Okay. So thanks, everyone, for coming. As you know, I've been working with the Healing Clinic, addressing stigma for patients or healthcare workers, taking care of patients with a substance use disorder. So I've partnered and have been collaborating with the Opioid Response Network. And Annette Hubbard from the Opioid Response Network is going to be presenting today on addressing stigma for patients with a substance use disorder. She has seven years of experience as a case manager in Menilchik, Alaska, which is a tribal clinic up there. And so with that, I will turn it over to her. Oh, yes, Donna just reminded me there's a sign out sheet for everyone that's attending in person. And then for those on Zoom, if you wouldn't mind putting your names in the chat. It just helps me keep track on who's here. Okay. All right. I'm going to stop share for a second. All right, everybody can see my screen? Yeah. Yeah. Hi, everybody. My name is Annette Hubbard. And like Megan said, I live on the Denina lands of Menilchik, Alaska. And today we're going to talk about stigma in substance use treatment. Chelsea, do you need to do this introduction here for this funding and stuff? We can just note that the Opioid Response Network is grant funded by SAMHSA. And so that's our acknowledgement here at the beginning. All right. I had a lot of fun with this. Thank you, Megan, for needing this training. This was a very fun training to work through. I have no financial disclosures. Like I said, my name is Annette. I am a person in long term recovery. For me, that means that I do not engage in people, places, things, or ideas that are damaging to my mental health, spiritual health, wellness. I am an addiction medicine case manager in a rural tribal health clinic. So I'm kind of a point person for our patients. I do outreach, community education. Our clinic focuses on harm reduction, low threshold care for people who use drugs and consume alcohol as well. I have previous experience working in inpatient psychiatric hospitals, emergency rooms, mostly behavioral health before I came directly to this position. And so what that really helped me do was kind of like working in an urban area helped me talking with people who lived in rural communities, understanding some of the gaps in rural communities, and which really kind of got me interested in working in rural communities. I'm also a consultant in different capacities, not just with the ORN in drug user health, harm reduction, treatment and recovery. And I do some work with SAMHSA. And I'm also a wife and a mother and I have two stepchildren who have been impacted by a parent who uses drugs. I'm also a board member and a volunteer at our local syringe exchange. And I think it's important to note that I work with a broad spectrum of people who use drugs, not just fentanyl or, you know, or directly looking for opiates. Sometimes it's substances that end up with cross contamination. And so, you know, educating community members about things like that with cocaine, ketamine, people who use substances at festivals. I think being in a rural community enables us sometimes to have some of that autonomy, where when you're in an urban community, there's more resources. And that kind of information can sometimes get spread around. And so I think being in a rural community, people can sometimes have a have a more access to more services when there's more concentration of education. So, you know, being a case manager, being the person who answers the phone when people need help. Yesterday, I got a call from one of our patients who has been in and out of our clinic many, many, many, many times. And she's currently in jail. And she called me and the first words out of her mouth was I have nobody else to call. And I thought, well, that's, you know, really great that I'm sometimes people's last option. And, you know, she's kind of one of those patients that's just like we commonly deal with that's just for the lack of terms frustrating. And one of those patients that I experienced my own kind of stigma to. But when I kind of listened to her about her ongoing living situations, and how using drugs is part of her housing situation, or how she manages her anxiety, or her chronic pain, or that she doesn't have anywhere else to go, or it's part of her dating situation. You know, also being somebody who's in recovery kind of meeting her where she's at, and explaining some empathy with her, and getting to know her and her history is a great honor. Number one, I think serving people who use drugs. I'm going to say this many, many times in this presentation, this is this is hard work. And so people come to us at their worst of times, just like I said, when I answered the phone yesterday, I have nobody else to call. You know, I don't know where to go. I don't know who to turn to. And so remember that when people are showing up to our clinic to seek services, sometimes we're the bottom is like we are rock bottom for some people. And for some people, they're just coming in to get some a boost in services to amplify their health care. And so it's important to remember that a lot of times I also get phone calls from people who I have dropped off at treatment and I dropped off a young man at treatment in January. And I talked with him the other day, he's graduating. And he's also kind of, you know, one of those street level dealers who just kind of got caught up in a sweep. And his only out was going to treatment. And he said, if I hadn't gone to treatment, I probably would be dead. So I think it's important to remember that we do save lives, regardless of what