Welcome, everyone, to today's PCSS training. We'll be focusing on integration of opioid use disorder treatment in clinical care today. My name is Dr. Todd Korthuis. I'm a professor of medicine at Oregon Health and Science University, and Chief of the Section of Addiction Medicine there. I'm also a trained general internist, and self-identify as a primary care provider, so this issue is very important to me. I have no financial relationships to disclose. The overarching goal of PCSS is to make available the most effective medication, pharmacotherapy treatments to serve patients in a variety of settings, including primary care, psychiatric care, and pain management settings. Our objectives today are to identify models for integration of opioid use disorder pharmacotherapy in primary care settings. To review keys to successful opioid use disorder pharmacotherapy implementation in clinical practice. And to identify strategies for preventing diversion of buprenorphine/naloxone. Opioid use disorder pharmacotherapy comes in three forms. The first is methadone, with over 40 years of safety data behind it. However, it requires administration through an opioid treatment program, and a primary care provider needs to refer to the OTP. Buprenorphine requires a DATA 2000 waiver training. However, it's allowed to be prescribed in an office-based or an OTP setting. Similarly, naltrexone can be prescribed in both an office-based and an OTP setting, and does not require any special training. The purpose of integrating pharmacotherapy and primary care settings is to expand access to opioid use disorder treatment in the US. There will never be enough specialty treatment programs to treat the many patients who have opioid use disorder. However, primary care is very well-positioned to expand access. Furthermore, buprenorphine and methadone both reduce opioid use overdose, HIV infections, hepatitis C infections, and criminal activity more than behavioral treatment alone. And consequently, the Agency on Healthcare Research and Quality, or AHRQ, recently commissioned a technical brief to identify promising models for optimizing pharmacotherapy integration in primary care settings. We identified 11 expert key informants from a variety of viewpoints around the country, and convened small group telephone discussions to guide the initial framework of the technical brief. And then conducted a literature review of publications between 1995 and 2016, as well as unpublished sources. That ultimately identified 27 papers that form models of care for integration of primary care and opioid use disorder treatment. This process identified four common components for integrated models, the first being pharmacotherapy, which typically involves buprenorphine or naltrexone. The second being provider and community education and outreach that many programs have. The third being coordination and integration of opioid use disorder treatment with other medical and psychological needs. And the fourth being psychosocial services integration. We generated a representative, but certainly not exhaustive, compendium of potential models that inform treatment integration. And I'm just going to focus on the three that are most pertinent for integrating in primary care practices. The first is office-based opioid treatment, or OBOT, and we'll talk about the details of how to implement this. As well as one example where it was evaluated in the Buprenorphine HIV Evaluation and Support Collaborative, or BHIVES, for HIV. We'll also talk about hub and spoke approaches and nurse care manager approaches. So to begin with, let's review the components of office-based opioid treatment. The pharmacotherapy agents are typically buprenorphine-naloxone. Some people have expanded this to naltrexone, but the majority of the literature centers on buprenorphine. The second component is a coordination or integration of care component, where some practices designate a particular clinical staff member as a buprenorphine coordinator. The educational and outreach components involve the prescriber that has to complete DATA 2000 waiver training. It also has access to PCSS, and other mentoring and support resources that I'll talk about at the end of the talk. The psychosocial component of OBOT includes on-site brief counseling, but this can be very streamlined, administered even by the prescriber or other staff member. And then, of course, options for off-site referrals for behavioral counseling for those who require additional counseling. The big news is that, in 2017, office-based opioid treatment capacity for buprenorphine was expanded to include nurse practitioners and physician assistants, who can also complete a DATA 2000 waiver training, with 24 hours of training also available through PCSS. This is funded all through regular provider reimbursements of billable visits, typically, so just like a visit for diabetes or hypertension. So it's important, as you think about initiating office-based buprenorphine, to prepare the whole team to the greatest degree possible. And this can typically involve the front desk staff, medical assistants, nurses, physicians, counselors, and clinical medical directors. I think it's useful to designate a coordinator, affectionately known as the glue person, the person who sort of holds the program together. And this is almost never the prescriber. In my practice, doing this since 2004, I have, at different times, had a nurse, I've had a social worker, a counselor, and even a medical assistant who really knew the patients and monitored them. And knew exactly when whoever needed to come in for whatever monitoring and refills, and really kind of managed that aspect of the practice. Do you have to have all of these components from the get-go? No, the important