to you. Thank you, Dr. Spencer. Okay, great. I will get started here. And while we're doing the presentation, I may not be able to see your questions in the chat, but feel free to put questions in there. If you're afraid that you're going to forget to ask them later, Chelsea can kind of monitor that. If it looks like something that it will be, um, or, you know, if they have a burning question that can't wait to the end, you can, you know, this is a relatively small group. It's okay to, to unmute and ask your question then, but we'll, we'll, we'll take a break between the two, um, presentations to ask questions and kind of stress our legs and that sort of thing. So, uh, so I'm, uh, my name is Sarah Spencer. I'm an addiction medicine physician. I'm also a family medicine physician and I work, um, I've been providing care for people with addictions in rural Alaska for about 15 years now. I work in tribal health on the Southern Kenai Peninsula, um, where I, uh, do both family medicine and addiction medicine at our local, at our community clinic. And also, um, uh, I'm the medical director of our local syringe access program. So, uh, today we're going to start out by talking about some of the common myths and misconceptions around medication for opioid use disorder. And, uh, the, um, ORN is funded by a grant from SAMHSA. Um, and there are, um, teams of consultants in every state, uh, around the country in, um, prevention treatment and, um, recovery and harm reduction efforts. And, um, the ORN provides free training and consultation to help improve, um, addiction treatment services. So anyone can reach out to them to put in a request to get, uh, extra assistance. The learning objectives, what we're going to cover in this chat, we're going to talk about, um, some of these myths and misconceptions that surround treatment and how, um, these can, um, reinforce stigma and act as barriers to people accessing care and, um, uh, kind of review really what the evidence is, um, behind interventions that help to improve outcomes in people who have opioid use disorder. All right. So let's just dive right in. So number one myth probably hear the most commonly, uh, especially in people who aren't familiar with these medications is that methadone and buprenorphine are just replacing one addictive drug with another, and that these, um, medications aren't really effective to treat opioid use disorder unless they're also combined with, um, kind of intensive behavioral health treatment or counseling, but that is not true. Um, so these medications can be effective in reducing, um, morbidity and mortality and, um, uh, all kinds of measures that we look at with retention and treatment, reduction in use, even if people are unable or unwilling to access behavioral health treatment. And so the lack of available behavioral health support should not delay the initiation of these medications for opioid use disorder. And that, um, is in the ASAM 2020 treatment guidelines. And I just want to touch on the, um, some language. So the term you may hear, and you see a lot still in, in kind of published in online resources, the term MAT or medication assisted treatment. Um, this language is actually fallen out of favor. Um, and, uh, if you look kind of the new updated ASAM language guidelines, the new recommended language use is medication for opioid use disorder. So you'll hear and see that abbreviation doesn't roll off the tongue as nicely as MAT does. Um, but the reason for that is because that terminology itself actually can, um, can support, um, some of these, um, uh, stigma and, um, views in that, um, when we use the term, uh, assisted treatment, um, some people misunderstand that to say that the medication is only a small part and the main treatment for opioid use disorder is the behavioral health component and that the, you know, you can't really have one without the other. And, um, and really that the gold standard treatment for opioid use disorder is medication to treat opioid use disorder. There is no other intervention that as is as effective as that. And it can be effective even without behavioral health interventions, although we always want to be able to offer psychosocial support whenever possible to patients. So, um, so that change in, um, in terminology now, um, most people will say MLUD or just pharmacotherapy for opioid use disorder and that the medication, um, is just as much of a treatment for this chronic disease as insulin would be for diabetes. Um, you know, all these sorts of things. And, and we, uh, for every chronic health condition, there are also always behavioral interventions that can, um, support patient's wellness, but the, the medication is actually kind of the gold standard and the main part of the treatment when we're dealing with opioid use disorder. Um, now, uh, the medications just replacing one addictive drug with another. And I hear this from patients all the time when they come into my practice, like, Oh, I don't, I don't know if I want to be on that medication because, or, you know, I I've heard it's just like, uh, that's just as addictive as, as heroin, right. And I'm going to be dependent on that. And, um, I don't want to do that. So the truth is that, um, dependence and addiction are two very different things. Addiction is the compulsive use of a substance or engagement in a behavior, despite its harmful consequences. So people keep using the drug, even the horrible things are happening in their life. You know, they're, um, they're, they're overdosing. Maybe they got arrested, maybe their spouse left them. Maybe they spent all their money, all these horrible things that can happen getting a DUI. Um, however, they no matter how hard they try, they can't control the compulsion to keep continue to use that destructive substance. That is very different than taking a prescription medication that improves your quality of life, reduces morbidity and mortality. Um, and, um, uh, that, uh, that you're able to control the use of it. So physical dependence is a very, it's a normal and common characteristics of a number of medications that we use to treat chronic diseases. You know, there are other medications, there are blood pressure medications and seizure medications that you can't stop taking them cold turkey because bad things will happen and withdraw symptoms. So the physical dependence is just part of how the medication works. Um, and it's actually, um, quite rare for people to become, um, develop a substance use or addiction disorder related to buprenorphine. Another common misconception that you will hear, um, I'll have patients often coming in asking me like, Hey doc, can you just help me to detox? I don't want to be on medication. I just want to test the medications, help me get over these withdrawal symptoms. And then I'm going to be good to go and I'm not going to use anymore. Um, so, um, uh, and before we had effective medications for opioid use disorder, uh, we used to offer, um, detox or withdrawal management as, um, a treatment for opioid use disorder followed just by behavioral health without any medications or what we might call medication free treatment. Um, however, what we know now, um, uh, looking at the data is that, um, medically managed opioid withdrawal followed by medication free treatment is actually shown to increase mortality and is not considered a treatment for opioid use disorder. So this is not a treatment that we offer people when I'm discussing with the patients, um, to get informed consent of all the available treatments for opioid use disorder. This detox alone is not a treatment. And in fact, it can result in significantly worsening outcomes. So if you look at, um, people who, um, you know, go through withdrawal management or detox, and then they just get psychosocial support or counseling, and they just try not to use, um, that medication free treatment actually increases the risk of death by up over 77% compared to people continuing to use the drug. So if it's better, if people aren't ready to start taking a medication, it's actually safer for them to just continue to use the drug than to go through, um, detox. Um, when people go through withdrawal management detox, um, they lose their tolerance to opioids. And then over 95% of people are going to return to use. And most of that return to use happens rapidly, like within the first month or so. And that's a very, very dangerous time when people have lost their tolerance because of abstinence and then return to use. So we never want to recommend withdrawal management and medication free treatment alone as a treatment for opioid use disorder. The medications themselves are very effective at reducing mortality. There's very few medications that exist in modern medicine that are as effective as methadone and buprenorphine are for, um, improving treatment outcomes and reducing mortality. So, um, the statistics vary depending on, on the source you look at, but overall most show that, um, that these medications can reduce death rates, uh, by, um, 60% or more. They only work when you're on them though and take them. And when you stop taking them, um, we go back to an increased risk of overdose death. Next myth, um, uh, medications like methadone and buprenorphine are really intended for short-term use just to help people stabilize and stop using. And that the kind of ultimate goal of treatment is for patients to, once they're stabilized, to taper off of their medication. And many patients, you know, patients, one of the first questions they'll ask is, well, what's the point of taking this medication? Um, patients, no one wants to be on a chronic medication. It's not fun to take a chronic medication every day. And I think we see this in other chronic diseases too. People, you know, oh, you feel my blood pressure medication. Well, I took it for a month and it worked great and that, and the prescription was done. So I figured I was done and go off it. And of course the blood pressure goes right back up again. Um, so, um, same thing with, with, um, MOUD, these medications are, um, medications that are used to help people stabilize, um, are, um, medications to treat a chronic disease. They are intended for long-term use and discontinuation is associated with high levels of return to use and, um, kind of a return to those, um, levels of mortality that would be associated with, um, people not having untreated disease. And that when we think of, you know, how long patients ask how long, how long do I have to be on this medication? And there is no one answer for that. We don't, um, we don't know there's no magic time of two years, three years, five years. What we do know is that if people stop taking their medication in the, within the first year, over 90% of those people are going to return to use. Um, this is, um, a study, an older study, but it has a large amount of data looking at Medicaid patients. The green line here that you see at the top is, um, let's see if I can get my cursor now, um, is, um, this is looking at relapse rates or return to use rates. The green line is patients who are only getting, um, behavioral health or counseling support. And the red and blue lines is patients who are on methadone and buprenorphine. So we see that, um, patients who continue their medication, um, even at three years out, they're, uh, uh, two thirds, uh, less likely to leave treatment and return to use. And even five years out, there's data showing that people are still, um, have half the risk of, um, leaving treatment and return to use if they stayed on their medications versus if they discontinued their medication. So there really is no end to the benefit of medication. I always tell patients the longer you're on it, the better. Um, but, um, but we certainly, uh, you know, I tell my patients kind of, uh, as a short-term goal, let's plan on you staying on this medication for at least a couple of years. Another myth about, um, and we're going to focus here specifically on buprenorphine since we're not going to be describing methadone that's going to be through an opioid treatment program or an OTP. Um, one, um, misunderstanding is the thought that lower doses of buprenorphine, um, are preferred. So one of the reasons why that might be preferred is that, oh, hey, if we prescribe too high of a dose, then patients are just going to take some of it and they're going to sell the rest of it. Um, and we should really just kind of, um, dose to the minimum needed to control someone's withdrawal symptoms, which is part of where the old, um, recommendation for us to, um, actually dose the first doses of buprenorphine in the office was to actually, you know, just give them just enough to bring that cow score down and reduce their withdrawal symptoms and no more than that. Um, but we know now that actually higher doses of buprenorphine are associated with significant improvement in retention and treatment and that there is no, um, evidence to suggest that higher doses are more associated with diversion. So the, um, 2020 ASAM guidelines recommend that the, um, the minimum dose and for those in early recovery and treatment is 16 milligrams a day of buprenorphine and that, um, quite a bit of data and papers evidence have come out in the last couple of years to show that, um, higher doses actually have superior retention in treatment. Um, and also, um, we'll talk more about the, the importance of blocking the effects of fentanyl as well. Uh, so this, um, this, uh, study came out last year showing that, um, people, um, who were on 24 milligrams a day were 20%, people who are in 16 milligrams a day were 20% more likely to discontinue treatment than those who were on 24 milligrams a day or higher. Uh, and this is a really, if you want to read more about, um, some of the, um, kind of a general review article around buprenorphine dose limits, um, and the, the, uh, trend towards prescribing higher doses of buprenorphine. This is a really excellent review article. It's, um, a great read and I would highly recommend checking it out. This is also true for long acting injectable buprenorphine, at