Speaker A: CASAT Podcast Network.

Bianca McCall: Welcome to the NOCE Dose Opioid Crisis Unplugged. The NOCE Dose Opioid Crisis Unplugged is a concise and insightful podcast offering a deeper dive into the realities faced by professionals combating the opioid epidemic. Join us as we reconnect with expert panelists from our listening sessions, providing a behind the scenes look at their work and insights into the pressing issues of prevention and diversion, harm reduction, opioid use, treatment, recovery and reoccurrence prevention. Welcome to the NOCE Dose brought to you by the Nevada Opioid center of excellence at nvopioidcoe.org. I'm your host with the NOCE, Bianca D. McCall, going behind the scenes of the front lines, having courageous conversations with those who support the opioid response programming in Nevada state. And today we are all set to debrief after the latest the greatest no sponsored listening session. And joining us today is Kim Nischik, a board certified physician's assistant and mat medical program co coordinator at Northern Nevada Hopes. With nearly two decades of, clinical experience in addiction medicine in women's health and primary care, Kim is a dedicated champion for underserved populations, including services to pregnant women and unhoused individuals. Now, Kim is a Chicago native with a passion for community focused care. And, and I joke all the time and say, hey, I'm a foodie. So of course the first question, question I, I'd like to ask you, Kim, is where do you find good pizza in Northern Nevada? Right. But, but Kim, she holds degrees from Boston University and Pacific University and serves as a clinical instructor at the University of Nevada Reno School of Medicine. I want to, I'm excited to dive into Kim's inspiring work and her approach to improving health equity. Kim, thank you so much for, for joining the platform and connecting with us today. And for the real first question, I'd like to start off and ask you, how the heck are you? How are you doing? And how have you been since the listening session?

Kim Mishek: Hi, thank you so much for having me. I'm doing great. survive the holidays and we're just right back in it here. 2025. Just, you know, I can't believe it's almost the end of January.

Bianca McCall: That's right. We've almost concluded the first month of the year 2025. so much. It seems like the listening session was actually so long ago. Right. Way back in 2024 is what I've kind of been, been telling folks and had a conversation yesterday with a colleague and Said, where the topic of the conversation was. Is it, Is it. Are we still supposed to be saying Happy New Year? You know, is it. Is it too late to say that? And, and, And I don't know what the answer to that is, Kim, but with the listening session being, what feels like so long ago, I want to draw upon, you know, our experiences and our conversations that we had back then. And, and, and I'd like to know from your perspective, what was maybe the most profound takeaway from the session for you, you know, what really seemed to. To land and to stick around, something that you will carry into your practice early on in 2025.

Kim Mishek: Well, one thing that was a takeaway is that we have, such incredible providers in Las Vegas who I was not, you know, besides Kayla Shannon, who is my counterpart here at Hopes. I had not met the other two, professionals, and they were incredible. And so that was a great exposure for me and I think for Kayla as well, in terms of, hey, these people are great resources. Glad we got to meet on the nose dose. And, hopefully we can use that to reach out in the future if needed.

