OUD Patient Withdrawal Management and Initiating Relapse Prevention with XR-Naltrexone

Adam Bisaga, MD Professor of Psychiatry Columbia University

Tuesday, March 31st, 2020 12:00 PM – 1:00 PM EST Webinar Housekeeping

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2 Disclosures

• Alkermes: Received grant support (medication samples, funded research) • Unpaid consultancy: Alkermes, Go-Medical

The content of this activity may include discussion of off label or investigative drug uses. The faculty is aware that is their responsibility to disclose this information.

3 Educational Objectives

At the conclusion of this activity participants should be able to:

. Enhance their knowledge of the latest evidence-base for the effectiveness of XR-naltrexone in treatment of opioid use disorder

. Identify patients that may benefit from the relapse-prevention treatment using XR-naltrexone

. Adopt new protocols for managing opioid withdrawal to initiate antagonist-based relapse prevention treatment

4 Outline

1. Evidence for use of XR-naltrexone for relapse prevention treatment following detoxification

2. Selection of patients

3. Strategies to initiate treatment

4. The evolving model of OUD care

5 XR-NALTREXONE FOR RELAPSE PREVENTION TREATMENT FOLLOWING XR-NALTREXONEDETOXIFICATION FOR RELAPSE PREVENTION TREATMENT FOLLOWING DETOXIFICATION

6 OUD TREATMENT STRATEGY

• Most effective treatment involves a combination of several approaches

– Pharmacological Treatment (MAT/MOUD - medication + intervention to increase medication adherence)

– Psychosocial/behavioral Therapies (helping patients develop skills necessary to maintain abstinence)

– Self Help/Mutual Help Groups (social network supportive of abstinence and recovery)

– Recovery-oriented activities (help patients develop satisfying lives)

7 MEDICATIONS FOR OUD (MOUD)

Buprenorphine MMetehtahdaodnoene Buprenorphine PaPartriiatillal AAgognionistst XXRR-N-Nalatrlterxeoxnoene FulFulll l AAgognionistst AAntntagaognionistst

μμOROR μμOROR κ OR μμOROR n OR

↓NMDA κ OR

Opioid Receptors Opioid



FDA-APPROVED MEDICATIONS: AGONISTS

• Methadone (MET), buprenorphine (BUP) . “Stabilizes” system’s functioning via constant stimulation of opioid receptors . Prevents withdrawal, relieves craving, stabilizes affect, minimizes pathological brain responses, blocks effects of other opioids

• Limitations BBuupprreennoorrpphhiinnee . BUP requires mild withdrawal to initiate MMeetthhaaddoonnee PaParrttiaiall AAggooninisstt XXRR--NNaallttrreexxoonnee . Potential for side-effects (overdose with MET) FFululll AAggooninisstt . Regulatory oversight AAntntaaggooninisstt

μμOROR • Concerns 5 HER 4 μμOROR μμOROR . Risk of misuse 3 METH

2 and diversion BUP 1

. Difficult to retain 0 0 5 1 0 1 5 2 0 2 5 3 0 long-term -1 -2

-3 9 FDA-APPROVED MEDICATIONS: ANTAGONIST

• Naltrexone . “Stabilizes” system’s functioning after “resetting” opioid receptors (post-withdrawal) . Blocks effects of exogenous opioids and re-development of physical dependence, relieves craving,Methad ostabilizesne affectBupr e norphine Partial Agonist XR-Naltrexone Full Agonist • Limitations Antagonist . Requires resolution of physical dependence before initiation μ OR

5 μ OR4 μ OR • Concerns 3 HER 2

. Difficult to initiate and 1

difficult to retain 0 0 5 1 0 1 5 2 0 2 5 3 0 NTX -1

-2

-3

10 NALTREXONE: EFFECTIVENESS AND SAFETY

EFFECTIVENESS XR-naltrexone is effective vs. oral naltrexone (2009, 2018)

XR-naltrexone is efficacious vs placebo injection (2006, 2011)

XR-naltrexone is effective vs. treatment-as-usual (2015,2016)