least for the formulation. This is looking at the formulation sublocade that, um, people, uh, people who use IV drugs were, um, significantly more likely to stay on treatment if they were on, um, stayed on the 300 milligram or the, or the higher dose rather than dropping down to the lower dose shot. Um, in my, um, in my practice, um, I have a lot of patients who use high doses of fentanyl and who use IV, and we definitely find that most patients prefer to stay and tend to do better when they stay on, on the higher dose of this medication. The other myth related to buprenorphine doses is that lower doses must be safer and that, um, um, the, uh, and this is, you know, we think of a lot of medications, with a lot of medications, we think, okay, we're going to start with the lowest possible dose and we're going to slowly increase until we get to the effective dose. Um, uh, but with buprenorphine, higher doses of buprenorphine are actually more protective against fentanyl-induced respiratory depression. And that's one of our main goals when prescribing MOUD is to prevent overdose death. So we know that, um, that this is a, it's in a dose-dependent fashion. Buprenorphine itself is a very, very safe medication. Um, this is an older study, um, that is looking at, um, administering a high dose. So they administered 32 milligrams of buprenorphine in a single dose to patients who were opioid naive. So they did not have an opioid tolerance and they had no significant, no clinically significant respiratory depression, even in these people who are opioid naive. So essentially, um, buprenorphine itself, by itself, is almost never the cause of an overdose. Almost every, um, and it is very rare to see an overdose, um, fatal overdose that involves buprenorphine. Typically when that is true, it has, um, very high doses of many other substances. Um, but we, we don't see it very rarely. Honestly, you know, myself, and I've heard this from other clinicians too. Um, I, I have never experienced, uh, having a patient die who was actively taking their buprenorphine. Um, uh, only patients who had stopped, stopped taking it. So it's very protective against, um, overdose when people take their buprenorphine. And, um, that protection, um, uh, part of that protection is not only controlling the cravings. So people are using less, but it is actually providing a blockade of opioids. Buprenorphine, um, binds those opioid receptors very tightly and it helps to block other opioids from binding. Um, and this study was looking at, um, uh, patients who, um, were, uh, they monitor them in a clinical setting where, um, this control side on the left were patients who were not taking any buprenorphine and they gave increasingly high doses of fentanyl, up to 800 mics of fentanyl in a single dose, which essentially caused them to stop breathing as we would expect. Uh, however, when we look at studied, um, patients who had serum drug levels of buprenorphine that were about five nanograms per milliliter, uh, which is what you might see if someone's on, um, long acting injectable buprenorphine at a high dose, even when they received the highest doses of fentanyl of 800 mics, they did not have any significant respiratory depression. This is a dose dependent effect though. And we see as serum drug levels drop down below two nanograms per milliliter, which you can see in patients that are on 16 milligrams a day, especially if they miss a dose, that's when you start to lose that protective effect against the fentanyl, um, because fentanyl also has a very high binding ability. Uh, so it's really fentanyl is competing with the buprenorphine for these sites. The higher concentration of buprenorphine, the more effective we are at blocking the effects of fentanyl. Uh, another myth, uh, naloxone that is included in the combination product. When we think about what, what buprenorphine products are available to prescribe for opioid use disorder, the most common products that we're going to see are the daily sublingual buprenorphine products that come in either the combination products, which are either films or tablets that contain buprenorphine and naloxone in a ratio of four to one. So an eight slash two milligram film of, uh, buprenorphine naloxone would be a very common formulation we would see, um, versus plain buprenorphine, which comes only in tablets, um, that does not have any naloxone in it. So a common misconception is that the naloxone included in the combination product helps to block the effect of other opioids if a person returns to use. So it's working, um, working to block other opioids and that, um, if a patient takes the plain buprenorphine, that they're not going to have a blockade of other opioids. Uh, and, uh, like we, um, like we just mentioned, the buprenorphine itself is, um, the, uh, medication that is responsible for blocking the effect of other opioids and protecting against respiratory depression if a person returns to use. The naloxone in the combination product, sublingual product, is when it's taken correctly, is almost none of it is absorbed, very little. It doesn't have actually any clinical effect. And any of it that is absorbed is rapidly excreted. We know that naloxone has a very short half-life and most of it is going to be eliminated like within the first hour of taking it. So there is no naloxone that's, you know, no clinical effect from the naloxone. It's not doing any good to help block the effect of opioids. It's the buprenorphine in the product that is doing that. So why is naloxone in the product? So the theory behind adding naloxone to sublingual buprenorphine is that, again, when taken correctly, it shouldn't really be absorbed and has essentially no clinical effect. And it doesn't alter the effectiveness in the medication in any way. However, when it's meant to be an abuse deterrent. So when the product is misused, particularly when it is injected, but also if it is snorted or insufflated, that then the naloxone is absorbed rapidly. Just like if you gave someone intravenous naloxone, if a patient is actively using other opioids or even has buprenorphine in their system, that can trigger precipitative withdrawal. It can make someone feel very sick, or otherwise also it can just block the effect of some of the buprenorphine that's being taken. The theory behind this is that this can, that prescribing the combination product may reduce the misuse of the formulation so that people, some very limited data, some studies have suggested that the combination product is about three times less likely to be misused like through injection than the plain product. But again, it's very limited data to support that. Some patients will complain of side effects to the combination product. And in certain circumstances, that might be an indication to switch either to plain sublingual buprenorphine or to long acting injectable buprenorphine. And there are increasing kind of arguments for this approach in the addiction specialty field that the most important thing is to make sure people are taking their buprenorphine. And if someone truly has intolerable side effects, and the most common would be that about an hour after taking the dose of sublingual buprenorphine naloxone, that they experienced a headache and nausea. That's the most common complaint. And again, the naloxone is gonna be really peaking like any that is absorbed in that period of time shortly after dosing and then be eliminated. So I have had a few patients that have had just kind of this intractable headache or nausea every time they tried taking the combination product. And in that cases, it may make sense to switch people to the plain buprenorphine product. There can be insurance issues with this. So depending on patient's insurance, most insurance have kind of the combination product is the one that's on their formulary. And the plain product requires, generally might require prior authorization other than for pregnant women. The other misconception about the naloxone being in the combination product is that the naloxone can actually trigger precipitated withdrawal symptoms. And so some patients are, they're afraid to take this product because they've been administered naloxone before. They know that naloxone makes you sick when you're dependent on opioids if you take it. And that can cause fear in them to start taking the medication. But again, the naloxone is only minimally absorbed and it's not the cause of precipitated withdrawal, again, unless it's misused and it's being injected. If it's injected, absolutely, the naloxone can trigger precipitated withdrawal. But what's actually causing precipitated withdrawal if the medication is not taken at the right time at the right dose is actually the buprenorphine. Buprenorphine can trigger precipitated withdrawal when given in certain doses and the person still has a large amount of full opioid agonist present in their system at that time. So what is precipitated withdrawal and why does it happen? So precipitated withdrawal occurs because of two characteristics of buprenorphine. One is that it binds very, very tightly to the opioid receptors. And so when someone takes buprenorphine, it really goes and it will kind of knock off any fentanyl, heroin, oxycodone, whatever opioids are on those new opioid receptors. And it binds to those receptors instead and it latches on very tightly, so tightly that it blocks those receptors from other opioids from binding. But buprenorphine is only a partial opioid agonist, meaning that it only partially activates the opioid receptors. So if a person goes from having very large, high levels of full opioid agonist effect in their body, and then they take this medication that then suddenly drops them down to only a partial activation of those opioid receptors, that sudden reduction and the stimulation of opioid receptors is what causes the precipitated withdrawal. When we see this, it typically is gonna occur about 30 to 60 minutes after the first dose of sublingual buprenorphine. Again, this only happens with the first dose, which is why we need to get the timing and the dosing right for the first dose so that we don't cause this adverse effect. It happens, it's a very rapid onset and the symptoms can be very severe. In some cases, they can be so severe that people have to go into the emergency room because they can't stop vomiting or they're just miserable. We can avoid precipitating withdrawal by ensuring that people are in an adequate amount of withdrawal before they take their first dose of buprenorphine. And we'll talk kind of more about how to evaluate, how much withdrawal people are in, but the COWS scoring is the opioid withdrawal scoring generally recommended for that score to be above 12 if the patient's in a monitored setting. So that's a moderate amount of withdrawal or for patients I say kind of, you know, when you're having three or four symptoms of withdrawal and you're feeling moderately uncomfortable. Precipitative withdrawal though actually is, it's not a common occurrence. It's becoming more common with people who are using fentanyl as their drug of choice because fentanyl can stay in the system for a while. But this study looking at treating people in the emergency room where most of the patients were using fentanyl and they administered buprenorphine to people that very few individuals actually experienced precipitative withdrawal. It was less than 5% of people experiencing precipitative withdrawal. Precipitative withdrawal is most likely to happen when buprenorphine is being used without medical supervision, you know, non-prescribed buprenorphine and people are unaware of how they should properly take the medication. We, I caution people about precipitative withdrawal, especially if they are concerned about it or have experienced it in the past. We really want to avoid this happening if we can because people then, it can scare people away from taking buprenorphine. They, you know, who wants to, you know, keep taking a medication that just made you feel very sick. You know, we really want to avoid this if we can. But I do explain to people if I am worried that they, or the patient is worried that they might experience precipitative withdrawal, the treatment of precipitative withdrawal, we used to tell people, you know, hey, if this happens, you know, maybe you should just stop and wait a little bit longer and then try again tomorrow. And we found that this approach is not very successful because again, people, first of all, if they experience precipitative withdrawal and we don't treat their symptoms to resolve their symptoms, most people are going to then use their drug of choice to relieve those symptoms. So they're going to take more heroin or fentanyl and they're not going to want to try the medication again because again, the medication just made them sick. So we explained to patients that really the only way to kind of push through this and to feel better quickly in a safe way is to take a very high dose of buprenorphine. So precipitative withdrawal, the most common dose of buprenorphine that triggers precipitative withdrawal is like a half a strip or four milligrams of buprenorphine. Four milligrams of buprenorphine is kind of the classic dose that it's just enough buprenorphine to kind of knock all of the opioids off the receptors, but it's not enough buprenorphine to give you enough opioid agonist effect to feel better. You have to have more opioid agonist effect to feel better. That is the underlying problem here. So the most effective and safest way to do that is to take a very high dose of buprenorphine so you get more opioid agonist effect. And so I instruct people to, if they experience precipitative withdrawal, to immediately put 16 milligrams of buprenorphine under their tongue, and they can repeat this every hour or two as needed. And you see reported very high doses sometimes of buprenorphine, it could take 40. I had a patient who took 60 milligrams of buprenorphine to relieve their precipitative withdrawal along with other adjunctive medications. And I give every patient, unless