Bianca McCall: Absolutely. And during the discussion, when we talked a lot about kind, of traditional care models, we talked a lot about the, disparities and despite our efforts to kind of, overcome this siloed model of care, you know, to really connect and especially in our rules and such. And so when connectedness is the theme of the listening session, when we're talking about medical treatment or medications in the treatment of opioid use disorder, when connectedness is the theme, certainly for your feedback, to be, hey, we learned about some great work that's being done in Nevada, and we made some connections. We walked away with some connections that just to me spells success, right? Absolutely, absolutely, 100%. And during the session, what you contributed to that conversation, it just, it blew me away. And it had, everybody kind of a captive audience hanging on every word. Right. Because during the session you mention, that empowering providers. Right. When we talk about, fostering this culture where we are reintegrating, within our communities, we're mobilizing champions from our communities. And we're doing that starting with self, in a way, pouring into ourselves as professionals, as providers, as practitioners. and when we talked about the pathways to achieving that, you mentioned that empowering providers requires ensuring that they feel supported and that they have access to mentorship. And with the healthcare workforce in Nevada facing shortages in many areas, as we all Know, and challenges such as burnout, an aging population requiring new care, solutions, care, migration outside of the hospital, model and skyrocketing costs and shrinking budgets, mentorship for providers, it appears to be one of the more distant solutions, you know, that we don't talk about too much and certainly secondary, maybe even tertiary to the money problems, and embracing and engaging in technology. Right. Or technological integrated care models. But it's important, it's important to create this, the psychologically safe spaces to learn both the explicit components of medical education, like the basic sciences, the clinical knowledge, clinical skills, but also the implicit curriculum expected of medical professionals. Right. How to, how to operate, in and lead multidisciplinary teams and clinical teams and communicate, and advocate for our patients and specifically those that are being treated for opioid use disorder, and also serve as future mentors themselves. So with all that being said, Kim, can you share specific strategies or perhaps success stories where mentorship made a tangible difference in perhaps yours or another provider's, ability to treat patients with opioid use disorder? And one more thing, if you could speak to why mentorship ranks higher as a priority for you.

Kim Mishek: So, so as a physician assistant, we are trained in a general medical model. And if we want to work outside of primary care, we have to be trained or mentored. And so that's how I learned to do what I do in all the specialties. And I was really lucky that when I, started doing addiction treatment at Northern Nevada Hopes that I had an addiction psychiatrist who was, he was like a consult. And he wasn't working, you know, on site at Hopes really prior seeing his own patients. But they Hopes hired him to help mentor and train me to do the medication assisted treatment program because we didn't have any providers at that time to do it. and so that's how I learned. And for me that's a very incredibly valuable tool. And as we discussed on the podcast, to be able to have another medical provider's phone number to call for anything is like a hidden gem. Right? And so I always. So Dr. Mark Brodhead, who he previously was working at UNR, and he was my mentor. And so that. And then I also worked with seasoned therapists who had been doing this work and really with the two of them. And Danica Pierce, I believe she works at UNR as well, still as a therapist, really with the two of them kind of training me and being available when I had questions, which that's the only reason that I was allowed to kind of do what I do, and they're the ones that have gotten me to this point now, and I feel like I've been able to pay it forward. And since we've grown in our substance use disorder treatment program, we've been able to add three additional medical providers. And it started by, okay, we have this need. Not a lot of medical providers do this. How are we going to fill this need in our community without, you know, looking outside? Because they had looked outside for medical providers before and were really unsuccessful at finding someone. And so the plan was like, let's train from within. So we took a survey of the medical providers that we already have at hopes that are all incredible. And some of them expressed an interest in learning how to do substance use disorder treatment. And so we brought them on and we did a mentorship program. So they did some shadowing to see what actually happened in our clinic. And then they would. We would have simultaneous clinics where we would both see patients at the same time and so that we would physically be next to each other if any questions, you know, needed to, you know, if there were any questions that needed to be answered or if they were complicated cases. And so being able to work side by side helped, I think really just help the new providers feel supported and make them feel more confident to treat alcohol use disorder and opioid use disorder. And then after they would feel comfortable kind of sharing clinic time, then we were able to expand to the point where we could have these same providers at a different clinic location doing the substance use disorder treatment. And so we now have, you know, three more, medical providers that are providing this care, which is amazing. We've never had this many medical providers doing it here before, and they're excited about it.

Bianca McCall: And I'm glad that you said this. So the hidden gem of mentorship is what's resonating with me. Right. And I'm so happy that you mentioned, just really the gift of carving out time for mentorship. Right. And also, you mentioned this, confidence building and excitement and attitude of excitement about, specifically the mentorship, the mentor mentee relationship. that's required. Right. It's a requirement to have a certain type of attitude when approaching mentorship. And so I gotta ask you, Kim, how do we overcome those challenges of burnout of providers feeling overworked and underpaid. Right. and perhaps their attitudes being impacted. Right. Their motivations and attitudes being impacted by these challenges? How do we overcome those in order to survive?