thing is to just start, and many practices find it useful to start small and go slow. And then, as you get two or three patients and sort of figure out what this looks like and how it's going to work best in your practice, you can build on that from there. But the important thing is to just start. So who does what? In terms of the front desk or phone room staff, it's important that they're aware of buprenorphine for scheduling purposes. They're the face and the voice of the practice, and so it's important that they're in agreement with the overall scope of practice and philosophy. The medical assistant or nurse can often administer the COWS scale that we'll talk about, if needed during induction, they can collect and run urine toxicology screens, and check the prescription drug monitoring plan in your state. And the primary care provider confirms the diagnosis, assesses comorbid conditions, and monitors progress over time. The clinical medical director ensures that there are protocols in place so that there's coverage, for example, in the clinic, and that services are being billed appropriately. And then, some practices are lucky enough to have an embedded counselor or behavioral therapist. However, the absence of this person should not prevent a practice from considering starting office based buprenorphine. But this person, if available, will do on-site behavioral counseling and monitoring as well. In my view, the most essential training aspect for the clinical team is to develop a shared philosophy and scope of how you're going to roll this out. And this involves sort of addressing a lot of common myths, and even a little culture change in some settings. For example, one of the things that's important to address is the capacity to recognize and monitor withdrawal symptoms from opioid use disorder versus front desk staff or other staff labeling the patient as just acting out or being problematic. There may be behavioral issues, but they will almost certainly go away when those withdrawal symptoms are addressed. And letting staff know that that's the real key to conflict de-escalation in someone who's in withdrawal. Educating the staff on importance of timing of buprenorphine refills, and making sure that there's not a gap in that prescription. So when the patient calls in, instead of we'll let the provider know, and it ends up in an inbox that's addressed three days later, there's a more streamlined process for the buprenorphine refill. And the staff knows that this is a priority that the patient should not miss this or they're going to experience withdrawal symptoms. There's also a component of embracing substance use disorder as medical condition versus a moral failure or a character issue, and really understanding this as a chronic, relapsing remitting disorder that is not dissimilar to asthma or diabetes. And we're just going to ride the ups and downs just like we would in our other patients with chronic illnesses. And then, it's also important to address the role of urine drug screening or toxicology screening, framing it as a medical safety issue rather than a policing activity. We're not looking for gotcha moments. We're using urine drug screenings to make sure that the patient is receiving the safest care possible and to inform counseling. It's also helpful to talk with the staff about the timing of buprenorphine induction that we'll talk about in a minute. And then, emphasize the role of relapse, and prepare people for this. Relapse is common, but it doesn't equal failure. And the goal is to really reduce the number of relapses that a patient may experience, and the amount of time involved, and turn those good days into good weeks, and those good months into good years. But when people have a slip-up, make sure that it's a relapse for one or two days and not six months. The timing of buprenorphine induction is important to consider in office based buprenorphine. The patient should be scheduled for induction soon after an initial intake visit. With the option of provider education on home induction, as well, that I'll talk about in a minute. The patient must be in at least mild to moderate opioid withdrawal in order to get their first dose of Buprenorphine. The more severe the withdrawal symptoms, the greater the relief. Withdrawal symptoms will typically begin for short acting opioids like heroin or hydrocodone within 12 to 24 hours. And within two to four days after the last dose of long acting opioids, like methadone. Depending on how long they've been on the long acting opioid, and at what dose. We use the clinical opioid withdrawal scale, or COWS scale, to measure symptoms of withdrawal in a quantitative fashion. And this guides the timing of that first dose of buprenorphine,. It's easily administered by medical assistants or nurses right as the patient comes in. The COWS assessment rates 11 symptoms of withdrawal on a scale and develops a score. If you're using an electronic health record, one example in our practice from EPIC electronic health record, where we just build in a flow sheet for the COWS scale. And you can see, for example, resting pulse rate, there's a drop-down menu, and they get one point for the first pulse category, etc. And then, it forms a sub-total at the bottom of the screen, it gives you a score of f4. But you can do this on paper by hand just as easily. Withdrawal severity is considered mild with a score of five to 12, and moderate with a score of 13 or more. A rough guide for giving the first dose of buprenorphine is to shoot for COWS of at least 8. And depending on the story and whether or not they've been on long acting opioids, I may wait for a COWS of 12 or higher. But eight is kind of the minimum cut point that somebody needs to be at. You can also safely