Good morning. My name is Emily Mossberg, and I am a technology transfer specialist with the Opioid Response Network. Before we start today's training, I'm going to briefly share some information about the Opioid Response Network and the work that we do. And actually, Dr. Jackson, can you go to the next slide? I was just about to ask. No worries. Okay. Thank you. The Opioid Response Network is funded by a grant from SAMHSA to provide free technical assistance to communities and organizations across the nation so that they may address opioid and stimulant use locally. Technical assistance is provided in the form of training, consultation, or the sharing of resources that support evidence-based prevention, treatment, recovery, and harm reduction efforts. And you can go to the next slide. To provide this support, the ORN utilizes a pool of experienced consultants who are located all over the country and who can respond to local needs. We operate on a request basis, and anyone can submit a request for assistance on our website. Each state or territory has a designated team who receives and coordinates requests in their area. You can go to the next slide. If you would like to submit a request for assistance, please visit our website at opioidresponsenetwork.org. And today, we are honored to be here with you to provide training on Opioid Use Disorder 101. Continuing education credits will be available for this session, and I will share instruction for claiming credit at the end of the presentation. Please note that this session is being recorded and will be available for viewing in about two weeks. And our session today will be led by our consultant, Dr. Danielle Jackson, and I want to go ahead and share her introduction. Dr. Danielle Jackson completed her adult psychiatry residency training at Yale University Department of Psychiatry. She is the Medical Director of Substance Use and Co-Occurring Disorders at Sunset Terrace Family Health in Brooklyn, New York, and Clinical Assistant Professor in the Department of Psychiatry at the NYU Grossman School of Medicine. In addition to clinical care, her work focuses on improving interdisciplinary training in mental health and substance use disorders to promote increased access to care. And with that, I will go ahead and pass it over to you, Dr. Jackson. Thank you for being here. Thank you. Thank you, Emily. Happy to be here. So, let me start out with, I have no disclosures, and I'm going to skip past this. And so, just to overview what we're going to talk about today. So, today we're going to review the definition of substance use disorders, opioid use disorder, and addiction, discuss stigma and factors which contribute towards stigma, and also develop an understanding of the waves of the opioid epidemic and the current state of the overdose crisis, and review FDA-approved treatments for opioid use disorder. Okay. So, what is addiction? According to the American Society of Addiction Medicine, it is defined as the inability to consistently abstain, impairment in behavioral control, craving diminished recognition of significant problems with one's behaviors and interpersonal relationships, and a dysfunctional emotional response. Substance use disorders occur when the recurrent use of alcohol and or drugs cause clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home. In particular, today we're going to talk about opioid use disorder. Opioid use disorder is a chronic disorder. The risk of symptom recurrences or return to use persists for many years, and even following treatment, and likely folks will have to have multiple treatment episodes or treatment periods. Therefore, periods of symptom remission and exacerbations should be expected through the course of patient treatment. And it's important that we recognize the chronicity and relapsing course of the disorder. That may occur even despite treatment, and it should not imply that treatment is ineffective or ever useless. So, simply, it is a chronic relapsing disorder with the highest mortality of all psychiatric illnesses. So, some numbers. Dr. Jackson, sorry, I don't want to interrupt you. It looks like, Ron, do you have a question? Yes, I just, I know, doctors explain the things, and I know this is a refugee and immigrant organization. I just want to make sure, folks, if you have a question or you don't understand something that's being said, that you please let Dr. Jackson know so that we can respond to it, because I know sometimes the language is different when it's clinical or when it's this level of communication. So, I just wanted to qualify. Thank you. Yeah, thanks, Ron. And please interrupt me. I can't see the hands raised icon, and so if there are questions, just let me know. Yes, I'll open them, and I'll let you know. Okay, awesome. So, I just wanted to go over some numbers quickly. So, according to the CDC, there were 107,622 overdose deaths from drugs in 2021, which is a 15% increase compared to 2020. These overdose deaths occurred from synthetic opioids, primary fentanyl, and stimulants such as methamphetamine and cocaine, which also increased in 2021. Now, more recently, there were 107,543 drug overdose deaths during 2023, which is a decrease, a decrease of 3% from the formal number that was obtained in 2022. That time was the first time that there had been a decrease in overdose deaths since 2018. So, keep that tidbit in the back of your mind, and we'll revisit a little later. Okay. So, like before, one should not expect a cure after a one-time treatment episode. Sustained remission or recovery can occur in about 30 to 40% of patients despite prior history of relapses or return to use at any given treatment episodes. Some treatment principles include that all patients with opioid use disorder should be