there are specific contraindications, I give every patient a prescription for ondansetron because nausea is so common regardless of whether people experience withdrawal symptoms or not. It's a common side effect just of buprenorphine, but certainly in precipitative withdrawal, the nausea can be severe. So I give everyone ondansetron as well as clonidine. You know, clonidine alpha agonist, it's the old fashioned medication that we use to treat opioid withdrawal. It helps with the restlessness, the sweating, just that creepy crawly feeling like you want to crawl out of your skin and some of the anxiety. It helps to kind of calm down the nervous system from that point of view. And then additionally, there are a number of other medications that might be helpful in withdrawal. Tizanidine is also an alpha agonist, but also muscle relaxants that can help with muscle spasms. Hydroxazine might help with anxiety. If people really struggle with trazodone when they're trying to deal with insomnia, when they're trying to deal with withdrawal, I'll sometimes prescribe trazodone or some other non-narcotic sleep medication. You'll NSAIDs for the achiness. You'll see some protocols that involve the use of gabapentin, especially for that restless feeling. And then if the patient, despite having these oral medications to take in the outpatient setting, and despite taking high doses of buprenorphine to treat the symptoms, if their symptoms are still severe and uncontrolled, which again is very rare, that might be a situation where a patient may need to go to the emergency room for treatment. In the emergency room, they can give medications, IV medications, like ketamine, benzodiazepines, and IV opioids to control the symptoms. And again, this is very rare for this to happen in people. The ACM recently published this consensus document about treating, utilizing buprenorphine in patients who are using fentanyl. And it really addresses some of the challenges in patients who are using fentanyl, such as the dose of buprenorphine that may need, their risk of precipitative withdrawal, all different things like that. So this is another very high yield free article, if you want to really kind of get up to date, up to speed with how things have changed in the world of buprenorphine prescribing in this era that we're dealing with where fentanyl is the drug of choice for most patients. Okay, next myth. So we know that opioids, I think in 2016, the FDA issued a black box warning on all opioid containing, all opioid agonist medications that they should not be combined with benzodiazepines, you know, or other CNS depressants. And so buprenorphine being also an opioid agonist, a partial opioid agonist also has this warning label on it. And so that causes some providers to be worried that it's not safe to prescribe buprenorphine to patients who may also be using alcohol, be taking benzodiazepines or other CNS depressants because of the risk of overdose that might be associated with combining multiple CNS depressants. However, what we know is that buprenorphine can be effective to reduce morbidity and mortality in patients, even when they are using other CNS depressants. And when we think of this, it's important to remember that if that patient was not taking their buprenorphine, yes, there is some risk of combining buprenorphine, you know, with Xanax and alcohol, and there's always risk in combining CNS depressants, but buprenorphine is so effective at blocking the respiratory defects of fentanyl. If the person wasn't taking buprenorphine, then they almost certainly would return to use with their drug of choice, which is typically fentanyl. And we know that almost nothing is more dangerous than combining fentanyl with alcohol and benzodiazepines. That's kind of the deadly trigger for overdose. That's kind of the deadly trifecta there of medication. So the person's risk is going, we're going to reduce their risk of mortality if they take buprenorphine, even if they aren't able to stop using the other CNS depressants. And the FDA, a year after, so this is 2017, issued a very specific addendum to that black box warning to say, hey, this warning doesn't necessarily apply to patients who are taking buprenorphine or methadone. So it ends the ACM 2020 guidelines also say that these MOUDs should not be withheld from patients who are taking CNS depressants. So what we can do is we can educate patients about the potential risk and offer them treatment and support to help to reduce these risks. So this is along the FDA guidelines of what things can we do to help reduce patients' risk. So we can educate patients. And I think most providers and thing will have treatment agreements and patient education materials that one of the main things that we'll say on that is that it's not recommended to take alcohol or benzodiazepines with this medication. And generally, again, the risk combined, and when there's been studies that have looked at patients who are taking prescribed benzodiazepines versus patients who are not with their buprenorphine, there is a slight increased risk of mortality in patients who are taking the benzodiazepine with the buprenorphine, but it's not nearly what you would expect. So what we wanna do is kind of offer patients strategies to help them kind of manage the use of their other CNS depressants. When it's appropriate, it may be appropriate to help the patients taper down off of the benzodiazepine or the other CNS depressant if we can get them on board with that. Tapering benzodiazepines is a huge challenge in and of itself and so it's not something we wanna kind of push on patients immediately. We like to, first of all, stabilize their opioid use, but then also offer them assistance if patients have an alcohol use disorder. We want to offer them assistance with helping to stop or reduce their use of alcohol if they're open to that and kind of offering them other alternatives, safer options to treat their issues like insomnia or anxiety and really working with this over time in the longterm to slowly and gradually reduce the risks to this patient health. It also helps to coordinate with the patient's other prescribers if they're getting their benzodiazepine from the psychiatrist or someone else that with the patient's permission to be able to coordinate care between providers can always be helpful, of course. Another common myth is when we're taking care of pregnant women who have opioid use disorder. So in the past, when we prescribed buprenorphine for pregnant women, we generally only prescribed plain buprenorphine rather than the buprenorphine naloxone product and that product was really kind of created specifically and utilized almost exclusively for pregnant women in like the first 10 years that buprenorphine was on the market. And moms who are pregnant may be very worried about what their baby is going to experience after they're born. You know, the moms they've experienced opioid withdrawal before they know how horrible that is. They don't want their babies to experience that after they're born, but babies who are born to mothers who are taking buprenorphine and methadone, they do need to be monitored for neonatal absence syndrome after birth. However, what we found in looking is that it doesn't help for moms to try to taper down their dose of buprenorphine before the birth. And I've had moms try to do that before, like I'm going to try to taper down and get to a low dose as I possibly can. But again, at these very low doses, that may cause, you know, trigger cravings or return to use, or they might not have protective levels of buprenorphine if they do have a return to use to protect them from overdose. And studies that have looked at the difference between moms who took higher doses versus lower doses of buprenorphine, they didn't see any difference in whether the baby needed medical treatment for their withdrawal symptoms after birth. So the dose of buprenorphine is not associated with the need for medical treatment of neonatal withdrawal syndrome. Most babies who are exposed to buprenorphine are able to have their symptoms controlled through conservative supportive care. There's a protocol called Eat, Sleep, and Console that really focuses on comforting the baby and meeting their basic needs. And that has dramatically reduced the number of babies, you know, that need to be treated with medication and reduce the length of hospital stay. And, you know, neonatal abstinence syndrome in and of itself does not have long-term consequences on growth and development. So it's a temporary condition that's highly treatable, and we wanna encourage moms to stay on the dose of medication that is most helpful to control her disease. Now, the formulation of buprenorphine that is used over the last five years, there's been a number of papers published that indicate that from what we can see, the use of the combination product with the naloxone appears to be safe in pregnant women. And again, minimal absorption and don't believe that it has any effect on safety in pregnancy. Some of the concern actually around the buprenorphine naloxone product in pregnancy, it's not actually the absorption of the naloxone that is so much of the concern. I think when this recommendation was originally created, the fear was that what if the pregnant woman was using IV drugs and tried to inject the combination product? Would that put her into precipitative withdrawal and would that be dangerous for the fetus? So that actually was one of the concerns when these recommendations were initially made was the worry of the misuse of the product and triggering precipitative withdrawal. So essentially the recommendations are now is that really any formulation of buprenorphine can be used. There are some programs just say, hey, we're gonna use the combination for product for everyone, no matter what, no exceptions. The ASAM guidelines actually say that this should be kind of an informed consent discussion between the provider and the woman about what do they both feel comfortable with. In my practice, I personally, I kind of lay out the evidence for the moms, but if they feel very strongly, cause they've read things online and they really only feel comfortable with taking the plain product, then I'm okay with that. The most important thing is that they take their buprenorphine every day. I'm not really too worried about which formulation that they're taking, whether it's the plain and the other. Long acting injectable buprenorphine has, there's very little studies of that in pregnancy. The newest formulation that has come out, the weekly form of Bruxadi is the one that has the most evidence of safety in pregnancy. Another common myth and misconception is surrounding the use of urine drug testing. So essentially almost all substance use treatment programs utilize drug testing as part of their monitoring for patients and with the thought that that will hold the patients accountable and they'll be more likely to be able to be abstinent and they're going to stay in treatment longer. And there is a misconception that there are specific laws around testing that you have to do. Drug testing, you have to do it a certain number of, you know, a certain number of times per month or per year. And also we kind of assume that providers know how to interpret drug testing, even though in reality, most providers actually haven't been trained in the appropriate interpretation of drug testing results. So the actual fact is that drug testing is not an evidence-based practice. It has not been shown to improve treatment outcomes or to reduce diversion. And we really kind of saw a real life example of this during COVID, especially the first two years of COVID. We were prescribing a lot of buprenorphine and doing almost no urine drug testing or other drug testing, just because people, it just wasn't accessible because people couldn't physically access care. And we didn't see any increase in diversion or other issues, safety issues around that when we weren't using drug testing the way that we had been in the past. And actually, although states, some states do have guidelines around minimum frequency of required drug testing for controlled substance prescribing and, or for buprenorphine specifically, there is no national guidelines that outline what the appropriate testing frequency would be in patients who are prescribed buprenorphine. The ASAME 2020 guidelines recommend considering the use of this and that it could be helpful in certain cases, but they also suggest no suggested frequency of how often we should be doing this. And what we also know is that most providers don't have adequate training on how to interpret drug testing results and often can misinterpret that in a way that can be detrimental to patient's treatment plan and progress. There's a really excellent standing room only talk at this year's ASAME annual national convention about drug testing. You know, why do we do it? Is it useful or not? Should we still be doing it in the same way that we've been doing it? So potentially, drug testing potentially has the advantages that to monitor the use of illicit drugs and that we could potentially use that in some way as a measurement of success in the treatment program. And there are definitely studies that utilize drug testing to monitor for absence rates and then that is what they're looking at for quality of care outcomes. The other people argue that it can really be useful just as an additional communication tool to help to improve kind of this relationship between the counselors and the patient for the providers and the patient so that we have more information about what might be going on in the person's life. What we, the possible downsides of urine drug testing are, there's a number of them. One is that we know that the most commonly used tests which are the rapid in-office tests where we get the immediate result have very low kind of bad outcomes, low specificity and sensitivity. So they're really, they're crappy tests. When you think about like the quality of the test, we see false positives and false