Solving major substance use disorder treatment gaps during COVID-19 [PODCAST]

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“As if COVID-19 weren’t bad enough during the pandemic, another public health crisis – substance use disorder (SUD) – has gone from bad to worse, while access to behavioral health services is shrinking.

As of September, more than half (52%) of community behavioral health organizations have seen an increase in demand for services, and half of those that offer SUD services saw their demand jump in the previous three months. At the same time, due to lack of revenue or pandemic-related restrictions, 65% have had to cancel programs, reschedule, or turn patients away. Nearly 40% of these organizations reported they may not last six months, given the revenue shortfalls.”

Nishi Rawat is a critical care and emergency physician.

She shares her story and discusses her KevinMD article, “The COVID-19 vaccine won’t solve major substance use disorder treatment gaps.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Nishi Rawat. She is a critical care physician, and she wrote the KevinMD article “The COVID-19 vaccine won’t solve major substance use disorder treatment gaps.” Nishi, welcome to the show.

Nishi Rawat: Thank you for having me, Kevin. Great to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Nishi Rawat: As you mentioned, I’m a critical care physician, also trained in emergency medicine, and I practiced critical care for over 10 years within Johns Hopkins Medicine before starting a company, OpenBeds. I’m Canadian. Like many of you out there, I moved to the U.S. to do my residency and fellowship, and then had a pretty tough time staying. I ended up working at a few smaller community hospitals on a J-1, H-1B, and learned some really good things working at these smaller hospitals, just how hard it is to get people to tertiary and quaternary care services, especially critical services.

And then I also had a really tough time getting my patients into definitive substance use disorder treatment, as well as mental health treatment. So I ended up building OpenBeds around that pain point, trying to get people into behavioral health treatment. I teamed up with my father, actually. He’s a systems engineer, an electrical engineer. We started the company, built the product, and a few years later we sold it to Appriss Incorporated. They’re a leading data analytics and solutions provider. I’m now senior vice president there, and I wear a number of hats: building products, influencing strategy, and I sell as well.

Kevin Pho: Wonderful. Over the past year, of course, there have been so many challenges facing critical care, facing physicians everywhere. From your lens, what would you say were some of the biggest challenges that you faced over the past year?

Nishi Rawat: I think working at Appriss, it’s wonderful. What we have seen is that accessing behavioral health treatment is more challenging than ever at present, despite a record need. As I mentioned in the article, we find ourselves right now in twin epidemics. We’ve got a worsening substance use and opioid epidemic driven by COVID. Overdose deaths right now are at a historic high. In addition to that, we find ourselves in the midst of a pretty significant mental health crisis here in the U.S., with the prevalence of mental health conditions being extraordinarily high, again driven by stress, anxiety, financial hardship associated with COVID.

So what’s been challenging for us at Appriss Health is how we go about ensuring that our products are being used by those in need, despite state governments relatively shutting down or not having the funds to be able to support our technology and services, despite behavioral health providers saying, “Look, we’re subsisting on fumes right now. I don’t know if we’re going to be open a couple of months from now,” and then hospitals, physicians there, social workers, case managers saying, “My goodness, we need to get our patients into acute inpatient psychiatric care. We need to get our patients into inpatient withdrawal management, and we just don’t have a good way to do it.” So I think that’s probably the biggest challenge we faced: again, a worsening situation with respect to need for behavioral health services, and yet shrinking access in general.

Kevin Pho: So let’s transition now into your KevinMD article that you wrote. It’s titled “The COVID-19 vaccine won’t solve major substance use disorder treatment gaps.” You talked a little bit about that article, but can you go into a little bit more detail? Walk my audience through it for those who didn’t read it, and share the story of why you decided to write it.

Nishi Rawat: Yeah, sure. It’s been some time now. We wrote it back in November. Gosh, time flies. I think you published it in December. Like I said, we work with 10 states now with the OpenBeds product, connecting people to behavioral health treatment. At the time, based on our interactions with state government officials, treatment providers, ED physicians, social workers, case managers, people who work within the criminal justice system and the homeless care system, we could tell that the situation and the system were deteriorating. Again, more demand than what the system can handle, and then the system actually shrinking in terms of behavioral health care services and access.

So we wrote the article really to sound that alarm: “Hey, it’s great that we have a vaccine for COVID, but COVID has served as a tailwind for deterioration with respect to our overall mental health, and we need to do something about it.” That was really the gist of the piece.

Kevin Pho: Now, we’re speaking in the beginning of April, and I think, I looked at a newspaper today, about 30 percent of the American population has had the COVID vaccine now. Are you seeing a little bit of a change in the trends when it comes to availability of behavioral health beds?

Nishi Rawat: Yeah, so I do think that more of the inpatient facilities are opening up or operating at full steam, and so that’s great. I think the one thing, the silver lining of this pandemic, has been that these technologies that had been previously operating at the periphery, we’re talking about telehealth, accessing behavioral health care via telehealth, or cognitive behavioral therapy by an app, these were not mainstream a year ago. Now these are mainstream technologies and services, and these have democratized access to behavioral health care. That’s the silver lining, and I don’t think that this is going to go away. This is here to stay.

