all the time in the middle of the night. We have providers. So, let's start doing that, and just get the show on the road.

[Dr. Volkow speaking]

There's something else to that, you spoke about in your commentary that resonated very much with me. Because I actually had been at one point in visiting those shooting galleries where people go to inject heroine. And I was in one of such galleries in Puerto Rico. And the man that was manning the place, and it was actually a very, very poor area, and it was in a tent, it wasn't even a building, and people were sitting on the floors. And it wasn't even cement floors. It was very, very primitive. 

And the man had a horrifically infected leg. And he himself was trying to inject himself, not in that leg, but someplace else. But I was horrified about the state of that leg. And I said, you know, I apologise for bringing this up, but I very strongly urge you to go to an emergency department to take care of that leg. And he said no, I don't want to go there, because they mistreat me. So… And that is where, again, the issue of the stigma, and discrimination against people with substance use disorder is interfering with them getting into treatment. 

And you bring up that as one of the actions. So, yes, we need to have guidelines of evidence care, but you also address the issue of education and stigma. And I guess part of that education is against the stigma that persists. So, what are your thoughts and how are you dealing with it in your emergency department?

[Dr. Gail D’Onofrio speaking]

Well I think one of the things is you just have to address it, right? It's like racism that we're in the midst of now, you just have to address it and say, it exists. And highlight it when it does exist. And sometimes it's sort of not… It's really unbiased kind of stuff, people don't even know that they do it. So that when you hear someone saying a word, you just say, you know it might be better to use this other word. 

And we stress this all the time, and we role model that we try not to say addicts, that they're people, they're people. We don't say that diabetic over there. We say that person with diabetes. And so we role model it. But it's really a climate change. It’s not something that can easily be done. But I'll just tell you that I think behaviour in terms of quality has to happen. I don't ask a doctor how do they feel about giving out a tetanus shot, right? We don't see tetanus. I've never seen a case of tetanus. 

But, you know, ten people will ask a patient about their tetanus status before they get out of the ED. I don't ask them how they feel about it. It's just evidence based treatment, and you do it. So I do believe that will… We can address stigma, and we should. But on the other hand, we just need to have great leadership. The leadership says you need to give out this medication regardless of, you know, any, any peoples' ability to pay, or whatever, or what they look like. And that's just the bottom line. 

And so the leaders have to come out and say that. In my shop, you know, you don't work here if you don't have a waiver. It's expected. I'm trying to get all of my residents waivered. All of the students at Yale are… Have all received their training for waivers. All of the PA, all the medical students. We're doing most of the nursing school now. It's just expected. It's just part of the thing. So people… We need to just build up. And the residents are great. They're kind of teaching up. 

When I go places, the residents are learning about this. And then they're saying to their attending, well why aren't you offering this, right? And they've all told me, you know, if I could just get a policy written, I could just show them that it's this policy over here. And emergency physicians follow, like, orders really well. So they said, okay, here's the order, go ahead and do it. But it’s not something we can simply just turn over.

[Dr. Volkow speaking]

But I think though, Gail, in my perspective, in terms of… For that to work, of course you have to have the patients getting to the emergency department for which they need to have… Feel that they are welcome, that they are not rejected. And that were, again, I think that there are more actions that we could do, so that patients that may have substance use disorders. 

That maybe African Americans with substance use disorders where they've been mistreated again and again can feel comfortable to end up… So, I mean, that's where… What are your thoughts on how to change that?

[Dr. Gail D’Onofrio speaking]

Well one of the things I could tell you that was done with California Bridge, which is this huge program that Doctor Herring's running, who's over 70 hospitals. He has, and I wish I had… He has this great card that's up, when patients walk into the ED, it's a sign. And the sign says, do you have a problem with heroine or prescription narcotics? We're here to help. Ask us. And that is so empowering right there. Like we're here, we can help you. 

So, I'd like every ED to have that sign up, if you have a problem, if you want to talk about heroine, please let us know. If you need help, let us know. That's what we're here for. And we do those public health messages in our federally funded health centres. We call… We tell them what we can have be available here. We've told… We have a, you know, a great investigator here who works in the black churches who's trying to work with them, to know that we aren't as horrible as we may appear and give us another chance. 

And here in New Haven, people do know that we have medication. I think what happens is people think, oh everybody's going to run to the emergency department. You put out these public health messages, I'm going to be overrun, like what's your problem Gail, you can't do that. And I'll tell you that they're already in your ED with their complications, like you said. Whether it's an injection abscess, or something else. They're already using your healthcare facility, so just identify the problem and start the treatment. 

But, you know, stigma from the community. Getting patients with addictions to understand that we recognise their stigma, and we're trying to fix it is a huge problem. And it's got to be a lot of public health messaging out there. And it's got to be a lot of people changing their behaviours, and I don't have the total answer. But I know we can do better.

[Dr. Volkow speaking]

But like you were saying about… In your commentary, that we can create guidelines and metrics. I think that we can establish it and make every person accountable to them. Because that's what motivates behaviour. And you also had in your commentary something that I think is too, very, very important. And says give feedback to the providers of what happens to their patients. Because that is one of the most effective ways of changing practices.

[Dr. Gail D’Onofrio speaking]

Yes. We found that, actually, from doing a tremendous amount of focus groups in multiple cities, that one of the best things that we can do is to give that person a positive. Because remember, in emergency department always hear the bad things. We only see people coming back. We don't see people we don't see again. So the best thing you can do, and we try to do this, is to have somebody follow that person, and just ask whether they showed up at the referral site. Or if you can get permission to call the patient afterwards. 