negatives every single day in practice. And so that, and also the results can have to be misinterpreted especially with the rapid tests. So we never wanna use a rapid test to guide our treatment or to actually change a patient's treatment plan because those tests are often inaccurate. The other real issue is that snapshot in time of all a drug test tells you is what is in that person's system at that moment in time. It doesn't tell you anything about what that person's quality of life are, how are their relationships improving, is their frequency of use of drugs decreasing? All of these things that are more important when we think of treatment goals and quality of life, it's not all about 100% abstinence. And there are ways in which we can talk with the patient about how they're doing and are they meeting their goals that we don't really need a drug test to tell us how a patient is doing. When they look, and I've done this a couple of times, kind of give providers kind of test them on their skills in interpreting drug testing, they find that providers generally do not have a poor level of proficiency in drug test interpretation. Drug tests, they can be really confusing, the test results and without specific training and learning about how to interpret those test results, they can often be misinterpreted and misimplied. If you do choose to utilize drug testing in your practice, I think it's especially helpful to utilize confirmatory testing. Confirmatory testing is when the sample is sent to a lab for specific gas chromatography or other specific confirmatory testing that actually measures the exact amount of everything that's in their urine and helps to eliminate the false positives and false negatives associated with the rapid tests. What you also get with confirmatory lab testing is you get the ability to contact the medical review officer. The medical review officer is the physician employed by the laboratory that helps to interpret the lab, the drug testing results. So anytime you order a confirmatory drug test, there'll be listed on that a contact to contact for questions, the medical review officer. And I highly encourage you to use that resource to reach out and talk with that doctor who has that special training about how to interpret these results when they are confusing. And there is no studies have demonstrated that drug testing improves outcomes. There just isn't, there is no data that improves outcomes and the ACM guidelines, they highlight this as well that this is not an evidence-based practice. It's something that we've sort of done because that's just the way we've done things. And so we should just keep doing it that way without any evidence. So that's really important to remember when we're utilizing this, how is it actually, how are we actually utilizing it in our practice and is it actually helping the patients or could it potentially be causing harm? So one way in which it can cause harm is that there is an association between the frequency of testing and treatment discontinuation. So patients who are tested less frequently are actually maybe more likely to stay in treatment longer. So it can actually, drug testing, frequent drug testing may actually cause people to want to drop out of treatment, which is the worst case scenario is people dropping out of treatment. And these are some, during COVID-19, we really got a closer look at this when we say, hey, we're not doing this, what's changing to really rethink the way, why are we doing this? What information are we getting out of this? And is this actually improving the quality of our care or are we putting up additional barriers to patients? And just to touch on that as well, I think it's really important to understand that there can be other negative consequences to doing drug testing, especially for people who are involved in the criminal justice system or pregnant or parenting people. Those test results could be used against those patients in the future to, you know, in legal cases against them, they can be subpoenaed by the court. They can be used in people, against people in child welfare cases as evidence to take, remove children from parents' custody. And so they can have really significant, limited bad consequences. And patients also, they may be scared, for whatever reason to give a drug test, they may, and so may, you know, if they're afraid that you're gonna take their medication away from them, if they test positive for a substance, then they may just like not show up for their appointment at all. And, you know, so it's really important to think really critically about how we're using these testing to make sure that we're actually using them if we do use them to improve the quality of our care. Lastly, and then we'll take some questions and we'll breather, is this myth that patients, when we're thinking of families and loved ones that are supporting people who are using drugs, is this myth among the support people that, hey, you know, we really, people have to really hit rock bottom before they accept treatment. We need to just kind of give them tough love and not give them any support until they get into treatment and really separate ourselves from the people that are using drugs. But isolation, loneliness, and lack of support is a clear trigger and makes it more difficult for people to recover. People who have substance use disorders and are offered community support, family support, and really just holistic all around support, any way that we can give them is going to help them to succeed in their recovery, especially in the longterm. And that really learning to meet people where they are at, no matter what they are dealing with in their day-to-day life struggles, is really consistent with indigenous values. When we think of, particularly in people who come from tribal communities and indigenous communities, studies that have looked at, you know, how can we make medical care more culturally appropriate for these populations? One of the most important things is to offer a holistic approach and to provide that connection with the person's family, tribe, and community of how important that is for people's longterm success. One way in which families can be really helpful to support loved ones is through community reinforcement and family therapy, or called CRAFT. So CRAFT is actually therapy not for the patient, it's therapy for that person's loved ones. So for their family and friends, spouses, whoever, this is training for the family members to help them learn how they can best support their loved one and how they can also take care of themselves as they're dealing with the struggles of, you know, loving someone who is dealing with a substance use disorder. So more than two thirds of family members who get training in CRAFT are able to then successfully help to engage their loved one in treatment so that effective support from family and friends can really be key in helping people access and stay in treatment. The, there's this great website, helpingfamilieshelp.com that has a lot of online resources. There's online support groups that list lots of books and other things in case people don't actually have, you know, with all behavioral health treatment, I think we know there's a huge shortage nationwide of behavioral health professionals. So it can be hard to find this in person sometimes. So these online resources can be helpful for people. Also online support groups like the White Bison Walbrighti website. They're great to check out. They have weekly talking circle meetings to really help, again, to help people connect with the recovery community and connect with that support that, to combat that isolation and help people to reconnect to a community that's going to support them in their recovery. Okay, well, that is the end of this first presentation. I see we have a number of, and there is evaluation. This'll be, this'll come at the end of the other thing too, just for later reference for helping give us some feedback. Let me just take a look at the chat box here to see some of the questions that have- There were two in there, Dr. Spencer. The first one was, can you discuss what happens if a patient needs opioids for surgery? Yes, yep, that is a great question. So the, so in the past, there were some hospitals that would recommend that patients try to stop taking their buprenorphine before surgery. And the, what we found is that actually makes pain and pain control worse and more difficult during surgery. So the current recommendations are that in certain cases, if possible, you could consider reducing dose of buprenorphine, like to around 12 milligrams a day, but it's not necessary, it's not absolutely necessary, but really it's all about multimodal analgesia, making sure we're offering all the different forms of pain relief, like including nerve blocks, all of the other non-narcotic things, things like low dose ketamine and other things like that. But you can give high doses of potent IV opioids to get pain relief in a post-surgical patient. So that's generally, the hydromorphone and fentanyl are usually the ones that you use because they have higher affinity for the opioid receptors, they're better able to compete with buprenorphine and they may need doses that are like three times or more higher than doses other people may need. But it is, and there's been a number of great studies that have published recently show that people can get adequate pain relief and they get better pain relief if they're continued on their buprenorphine than if that is stopped. Another one, someone said common mistakes in interpreting drug screens. So there's a number, so there's a lot of false positives and false negatives. There's a lot of false positives. False positives can be a big one, like amphetamines and methamphetamines. There's tons of over-the-counter energy drink supplements and things that will show up false positives for that. So you really have to send it out to see is that a true positive or not. It's important to understand that fentanyl does not show up on most urine drug screens. So it will look like the opioids or morphine or whatever will be negative. So it can make it look like a person is not using when they actually are. If you are testing for fentanyl, it's important fentanyl stores in the fat and you can, someone who's using high levels of fentanyl can continue to test positive for up to like a month after they stop using. So you can look like someone's still using when they're not. Things like certain things are often negative on drug screens. And so clonazepam doesn't show up on rapid screens. Methylphenidate doesn't show up on rapid screens. So people may be accused of not taking their medication. If people are on long acting injectable buprenorphine, they can test positive. Even if they stopped taking their medications can test positive for up to a year after discontinuing their medication. So I've had patients who get accused by probation and parole of taking non-prescribed buprenorphine because they're still testing positive. So there's a number of them. Those are probably like the most common ones. But I think the most important thing to understand is that rapid testing is a very poor quality test and we should never use a rapid test to change our treatment plan. We should always, if there's something, if we really feel like we have to do a drug test, that's gonna change our treatment plan, we need to probably be sending that out for confirmation. We received one more question, Dr. Spencer. Can you address dosing beginning and knowing when stable will they need higher doses over time? And I know we might talk about that in the next. Yeah, we're gonna talk about that in the next talk. And do we wanna take a minute for like a stressed legs and for like a bathroom break or do you wanna just jump into the next talk here? We have some that would like to go to the restroom. Okay, let's just do five minutes. I have 1.20 on my clock, so maybe 1.25 and we'll start the next talk here. Sounds good, thank you. Thank you, Dr. Spencer. Okay, it is 1.25. See if we hopefully we have people who have joined back in and we can get started again on the next presentation. I do wanna say quickly, it looks like we might go over time a little bit. Dr. Velez and your team, are you guys okay staying on a little bit longer? We're also recording. So some of you have to jump, we will have a recording for you. I'm certainly okay with that. Awesome, sounds good. Thank you. Right, so in this presentation, we're really gonna get down into kind of the nuts and bolts of actually prescribing buprenorphine. And we'll touch on some of the topics that came up in the last presentation. So we're gonna talk about assessing someone who has opioid use disorder, a little bit more about how the medication works and some strategies to start buprenorphine in people and kind of deal with some of the issues that might come up when we're prescribing this medication. So again, one of the most important things about this medication is that it helps to reduce mortality related to opioid use disorder. And when we're dealing with, of course we're in an epidemic of overdose deaths right now in the country and have been for over 10 years. The overdose is the number one cause of death for people under age 50 in the United States. So this is an issue that affects all of us and everyone in primary care is going to encounter people who have opioid use disorder and might be at risk because of that. So when buprenorphine was first released, over 28 years ago, they didn't really know how to manage this medication. There was no framework for this outpatient prescribing of the medication for opioid use disorder. All we had to look to was methadone and the methadone clinics, which is incredibly tightly controlled. Everything is kind of outlined, all the regulations of exactly how to utilize that medication under very tightly controlled circumstances. So when they started allowed for buprenorphine, they put all these regulations in place initially saying that we have to have the specialized training