offered an option of treatment with FDA-indicated medications, including buprenorphine, naloxone, or suboxone, either the sublingual or in injectable form, extended-release naltrexone, or methadone. And I'll talk more about the medications in a little bit. Treatment should be based on shared decision-making, and evidence-based psychosocial interventions, including web-based programs, therapies, should be used in combination with medication and may improve outcomes. But medication for opioid use disorder should not be withheld if someone does not elect to partake in therapy-based interventions. And FDA-approved medications are the standard of care and are effective for treating opioid use disorder and reducing overdose deaths. So let's talk for a little bit about the opioid epidemic. How did we get here, and when did this all start? So historically, when looking at the first opioid epidemic, which occurred in the mid-19, early 1900s, 1914, when the Harrison Narcotic Act was passed, that ended the first opioid epidemic, which started at the turn of the century. At that time, heroin became illegal. All opioids required a prescription, and cocaine required a prescription. Prescribing a controlled substance or controlled drug to a person with a substance use disorder became illegal. And that was the rule of law and the way it went, and not much kind of happened in terms of treatment over the course of the next around 50 years. The second opioid epidemic started in the 1960s during the Vietnam War. It was an epidemic of heroin. With the end of the Vietnam War and GIs returning from Vietnam prompted the introduction of methadone clinics or opioid treatment programs, OTPs. This helped to end the second opioid epidemic. And so where are we now? The current opioid epidemic essentially started in the 1990s, and it occurred in three, now four, five waves. The first wave was due to a rise in prescription opioids and prescription opioid overdose deaths that started in the 1990s and continued into the early to mid 2000s. Wave two began, excuse me, in 2010 with a rise in heroin overdose deaths specifically. And then the next wave, which is wave three, occurred due to a rise in synthetic opioid overdose deaths instead of heroin, which started in around 2013. And you can see on the infographic there, the sharp increase in synthetic opioid deaths, things like tramadol, fentanyl, either those prescribed or illegally manufactured in purple, beginning around 2012, 2013, and continuing to increase, and has continued to increase since that time. And so over the past few years, specifically the use of fentanyl and the adulteration of methamphetamine and cocaine with fentanyl has increased, leading to the fourth wave. And now in literature, there's even discussion of a fifth wave, which is due to the mixing of xylosine and fentanyl in the illicit drug supply, which primarily has impacted much of the East Coast, but continues to increase throughout the country. Okay. So what is fentanyl? So fentanyl is, excuse me, a synthetic opioid that essentially is about a hundred times stronger than morphine. Historically, it has had its place in healthcare and in treatment in terms of treating very severe chronic pain conditions and severe pains associated with cancer. But that is not the fentanyl that is in the current illicit drug supply. Much of that are, excuse me, are synthetic fentanyl that has been manufactured and introduced into what was the heroin supply, which is now mostly fentanyl and other drugs, other street drugs, severely increasing the risk of overdose because of the potency of fentanyl compared to say, just heroin. So what can we do about it? What is recommended is fentanyl testing. While fentanyl testing is one tool used in harm reduction to reduce risk of overdose, it does not completely eliminate the risk of overdose. There are about over 200 fentanyl analogs on the streets in the US drug market. The most common ones can be tested with fentanyl testing strips. And here in the image, you can see a depiction of what the results on the strip would look like. Essentially someone would take, the strip looks like, I'm sorry, I don't have one to show you today. It looks like a little dipstick and someone would dilute their drug of choice with a little bit of water, dip the strip in to test it, wait for a few seconds, and then lines would or would not appear looking like this. And so if one line appeared, that sample that they tested is positive for fentanyl. And then if two lines appeared, they can read it as negative for fentanyl. But, give me one second, because of the way that it can be present in a drug sample, testing one piece or one portion of someone's drug supply does not necessarily mean that it does not contain fentanyl. And so when you're talking to clients about the risk of overdose, always educate them on this particular topic, which is the chocolate chip cookie effect. Essentially, say if you're testing a portion of a pressed pill, the chunk that you break off very well could not contain fentanyl in it, in which case your test would come up negative. But that does not mean that the entirety of the pill that you have is free of fentanyl and or like free of risk. The other major issue that has creeped up in recent years is a drug called xylosine. Xylosine, first of all, is not approved for use in people. It is used in an animal population. It's also called tranq or tranqdope. It's a non-opiate, non-controlled substance, sedative or tranquilizer. In April of 2023, it was declared an emerging threat by the administration. Its effects can cause sedation, difficulty breathing, low blood pressure, slow heart rate, wounds that can become infected, and even death. What we've seen is the number of xylosine-positive overdose deaths markedly increased by region from 2020 to 2021 and moving forward. 