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of 2019 and Q2 of 2021 [3]. Anecdotally, based on our experience at our county hospital in San Mateo, it
is seeming as if a larger and larger fraction of psychiatric ED visits - if not an outright majority - are
precipitated or exacerbated by methamphetamine use.

With our nation’s mental health system straining to address this surging need and demand for substance
use treatment, it is magnifying and laying bare all the cracks that have long plagued the system. For our
psychiatry residents who frequently straddle multiple systems of care, perhaps the most frustrating of
these cracks has been the separation and siloing of mental health care and substance use treatment,
which continues to be perpetuated by historical inertia, disparate funding streams and regulatory
requirements around privacy and recordkeeping. In our outpatient specialty mental health clinics, patients
who seek medication-assisted treatment (MAT) for comorbid opioid use disorders are typically referred to
a separate specialty clinic contracted by the county. For many of our vulnerable patients who struggle with
transportation and keeping track of appointments, even one such additional visit can represent a
significant barrier to seeking and accessing much needed care. Furthermore, the lack of communication
between our respective EMRs encumbers our ability to stay up to date on our patients’ substance use
treatment, potentially jeopardizing not only their mental health outcomes but also their physical safety.

In an attempt to mitigate these barriers, our residents are working with county leadership and addiction
faculty champions to pilot the provision of medication for opioid use disorder (MOUD) directly in our
mental health clinics. With the removal of the 8-hour X-waiver training requirement for physicians
prescribing MOUD to fewer than 30 patients, psychiatrists now have an even lower barrier to becoming
MOUD prescribers. However, due to historical lack of familiarity with the medications and the lack of a
tried-and-tested protocol for delivering MOUD in our clinics, trepidation and hesitancy remain about an

immediate widespread rollout. Drawing on our more recent and fresh training from our addiction
psychiatry rotation, we hope to use this pilot to demonstrate the feasibility and practicality of providing
MOUD in our clinics, and to optimize and iron out any kinks in our provisional protocol. Furthermore, by
taking on some of the substance use treatment in our mental health clinics, we hope that we will be able
to alleviate some of the growing strain on the specialty substance use clinic.

Simultaneously, our residents are also working with the county leadership to pursue pilots of contingency
management, a non-pharmacologic treatment modality for methamphetamine use disorder whereby
patients are provided tangible positive reinforcements for abstinence from methamphetamine use, usually
in the form of monetary rewards or prizes. With a robust evidence base spanning decades of research,
and with only a handful of off-label pharmacologic treatments showing limited efficacy, contingency
management has long been the most promising tool to combat the methamphetamine epidemic.
However, its widespread implementation has been limited by the Federal anti-kick back statute, which
prohibits programs from providing monetary incentives to federal healthcare program beneficiaries. Had it
been passed, State Senate Bill 110 would have authorized Medi-Cal to pay for contingency management,
but it was recently vetoed by Governor Newsom in favor of a $58.5 million contingency management pilot
program for Medi-Cal patients over the next two years. Our county is in the process of applying for this
new pilot program, and, in the meantime, it has secured additional funding to pilot a contingency
management mobile app with 250 of our patients. Our psychiatry residents are eager to be involved in the
rollout of this mobile app, and we hope to use the resulting data and experience to advocate for more
widespread adoption of contingency management practices in our county.
As the COVID pandemic both exacerbates and obscures the epidemic of substance use, now more than
ever our communities need us to take action and change the status quo. The pandemic has exposed the
cracks in our system for all to see - let us hope that we can use this opportunity to fix them.
*The opinions expressed in this article belong to the individual authors and do not represent official
statements from the County of San Mateo.

NORTHERN CALIFORNIA PSYCHIATRIC SOCIETY Page 17 JANUARY/FEBRUARY 2022