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UK HealthCare's SMART Clinic · UK HealthCast

• 0:02
  Sam Greenberg (Host): Welcome to UK HealthCast, a podcast
• 0:04
  presented by UK Healthcare.
• 0:06
  I'm Sam Greenberg, and with me is psychiatrist Dr.
• 0:09
  Gopalkumar Rakesh as we talk about UK Healthcare's Smart Clinic,
• 0:14
  what is it exactly, who does it help, and why it matters for
• 0:18
  mental health care in Kentucky.
• 0:20
  Dr.
• 0:21
  Rakesh, thank you so much for your time today.
• 0:23
  Gopalkumar Rakesh, MD: Hi, Sam.
• 0:24
  Good to be here.
• 0:25
  So, I am a psychiatrist.
• 0:27
  I have been with, you know, the University of Kentucky for the last seven years.
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  I'm also trained in addiction medicine, which means I see people
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  with substance use disorders as well.
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  To talk a little bit about the SMART Clinic, the SMART Clinic is an endeavor
• 0:41
  that the Department of Psychiatry has had for the last five to six years.
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  We mainly see people with substance use disorders, sometimes they also have
• 0:51
  co-occurring mental health disorders as well, like depression, schizophrenia,
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  OCD, anxiety disorders, and PTSD, in addition to the substance use disorder.
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  And we provide treatment for both groups of disorders.
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  The clinic also offers a few primary healthcare appointments.
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  The clinic is spearheaded by Dr.
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  Danielle Anderson, who is also an addiction medicine-trained physician.
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  She's trained in family medicine and addiction medicine.
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  She's been the director of the clinic, and I am the associate director.
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  So, we kind of complement each other's skills with our trainings
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  in psychiatry and family medicine in addition to addiction medicine
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  and addiction psychiatry.
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  Host: So, Doctor, there are a lot of very qualified people obviously
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  running the SMART Clinic, but can we take it back one step and SMART is
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  actually an acronym for the clinic.
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  Can you tell us what that actually stands for and a little bit more
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  about who exactly you guys treat?
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  Gopalkumar Rakesh, MD: SMART stands for Supportive Mental Health and
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  Addiction Recovery Treatment, which I know is a mouthful.
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  But the clinic was started with the goal of treating people with substance
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  use disorders and people with substance use disorders co-occurring
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  with other psychiatric illnesses.
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  If you look around you, there is an area of big need especially in
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  the state of Kentucky, where we have elevated rates of tobacco use.
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  The deaths from opioid overdoses are reducing, but they are still
• 2:14
  at sustainable levels such that a lot of care and effort is
• 2:17
  needed to help these people.
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  We also have a burgeoning issue of stimulant use in addition
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  to the new substances which we see coming up in the market.
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  For example, xylazine, fentanyl, which has always been there.
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  Fentanyl being added to other substances and people presenting
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  with exacerbations of one substance use disorder as well as people with
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  multiple substance use disorders.
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  Substance use, it never exists in a silo.
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  Mostly, it exists in association with other mental illnesses or
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  with other substance use disorders.
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  The clinic sees a lot of people who have alcohol use disorder and liver disease.
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  Again, it's one of those examples wherein substance use exists in association
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  with medical illnesses as well.
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  We also offer services for people with people who are cancer survivors
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  and have substance use disorders.
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  For example, people who are cancer survivors who smoke, people who are
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  cancer survivors who have increasing uses of opioids for pain, et cetera.
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  So, bottom line, the clinic offers services and caters to a variety of
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  populations in addition to providing both medication and psychotherapy
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  while also trying to provide wraparound services, like transportation some
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  degree of assistance with housing.
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  We have a food pantry.
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  We try to provide wraparound services in addition to medications and
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  psychotherapy, which includes individual psychotherapy and group therapy sessions.
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  Host: Yeah, that is amazing.
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  It's a very all-encompassing clinic, and you guys are doing great work.
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  You have a variety of patients that you can see and help.
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  And, Doctor, how does a patient typically get connected with the SMART Clinic?
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  Do they need a referral, or can someone self-refer?
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  Gopalkumar Rakesh, MD: We get referrals in both ways.
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  Sometimes people present for treatment at the SMART Clinic.
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  Majority of our referrals come from primary care providers and through other
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  departments at the University of Kentucky.
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  Sometimes people get admitted on an inpatient floor, on an inpatient medicine
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  floor, on an inpatient psychiatry floor at the University of Kentucky.