103% increase in the Northeast, over 1,000% in the South, 500% in the Midwest, and 750% in the West. So it is a real problem. Fortunately, there do exist, similar to fentanyl test strips, you can obtain xylosine test strips and folks can test their drug supply for xylosine as well. Some more about the numbers, and we kind of looked at this a little bit earlier as well, just to drive home the point. When you look at the timeline of events, you start to see, from back in 2013 moving forward, this sharp increase in synthetic opioids other than methadone, primarily fentanyl and now more fentanyl derivatives, which have been responsible for drug overdose deaths. You also see, as expected, the decline in drug overdose deaths caused by prescription opioids and by heroin. And similar and kind of trending along with the increase in death due to synthetic opioids is increase in death due to psychostimulants, primarily methamphetamine and cocaine, in which fentanyl, pardon me, xylosine, now are often found contaminating the supply of these drugs, which becomes important because you will find folks that say, I don't use heroin, I've never used an opioid, I only use meth, I only use cocaine, I don't touch that other stuff. But that does not remove the risk of overdose for these folks. And so it's always important to counsel people that the likelihood of your drug containing fentanyl or xylosine is very, very high. And so no matter what you're using, you should be testing your product, testing your drug consistently. Okay. So in talking about medication for opioid use disorder, unfortunately, over 80% of people with opioid use disorder do not receive medication for treatment. And there's been some variation in the numbers, going from 22 to 25% of folks that receive treatment. But overall, the numbers are very, very low and continue to be low. What treatment options are available include methadone, buprenorphine, and extended release naltrexone. Now methadone is a full mu opioid agonist, meaning it binds fully and tightly to the opioid receptor. Buprenorphine or the suboxone products or line of medications are partial mu opioid receptor agonists. So they bind, but not as tightly and not as fully. This becomes important later when we talk about the effects of the medication and risk profile. And lastly, extended release naltrexone, which is actually an antagonist of the opioid receptors. Okay, so methadone and buprenorphine, pardon me, they constantly stimulate opioid receptors, stabilizing system functioning. It's important because they help to prevent withdrawal, relieve cravings, minimize pathological brain responses, and block effects of other opioids. Naltrexone, it didn't make it to the slide, blocks the effects of opioids and prevents intoxication. So suboxone is available as a sublingual tablet or films. Suboxone is a combination of buprenorphine and naloxone. It's one brand among several and also available as a generic. Buprenorphine is available as a monoproduct, so just the buprenorphine itself. That's called Subutex. It's frequently utilized by providers during pregnancy and also often utilized in the inpatient acute withdrawal management setting. It may be utilized by individuals who do not tolerate the naloxone portion. And it is also available in injection form as the brand Sublocade, which is given in two doses. So what are the limitations of these medications? One, for methadone, a huge limitation is government oversight and the reduced availability of methadone because it cannot be prescribed outside of opioid treatment programs or in the case of inpatient hospitalization setting. Other limitations are the potential for side effects. I spoke earlier about the mechanism, action of the medication and how tightly the drug binds to the receptor. That becomes important because buprenorphine is a safer medication due to having something called a sealing effect. This prevents an increased risk of respiratory suppression with increased, with escalating doses of the medication. That does not exist for methadone. And so with methadone, there's a greater overdose risk if someone were to misuse the methadone or attempt to use an additional opioid like heroin or fentanyl at the same time as when they were using methadone medication. And naltrexone works in a different way in that it prevents activation of the opioid receptors. This blocks the effects of outside opioids. So it blocks the intoxication piece if someone were to take an opioid and development of physical cravings. A limitation of this medication is it can only be administered after the opioids are stopped and opioid withdrawal resolves. If it's used for treatment prior to that time, it will cause a precipitated withdrawal. So folks will go into withdrawal very fast and very hard and it will be very uncomfortable for them. In addition to medication, treatment can and should, if possible, involve multiple other types of therapy such as motivational interviewing, CBT, contingency management, and community reinforcement and family training. Okay. One second. So in terms of overdoses, I apologize, this is a very busy slide. Between 2001 and 2020, I'm sorry, 2021 and 2022, the age-adjusted rates of drug overdose deaths increased for American Indian and Alaskan Native, non-Hispanic and Asian non-Hispanic people. For white non-Hispanic people and Native Hawaiian or other Pacific Islander folks, age-adjusted rates of drug overdose deaths were lower in 2021 than in 2022, and that's continued into 2023. In both 2021 and 2022, age-adjusted rates were higher for American Indian and Alaskan Native, non-Hispanic people. And American Indian and Alaskan Native people experienced the largest percent increase in the