Once initiated, XR-naltrexone and buprenorphine are equally effective and safe (2017,2018)

SAFETY XR-naltrexone and buprenorphine have comparable effects on mood (2017,2018,2019)

XR-naltrexone is not associated with depression/anhedonia (2010,2011,2015,2016,2019)

XR-naltrexone is not associated with excessive overdose (2010,2016,2017,2019)

11 NALTREXONE EFFECTIVENESS: ORAL VS. XR

• XR-naltrexone (injections, implants) are more effective than the oral preparation because effectiveness is primarily dependent on adherence . XR-preparations should be the treatment of choice where available . Treatment with naltrexone should include behavioral strategies to improve adherence

Implant vs. oral naltrexone Time to dropout: XR- vs. oral naltrexone

12 XR-NALTREXONE: PATIENT SELECTION AND STRATEGIES XR-NALTREXONEFOR TREATMENT FOR INITIATION RELAPSE PREVENTION TREATMENT FOLLOWING DETOXIFICATION

13 CANDIDATES FOR NALTREXONE

• Patients who are not interested or able to be on agonist maintenance • Patients who are detoxified and abstinent but at risk for relapse • Patients who failed prior treatment with agonists • Patients successful on agonist but who want to discontinue them without risking relapse

• Patients with less severe form of a disorder?

• Young adults that are often unwilling to commit to a long-term agonist maintenance

• Individuals who use opioids sporadically (high-risk group)

14 NALTREXONE TREATMENT INITIATION

Level of physical dependence at treatment outset is the main consideration

Using large amounts of Using daily long-acting or Using daily low dose/oral agents potent short acting Using opioids Detoxified, agents agents sporadically or abstinent (heroin) (high-risk) >10 days

Maintained on Maintained on methadone buprenorphine Physical Without Dependence Physical Dependence

Naltrexone will precipitate Naltrexone can be given with no severe and prolonged risk of PW withdrawal (PW) after confirming absence of physical depend.15 using naloxone or naltrexone challenge METHODS FOR INITIATING NALTREXONE

• No single best method but rather a set of approaches/tools that can be individualized to the patient and treatment team experience • Effective method will balance the degree of discomfort and the

duration of treatment

Withdrawal Severity Withdrawal

1 DAYS 10 • Always confirm absence of opioids and physical dependence prior to the first dose of naltrexone – Patient must understand the risks of precipitated withdrawal if underreporting – Always perform naloxone challenge if unsure of the abstinence and the absence of physiological dependence 16 NALOXONE CHALLENGE

• Naloxone is a short-acting opioid antagonist used to reverse overdose and to detect physiological dependence • In dependent individuals, naloxone will precipitate withdrawal that usually emerges within 5-10 min and dissipates within 30 min – Severity can be measured using standard instruments (e.g., COWS) – Severity of withdrawal is proportional to the level of physical dependence and the dose of naloxone – Any change from baseline, particularly appearance of objective signs, evidences positive test • Naloxone is given IM (deltoid) at the 0.8-1.2 mg dose (2-3 cc) – To minimize risk of withdrawal, may administer in 2 stages, 0.4 mg followed by 0.8 mg • With the negative test, full dose naltrexone can be started – Naltrexone should not be given after the positive test (it will precipitate withdrawal lasting many hours), in that case naloxone challenge can be repeated the next day

17 APPROACHES TO MANAGE OPIOID WITHDRAWAL

• Agonist-assisted • Symptomatic-treatment alone • Rapid withdrawal using antagonist • Ultra-Rapid withdrawal under anesthesia

18 AGONIST-ASSISTED

• Low doses of opiate agonist (MET 10-20 mg or BUP 4-8 mg) are given for 1-2 days to substitute for heroin and prevent severe withdrawal • Subsequently agonist is tapered off slowly to minimize withdrawal • Washout period needed (7-10 days) to eliminate residual dependence • Adjunctive medications can be used to alleviate the residual withdrawal • Allows for safe completion of detox over an extended period • Can prevent severe complications in medically or psychiatrically ill patients, and in those with mixed-dependence Withdrawal NTX Induction agonist-assisted BUP taper washout NTX + opioid washout Day 0 5 10 15 19 SYMPTOMATIC TREATMENT ALONE