Kim Mishek: Mentorship, that is the million dollar question. And I don't think it's necessarily surviving mentorship. I think it's, you know, medicine in general has such a high, like burnout rate. and what I found is that doing specialty work helps. It kind of helps pivot in a little bit different direction. And so when you have your day of seeing patients every 20 minutes, when you have a set block of time to just do something else, focus on alcohol and opioid use disorder, it's a way to kind of switch your brain a little bit different direction. And it's not that different than what you're doing otherwise, but it just helps to have more variety. That's what I found.

Bianca McCall: Well, and also during the session, the listening session, you mentioned how, medicine, in the world of medicine and medications for opioid use disorder, it's really kind of the simple formula, right? When you're looking at accessibility, costs and coverage, and you even went into, the different medications that were being used, for the treatment of opioid use disorder, like methadone, buprenorphine and naltrexone, and how each, play a distinct role in stabilizing the brain and supporting recovery. so my question for you is, how do you approach educating patients about these options, these options for medications, and how do you do so, in a way that empowers them in making informed decisions about their treatment? Because I'm just wondering, how do we avoid patients being at the mercy of their insurance coverage and not necessarily receiving, the best medication for their circumstances?

Kim Mishek: Right. I. I think that education is really important for patients in general. And my attitude when I see patients is that, hey, oh, sorry, I'm in a room with. There we go.

Bianca McCall: We're in the dark.

Kim Mishek: Sorry, I'm in the dark. I wasn't moving enough. so I. My philosophy when I see patients is, hey, like, I'm here to. I'm here to help you and like, let me be part of this journey with you. And the first part is, do you feel well enough to be able to have a longer conversation to help understand what we're doing today, what the options are and what you want to do moving forward? Because, you know, if people are uncomfortable, if they're in withdrawal, if they're sick, it's all they can do to sit longer than a few minutes anyway. So that's kind of like the first part is, are you in a space where we can actually have this discussion? And then, you know, part of it is this is, you know, what we're doing here. This, like, treatment plan is directed by you, and I'm just here to help support you. And so I say these are the medication options. These are the reasons we use these medications. This is why you might choose one medication over another. And what do you think? And you know, a lot of patients, when they've, by the time they've come to see us, they've tried, they've tried these m. Some of these medications before, whether they've been in a program, whether it's been prescribed, whether they've tried it on the street, most of them have tried one or all of the medications before. So it's generally not brand new information. and so whether their insurance pays for it or not, you know, is a, is a whole nother thing. we are very lucky to have a nurse on our team who advocates very hard for our patients. Lots, of phone calls with insurance companies to have these medications approved and that. She's a gift to our team. She makes my life so much easier. so there's that. And then we also have this other wonderful thing that has happened is that HOPES was awarded a financial grant to expand our opioid treatment program. And part of that was helping with medication assistance for those who don't have insurance or if their insurance is, you know, if they're underinsured and they can't afford it. And so that now has allowed us to start the Medicaid, the patient on medication, maybe before the insurance is approving it. And so that has allowed us to say, the patient is here, they are ready, we need to treat them now. And let's get this started. Come on, insurance, let's get going.

Bianca McCall: well, gosh. And you just bring up so many additional challenges, right. And barriers that exist for our patients in accessing the appropriate, appropriate care. Right. That even outside of or beyond, insurance coverage. Right. But even with their circumstances. And I love how you said the attitude shift for you was, was joining in the journey with the patients. Right. To get to know, to get a clear idea of all the barriers. Right. To be able to forecast the barriers that may exist. another example of this, is given the, naltrexone. So when you talk about, that, requiring abstinence for that type of treatment, I'm thinking, for naltrexone, requiring absence before initiation, that could be a significant barrier for people who are using drugs and actively using drugs. Right. And so, Kim, what strategies or support systems do you think that could help patients overcome this challenge and access this medication when it may be the most appropriate option for them.