to prescribe it. There was a recommendation that you had to be able to refer people to behavioral health in order to prescribe it. There was limits on the numbers of patients, all of this that made it really difficult to access the medication, but also very intimidating for prescribers to say like, gosh, that looks complicated. I'm not even gonna go there or take that on because that's beyond my expertise. So one of the goals that we know that this last year that the government really removed essentially almost all of the restrictions around prescribing buprenorphine. Because, and the reason they did that is they want all doctors to feel comfortable prescribing buprenorphine. So you're trying to take away all these barriers, these things that could cause us to be scared to prescribe this medication. We haven't seen the uptake yet in prescribing. So there's still a lot of work to go as far as that goes. So the new way that we really want people to perceive and think about buprenorphine is that is a very safe, very effective medication that is the gold standard treatment for a deadly disease that all doctors and medical providers should be comfortable in prescribing. So when they removed the buprenorphine waiver, essentially now buprenorphine is like any other schedule three controlled substance. So if you have a DEA license and you're allowed to prescribe schedule three substances, then you are allowed to prescribe buprenorphine. There's no limits on how many patients you can have, what formulations, how much doses and all these sorts of things. Some people think, oh, I can't prescribe the long-acting injectable because I don't have training. No, any formulation that's approved for opioid use disorder, you can prescribe to patients. You don't have to be able to refer to counseling, although that's always preferred. And there is no special education required. Now, some people are confused because they see that along with this law, another law got passed at the same time by Congress that requires all providers who have a DEA registration to get education, eight hours of CMA education in addiction medicine in order to renew your DEA. That is only required to renew your DEA. So if you haven't already done that in the last year, sometime in the next two years, it will be coming for you. When you go to renew your DEA, there'll be a checkbox saying that I attest to have completed eight hours of addiction medicine education. And but it has nothing to do with prescribing buprenorphine. So even if you haven't completed those education requirements yet, that's fine. You can still prescribe buprenorphine for opioid use disorder. And the other thing to really remember is that every day that a patient takes buprenorphine is going to be a day when they are safer, when they are less likely to use opioids and they're less likely to have an overdose. Sometimes it can be kind of frustrating sometimes because sometimes we don't know exactly where a patient's going to go. Like when they're seeing the emergency room, are they going to follow up? We don't know, you know, we're prescribing them, you know, we can load the truck, but we can't drive it. We don't always know what a person's going to do when they leave the facility. But what is important to remember is that if you encounter a patient who has opioid use disorder, that starting them on medication is the standard of care. And patients of course can refuse that, but we need to offer the standard of care and not offering medication for opioid use disorder is not following the standard of care and clearly results in worse outcomes. So a little bit closer look of the pharmacology of buprenorphine. Buprenorphine is a partial opioid agonist. And when we think of a full opioid agonist, it's kind of a linear relationship. The more you take, the more opioid effect you have until the point where you become intoxicated or you have an overdose. With buprenorphine, that's not true. We see in very low doses, we see kind of a linear effect, but very rapidly that levels out and because of the fact that it's kind of saturating the receptors and we have only a partial activation of the opioid receptors. And even if you take very, very high doses, it's not going to result in intoxication or overdose, especially in a patient who has an opioid tolerance. If a patient does not have an opioid tolerance, if they're opioid naive, they've been absent, or like say it was a teenager or a young person, they can feel intoxicated from taking buprenorphine because they don't have an opioid tolerance. But anyone with an opiate tolerance generally is not, that's not going to happen. It's a very, very long acting medication. So it stays in the system for days after taking it. And that it does take about five days of taking it to build up kind of stable serum drug levels. Formulations of buprenorphine that are currently available on the market for treating opioid use disorder. And this can vary, the most common one that you might think of people might recognize the name Suboxone, but that is just one of many brands of combination of buprenorphine and naloxone films. There are many generics of this. There are also, it also comes in sublingual tablets as well as films, it comes in a number of strengths. So that would be the combination sublingual product. There is also the plain buprenorphine sublingual, sorry, these are the tablets, the combination tablets. And then there's also the plain buprenorphine sublingual tablets that come in two and eight milligrams. So the most common strength you're going to see prescribed most of the time is either the eight milligram tablets or films in like somewhere between 16 to 24 milligrams a day. That's going to be the most common dose and formulation that you're going to see. Buprenorphine also comes in a long acting injectable formulation. So for about six years now, we've had this first brand that was FDA approved Sublocade. That's a monthly subcutaneous long acting injection of buprenorphine. Also this past year, just released, but it's been used in Europe for quite a while is this other brand Bruxadi that comes in more of a variety of different doses. And it also comes in both weekly and monthly formulations. And it's the weekly formulation of Bruxadi that is the one that is likely preferred in pregnancy, although other formulations are used as well. There is an intravenous form of buprenorphine that would be obviously only used in the hospital, but it can be used to manage withdrawal in the hospital when a patient's having trouble with taking something sublingually. There are a few formulations of buprenorphine that are FDA approved to treat chronic pain. These are the Transdermal one, Butrans, and the Bucca one, Belbucca. These are very, very low doses of buprenorphine. They are only FDA approved to treat pain, and it is not legal to use these formulations to treat opioid withdrawal or opioid use disorder. They are sometimes utilized in the hospital to kind of help people get started on treatment. You can do anything you want to when someone's in the hospital. You can give them any medication you need to control their symptoms, but these medications, when you see these, they are strictly to be used for chronic pain. They're not legal to use those for opioid use disorder. So when we are seeing a patient who has opioid use disorder and is seeking treatment, first of all, the diagnosis of opioid use disorder is, I don't think I include that in here, but the DSM-5 criteria for opioid use disorder, essentially, it's a checklist, and if someone has more than two or three symptoms and they qualify as having opioid use disorder, by the time a person comes to you for treatment, it's going to be pretty clear that they have opioid use disorder. Most people are going to have moderate to severe, generally severe opioid use disorder by the time they seek treatment, but it is important to document the diagnosis that they do meet criteria for opioid use disorder. When we're getting a history on these new patients, in part, we're going to get a similar medical history for all of our patients who come through door. We want to know what medications they're taking. We want to know what medical problems, have their allergies, all the kind of standard things, but we're going to focus a little bit more heavily on certain parts of the history, particularly on the social history. So we want to know more history about their substance use. What kind of substances are they using? How long have they been using them for? Do they use IV? Do they smoke or use in other ways? How much are they using? We want to know, what did they try before? What did they try to help stop using? Did they take medications before? Did they go to rehab before? Did they use 12-step programs before? What did they try before? What worked in the past? What didn't work in the past? That all information is all very helpful trying to plan a treatment plan for people. The other is really kind of what are their, what is their living situation and their psychosocial supports? Because that can have a huge impact on their treatment plan and the supports and success things that they might need in recovery. So we want to know where are they living? Do they live by themselves? Do they have family? Are they living with other people who are using drugs? If so, are those people also able to get into treatment? Do they have a job that's going to affect whether they can come in or not? Do they get drug tested in their job? Are they worried about that? Do they have transportation? Do they have a way to get to the clinic? Do they have a way to get to the pharmacy? Insurance, of course, they have a way to pay for their medication. Do they have children? Have they had child protective services involvement? Do they have open legal cases? Every single person that comes to the door, I ask them, do you have any open legal issues? Because unfortunately, when people have a diagnosis, especially of severe opioid use disorder, they have a very high risk of interacting with the criminal justice system. And that can have huge impacts on their treatment plan, especially if they're at risk for reincarceration. So I always bring that up to patients in the beginning to figure out what other issues do they have going on that might become barriers to treatment or supports they have in their life that can be assets to their treatment. Like their family members that are supportive and are willing to help them with their medications or willing to bring them to their appointments, even come to their appointments with them. Those can be assets for them. Most states, of course, have our requirement to check the prescription drug monitoring system. And this can be helpful particularly to see what other, is the patient taking benzodiazepines and they didn't tell you, and how can you kind of make a safety plan around that or coordinate treatment with other providers and that sort of thing. When we're doing that initial assessment, the physical exam can be pretty limited. I personally, I do most of my intakes for new patients seeking treatment, I actually do via telemedicine. And I find that that has a much lower no-show rate than trying to get someone to come in person. There's so many barriers to people trying to show up in person to an appointment. But if you can get someone to come in person, sometimes that first appointment, especially people can be really uncomfortable. They might be in withdrawal at that time, which you want to document. They might be, maybe they just use and they're a little over sedated and they're kind of like nodding out and having a hard time paying attention. The focusing on some of the physical findings that are specifically related to addiction as complications. So listening for a heart murmur, looking at how's your skin doing? Are they having active skin infections right now? Are they having active dental infections right now? Those kind of what the immediate need sorts of things and just documenting those physical findings associated with their use disorder. So useful, but not absolutely necessary, at least on that first visit. Laboratory testing, the most common tests that you're gonna see done in the first visit would be a urine drug screen. Although it's hard to say again, if that is very useful on the first visit. So maybe they're using, maybe they're not using. If it's tests, if they're using fentanyl, probably won't even show up on the initial tests. A lot of times you're not gonna see, you're not gonna be able to have an in-office test for things like alcohol. So it's the urine drug screening for the initial, isn't necessarily particularly helpful when we're gonna be starting to prescribe for people. The only time I might say it might be helpful is like if someone tests positive for methadone, which can make the transition to buprenorphine a little bit higher or something like that. It can help with the conversation, but oftentimes we're starting our treatment without any initial drug screening. A pregnancy test also useful. Again, it's not necessarily going to affect what kind of buprenorphine that you're prescribing or whether you're gonna prescribe buprenorphine or not, but a lot of times people may not know that they're pregnant and of course this is a key time that, can be really helpful to get people in to connect it with care if they're not. So that's something for all people capable of pregnancy to consider an initial treatment and during treatment if they are having any concerns or symptoms of possible pregnancy. Most, there's a very large comorbidity in people who have ever used IV drugs and hepatitis C in particular. And in certain regions also HIV that obviously the prevalence varies depending on the area that you're in. The CDC says that we should be checking everyone at least one time in their life for hepatitis C and HIV regardless and more often if they have risk factors. So we keep rapid tests kits for hep C and HIV in our office so we can do just a really quick poke, finger poke kind of screening. They also make oral screenings that