• A variety of adjunctive medications are used to decrease specific symptoms of withdrawal • Autonomic arousal (clonidine, lofexidine) • Anxiety/restlessness Benzodiazepines vs. non-controlled agents • Insomnia • Musculo-skeletal pain (NSAID’s) • GI Distress (hydration, anti-nausea, anti-diarrhea, anti-spasmodics) • No opioid agonist used so NTX can be started in ∼7 days

clonidine/bdz NTX

symptomatic washout only 0 5 10 15

20 RAPID WITHDRAWAL USING LOW-DOSE ANTAGONIST

• Addition of an opioid antagonist accelerates detoxification • “Speeding” up the replacing of desensitized receptors with new, fully active receptors • BUP, naloxone, and naltrexone shorten OWS unlike clonidine or BDZs • Withdrawal symptoms are prevented and alleviated with adjunctive medications • Low-dose antagonist • Naltrexone is added few (1-3) days after the last dose of opioid starting with very low doses (0.5-3 mg) to minimize precipitated withdrawal while accelerating time to the full dose tolerability BUP clonidine/bdz

low-dose antagonist NTX + symptomatic 0 5 10 15 21 ULTRA-RAPID WITHDRAWAL UNDER SEDATION/ANESTHESIA

• Large dose of antagonist given during the first day • requires deep sedation (midazolam or GA) to decrease the experience of precipitated withdrawal and symptomatic treatment • Followed by full-dose NTX maintenance (almost 100% induction success) • Not recommended by most guidelines because of higher rates of complications (including deaths) • May be appropriate in selected, low risk cases when followed by XR- naltrexone

• Asturian method (outpatient, Carreno ea., 2002) • 12 hours opioid abstinence • clonidine 0.45mg, famotidine, loperamide or octreotide, ondansetron, midazolam 22.5mg, clorazepate 50mg • (1h) metoclopramide 10mg, naltrexone 50mg • (1h) hyoscine 20mg, clonidine 0.3mg, metoclopramide 10 mg

22 COMPARING TWO METHODS OF INITIATING TREATMENT WITH XR-NALTREXONE: OUTPATIENT

Wit hdrawal NTX Induct ion • Individuals with OUD were randomly Standard BUP taper washout NTX assigned to Standard (N=52) vs. Rapid Protocol (14 day) Day 0 5 10 15 (N=98) Method of outpatient induction onto Wit hdrawal XR-naltrexone VS NTX Induct ion BUP clonidine/bdz

- Patients inducted using Rapid method had greater success Rapid NTX Protocol (7 day) - Users of RX opioids were more likely to initiate XR-NTX 0 5 10 15

100% 90% 80% 70% Rapid Method

60%

50% Standard

40% Method Injection 30% 20%

10% Percent Receiving First Naltrexone 0% Odds: 2.9 - Withdrawal severity was mild and comparable 30% of patients (p=0.01) - No difference on safety measures dropped out before the injection during the wait period (Sullivan, Bisaga et al., 2017) 23 RAPID NALTREXONE INDUCTION (COLUMBIA PROTOCOL)

BUP NTX clonidine/bdz/zolp • Buprenorphine is administered as soon as opioid withdrawal emerge – start with low dose if positive for synthetic opioids (fentanyls) • Standing doses of adjunctive medication to prevent withdrawal – rather than as needed • Low starting doses of naltrexone (0.5-3mg) to minimize precipitated withdrawal – given in divided doses to assess tolerability • Protocol may be modified (accelerated or slowed) depending on the tolerability of NTX titration (4-7 days) – higher rates of completion among users of prescription opioids

RAPID NALTREXONE INDUCTION PROCEDURE: INPATIENT

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Buprenorphine admission 4-6 mg

Naltrexone 1-3 mg 3-6 mg 12.5 mg XR-naltrexone (.5+.5) (1+1) (3+3) (6)