administer buprenorphine in the non-physiologically dependent patient to prevent relapse, for example. Or someone who has come out of medically supervised withdrawal or jail and hasn't been using, they may have a COWS <8, and it's okay to administer if they have no self-reported opioid use in the past three days, and a clinical urine toxicology screen is negative for opioids. Prior to buprenorphine induction, it's helpful to counsel the patient on first of all, the alternatives of methadone and naltrexone. The timing of induction of how, plans for how we're going to avoid precipitated withdrawal and the role of behavioral treatment. I, in my practice, will have them sign a treatment agreement, just like I would on anyone with chronic controlled substances. We do checks frequently of the prescription drug monitoring program in our state and collect a urine toxicology screen, baseline, HIV, hep C screening, etc., as well as pregnancy screening. One of the most important aspects of doing this in the office-based setting is to actually write the buprenorphine prescription, give it to the patient or send it to the pharmacy and have them fill it before the day of induction. And the reason for this is I've run into issues with prior authorizations. And you don't want to be in the position of having the patient come in for their induction and then all of the sudden realizing that a prior authorization was required. And you have to jump through those hoops while they are in withdrawal. So I've found it's just safer to give them the prescription or have them pick it up on their way to the office visit and bring the rescription with them. So I'll go ahead and present some rough guides to dosing and scheduling of patients with office-based buprenorphine practices. But these really need tailored to the individual patient and these are not hard and fast rules. On the first day when a patient comes in to the office with withdrawal, I will typically start 4 milligrams. If I'm worried that they have low tolerance or not physiologically dependent, for example, or if I'm worried that they've been on long-acting opioids and I'm cautious about avoiding precipitated withdrawal, then I'll start with 2 milligrams. But typically, we'll start with 4, wait 45 minutes. If they're not feeling completely better, and they're usually not, repeat another 4 milligrams. And then sometimes I'll give them an additional 4 milligrams to take at home that night. But typically after those first two 4 milligram doses, they're feeling a lot better. The first day maximum dose, the slide says here 8 to 12 milligrams, but there is evidence to show that the faster the induction, the less the chance of relapse. So when in doubt, I err on the higher side of these ranges. On day 2, you take the total milligram amount that was administered on the first day and assess if they're not feeling completely better, add another 4 milligram and give that total amount as a single dose. Again, rough dose maximum range 12 to 16 milligrams on day two, okay to err a little bit higher if you need to. And then on day 3, same story, and typically people will stabilize on a maintenance dose somewhere after day 3-ish. And this can be adjusted periodically by 4 milligrams at a time up to a maximum dose of 24 milligrams of buprenorphine. And there's some dose conversions in the footnotes for particular formulations of Zubsolv and Bunavail which is slightly different. I should also talk about home induction. And there's a really nice section of this by the way in the tip 63 guidelines in the references if you'd like to do further reading on this. And the story here is that office-based inductions can be a barrier to treatment initiation. And pilot trials of home versus office-based inductions demonstrate comparable retention rates and safety. It's important to have good patient selection if you're going to attempt a home induction. And I encourage you if you're doing this for the first time, the first few inductions, it's good to have two or three inductions under your belt just so you know what the patient is going through in the office before trying home inductions. But home inductions are really quite safe. The patients who tend to do the best with this are those who understand the induction process so I do extra counseling with them. And particularly those who have prior buprenorphine experience in the clinical trials, this predicted success. So for example, somebody comes in and tells me that they're recently using eight milligrams a day of unsupervised buprenorphine that they got somewhere, I ask them, well, gee, how did you tolerate it? How did you feel on that? And if they say great, I'll just write the prescription and get that going and then plug them into the monitoring process afterwards. It's also important that for home inductions, there's contact with the prescribing provider in case there are issues or problems. So I will typically call the patient later that night after their first dose, or the next day or two and just touch bases with them a little more frequently than I would otherwise and then definitely see them the next week. There are handouts. This is one handout example from the original publication of one of the clinical trials that demonstrated the safety of home inductions. I like it because it has these little hand-drawn smiley faces and frowny faces, but there are many others online that you can get as well for patient instructions. We talked about the induction phase that typically lasts 1 to 3 days. The importance is to be in mild to moderate withdrawal, and we've talked about some of this. For the stabilization and maintenance phase, this is typically combining monitoring with random urine toxicology screens and counseling if available. And we've