we can get a rapid result within about 20 minutes for these. And then we sort of know whether there's signs that a person has been exposed to these and we need more lab to check in. When I have a person who's there and especially if they, for liver function tests, you don't have to have a CMP to prescribe buprenorphine but often, especially if people have hepatitis C they're gonna have issues with their liver and so it can be helpful to monitor that and when I have someone in person especially if they have a hepatitis C positive test I'm gonna do everything I can to try to get a blood draw because I wanna also treat their, I wanna treat their hepatitis C while they're in treatment. So, but none of these laboratories or physical examinations are required and able to initiate treatment. In the longterm when we have people in front of us and we have enough time, of course we want everyone to get holistic medical care. Most of the people, a lot of these people have not had medical care in years. There may be a lot of primary care needs that they have that haven't been met. And so we want to offer all those things but we don't need to do a complete workup in order to safely initiate treatment. When we're counseling patients on important safety points on how to take their medication correctly we want them to understand that they, it's very, it's not safe for them to stop taking their buprenorphine. If they choose to stop taking their buprenorphine there's a really high risk of return to use and a high risk of overdose. We do want to counsel them against combining with CNS depressants. But again, that's not a contraindication to prescribing buprenorphine. We want to offer people contraception if they're capable of pregnancy and to kind of keep an eye on that so we can give people support if they do become pregnant and make sure that they reach out to us if they are having a trauma or a painful surgery so we can work with their surgeons on helping to make a plan to control their pain. So this is a really nice patient education handout. The California Bridge Treatment Program has all kinds of wonderful handouts that you are open access that anyone can use. And this is great because it really touches on all the important educational points for patients that you can just hand out to them when they come into the office so that you don't have to recreate your own educational handout for patients. Again, when we're choosing that first dose of buprenorphine, the minimum recommended dose is going to be 16 milligrams. And when they're taking that medication, if you look at the package insert, it says that sublingual buprenorphine can be dosed once a day. It's very long acting. It stays on the receptors for a long time. And once a day dosing can be sufficient to control cravings for some patients. However, I think what many people find is that many people prefer to split their dose. Splitting it twice a day is the most common that I see. Some people, especially if they're on higher doses like 24 milligrams a day, prefer to split it up into TID dosing. And what I tell patients is it doesn't matter how you take this, as long as you take it the same way every single day and that you have that routine so you're always taking it the same way. So an advantage of taking it once a day, it's easier, you can do it when you get up in the morning, you don't have to worry about the rest of the day. Some people feel like they just get better relief when they split their dose up, but that it's hard for people to take any medication three times a day, and you're going to increase medication errors, missed dose, who's taking an extra dose. You got to worry about taking medication with you during the day. So I tell patients that it really doesn't matter how you take it, as long as you do it the same way every day and you take the same dose of medication every single day, that's the most important thing. Interestingly, the pain relief effect of buprenorphine is actually only six to eight hours. So I find that most patients who have chronic pain prefer to split their doses up a couple of times a day at least. To actually take the medication, we want to start by wetting the mouth and the medication is going to go under the tongue. It also can go between the gum and the cheek as well in the buccal area. And then we want to encourage people to just sit quietly for at least 15 minutes, don't eat, drink, talk, smoke during that time to allow the medication to absorb. I remind people that this medication is not absorbed in your stomach. It doesn't do you any good to swallow this medication or to swallow the saliva. And some people feel like swallowing a lot of it actually increases the side effect of nausea. So I tell people, after that 15 or 20 minutes, then you can spit out any excess saliva you have and you can rinse out and spit. There has been some concern. There was a warning published a few years ago that sublingual buprenorphine might soften the enamel and might increase the risk of dental decay. And so it is recommended to rinse the mouth out after dosing and to wait at least an hour before brushing your teeth. And then the peak effect of the medication is going to be seen in about an hour, hour and a half after the dose has been taken sublingually. The most common side effects that we counsel patients on, I tell everyone that you might be nauseous the first week or two that you take buprenorphine. It's nausea, it's normal. It's like half of people experience some amount of nausea when they're taking buprenorphine. It almost always goes away. Same thing with kind of headache. Very common early treatment for most people once they adjust and develop a tolerance to the medication, those side effects are going to go away. If you have someone who's been abstinent, trying not to use for a while and they're trying to ramp up on their dose, they might feel a little over-medicated or a little over sedated that first couple of days to a week but then they're just gonna normalize and they're gonna feel normal again as long as they're taking the same dose every day. The main side effect that doesn't go away is constipation which can be quite severe. So every time I see people, I talk to them about how your constipation is controlled. And we really try to work with people to counsel them on developing an appropriate bowel regimen to prevent constipation. We don't want someone to end up in the emergency room because they're impacted or like just be so uncomfortable with constipation, saying like, I don't even wanna take this medication anymore because I'm so uncomfortable. So that's a key common side effect to monitor. So we already talked a little bit about precipitated withdrawal. I also wanna talk a little bit more why you're hearing a lot more about that. And that is because of the use of fentanyl. Fentanyl we think of as being a very short acting medication but fentanyl actually is lipophilic, meaning it stores in your fat similar to like the way cannabis does or benzodiazepines do. So you can store large amounts of fentanyl up in your fat. And so it's acting actually like kind of like a long acting opioid instead of as a short acting opioid. And we can see again, sometimes very heavy fentanyl users, we can see fentanyl metabolites still eliminating weeks later from the urine. And so the reason that this can potentially increase the risk of precipitated withdrawal is we have people who are here, 24 to 48 hours out of stopping using their fentanyl, they feel like they're in a moderate amount of withdrawal, they're feeling pretty uncomfortable, but there's still high levels of fentanyl left in their system. So they may seem like they're in the right amount of withdrawal, but when they take it as a buprenorphine, they may still experience precipitated withdrawal. So this is kind of the fear around the increasing risk of precipitated withdrawal when people are using fentanyl. So when I'm talking to people, this is where it's really important to talk with them about their previous experience with buprenorphine. And I can tell you most, almost all patients who are going to come in seeking care have at least tried buprenorphine before, even if they weren't prescribed it, very often people have tried it, a friend has given it to them, so they've been able to try it. So I talk with people about like, hey, what was your experience like when you took buprenorphine before? Did it help you to feel better? that question is a really important part of the interview so that I can plan for, you know, helping to support the person to successfully start taking their medication. So when I get that history of like, you know, every time I try to take buprenorphine, I get really sick and I'm just not sure what to do or how to do it, that's when I might, that person might need extra support and more options on how to start taking their buprenorphine rather than just the standard dosing. So again, we want someone to be in withdrawal when they take their first dose of buprenorphine and in a clinical setting, we check what's called a CALS score, we want it to be over 12 or 13 to be in moderate withdrawal, but a patient is, they're not gonna calculate a CALS score for themselves when they're at home and patients are almost always gonna be starting this medication at home. So that's not particularly useful for patients at home. So what I tell people is, you want to try to wait at least 12 to 24 hours after your last dose of opioids. You wanna have at least three or four of the common symptoms of the runny nose and sweating and your eyes watering, you're sick to your stomach, you can't sleep, you're feeling like you're gonna crawl out of your skin, you're yawning, at least three or four of those symptoms you're having and just tell people like, you should just wait until you feel like you can't wait anymore. Just wait as long as you feel like you can possibly wait and that's usually the right time to start taking your buprenorphine dose. At that first visit, the prescriptions I'm typically going to write for a patient, I'm going to write the prescription for buprenorphine, usually the combination product, the eight milligram. I'll ask people if they have a preference for the tabs or the films, if they don't have a preference, I'll usually prescribe the films because they're easier to cut in case they need to cut them in half. They cut really easily with scissors. Typically, I will prescribe for them to take up to three a day, especially that first week, because I always want people, it's better for people to have extra medication than not to have enough and then give up and return to use. So I usually prescribe up to three a day, but I say, hey, if you can get by with taking two a day, that's great, because then you have more wiggle room, you can go up in the future if you need to. So you take the amount that you need to control your symptoms. Some, your state may allow for up to 32 milligrams a day for certain patients. So knowing what your state insurance covers is important. I always prescribe Zofran and Clonidine for people to help them manage that restlessness. And for some people, I'll even have them take these medications prophylactically, like about an hour before they take their first dose of buprenorphine to try to help to reduce any withdrawal symptoms that they might experience. And it's important for everyone to have a naloxone kit on hand. Most people who are in treatment programs who are prescribed naloxone don't actually, the naloxone doesn't end up being used on themselves, but they are more likely to use it on family and friends around them. So anyone who's at risk for witnessing an opioid overdose should have a naloxone rescue kit. Other things, I'll ask people, especially if they're really worried about their ability to tolerate withdrawal, and it's been very difficult for them before, I'll talk to them like, what are your worst withdrawal symptoms? What are you the most worried about? And if someone's like, oh, every time I can't sleep, that's the worst thing, I can't sleep, and I always give up because I can't sleep. So I prescribe them some medication for sleep, talking about, is it their anxiety? Is it their muscle aches? What is it that's the worst for them? And recommending adjunctive medications if needed. Most patients I only prescribe ondansetron and Clonidine, but for those who have high levels of concern or kind of low tolerance of withdrawal in the past, I might offer them more supportive medications. My standard instructions for people to start taking their buprenorphine is to, again, wait, wait 12 to 24 hours, wait until you feel like you can't wait anymore, and then you're going to take your first dose. The first dose is generally going to be one to two strips or tablets, and especially if they have a high level of tolerance, I encourage them to just start out with two for their first dose. That's your goal anyway. Why not get there as quickly as possible in someone that has a high tolerance? And however, in patients, you may have a patient who maybe they just got released from jail or rehab, or they've just been trying not to use, and they actually don't have an active opiate tolerance because they've been abstinent for a couple of weeks. Those people actually start with smaller doses of two to four milligrams because it's not for safety issues. It's purely for tolerating side effects. If you give too high of a dose to someone who doesn't have a current opiate tolerance, they're going to feel really nauseous. They're going to feel really dizzy. They're going to feel really over-medicated. It's an unpleasant feeling. So again, we want to help people to feel as well as possible so that they want to continue taking this medication. But typically it's going to be, put it one to two tablets or strips under your tongue, and then see how the rest of the day goes. And you can take another half to a whole strip tablet every couple hours as you need to. The typical package insert and instructions will say kind of a goal of 16 milligrams on the first couple of days. But I tell