age-adjusted rate of drug overdose deaths from 2021 to 2022, with the rate increasing 15 percent during that time. And so this graphic just shows that data, and you can see for essentially all racial categories, with the exception of white non-Hispanic, there's an increase in age-adjusted overdose death rates between 2021 and 2022. Why is this important? Because recent data has shown that the overdose death rates have decreased in 2023 for the first time since 2018. So there were 107,543,000 drug overdose deaths in the United States during 2023, which is a 3 percent decrease from the estimated deaths of 2022, while only 3 percent is still a decrease. The issue is that that is kind of all comers in the U.S. population, but not stratified by race and ethnicity, because in certain racial ethnic groups did not appreciate that decrease in drug overdose death rates, and that includes the American Indian and Alaskan Native population and the Black American community. In Oregon, you can see the drug overdose deaths continue to climb. Oregon did experience a decrease in overdose deaths in 2023, but unfortunately, the final detailed count in data by race and ethnicity is not yet available. So we'll spend a few minutes talking about stigma. What's stigma? So it is a characteristic or condition that is socially discrediting, and it is mainly influenced by whether you think someone is to blame and whether they have control over their behavior. Two main factors influence stigma, cause and controllability. Stigma decreases when it is perceived as it's not someone's fault or that they can't help it. There are a number of types of stigma in substance use disorder and substance use disorder treatment that contribute, including someone's self-perceived stigma or stigma from within, feelings of helplessness, blaming oneself for their condition, stigma from the recovery community that's often seen. And this is particularly in looking at medications as replacement for their substance of choice and substance use and preaching of, say, an abstinence-only model as the only model of recovery, which is not true and is very harmful to the community. And then stigma from outside, stigma from others, family, including thinking that, oh, it's that person's choice that they have a substance use disorder. They just didn't try hard enough to quit, that it's not a disease. And then other, and the most kind of harmful stigma, in my opinion, is the stigma from clinicians, belief that treatment is ineffective or that certain populations wouldn't benefit from treatment or aren't worth treatment. It can be a belief, a value, or an attitude. In action, it leads to prejudice and discrimination. And language can be a bridge or a barrier for defeating stigma. And so how does stigma impact treatment and impact the care of folks with substance use disorder? It erodes the confidence that substance use disorder is a valid and treatable condition, creates barriers to jobs, housing, relationships, all of the factors that help to stabilize someone with a substance use disorder and improve their wellbeing and overall outcome, deters the public from wanting to pay for treatment, allows insurers to restrict coverage, and stops people from seeking help. It impacts clinical care and treatment decisions. And so you may ask, what can you do? How can I avoid stigma? One way is to, within your institution, perform a language audit of existing materials for language that may be stigmatizing and replace it with more inclusive language, like using search and replace and replacing the word addict with person with a substance use disorder or search for abuse and place it with use. And reviewing internal documents, policies, excuse me, and policies, mission statements, things that are circulated amongst clinicians, as well as patient-facing external forms, like forms that they would fill out and brochures. And so you ask, what terms can you avoid? What should I use? How do I have conversations about substance use and substance use disorder without further contributing to stigma? Instead of using words like addict, user, drug abuser, you'd want to use person-first language, person with an opioid use disorder, person with an opioid addiction, patient, or person in recovery, for someone who's engaging in heavy alcohol use, unhealthy alcohol use, harmful or hazardous alcohol use, or person with an alcohol use disorder versus other colloquial terms that are frequently used, like alcoholic or drunk. And we do this because person-first language shows that a person has a problem versus that they are the problem. The terms to avoid, avoid elicit negative associations, punitive attitudes, and individual blames. When talking about children and babies, you don't want to use terms like addicted baby. It's a baby born to a mother who uses use or use drugs while pregnant, a baby with signs of withdrawal from prenatal drug exposure or neonatal opioid withdrawal or abstinence syndrome. And it's simply because babies cannot be born with addiction because addiction is a behavioral disorder, but they are born manifesting withdrawal symptoms. Other recommendations replacing habit with substance use disorder and or drug addiction habit implies that a person is choosing to use a substance and equally can choose to stop. It also undermines the severity of the disease. And instead of abuse, you would use use for illicit drugs or misuse or use other than prescribed for prescription medications. Abuse has a high association with negative judgments and punishments. And the legitimate use of prescription medication is limited to use as prescribed by the person to whom they are prescribed. And consumption outside of these parameters is misuse. And you want to consider the motivation and intent of misuse