already discussed that counseling really shouldn't prevent treatment. Medical management by the the prescribing clinician can be also considered counseling from a DATA 2000 waiver standpoint. And then I get the question a lot. How long is it that I should keep somebody on buprenorphine? And there is really no outer answer to this. What we do know is that patients who come off of buprenorphine are at higher risk for Overdose and overall mortality, falling discontinuation of buprenorphine. So I counsel patients to go into it planning on at least 12 months of treatment. Before we'll even talk about if they want to try titrate and I encourage people to stay on it and definitely actually. My longest running patient has has now been on it for 14 years and doing really well. Another rough guy It's for scheduling of the office based buprenorphine visits, we talked about the importance of things to do before induction with the prior authorizations if needed, treatment agreements et cetera. During the induction phase, I try to see patients at least twice that week if that's not feasible, at least making a quick phone call and touching basis by phone after that first visit. During the first month we tried to see people weekly and write seven day prescriptions. In the second month that they've done well with those weekly prescriptions will stretch that out two weeks with every two week monitoring, if they're doing well after two months will then go to monthly follow up visits and counseling and refills. And as patients stabilize, as three months becomes nine months, And longer, quite honestly these patients do well with less frequent visits. I see people every three months at a minimum. But that just means tailored to the individual patient. And then the reason we continue monitoring is things change. And so when there is a recurrence of use, I revert to the month one schedule until the patient is stabilized again and we pick it up and go from there. One example of an office based buprenorphine model is BHIVES model that used all of the same components had a little bit heavier Integration with a non physician staff care coordinator in HIV practices. And in an observational study of 11 HIV clinics with 386 patients at 12 months this integrated approach decreased heroin and opioid use. It increased antiretroviral therapy uptake as well as improving Quality of care and quality of life so that we concluded that even in HIV primary care settings, integration of buprenorphine is very feasible and very safe, just like general primary care settings. The next group of integrated models or collaborative care models, and I use this term, generally to refer to collaborations across the healthcare system. I know there are other uses of that term. And I'll lump hub and spoke models under this rubric, haven't spoke typically rely on buprenorphine Naloxone for their pharmacotherapy agent. And there's a lot of Coordination and Integration of care between the hubs. And in the spokes. As well as within each spoke, there's typically an RN case manager or care connector of some sort like a peer or behavioral health specialist who organizes care coordination. The hub, generally, and I'll Opioid treatment program provides consultation services and it's available to manage clinical complex patients, After recurrence of use or for tapering, etceteraa. There's typically quite a bit of outreach to community prescribers to increase the overall pool of physicians and nurse practitioners and PAs with buprenorphine prescribing waivers. And typically there's some sort of psychosocial elements that's embedded within each primary care spoke site. This may include social workers, counselors and community health teams. So far, it's typically been implemented in states with CMS state Medicaid waivers. The Vermont model is where this was developed initially. And they have Desiccated links with hubs and spokes, actually, that include a variety of services, Family Services, residential treatment services, et cetera. In a highly integrated model across the healthcare system. In Vermont, this model was associated with a rapid increase in buprenorphine prescribing over time between 2013 and 2015. And then there are variations on Hub and Spoke that are very loosely sort of lumped into this category. For example, group practices with a number of. Primary care providers, but who have sort of an internal buprenorphine team of one to two providers, who may be focused on buprenorphine inductions as a mini hub. And then send the patients back to their primary care providers in the same practice, who continue refills and monitoring as sort of mini spokes. But it's the same sort of idea of collaboration between sort of a team that's really taking ownership of getting the ball rolling and taking care of patients when their questions or not when they're not doing well. But that you have a large number of prescribers in the practice to cover for refills, etcetera and do the maintenance visits. There are also a number of examples out there of primary care opioid treatment program partnerships, where the OTP serves as a hub for initial induction and behavioral support services and then transfers the patient. To primary care practices for maintainance. This has been highly successful, for example, in Baltimore and other places in Maryland. The nurse care manager model also called the Massachusetts model after where it was developed again has typically relied on buprenorphine-naloxone. There's some naltrexone in that model as well in Massachusetts. But they have a sophisticated system for nurse care manager Managing of patients coordinate with the primary care provider and medical assistant. They use the care partner to assist with screening and brief intervention. There is