my patients that you can take up to three a day if you need to, to control your symptoms. And sometimes that first day, when people have really bad withdrawal symptoms on that first day, some people need to take more than that. But I caution them, like, if you're taking more than three on the first day, you're going to have to cut back, you know, towards the end of the week, or you're going to run out of your medication early, so. And this is another fabulous handout for the British Treatment Program that essentially is the exact same instructions that I just gave you. So this is the instructional handout that I prefer to give my patient. And it also talks about, you know, hey, if you're not using very much, you might want to consider a lower dose. And it has all the information, very easy to read in a concise format that's free for you to print out and hand out at your clinic. Again, if people, I caution people, you know, if they do have, if they have had a history of experienced precipitator withdrawal in the past, and they're worried about that, to really explain to them how important it is that if that happens, that they need to take more buprenorphine and they need to do it quickly, which is very kind of antithetical to, you think like, I just took this medicine that made me super sick, and now you're telling me to take more of it. So that can be confusing for patients and hard for them to make themselves do, but say like, hey, this is the way that you're going to feel better faster. You just have to push through it and just take a very high dose of buprenorphine and you are going to feel better. If you just stick with it and keep taking it, you are going to feel better. So again, if they experienced precipitator withdrawal, immediately taking 16 milligrams of buprenorphine and then as much as needed with adjunctive medications until the symptoms are tolerable. The buprenorphine also comes in long-acting injectable formulation. So that has some advantages. Some, you know, we don't need to worry about diversion with long-acting injectable buprenorphine. So if we have, you know, patients that were worried about that and for some reason, we don't have to worry about, we don't have to check their drug testing to see if they're taking their medication because we know that they're taking their medication. And also the medication wears off very, very slowly. So if a patient misses their appointment for their injection, they're still going to have medication in their system. So they're not going to immediately go into withdrawal. So it gives people a lot more flexibility to kind of schedule, reschedule their appointments. And when people are at risk for medication interruption, the medication is going to stay around the system for a while, even if they miss their appointment for their next injection. And this is specifically the pharmacokinetics of sublucade, which is the long-acting injectable that has been around for the longest here in the United States. It, every month that you're on it, it's going to build increased serum drug levels. It takes about four to five months to reach peak maximum serum drug levels of that medication. That medication, you'll end up with serum drug levels that are about twice as high on that medication once you stabilize than if you were taking 16 to 24 milligrams a day of sublingual buprenorphine. And it's a very, very, very, very long-acting medication. So if their medication is interrupted, so it's showing here the last shot being given, they will maintain serum drug levels above, in the protective therapeutic range, above two nanograms per milliliter for up to five months after their last injection. So this is fabulous for anyone who's at risk for interruption of care. If they've fallen in and out of care a lot in the past, maybe they're moving, maybe they're afraid they're going to lose their insurance. Maybe they're afraid they're going to get arrested. Maybe like in my circumstance, people are in fishing jobs and they have, they're going to be out fishing for three months and they're not going to have access to their medication. This allows us, we can stabilize them on the monthly injectable. And then if they lose access to that care, they're still going to be protected for a while. It allows us time to get them back into care. This medication, long-acting injectable, has a very, very high patient satisfaction rating. People really love the fact that they don't have to deal with the hassle of taking a daily medication and they kind of just feel well every day. It's just so much easier from the patient's perspective and from the provider's perspective, really. The one caution related to this medication is really important to understand that you don't get those high levels with the first shot. With the first shot, you actually have levels that are more like 16 milligrams a day, not 24. So if you have someone who's stabilized or needs 24 to feel well, the average serum drug level is going to be less than that first shot. And also you're going to drop down, at the end of the month, you're going to drop down to levels significantly below two nanograms per milliliter, meaning that they probably are not going to have an effective blockade of fentanyl towards the end of that first month and may not have control of their cravings. So I caution people that that end of that first month, especially with the long-acting injectables, they may need some supplemental sublingual buprenorphine to help take the edge off those cravings until they're able to get a few more shots and stabilize on the long-acting injectables. It's really important to help people, give people the support they need to stabilize on this medication. And so that every month that you get it, your drug levels are going to get higher, you're going to start feeling better, and any side effects you experience are going to be less with each injection. So just really encourage people to just stick with it, even if they're struggling the first month or so, that in the long-term, most people have very high level of satisfaction with this medication, and the side effects are going to go away, and the cravings are almost always going to go away if they just stick with it and stick on it. The other caution with this medication is they may not feel it wearing off, especially if they've gotten two or more injections, because it wears off so slowly, people love this. They love that they don't have a withdrawal when they miss their appointment or miss their shot, but it also can be dangerous because people say, I feel so good, I feel great, I don't feel like we're not having cravings, I don't even need to go back and get my shot, or they lose track of time and they don't realize, oh gosh, it's been three months since they had their last injection. It is wearing off, even though they can't feel it wearing off, and it will drop down below protective levels, and almost everyone will return to use, it just takes a little while. So in the same dangers here, with return to use and risk of overdose, to caution people that it may happen, even if you don't feel it happening, the medication is wearing off, so it's critically important to keep getting your injection, even if you feel like you don't really need it. For stable patients, we're just a little over the hour here now, but just a few more slides, for stable patients, how do we monitor them in their maintenance fault treatment? And so initially, initially I'm typically gonna see people once a week to assess how they're doing, adjust their dosage, address any side effects, cravings, and all those sorts of things. Once they're stable and meeting their goals, then we're gonna try to see them generally every two weeks, and then eventually in long-term stable patients, I'm just refilling their prescriptions and seeing them once a month. When they come in, I'm checking their PDMP, I'm considering doing drug testing, I offer it to patients, I generally am not gonna require it, we require occasional tests to test for buprenorphine metabolites to show that people are taking their medication, but otherwise we don't require any drug testing at all for people that are taking sublucade. But it can, in some, if you use it appropriately, it can be a tool to kind of facilitate that open communication for some patients. I'm gonna ask people about how they're taking their medication, just because I wrote on there 16 milligrams a day or three times a day or whatever, that does not mean that they're taking it that way, we should never assume. So I always ask people, tell me about how you're taking your medication, how much are you taking? How often are you taking it? Are you taking the same dose every day? Are you taking it differently every day? And talking about their cravings, the number one most important question is, are your cravings controlled? And if they are having uncontrolled cravings to kind of get to, what was triggering your cravings? Often related to stress, it might be related to pain, to anxiety, to insomnia, trying to get to the root of what is triggering those cravings. Uncontrolled cravings can definitely be a sign for some people that they're not taking a high enough dose of medication. So when they're having uncontrolled cravings, that often I will talk with them about the possible benefits of increasing the dose of their medication, if possible, or maybe changing to a different formulation of medication. The other thing is like, maybe they're already at the maximum dose of medication, but they have comorbid issues, like they have longstanding depression, anxiety, pain, insomnia. So these monthly visits, these follow-up visits, often are time when we really spend addressing those comorbid conditions that were some of the root issues that were causing them to want to use drugs and continue using drugs that they were self-medicating for the first. And a lot of people really, they haven't really stayed in care long enough and kind of had that environment where they can have that holistic treatment in the primary care setting to really address all these comorbid disorders. So we can really help people have a much better quality of life if we take advantage of these visits to really kind of offer holistic care and address all these comorbid disorders that are occurring. Again, we want to keep people on treatment for a long period of time. We already looked at this slide before, but when patients ask that question, like, hey, I think I'm thinking about stopping taking this medication. I think when they bring that up, I want to stop taking this medication, the first question is always, why? Why do you want to stop? Because often patients will cite something that is not a healthy reason for wanting to stop taking this medication. So, and the plan to reduce the dose or stop taking MOUD should always be patient-initiated. So I never ask a patient, hey, do you want to go down on the dose of your medication? What do you think about taking off the medication? I never, ever ask patients that. That is something that patients can ask me and they do all the time when they feel like they're ready. And most of the time I tell them, I don't think it's a good time for you. I don't think this is a safe time for you to stop taking or taper off your medication. Often they'll bring up reasons like, hey, my mom told me I should stop taking this. My wife told me I should stop taking this. I'm worried about what if I go to jail and I'm going to go through a withdrawal if I'm on this. So I should probably get off it right now. I'm worried that I might become dependent on it. Like all these issues that almost always are related to myths and stigma that we talked about last time. So really getting to the root of why do you want to stop taking it? Is it for the right reason? Is this a safe time for you to stop taking your medication? So a safe time for someone to consider reducing their dose or stopping taking their medication should be, the person should be very stable in long-term recovery. So what I tell people is generally that you've been in treatment for at least a couple years. This past year or so, you haven't been using any drugs, no return to use. You have a really great supportive recovery network. You have a stable place to live. Maybe you have employment or you're financially stable. You have family and friends around you that are sober and supportive of you. You're not dealing with like stressors right now, like financial stressors, legal stressors. Your mental health is stable and you're surrounded by a strong recovery network of support. This is the kind of situation that we want people to be in before we consider tapering or stopping their medication. And tapering should always be done very, very slowly, just like it's done for any opioid or benzodiazepine. Slow tapers are much more successful than rapid tapers. And we really wanna work hard against counseling patients not to stop taking their medication when they're in these high-risk times. So how important it is to continue taking your medication during pregnancy and postpartum periods that are very high-risk times. When they're going through a lot of stress, they're dealing with legal issues or other divorces, moves, that that's the most important time for them to continue taking their medication. We don't want them to stop taking it if they go into the hospital or anything else. So we spend most of our time kind of helping people to get the supports they need so that they're able to stay on their medication for the long-term. Again, just one more shout out of this article that really gives a lot of great strategies for helping people in treatment stay successfully in treatment when they're using fentanyl and some of the challenges that fentanyl presents. These are just some links to those resources. The number one I would recommend for patient resources for handouts, policies and procedures, patient education, is the Bridge to Treatment Program. It's really, really excellent handouts for patients on that and also information for providers on that and these other