to determine whether the specific instance suggests a substance use disorder. And instead of opioid substitution or opioid replacement, we discuss it as opioid agonist therapy, medication for opioid use disorder, or just simply pharmacotherapy. It's a misconception that medications substitute one drug for another or one addiction for another. And then lastly, in terms of talking about testing and use, instead of clean, if you're talking about test results, you can say testing negative. And if you're talking about someone being in recovery or abstaining from drugs, you can use the words they're in remission or recovery, they're abstaining, they're not currently or actively using drugs. And this enables us to use clinically accurate non-stigmatizing terminology the same way it would be used for other medication or other medical conditions. And setting an example with your own language when treating patients who might use stigmatizing slang, use of terms may evoke negative and punitive implicit cognitions. And then lastly, instead of dirty, if we're talking about toxicology screening, they're testing positive. And then for non-toxicology purposes, referring to persons who use drugs in the same reason, you want to use clinically accurate non-stigmatizing terminology the way it would be used for other medical conditions. Okay. And I think that the link to the survey works. So that is all I have covered. I think there's something in the chat. Sorry. Are there any questions? I know I have plenty of time for questions. Yes. Dr. Jackson, will we have access to the slideshow? Yes. Okay. That's right. It's going to be recorded. That's right. Two weeks. I just want to say it's a great presentation. Thank you for the information. And just I appreciate the fact that you talked about the science, you talked about the impact, showed the data, you talked about the diversity of populations and how it manifests. And so really a good foundation. And so I just want to say thank you. I don't have any questions. I think some of the things about language will be helpful because we'll have the slideshow and we can work with it and look at things in a pace that's more conducive to some of our variety of profiles here, our diversity and stuff. So great presentation. And I can put together a list of resources to access as well for further information on language and stigma and some of the data as well. Thank you. We encourage you to take a minute and fill out this quick survey. It really does help us improve our services and also helps us maintain funding to continue providing services. It looks like Trevor has a question. Go ahead. No, thank you. Thank you for clarification. Thanks a lot. I don't have any question. Okay. Yeah. I have a question. If you could speak just a little bit about the prevalence of dual therapy and what the purpose of dual therapy is. I think that just in speaking with the public and clients when it comes to suboxone, there's a little bit of misunderstanding about the difference between mono and dual therapy formulations. Oh, okay. In terms of the mono product? Yeah. Versus like suboxone. Buprenorphine versus the buprenorphine naloxone. The mono product is just the buprenorphine piece. So just the opioid agonist piece. It's kind of similar to methadone without the naloxone. The naloxone piece is added essentially as a deterrent for misuse because that helps to reduce cravings and also reduce the kind of intoxicating effect of the medication and allows for there to be that sealing effect. So it's a little bit of a mix of both. Where someone, say if they're prescribed more suboxone, won't experience the respiratory depression but would continue to experience relief from pain or the analgesia part. Any other questions, they can also be typed into the chat. Okay, well, I'm going to go to the next slide. It just has the information about continuing education. Yes. Okay. Yes, so you all can take a screenshot of this, but I actually what will probably be easier is I will send Ron this information in an email and Ron, are you okay with sharing this with your team so they can access the recording, or this will be asked access to the claiming continuing education credits. Yes, I can do that. And set it up. Okay, yeah, so yeah, that you do have to create a PCSS account but that's free takes just a minute, and then you should be able to claim that credit. And then I will also be sharing the recording from today and within about two weeks. Okay, Emily will the credit, let's see most of course, what form will it come in is it a certificate is it a. I. Yes, I believe you would download a certificate. Okay, and we all be requested. Okay. Yeah. Thank you. Are there any other questions from anyone. If not, I just want to give a praise again the doctor Danielle Jackson for her willingness to formulate this for us and I look forward to future trainings. And thank you Emily for coordinating and putting things in place. We'll get ahead of this a little better next time and probably have more participants but good information, and anybody that has any questions feel about SUD staffer locally here that is on the screen please feel free to reach out to me to Trevor Gillies, or myself in the program, and we'll try to see if we could be a resource to find a resource to get you some feedback. I just want to thank you all for attending a special thanks again to Dr. Daniel Jackson and Emily Mossberg from the more opioid resource network. And I think if we don't have any questions or comments or anything else to be added. This is includes us and I wish everybody a happy weekend. Thank you all. Thank you.

opioid use disorder

stigma

person-first language

medication options

harm reduction

fentanyl

evidence-based treatments

community support