Supportive clonidine 0.1-0.2 mg qid, clonazepam 0.5-1.0 mg tid, medications prochlorperazine, zolpidem, trazodone

25 RAPID NALTREXONE INDUCTION PROCEDURE: OUTPATIENT

Day 1 Day 2 Day 3 Day 4 Day 5 Buprenorphine 2+2+2mg (+2hs) 6+6+12 mg Naltrexone 1+2 mg 3+3 mg XR-NTX Supportive clonidine 0.1-0.2 mg qid, clonazepam 0.5-1.0 mg tid, medications prochlorperazine, zolpidem, trazodone

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0.1 0 BASELINE DAY1 DAY2 DAY3 DAY4 DAY5 0 BASELINE DAY 1 DAY 2 DAY 3 DAY 4 DAY 5 (Sibai et al., 2019) 100 26

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• An outpatient procedure appropriate for patients with severe use disorder (e.g., injecting large doses of heroin) and those who are not able to tolerate more rapid transition onto naltrexone • A period of treatment with buprenorphine allows patients to stabilize (stop) their drug use first prior to undergoing opioid withdrawal STABILIZATION WITHDRAWAL/INDUCTION

28 PROTRACTED WITHDRAWAL: NALTREXONE FLU

• Patients who start naltrexone right after withdrawal commonly experience a “flu-like” symptoms (low-grade withdrawal) . Somatic complaints: insomnia, GI distress, hyperalgesia, anergia . Anxiety, irritability, dysphoria, anhedonia . Symptom severity correlated with naltrexone dose and timing . Severity may be lower if naltrexone initiation is postponed (but relapse risk) • Partially alleviated with aggressive symptomatic treatment, . Insomnia (v. frequent, often severe): zolpidem, trazodone, quetiapine . GI distress: H2 blockers . Anxiety/hyperarousal: clonazepam, clonidine, gabapentin • Most of these symptoms remit by 2-4 weeks . True prolonged symptoms are rare and likely reflect additional psychopathology

29 OUD TREATMENT: TRANSITION TO A NEW MODEL OF CARE

30 OUD TREATMENT IN TRANSITION

• Chronic disorder model: different levels of care over time, medications and additional treatments needed may change over time • Inpatient detoxification is no longer a primary treatment, phasing-out detox units to become medication-induction units • Shift away from residential treatment towards (long-term) outpatient treatment • Extended-release preparations and behavioral interventions to overcome nonadherence, the major challenge in medication treatment • Focus on offering patient choice of medication: methadone vs. buprenorphine vs XR-naltrexone

31 OUD TREATMENT IN TRANSITION (2)

• Comprehensive treatment system (One-stop-shop) • Expanding of care models (from low-threshold to comprehensive) • Staged treatment: methadone buprenorphine XR-naltrexone • Acceptance of other measures of treatment success than complete abstinence: harm-reduction framework • Incorporating recovery framework and peer advocates • Treatment of co-occurring disorders

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Hulse, G. K., R. J. Tait, S. D. Comer, M. A. Sullivan, I. G. Jacobs and D. Arnold-Reed (2005). "Reducing hospital Hulse, G. K., R. J. Tait, S. D. Comer, M. A. Sullivan, I. G. Jacobs and D. Arnold-Reed (2005). "Reducing hospital presentations for opioid overdose in patients treated with sustained release naltrexone implants." Drug presentations for opioid overdose in patients treated with sustained release naltrexone implants." Drug Alcohol Depend 79(3): 351-357. Alcohol Depend 79(3): 351-357.

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Latif, Z. E., et al. (2019). "Anxiety, Depression, and Insomnia Among Adults With Opioid Dependence Treated Latif, Z. E., et al. (2019). "Anxiety, Depression, and Insomnia Among Adults With Opioid Dependence Treated With Extended-Release Naltrexone vs Buprenorphine-Naloxone: A Randomized Clinical Trial and Follow-up With Extended-Release Naltrexone vs Buprenorphine-Naloxone: A Randomized Clinical Trial and Follow-up Study." JAMA Psychiatry 76(2): 127-134. Study." JAMA Psychiatry 76(2): 127-134.