articles I brought up earlier. So I will stop there and see if we can take any questions. I know we ran over about 10 minutes, but I certainly have time for questions if anyone has questions. I see a question about Brixadi. So Brixadi, the possible advantages of Brixadi. So some of the differences between Brixadi and Sublocade. Brixadi, number one, it doesn't need to be stored in the refrigerator, although they're changing sublocated packaging so it also can be kept out of the refrigerator for up to three months. So that won't be as much of an issue. It's a smaller volume shot, so it's a little bit less uncomfortable. Little bit less painful of an injection. Once people are stabilized, it can be given in other locations like the back of the arm and stuff instead of in the stomach, which some people like. It comes in a more variety of strengths, especially like it comes in a very, very low dose that's meant to be given to people who like have been abstinent and aren't currently taking buprenorphine. It's been, and just the variety of doses like can give you a little bit more flexibility in trying to like find the dose that the patient feels the most comfortable at, which is kind of nice to have that option. It does come in the weekly formulation, which can be helpful for people like if you're not really sure what their dose is at first, you can give multiple additional doses in that first week as you're trying to stabilize someone and get them on the right dose. The weekly formulation has been studied specifically and used in the emergency room without giving any buprenorphine before you give it. Sublocade is, Bruxadi has the labeling to give one dose of buprenorphine to test it before you give it, which I think is a horrible idea. They did not do that in the emergency room. They just gave people the Bruxadi when they were presenting to the emergency room. The sublocade has the labeling saying that you need to, your supplement's supposed to be on buprenorphine for a week before you give the sublocade, which we recommend in our office, but we also give it to people who are not taking any buprenorphine yet. If they just come into the office and they weren't able to start taking their buprenorphine, we'll still administer it. So that's kind of, those are some of the main differences between, otherwise it has kind of like the price is the same. It's not as widely available from as many pharmacies yet as the sublocade. Let's see. Do we have any other questions today? I know that was a ton of information to go over in a short period of time. I don't have a question, I just want to say that was a really wonderful presentation. Thank you so much. If you clearly know so much about this, it was amazing to learn from you. Well, thank you very much for attending and listening. Yeah, that was excellent. Thank you. It was very good. I do have one brief question. Patients are going to undergo a significant surgical operation where general anesthesia is needed. How does the naloxone affect the anesthesia? So the naloxone, do you mean buprenorphine? The naloxone is not absorbed. Yeah. So in general, it's not going to affect anesthesia in general. It won't affect any of the actual anesthetic medications. It's not going to interact with any of those. The main issue is like if patients having like, for example, let's say they're having conscious sedation and they're going to be using midazolam and fentanyl. That would be a common combination for right for conscious sedation. One of the biggest things is like if you're able to, if it's a planned surgery, is communicating with the surgery and anesthesia time ahead of time, if you can. There's wildly different levels of comfort among surgeons and anesthesiologists around managing this. So kind of, you know, so if someone's having conscious sedation, they can still have it with midazolam and fentanyl, but they may need three times a dose of fentanyl before they get the effect that they're looking for. You know, and they may need to rely a little bit heavier on a heavier dose of midazolam. And for, you know, just general pain control, you know, it doesn't affect like spinal anesthesia or anything like that. For general pain control, the pain, you know, and I have a, like, I have a form letter that I have written out for patients who are on buprenorphine, especially like on, I have a lot of patients on sublocated in my practice, which you can't, you can't take that out, right? You can't change it. You can't change the dose. You can't reduce it. There's nothing you can do. You're stuck with these high levels of buprenorphine to educate the surgeon and anesthesiologist about, you know, the fact that this person is going to need very high doses of full opioid agonist when they're having that, especially if they're, you know, they're having a knee replacement, right? So that's a major, something that's seriously painful that for them to understand how important it is to treat the patient, not the numbers, right? You can look at these numbers and be like, oh my gosh, like eight milligrams of Dilaudid, holy smokes, that's crazy scary. Sublocade is actually tested to block the liking effect of 18 milligrams of Dilaudid IM, which is different than IV. But I mean, can you imagine giving someone 18 milligrams of Dilaudid IM? But blocking the liking effect is different than blocking the pain control. So people can still get pain control, even though they're not feeling intoxicated, they're not feeling pleasure from the injection, they're not feeling high, but they still can get analgesic effect from high doses of opioids. So just to counsel these patients that like you just, you know, if they're in the hospital, they have access to cardiorespiratory monitoring, right? They can monitor for sedation. So you're just titrating to effect. You're giving them as much as you need to, to help them to feel better. And you're looking at the patient. You're not looking at the numbers of how many milligrams you're giving them. You're looking at their vital signs. You're looking at the objective findings of over sedation and holding for over sedation and treating titrating to effect. That's really the most important part. And also really utilizing all of your adjunctives like scheduled NSAIDs, scheduled Tylenol, gabapentinoids, all these kinds of things, local and regional blocks. Great if you can do that. And then, you know, for minor outpatient procedures, like someone's having their teeth extracted, they're having their gallbladder out, something like that, right? They're going home the same day. That I actually, you can just use additional doses of buprenorphine along with your Tylenol and NSAIDs to manage their pain. So there's no ceiling limit on the analgesic effect of buprenorphine. So you can use as much buprenorphine as you need to get their pain controlled. And higher doses tend to be more helpful for pain. So if a person, they're on sublocated and they're already, you know, they have high levels of buprenorphine in their system already, but I can give them an additional prescription for an additional 24 milligrams a day of buprenorphine, they can take that extra dose three times a day to help relieve some of that pain. So extra buprenorphine doses is my go-to for a minor procedure. And then if someone's going to be hospitalized, really reaching out to the surgical team about how important it is to, you know, really believe the patient and understand the very high levels of, if you're going to use opioids, the very high levels of tolerance. And so high doses that you're going to need. Thank you. That's great. I do actually have a question as long as I don't want to interrupt anyone else. But I know a patient who, this was maybe about a year ago, patient has like severe chronic back pain and has been on a chronic opioid script for like decades. And it's pretty low. We're talking like 10 milligrams of Oxycontin a day. And went to a provider who prescribed her Suboxone really for the chronic pain. It was also to try to get her off the opioid script because PCP didn't want to prescribe anymore. And I believe, you know, they went like the window that she needed to detox the Oxy out of her system. And I think they started her on four milligrams of a sublingual. And she had like, it's basically the withdrawal syndrome you were describing. It's severe, not just severe, like violent vomiting. And I think they tried to, they tried like two days in a row and it failed both days. I'm just curious, should they have done more? It sounds like too much. It sounds like too much buprenorphine. So sometimes, especially with people who have lower levels of tolerance, that's kind of the situation, especially, you know, if they're like, so that, you know, 10 milligrams of Oxy, so that's like 20 morphine equivalents. When you look at, for example, the formulations that are approved for chronic pain, like that would fall in the category of that ultra low dosing of buprenorphine, like you would see in the Butrans dosing. Or, you know, if I was going to start someone on buprenorphine, it's only taking that because some people do, they just like, a lot of times people just, you know, it's a whole different subject, buprenorphine for chronic pain, which I do presentations on, but it can be very helpful for chronic pain. People can have, feel better on it than they do on their regular opioids and have less side effects. But, but there is no, there's no conversion. There's no MME conversion for buprenorphine. And so, because it's not, it's like logarithmic, it's not linear. And so for, for, for that, if I was starting that patient and their insurance would not pay for the FDA approved formulations, I would usually recommend ButransPatch for that patient. But if their insurance didn't pay for that, because it's very expensive, then I would say, okay, we're going to start with a tiny little dose of sublingual. And it's, you know, it's, OxyContin is a short-acting medication. So as long as, you know, they took their last dose the day before, we should be able to start buprenorphine in the morning. That shouldn't be a problem. But we would, I would give them two milligram films and tell them to cut into a quarter and take a half a milligram as their first dose. And then just to repeat an extra half a milligram every hour or two until they felt the desired effects. And if they started to feel, and everyone gets nauseous, so you have to prepare them for that, that nausea is the most common sign. And especially if you're over, if you're overshooting the dose, it's going to be bad, like severe nausea. That is just like, you really want to avoid that. So in the, you know, in that, from the chronic pain standpoint, you know, we're not worried about like, we don't have to like rapidly titrate it up as quickly as possible. And that's the kind of situation where it's totally fine to start with a low dose and then, then be able to titrate it up as rapidly as you need to to control the symptoms. But, but then you're undershooting in case of, you know, you don't want to cause those kinds of side. I've seen that happen a number of times to patients where they were prescribed a dose that was too high. And then they're like totally turned off the medication like that. You know, I must be allergic to that. That's a horrible medication. When it's just really that they were prescribed too high of a dose and, and, and had difficulty with this. And if they stayed on that dose for a couple of weeks, they would feel fine. They, those symptoms will go away, but it's hard to get people to take a medication that's making them feel sick. So. Yeah, absolutely. That's what happened. She stopped and did not try again. So yeah. Thanks for that information. That's helpful. And I do want to just mention, we will have a training on June 5th where Dr. Spencer will be talking more about chronic pain and buprenorphine prescribing for chronic pain. So that session was coming up. It's just a real quick question. I know you all have to go, but it is, Suboxone now indicated for chronic pain syndrome. I knew that for a while, it was approved for that indication. Yes. So it's, so there are two formulations of buprenorphine that are indicate that are FDA approved for chronic pain, which are the low doses, which is the Butrans and the Bell Bucca. The other form, the sublingual formulations or long-acting injectable formulations are not FDA approved for chronic pain, but it is 100% legal to use them off label for chronic pain, right? Just like we use Trazodone off label for insomnia, right? We use off label. So it is a hundred percent legal, but the issue, the only issue really comes up is sometimes with insurance coverage that has changed. Now that the CDC and the VA and their opioid prescribing guidelines specifically say that we should be switching people to buprenorphine in certain circumstances when they have chronic pain. So now that we have those national guidelines that are saying that this is appropriate to use sublingual buprenorphine that I've never, like, it often requires prior authorization, but when I outlined the prior authorization, the reasons for prescribing it I pretty much never gets denied. So. Great. Thank you. Thank you. Yeah. Thanks everyone for attending and we will have some follow-up sessions. So we'll have a little bit more time to dig into some of these other issues and and you're welcome to have access to the slides to kind of look at some of those, those resources. I would definitely recommend checking out those resources. Awesome. Thank you. Thank you, Dr. Spencer. Our next session with Dr. Spencer will be on May 29th and then we'll have a follow-up session on June 5th. So we will get those zoom links out to you all. And then I will have a recording of this session in about a week or so, and I will send that out to Dr. Velez to get out to the team, but thank you all so much for joining us today. We will see you in about two weeks. Yeah. Thanks everyone. Thank you. Bye-bye. Take care. I think it's the bottom quarter.

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