What’s beautiful is that we’re hearing from treatment providers on the ground that perhaps outcomes are better. They’re telling us that their patients are sticking with treatment longer because they don’t need to arrange transportation. They don’t have to arrange for child care. So people are completing treatment in greater numbers, and I’m hoping that someone’s going to formally evaluate this. I’m sure they are, but that’s certainly what we’re hearing on the ground right now, which is wonderful.

Kevin Pho: No, access to behavioral care, even before the pandemic, was always a problem. I’m a primary care physician, and whenever I see patients who need behavioral health services or behavioral health beds, that access has always been an issue, and that has only been exacerbated during the pandemic. Now, you mentioned some of the technologies that are going to persist after the pandemic finishes. What are some other trends that you see stemming from the pandemic when it comes to behavioral health access going forward?

Nishi Rawat: Yeah, so one of the trends that I’m really excited about is the standardization of crisis care. SAMHSA had been working on this pre-pandemic, I’m pretty sure, but that work has accelerated during the pandemic. What I mean by that is this 988 initiative. I’m not sure if you’re familiar with that, but SAMHSA right now has a suicide hotline. It’s a 1-800 number, and what they’re doing is moving to this 988 number. I think it’s in July of 2022. It’s akin to 911.

So if you’re in crisis or not in crisis, and you need help from a mental health or substance use perspective, you can call this three-digit number. You’ll be patched through to a regional care center. You’ll be able to talk to a clinician, and all of these regional centers will be operating according to certain care standards, which is wonderful. You’ll talk to a clinician, and that clinician will then be able to de-escalate the situation and refer you to definitive assessment or treatment on the spot. And then if they feel like you need someone to be there with you to assess you, within your home, for example, they can dispatch a mobile crisis team to be there with you.

This whole process, the federal government is trying to standardize across all the states. They’ve provided the states with planning grants to implement the clinical infrastructure that’s necessary for this. So there’s the crisis line, the mobile crisis teams, and the crisis centers themselves, the 23-hour places. And then beyond that, one needs technology to coordinate all of these clinical services. How do you give that clinician who’s at the call center visibility as to what outpatient treatment and inpatient treatment facilities have capacity? How can you very easily send them a referral, a digital referral, after hours, and get that caller into a definitive assessment or treatment? How can you go about knowing where that mobile crisis team is that’s close to the caller? So there’s a GPS-enabled functionality that they can use then to dispatch these mobile crisis teams, and then have these mobile crisis teams document their assessments and plans such that these can be viewed longitudinally in a digital record. So the next time this person calls, there’s already a care plan there. You’re not starting from the beginning.

So this is what’s really exciting to me right now. It’ll improve access to behavioral health care, and although it’s crisis care, you’ve got to think about it as prevention. When people are at this end of the spectrum in terms of disease, they can use this line to call and get help to prevent the disease from getting out of control.

Kevin Pho: We’re talking to Nishi Rawat. She is a critical care physician, and she wrote the KevinMD article “The COVID-19 vaccine won’t solve major substance use disorder treatment gaps.” Usually, so we’re just over one year into the pandemic, and you’re at that unique intersection between COVID, behavioral health, and technology. Through that unique lens, share some of the top things that you’ve learned over the past year.

Nishi Rawat: What’s been beautiful from my perspective is the way that the medical and public health communities, and this is both in the private and public sector, the way that they’ve come together to do something extraordinary. We’ve developed a vaccine in record time. It’s been disseminated in record time. And then we’ve even been able to disseminate learnings regarding the care of COVID patients, especially the critical care of COVID patients, at seemingly record pace. Typically, these learnings go through the peer review process: You do this long study, it gets published two years later. And we’re circulating learnings and data within months to improve the care that we’re providing. So look, all of these things are, quite frankly, imperfect, and I’m not going to get into the details here, but I still think that these are extraordinary feats.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Nishi Rawat: I think number one, hang in there. This last year has been really tough on clinicians especially, and I don’t think that that’s being acknowledged enough, in part because we’re proud and we think we’re strong. But I think that it’s really important to take care of yourself and your family first and foremost, especially for the young clinicians out there. You really can’t take good care of patients unless you take care of yourself. It sounds simplistic, but it’s true. And so take that time.

In addition to taking time for yourself, I would encourage clinicians to stop and reflect, just like you asked me just now: What have you learned from the challenges of this past year? You are the experts. You’ve seen it all this past year. How could you best communicate your learnings to a broader audience? Could you somehow take your learnings and incite change? It’s possible to incite change. I think it’s really easy, when you’re working day in, day out in the clinical sphere, to just think that it’s hopeless, you’re not going to be able to make a difference. But the truth is, despite your exhaustion, you’re best positioned to make a difference and incite change, and I would encourage you to do so.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Nishi Rawat: Of course. Thank you very much.

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