Krupitsky, E., et al. (2016). "Anhedonia, depression, anxiety, and craving in opiate dependent patients Krupitsky, E., et al. (2016). "Anhedonia, depression, anxiety, and craving in opiate dependent patients stabilized on oral naltrexone or an extended release naltrexone implant." Am J Drug Alcohol Abuse: 1-7. stabilized on oral naltrexone or an extended release naltrexone implant." Am J Drug Alcohol Abuse: 1-7.

Zaaijer, E. R., et al. (2015). "Effect of extended-release naltrexone on striatal dopamine transporter availability, Zaaijer, E. R., et al. (2015). "Effect of extended-release naltrexone on striatal dopamine transporter availability, depression and anhedonia in heroin-dependent patients." Psychopharmacology (Berl) 232(14): 2597-2607. depression and anhedonia in heroin-dependent patients." Psychopharmacology (Berl) 232(14): 2597-2607.

References

Comer, S. D., M. A. Sullivan, E. Yu, J. L. Rothenberg, H. D. Kleber, et al. (2006). "Injectable, sustained-release naltrexone for the treatment of opioid dependence: a randomized, placebo-controlled trial." Arch Gen Psychiatry 63(2): 210-218.

Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108-1115.

Hulse, G. K., R. J. Tait, S. D. Comer, M. A. Sullivan, I. G. Jacobs and D. Arnold-Reed (2005). "Reducing hospital presentations for opioid overdose in patients treated with sustained release naltrexone implants." Drug Alcohol Depend 79(3): 351-357.

Kelty, E., D. Joyce and G. Hulse (2019). "A retrospective cohort study of mortality rates in patients with an opioid use disorder treated with implant naltrexone, oral methadone or sublingual buprenorphine." Am J Drug Alcohol Abuse: 1-7. 33 Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- 1115. 1115.

References

Krupitsky, E., E. V. Nunes, W. Ling, A. Illeperuma, D. R. Gastfriend and B. L. Silverman (2011). "Injectable extended-release naltrexone for opioid dependence: a double-blind, placebo-controlled, multicentre randomised trial." Lancet 377(9776): 1506-1513. Krupitsky, E., E. Zvartau, E. Blokhina, E. Verbitskaya, V. Wahlgren, G . Et al. (2016). "Anhedonia, depression, anxiety, and craving in opiate dependent patients stabilized on oral naltrexone or an extended release naltrexone implant." Am J Drug Alcohol Abuse: 1-7. Latif, Z. E., J. Saltyte Benth, K. K. Solli, A. Opheim, N. Kunoe, P. Krajci, K. Sharma-Haase and L. Tanum (2019). "Anxiety, Depression, and Insomnia Among Adults With Opioid Dependence Treated With Extended-Release Naltrexone vs Buprenorphine-Naloxone: A Randomized Clinical Trial and Follow- up Study." JAMA Psychiatry 76(2): 127-134. Lee, J. D., E. V. Nunes, Jr., P. Novo, K. Bachrach, G. et al. (2018). "Comparative effectiveness of extended-release naltrexone versus buprenorphine-naloxone for opioid relapse prevention (X:BOT): a multicentre, open-label, randomised controlled trial." Lancet 391(10118): 309-318.

Lee, J. D., P. D. Friedmann, T. W. Kinlock, E. V. Nunes, T. Y. Boney, R. A. Hoskinson, Jr., D. Wilson, et al. (2016). "Extended-Release Naltrexone to Prevent Opioid Relapse in Criminal Justice Offenders." N Engl J Med 374(13): 1232-1242.

34 Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- 1115. 1115.