a well developed educational program. The Health Department trains on best practices. There's aggressive outreach to clinicians for prescribing. And nurse care managers receive an initial eight hours and then the quarterly medication for opiate use disorder treatment training, site visits, etc., case reviews. And then typically the nurse care manager partners with integrated counseling services and facilitates the patient receiving counseling. This has been funded in Massachusetts through state Medicaid reimbursement of FQHC nurse care managers. So the challenge there is figuring out the model. In our last few minutes, let's turn to buprenorphine diversion, which I know is a big concern in a lot of communities. And there is variable data on this from the RADAR system, which is probably the most sophisticated system for monitoring abuse and diversion. It involves several data sources. And what we see here is that illicit diversion investigations tend to have more of the buprenorphine/naloxone combination product that's diverted through the Poison Center control program. There was also more of the combination product. But that's a rarefied population. This is probably because at the time the study was done, there was just more combination product out there. I think the equally informative data is from treatment program past month abuse data and the college survey data. Where there's a clear trend for self-reported abuse of the mono product of buprenorphine as opposed to the buprenorphine/naloxone some combination of product. And so the bottom line is there seems to be less propensity for abuse with the buprenorphine/naloxone combination product. When things are diverted, they're mostly diverted for management of withdrawal symptoms, or for treating a friend with withdrawal, or to make it home for a family reunion some weekend without using heroin. There's also, because of the way buprenorphine works, a low overdose risk in the event of diversion. S from a public public health standpoint and an individual standpoint, I worry much less about buprenorphine diversion than diversion of full opioid agonist. Diversion is unauthorized rerouting or misappropriation of prescription medications to someone other than the person for whom it was intended. Whereas misuse is taking a medication in a manner or by a route or dose other than prescribed. The reasons for diversion are often peer pressure or trying to help a friend or family member with opioid use disorder, or just to support one's income. Whereas the reasons for misuse of buprenorphine tend to center more around habit or the perception of underdosing, which can generate a really good conversation with the primary care provider. Most commonly relief of opioid withdrawal and craving. But also there are people who use this to get high. And that's typically in younger, less experienced users, and to relieve anxiety and depression and pain. And these are all things that need carefully discussed in the primary care setting. How do we recognize diversion? We recognize it when patients, just like anybody on long-,term narcotic prescriptions, is requesting maximum doses or super maximum doses, frequent early refill requests, a past history of diversion or misuse. So that's an important thing to assess early on. And then a partner or friends who are also using opioids. And then, of course, things like track marks or other signs of injection. We also recognize that sometimes through pill counts, having patient bring in the bottle and making sure that it looks along the lines of what we think it should look like. Having a negative urine test for buprenorphine or norbuprenorphine in somebody who's receiving ongoing prescribing. And then in prescription drug monitoring programs. And this is why it's so important. We check our PDMP at every visit to make sure that the buprenorphine is being picked up and other things aren't as anticipated. You need to be sure and check, though, with your state PDMP and make sure that buprenorphine is adequately reported in your own state's PDMP. It is in Oregon The other thing that I try to keep in mind is when it comes to diversion and misuse, full opioid agonists are much more preferred over, Buprenorphine or naltrexone. So for example, if somebody is going to divert or misuse something, it's much more likely to be oxycodone, or methadone, or some other full agonist than buprenorphine. Naltrexone has essentially no diversion or misuse potential as a opioid antagonist. With no action, activation, I should say, the opioid immune receptor. We've alluded to this already, but buprenorphine/naloxone does have a decreased diversion potential. The naloxone component precipitates withdrawal if the tab is melted or crushed and injected. And again, I try to just be really empathetic and compassionate with patients when I do learn of diversion. Since most of this, the lion's share of this, is really for self treatment of withdraw instead of trying to get high. And I use that as a leverage point to encourage people to engage in treatment. We discuss their dose and we talked about bringing their girlfriend or their friend or whoever into treatment, and I'll treat both of them. And then when diversion does occur, because Buprenorphine is a partial agonist, its overdose potential is greatly lower than a full agonist. To avoid diversion, it's always best just like any medication to use the lowest dose that works. Ongoing monitoring as we've already discussed. And then when there's clear, ongoing diversion and/or misuse, this is when I have a frank conversation about other alternatives. And fortunately, we've had extended release naltrexone, a once a month injection that can be done in the office. And now we have the more recently approved buprenorphine, long