Kim Mishek: Right. In the fentanyl era, starting patients with opioid use disorder on naltrexone is very, very difficult because going 14 days without using an opioid is. That's not appropriate goal. It's not setting the patients up for success. naltrexone can be an excellent option for people when they were coming, if they're coming out of incarceration or if they're coming out of a treatment program where they've been somewhere safe that they have not had the opportunity to use opioids. And studies have shown that both naltrexone and buprenorphine can be equally effective for treating opioid use disorder. The biggest barrier is for naltrexone is the abstinence that's required prior to starting it. So, you, know, I don't, I don't have any great pearls. You know how you have, you know, I just, I don't require patients. I presented that this is a treatment option. And I also say this is an option that I don't use very often because it's. Asking someone to remain abstinent from their substance of choice is just not, I mean, it's just not going to happen.

Bianca McCall: Yeah. And I mean, and when you described the, naltrexone being the only approved injectable. Right. And whereas the, like buerprenephrine, is, ah, you know, of course there's no risk of overdose, but it does come in like the oral, the, pills, the films, and then with methadone, requiring the daily, engagement and interaction. It just seems like, that might be. The injectable. Might be a more appropriate.

Kim Mishek: Well, so let me, Let me back you up quickly. Buprenorphine does come in injectable form, and we, and we use it a ton.

Bianca McCall: Okay. Okay.

Kim Mishek: Yeah, yeah. It's an excellent option. We use it a lot. A lot. A lot.

Bianca McCall: Ah. okay. And what about, what about costs? What are you seeing in terms of approval rates and costs for the buprenorphine?

Kim Mishek: So for injectable buprenorphine?

Bianca McCall: Yes.

Kim Mishek: Injectable buprenorphine is quite expensive. We have had really good success in terms of obtaining insurance approval for patients to start this medication. We are lucky that the majority of our patients that are insured have Medicaid, and we're very lucky to live in a state where Medicaid has deemed this medication a priority and will pay for it.

Bianca McCall: Yes, yes. so, and thank you so much, genuinely for identifying the ways that we are championing in this community. Right. And the things that we are doing well. kudos to Medicaid, for making this a, ah, priority. Kim, so you've talked to us about, and thank you so much. You've talked to us about, the medications and the treatment of opioid use disorder. You've talked to us about, achieving equity, and connectiveness, by means of focusing, on providers and practitioners, mentorship, as being a key there. and really just kind of what again resonates with me is the joining the journey. Right. And joining each other's journey with that and honoring, and embracing, the ups, the downs, the opportunities for transformation throughout that journey. To be transformed as a professional and to be active, in the transformation. Right. Collaborating with our patients to transform in their own lives. out of what we talked about today and from the listening session, if we were targeting at least one person, right. I always say, you know, during these podcast episodes that, you know, our goal is if we could just reach one person, right, and have something that we're, we're talking about, impact them and resonate with them. if you could think about just kind of the, our topic of discussion and what would be the message, your message that you would want to impact upon if only one person that's listening to our episode today.

Kim Mishek: I think the biggest thing is that relapse is part of the journey and that's okay. And there are places like hopes, where you can come for treatment, that you don't have to show up as your best self. We take you as you are. You know, we are here to help you. We are here to assist and we understand that things happen. And so we're. We're here as your life coach. Yes, we prescribe medications, yes, we do therapy, but we are here to help make your life better. And, and you can do it. And admitting you have a problem is a really hard thing. And asking for help is even harder. So when people come in, first of all, we applaud them for showing up. But we understand relapse is part of the journey and we're on the journey with you and that's okay.

Bianca McCall: Yeah, I love that, that, you know, it's not enough to just say, join the journey, but, but to also come in with, with a lens of compassion and understanding, that each individual's unique journey, it, it's, it's all encompassing. You know, it's not just the, they're not just seeing you, they don't have to wait for a crisis per se, to, to see you or to want to, to help or to make changes in their lives. Just the same as it's not always going to be, you know, Rosie and butterflies. Right. you know, at that particular juncture, of the journey. And so, as providers, as professionals, in this space, it's, it's joining the journey and being completely open, to, experiencing, you know, all different, all different encompassing, things that come along with that person's journey. So I love that, if you can, can you, end with telling us a little bit more about Northern Nevada hopes, what you have to offer, and then also how professionals in the opioid treatment spaces can connect with you and perhaps connect with the, Northern Nevada Hopes nurse practitioner who can gift us all with approvals for medications. But how can they get a hold of you? Right? How can they get a hold of you and what can they call you for, Kim?