References

Lee, J. D., R. McDonald, E. Grossman, J. McNeely, E. Laska, J. Rotrosen and M. N. Gourevitch (2015)."Opioid treatment at release from jail using extended-release naltrexone: a pilot proof-of-concept randomized effectiveness trial." Addiction 110(6): 1008-1014. Morgan, J. R., B. R. Schackman, Z. M. Weinstein, A. Y. Walley and B. P. Linas (2019). "Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort." Drug Alcohol Depend 200: 34-39. Morgan, J. R., et al. (2019). "Overdose following initiation of naltrexone and buprenorphine medication treatment for opioid use disorder in a United States commercially insured cohort." Drug Alcohol Depend 200: 34-39. Mysels, D. J., W. Y. Cheng, E. V. Nunes and M. A. Sullivan (2011). "The association between naltrexone treatment and symptoms of depression in opioid-dependent patients." Am J Drug Alcohol Abuse 37(1): 22- 26.

Ngo, H. T., R. J. Tait and G. K. Hulse (2011). "Hospital psychiatric comorbidity and its role in heroin dependence treatment outcomes using naltrexone implant or methadone maintenance." J Psychopharmacol 25(6): 774-782.

35 Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin Hulse, G. K., N. Morris, D. Arnold-Reed and R. J. Tait (2009). "Improving clinical outcomes in treating heroin dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- dependence: randomized, controlled trial of oral or implant naltrexone." Arch Gen Psychiatry 66(10): 1108- 1115. 1115.

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O'Brien, C. P., et al. (2011). "Long-term opioid blockade and hedonic response: preliminary data from two open-label extension studies with extended-release naltrexone." Am J Addict 20(2): 106-112.

Sullivan, M. A., A. Bisaga, M. Pavlicova, K. M. Carpenter, C. J. Choi, et al. (2019). "A Randomized Trial Comparing Extended-Release Injectable Suspension and Oral Naltrexone, Both Combined With Behavioral Therapy, for the Treatment of Opioid Use Disorder." Am J Psychiatry 176(2): 129-137.

Tait, R. J., H. T. Ngo and G. K. Hulse (2008). "Mortality in heroin users 3 years after naltrexone implant or methadone maintenance treatment." J Subst Abuse Treat 35(2): 116-124.

Tanum, L., K. K. Solli, Z. E. Latif, J. S. Benth, A. Opheim, et al. (2017). "Effectiveness of Injectable Extended- Release Naltrexone vs Daily Buprenorphine-Naloxone for Opioid Dependence: A Randomized Clinical Noninferiority Trial." JAMA Psychiatry 74(12): 1197-1205.

Zaaijer, E. R., L. van Dijk, K. de Bruin, et al. (2015). "Effect of extended-release naltrexone on striatal dopamine transporter availability, depression and anhedonia in heroin-dependent patients." Psychopharmacology (Berl) 232(14): 2597-2607. 36

PCSS Mentoring Program

. PCSS Mentor Program is designed to offer general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorder.

. PCSS Mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medications for addiction treatment.

• 3-tiered approach allows every mentor/mentee relationship to be unique and catered to the specific needs of the mentee.

• No cost.

For more information visit: https://pcssNOW.org/mentoring/

37 PCSS Discussion Forum

Have a clinical question?

http://pcss.invisionzone.com/register

38 PCSS is a collaborative effort led by the American Academy of Addiction Psychiatry (AAAP) in partnership with:

Addiction Technology Transfer Center American Society of Addiction Medicine American Academy of Family Physicians American Society for Pain Management Nursing Association for Multidisciplinary Education and American Academy of Pain Medicine Research in Substance use and Addiction American Academy of Pediatrics Council on Social Work Education American Pharmacists Association International Nurses Society on Addictions American College of Emergency Physicians National Association for Community Health Centers American Dental Association National Council for Behavioral Health American Medical Association The National Judicial College American Osteopathic Academy of Addiction Physician Assistant Education Association Medicine American Psychiatric Association Society for Academic Emergency Medicine American Psychiatric Nurses Association 39 Session Evaluation and Certificate

• Instructions will be provided in an email sent to participants an hour after the live session • Certificates are available to those who complete an evaluation • Recordings of today’s webinar can be accessed at: www.pcssNOW.org and education.psychiatry.org

40 Educate. Train. Mentor

@PCSSProjects www.pcssNOW.org www.facebook.com/pcssprojects/ [email protected]

Funding for this initiative was made possible (in part) by grant no. 1H79TI081968 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. 41