acting injections that can be given monthly. There's also a six month buprenorphine implant for very stable patients, which is more more difficult to get. As a checklist to prevent diversion, I talk with my patients about this. I look for non-healing track marks and abscesses, etc. Pay attention and listen to those early refill requests and dosing increases. And then monitoring as we've discussed, which often requires actually collaborating with family members, pharmacists, counselors, etc. I've been impressed by the number of times that it's really the counselor that or sometimes the medical assistant who gets the scoop more than I will. And so really talk with your team about this. When patients do misuse or divert, stress the willingness to continue working together. I think that's the key is maintaining the relationship. And using this as an opportunity for counseling and relapse prevention. And then you know, consider a higher level of care. Just like other things in primary care, we can't do everything. And it could be that the disease severity of the patient with opioid use disorder exceeds what's appropriate to manage or what your scope of practice that you've decided as a group to manage is going to work in your practice. I start with increasing visit frequency. Somebody's been on monthly subscriptions. We do weekly prescriptions for awhile. If that's not working and you have the option for opiate treatment programs in your community, most opiate treatment programs can now dispense both buprenorphine and methadone on a daily basis. And I have many patients that I'll refer to there and say, hey let's let's try this for a while. And I'll continue providing primary care. But then come back and let's talk. And I'm willing to reconsider this if things are improving. And then similarly, for residential treatment, and this is particularly challenging for patients who are using concomitant cocaine and methamphetamines. You know, I'll use this as a leverage point for continued prescribing. Yes, I don't want to cut you off. And I want to continue prescribing, certainly continue primary care. But this just isn't going to work out unless you actively pursue residential treatment for these other substances of use. However, whatever your comfort level is with referring to higher care, I would highly encourage you to make sure that higher level of care does not equal no care. It's far better from a harm reduction standpoint to have imperfect recovery than to take away life saving treatment and leave somebody with nothing. And I know that's a real issue in a lot of particularly more rural communities that don't have a lot of higher level of care resources readily available. And then, particularly in those settings, I think it's exciting to think about these newer options of long acting injectable treatments like naltrexone that's been around for a while or now injectable buprenorphine. There are several resources available for provider implementation of office based buprenorphine. One is the USCF substance use consultation warm line that's available five days a week. If they don't know the answer on the spot immediately, they'll call you back within a couple hours. It's really a remarkable service. The Provider Clinical Support System of which you're participating in today also has tremendous resources available. ECHO, I'll go into detail about that. But here's a weblink to ECHO opportunities around buprenorphine prescribing nationally. And then I'd highly encourage you to order online the SAMHSA TIP 63. This was just updated in May of 2018 and is available on request, free of charge, from SAMHSA. They really did a wonderful job recommending state of the art tips on integrating buprenorphine into your practice. Addiction Medicine ECHOs are tele-mentoring sessions that typically offer CME for a once a week login where primary care providers can present cases and then have a panel discussion and brief didactic with an inter-professional panel of addiction medicine clinicians, addiction psychiatry, counselors, peers with lived experience. And this is a remarkable resource that bypasses some of the geographic and time limitations of busy primary care providers, particularly in more rural areas. Here are the references that support what we've discussed today. For the peer mentoring program, I'd like to make you aware of a couple of different resources. The PCSS Mentor Program is designed to offer general information to clinicians about evidence based clinical practices and prescribing medications for opioid use disorder. And PCSS mentors are available for you. They're a national network of providers with expertise in addictions, pain, evidence based treatment, including medications for opioid use disorder. And there's a 3-tiered approach that allows every mentor/mentee relationship to really be unique and cater to the specific needs of the mentee. There are some mentees for example, that I just give my cell phone number to and they call me when they have a question. Others are more interested in the systems issues around integration. And we spend more time talking about that. But this is a great opportunity. There's also the PCSS discussion forum, which is comprised of the PCSS mentors and other experts in the field who helped promote responses to clinical cases and questions. There's a mentor on call each month that's available to answer any issues that are submitted as questions on the online forum. You can create a new login account by clicking the image on the slide to access the registration page. Here are our collaborating PCSS partners. And thank you so much for participating today. I really appreciate you taking the time to devote an hour to this important issue that's facing us all. Thank you very much.