We, many of us have nurses that follow up patients for all kinds of problems. In COVID, for example, we call people all the time, if we sent them for testing, we just want to make sure that they're doing okay. This is the same thing, we can call up and ask somebody, did you get to your treatment? What were the problems? How can I help you? And we need to do that. And I see no reason why we can't expect that we do that.

[Dr. Volkow speaking]

And also the issue that you commented upon, which I think is an extraordinary opportunity to do the follow up is Telehealth. I mean provided, of course, that the patients have access to it. But if they do, that's an extraordinary resource that you have to actually follow their outcomes. Now we're almost off time. 

But there's a question that has been burning in my brain, and I will feel bad if I don't ask you, because it's something that I'm very concerned. And that is the issue, as people are dying from overdoses. I mean it is clear in our brain that some of them may be intentional. We don't know exactly what's the level of intentionality. But we do know that some of them do qualify as suicides, even though they die by an opioid overdose. And they are… Though they are not scored as suicides. But… 

So the concept is with COVID and the social distancing, we've also seen concerns of increases in depression, anxiety, hopelessness. That of course you mix in with opioid use disorders, and you really have a very, very bad combination. So what have you seen in the emergency department? And what are you doing to ensure that you're screening, and that you are doing this very difficult to treat situation, but crucial not to neglect?

[Dr. Gail D’Onofrio speaking]

Well you're right. It's… There's a huge overlap between severe depression and suicidality and using. And it's hard to take that all apart. And I think for emergency physicians, their biggest concern is that there's not enough providers out there for mental health. And this is true everywhere around the country that there aren't. Here in New Haven, I can just say about our hospital, we also had a pretty large drop in our people who are requesting help. 

We have a… An emergency department for psychiatric illness right embedded in our main ED. And we have full time psychiatrists who are there. And they have reported that they've seen a marked drop, like almost 26% drop in patients that are coming through there. 

And we're worried about that, because in the face of COVID where there is a lot of despair, and a lot of reasons to be worse off than two months ago, we're extremely nervous about that. We don't know where they're going, and we're kind of reaching out to the community to make sure they know we're open. And the ED, we do ask everyone some questions about suicide. At least we do here. We're part of the Zero Suicide group. And we will ask questions. Some people won't answer them accurately. And then some people will. 

And then we're really lucky because we have psychiatry here to go through a bunch of questions with them to make sure that, do they need extra care? So they need to be hospitalized? Or do they… Can they go home with services. But it's really hard to find services. I just have to tell you that. Over all the country, it's not easy to find outpatients. It's even harder, by the way, when you have insurance here than when you don't have insurance. 

And it's… The answer is really difficult. It's hard to tease that out from an emergency point of view. And then once you do, and you feel like, well, they could do with outpatient counselling and help, it's really hard to find that. I'm hoping with all this new technology, maybe we can do some more group things outside. Some Zoom things. Maybe we'll be able to come up with some innovations, and having more people access mental health treatment.

[Dr. Volkow speaking]

And indeed, that has happened. And certainly there is… I mean, for once it's much easier to get reimbursed if you're a physician and you're providing Telehealth, including behavioural intervention, or a psychiatric assessment and follow up. So there is another example about the changes that have helped medicine through COVID, by making Telehealth so much more accessible. It's relatively new. So we need to understand how to optimally utilise it.

But I… They've been flagging me that I basically been stealing your time. But I do want to give you an opportunity, Gail, to basically bring up something that you feel is important that I may have not asked, or that you want the message to transpire.

[Dr. Gail D’Onofrio speaking]

I think, really, in my final thing, is that it's not only, by the way, opiates that we're seeing. We are seeing a lot of alcohol use disorder, a tremendous amount. Both in the emergency department and patients that are getting admitted to the hospital with COVID-19. And it's really… That's been what some people are using to deal with stress. And accentuating other problems. So it's… The ED is there for recognizing all kinds of substance use disorder. 

And it's on us to start with an initial treatment. And some of that is just the conversation that we have, we try to teach this to everybody. We have somebody to come brief negotiation interview, but it's just a conversation with our patients. Meeting them where they are, just asking them, first of all, permission to talk about it. Then what they think about it, what we, what our feedback is and then coming to some kind of a plan with them. And it's much better to do that. 

And if you talk to people like they're real people, you can move on. And so this has to be part of our [inaudible], it just has to be incorporated into our care. And we hope that some of these new changes will persist. We hope we can get rid of that X Waiver, at least for emergency physicians. We hope that we will continue to have places to send people, and use Telemedicine. 

We hope that methadone can be given more… And we really have to revise that whole system. Because for many people, this is working much better. They actually can have a job if they can. They can actually get to their places that they need to get to instead of spending the whole day trying to get their methadone. So we need to review that. And then just the general message is time is up, right? Time is up. We need to incorporate these quality measures into our care. And it's just not optional anymore.

[Dr. Volkow speaking]

Gail, I really thank you. Not just for being with us today, but the terrific work that you do. And for driving, actually you and the fill in medicine to other strategies for properly managing individuals with substance use disorder. Not just those with opioid use disorder. As well as the complexities medical situations that they find themselves right now in amidst COVID. 

And I also think that as physicians, we also have a unique opportunity to actually upfront address the issues of discrimination and racism. So that every single patient that needs us will get the quality care that they deserve. So Gail, thanks very much for everything you so.

[Dr. Gail D’Onofrio speaking]

Yes. And let me just add one thing I forgot before we go, is that with all of this, we recognize that we're… That all of us we’re addiction specialists are working 24 hours a day, and we need more. We just need more addiction medicine, and addiction psychiatry. And we've got to get that pipeline going, and we need the resources and funding to really increase the workforce. And nothing has shown up, we need it more than COVID-19. So thanks for having me.

[Dr. Volkow speaking]

No, thanks very much. And thanks to the audience for your attention to the program. Thanks a lot.