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  And then, just before discharge, their providers put in a
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  referral to the SMART Clinic.
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  The SMART Clinic, we work in association with the First Bridge
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  Clinic and the Pathways Clinic.
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  So, the First Bridge is under the Center for Drug and Alcohol Research,
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  and then the Pathways Clinic is within OB-GYN at University of Kentucky.
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  So, the SMART Clinic is one of these three clinics and all of us kind of
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  provide complementary services to people with substance use disorders.
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  Where I would say the SMART Clinic's niche is in being able to provide
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  services for both psychiatric disorders and substance use, while also having
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  a few appointments for primary healthcare, So, that's kind of the
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  niche that the SMART Clinic occupies.
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  And that is a very required niche, because the co-occurrence between substance
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  use disorders and psychiatric illnesses is somewhere in the 60% to 80% range.
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  So, I think the majority of people we see have both these illnesses co-occurring.
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  And treating one of these is not essentially enough.
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  You have to treat both.
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  You have to treat both simultaneously so that both illnesses improve and
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  there's actual recovery that you can see.
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  The official term for people with co-occurring psychiatric
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  illnesses and substance use disorders would be dual diagnoses.
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  And with dual diagnoses, even if one of the illness, for example, if somebody
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  comes in with PTSD and alcohol use, and if we don't treat both of them, then the
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  substance use is not going to—I mean, they'll have a temporary de-escalation
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  of the substance use, but then they will still have cravings, and the
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  severity is going to remain the same.
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  Essentially, unless you treat both diseases recovery is going to be
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  very difficult, which is a leading principle we have in this clinic.
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  Host: Sticking with those principles, can you walk us through the standard of care
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  for the SMART Clinic and the standard of care for the patients, why that matters,
• 6:27
  and maybe what someone might expect from coming into the SMART Clinic for maybe a
• 6:32
  first appointment or an initial visit?
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  Gopalkumar Rakesh, MD: If somebody wants to come into the clinic for
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  treatment, it's a big decision.
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  There's no sugarcoating it.
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  It is a big decision.
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  There is a lot of stigma that people associate with that decision.
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  That is something we try again and again to diffuse and deescalate.
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  And that is the case for so many other illnesses too.
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  But with substance use, there's this particular range of causes
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  which can lead to stigma.
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  For example, we have patients who present and they have a tough time telling their
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  families or friends that they are coming to the SMART Clinic for treatment.
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  And that just goes on to talk about how stigmatic it is for them to present and
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  accept that they are receiving treatment.
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  So, the stigma and the decision are initial big things associated with
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  that first step of getting treatment.
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  Once a patient comes in for treatment, they're usually
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  scheduled with either me or Dr.
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  Anderson or we have a nurse practitioner whose name is Whitney
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  Meyer, who's also an awesome clinician.
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  So, the patient is scheduled with one of us, and they also have an appointment
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  with our case manager, Danielle Dicken.
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  Both these appointments are meant to assay what the patient needs, what
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  are their treatment needs, and to educate them on what the schedule is,
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  what the principles are in the clinic.
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  And depending on the severity of their substance use, depending on the severity
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  of their co-occurring psychiatric illness, depending on active substance use or
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  if it's in remission, how motivated they are for treatment, we schedule them for
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  either weekly visits or monthly visits.
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  And there's a schedule which follows something called the ASAM
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  criteria, which is the American Society for Addiction Medicine.
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  The case manager who talks to them educates them on what the schedule looks
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  like and how people are assessed, the case manager always educates them on
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  what kind of schedule each patient would fit into depending on their
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  illness severity and other facets.
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  It's a collaborative discussion that happens.
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  At every visit, we try to have patients give urine drug samples
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  just to be certain to know if they're using other substances or if
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  they're on remission or if they're decreasing the use of substances.
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  A big portion of people we see have alcohol use disorder or
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  opioid and stimulant use disorder.
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  So, it becomes really pertinent to talk about medications and things
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  like medication-assisted treatment.
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  For example, we use a lot of buprenorphine both in the oral
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  formulation and in the injectable version.
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  So, compliance, are people being adherent to the medication, people
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  being adherent to the medications for alcohol use disorder?
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  So, patients are designated to visit providers either weekly or monthly.