Kim Mishek: Right. I am. First of all, I'm always available for questions by phone, text, email. I feel like as medical providers, when you have someone who works in a specialty and you have their cell phone number and you can reach out to them and like, hey, can you help me with this? And they respond, it's. For me, it's life changing. I'm like, thank you. You just saved me hours. And so I just, I feel like that's very important and I'm always happy to reciprocate on my end because I'll call anyone at any time.

Bianca McCall: Yeah. So, Kim, are you giving your phone number out on the NOCE Dose podcast? Are people here? So your phone number here?

Kim Mishek: So I guess so. I'm, I'm happy to share my phone number. The other thing we do have that's incredibly fantastic is we have a cell phone number that patients and people in the community can call or text at any point in time. It's, someone's operating it. We kind of share the responsibility Monday through Friday during business hours. But we found that to be incredibly helpful for people if they wanna become patients. If you're a provider that has questions, if you have a family member that needs help, if you're a patient that's having problems with your medication, you can always call or text. So that's been extremely helpful and we give that out to everybody. So that's a great phone number to start with also.

Bianca McCall: All right, yeah, let's give that one out. to start, and then we can make our way, towards you.

Kim Mishek: Okay. Okay. That'd be a good place to start. But I'm also, you know, happy to share my number.

Bianca McCall: All right, well, that sounds great, Kim, if you wouldn't mind, will you give that number to, the general number, that goes through, the organization and then, and then we'll also make sure that's available for our listeners to be able to find, and to connect with you via our platforms and our website. Certainly. but what is that number two? Northern Nevada Hopes. This is the, the, the call line for, for people to get it, more information.

Kim Mishek: So if you go into the Northern Nevada Hopes website, there's the main phone number that's for all type of care, and then there is. I'm sorry, I haven't been on it recently, but I believe there's a, there's a tab for substance use disorder treatment. And if you go on that tab, it opens up a page that explains what we do, and our cell phone number is on that page.

Bianca McCall: Wonderful, wonderful. Well, thank you so much. We will be sure to make sure that, our listeners, and everyone on the NOCE Dose platform has access to that. Kim, thank you so much for joining us today and for sharing your expertise on the treatment of opioid use disorder through those medications and, and your passion for improving accessibility and empowering providers. It's truly inspiring. Kim, we're grateful for the important work that you do in our communities. And then I'd also like to take this time to thank everyone who tuned into this episode. If you enjoyed today's conversation, don't forget to subscribe, leave a, comment and share it with others who might find it valuable. But stay tuned for more insightful discussions and as always, take care and be well. We will see you or we'll talk to you and we'll listen next time. Thanks.

Kim Mishek: Thank you.

Bianca McCall: Thank you for listening to the NOCE. The Opioid Epidemic. unplugged. We hope that you found this episode compelling and informative, and we ask that you please share this episode with your friends and your colleagues. And if you want to learn more, please visit our website at nvopioidcoe.org. the NOCE Dose podcast is brought to you by the Nevada Opioid Center of Excellence, or NOCE. NOCE is dedicated to developing and sharing evidence, informed training and offering technical assistance to professionals and community members alike. Now, whether you are a care provider or a concerned community member. No. Provides resources to support those affected by opioid use, funding for this activity was made possible in whole or in part by the Nevada Department of Health and Human Services DHHS Director's Office through the Fund for Resilient Nevada

Speaker A: CASAT Podcast Network this podcast has been brought to you by the CASAT Podcast Network, located within the Center for the Application of Satisfaction Substance Abuse Technologies, a part of the School of Public Health at the University of Nevada, Reno. For more podcast information and resources, visit casat.org.