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  And then, we also have a formal process wherein people are inducted into group
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  therapy sessions, which are also done weekly or monthly in addition to the
• 9:27
  one-on-one psychotherapy if needed.
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  So, the initial first two to three visits are mostly assessments and maybe
• 9:35
  treatment gets started, at least the pharmacotherapy piece gets started.
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  The goal is to have the pharmacotherapy or the medication proceed side by side
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  with the psychotherapy, which could be group therapy or the individual therapy.
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  And then, periodic assessments are done.
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  Sometimes people graduate.
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  Mostly, they graduate from weekly visits to monthly visits maybe to visiting once
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  in six months once they are at a stage wherein they've demonstrated recovery,
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  and they no longer need the intense acute visit schedule with the therapy schedule.
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  Obviously, there's times when we have to discuss deviations
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  from this schedule as a team.
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  Sometimes we encounter people who are not really motivated for treatment
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  but may have been motivated by, you know, family members, be it a
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  family or friends bringing them.
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  Most times, there needs to be a discussion surrounding how
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  we can keep up the motivation.
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  We've also had instances wherein, with substance use, it is a chronically
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  relapsing and remitting illness.
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  And what that means is relapses happen.
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  The term we like to use now is return to use.
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  And with return to use, that can happen frequently or intermittently.
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  It requires the clinic and the patient to have a discussion surrounding coming
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  back to the clinic when they feel like things are in a stable phase.
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  Most of the people we see also have psychosocial stressors including
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  childcare, family care, stressors from employment from paying their bills.
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  And those are things we see on a daily basis.
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  So, it's a very multifaceted approach.
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  It is completely free of judgment, and that's a high standard we hold
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  ourselves to the expertise we have in addiction medicine, and like I said, Dr.
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  Anderson, who's trained in family medicine.
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  That allows us to accurately ascertain how the medical illness piece is
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  playing into the substance use disorder.
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  For example, with opioids and chronic pain, that's one example.
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  Especially in cancer survivors, people with liver disease and
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  who are waiting for transplants.
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  So, it is a highly multifaceted, multi-team approach, interdisciplinary
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  in very much in all regards.
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  And we try to provide wraparound services with an umbrella so that we
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  can hopefully address most of what people are going through and ensure
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  that they are empowered to be successful in their journey towards recovery
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  Host: That sounds like amazing work, Doctor.
• 11:59
  And if someone listening thinks that they or a loved one might
• 12:02
  benefit from the SMART Clinic, what are some of the first steps that
• 12:07
  they should take to get connected?
• 12:09
  Gopalkumar Rakesh, MD: If you go onto the UK website and you type in Smart
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  Clinic, we have a phone number that you can call and schedule an appointment.
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  Our front desk staff are really well-entrenched in talking about the
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  specifics on whether your insurance works and what the schedule would
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  be, and they're pretty used to it and they're awesome at what they do.
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  Just give us a phone call.
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  Or you can ask your primary care doctor to put in a referral.
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  The referral process is, if the referral's coming from a facility outside
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  of the University of Kentucky, there's a button called Care Link that they can
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  press on and that they choose, and they can put in a referral to the SMART Clinic.
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  If the referral's coming from internally, then the department to
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  choose would be psychiatry, and then the order set would be a referral
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  to addiction medicine or there's a chemical dependency ambulatory referral.
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  Both these referrals work.
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  It's clearly stated on our website as well.
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  And once the referral's in, somebody will reach out to you from the
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  clinic and schedule an initial assessment appointment, like I
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  said, with the provider and with our case manager/social social worker.
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  Host: Doctor, you are all doing incredible work at the SMART Clinic
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  to support mental health in Kentucky and substance abuse as well.
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  Thank you again so much for your time today.
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  This is going to help a ton of people.
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  Gopalkumar Rakesh, MD: I'm really honored to be here.
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  And I'm glad I got a chance to speak on the podcast.
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  And we are all committed to helping people with substance use.
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  Most of us have stories in our own families wherein we've seen people
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  struggle and not have the help they need.
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  I would say all of us, not most, all of us who come into this clinic,
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  we come with the passion and with the mindset to encourage
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  people to get help to do whatever we can to help people recover.
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  So, thanks so much for having me.
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  Host: Thank you again.
• 13:59
  For more information, go to ukhealthcare.com.
• 14:03
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• 14:06
  to check out the entire podcast library.
• 14:09
  Thank you for listening to UK HealthCast, a podcast from UK HealthCare.