we think whether you know, and this is people that we hand out syringes to at our local syringe exchange. And we think, well, this is maybe as good as it gets. But to know that, you know, that constant working with people all the time, we get to see them through their darkest days, we do not get to dictate who gets better and who doesn't make it. It's not necessarily up to us. And so it's always walking with people along this journey that that makes it beneficial. So today, we're going to talk about patient barriers that can lead to provider stigma things. And we're going to address provider stigma to enhance just treatment services, whether that's general health care, access to medication for substance use disorder. And I've got a couple case presentations to mention in here, some stories to share. I really hope I'm going to share some of my stories, my personal stories about my own life, and a couple case presentations. I hope that, yep. I hope that that you guys kind of come along with this journey, we're going to kind of talk about some stigma. I just know, it is something that I come up against every day. And I have some really cool slides about that. If you have any questions, please feel free to ask. So my favorite quote, people don't care how much you know, until they know how much you care. So you can read about addiction, you can read about treatment, you can read about this stuff in books all day long. I think that until you've actually walked a mile in somebody's shoes, or sat down with them and cried or rubbed their back, it's a little bit of a different approach. And so a lot of our patients will say that our medical provider is the brains of the operation, and I'm the heart of the operation. And so that is kind of some of the, your staffing, the people who make up your, your group, the people who work within your clinic, how they talk with the people who come there. I think for me, my mentality is, is I'm here to serve the people who access the services at our clinic, not I'm here to set up services for you. So you need to get on board with what we're doing. That, that mentality, very quickly, I learned within the first three months of my eight year career here, that did not work. Trying to follow along some of these guidelines of, you know, this is a MAT program. If you do X, Y, and Z, you'll get better quickly seeing across these eight years, if that is not what happens. And, and just kind of following my heart with the people. So I have a, we've got a video to show. I'm only going to play part of the video. And it is a, it's a really great video. We'll see if I can get it to play. You need three things to survive. You need food, you need water, you need dopamine. Now, some of the people who get a little antsy say we also need oxygen. Yes. Well, we also need skin, but I'm not going to really talk about that today. We're going to talk about the three things we absolutely need to survive as a human in today's world. And that is food, water, and dopamine. We need dopamine because it's the chemical responsible for motivation. It's this thing that's responsible for us going and making a friend, having a mother, have a bond with a baby. It's the thing that motivates us when we do good to do better. When somebody pats you on the back and says, good job, and you go to do something more significant, that's because your dopamine has gotten pinged. And it's just something pushing you this invisible chemical that's pushing you along the path. On a normal day, we even know how much dopamine we're supposed to have. So on Monday morning, when I wake up and I have to get up and I go to work, I live in the range of about 50 nanograms per deciliter of dopamine that sits in the central part of my brain. And that's required for me to get out of bed and go get that first cup of coffee. Now, what about the worst day? The really bad day? The day you, you know, you call your office and you fake vomit in the phone and you decide not to go in. You're like, I just can't make it. That's about 40 nanograms per deciliter. So not much lower, but low enough to where you just want to sit around in your pajamas all day and do nothing. What about the best day ever? You know, the day where all at once you win the lottery, you have 2% body fat, and you're living on the beach. All of those things happen at the exact same time. We even know that one. That's 100 nanograms per deciliter. Our brain is meant to go all the way to there. It's not really meant to go above. And we can look at things like your favorite food, which is like 94 nanograms per deciliter. And sex, 92 nanograms per deciliter. Bummer, right? Couldn't have predicted that. Maybe they need to redo that research. But at the same time, we know that we're supposed to live within this relative normal state between 40 on a horrible day and 100 on our best day. So what happens when we add a chemical into the brain like methamphetamine? This chemical is really important because it pushes us way past that 100 nanograms per deciliter. In fact, it actually pushes up to 1,100 nanograms per deciliter, more than 10 times the amount of dopamine that our brain should be making. And then if we look at things like marijuana or alcohol or heroin, these are things that push it up into the high hundreds. This is not what we're supposed to be doing. As we look at this, we have the normal that we're supposed to be. We have this large jump for something like methamphetamine. And then we have these other drugs that drive that dopamine up. And when that happens, it starts to take over that part of the brain. And no longer does going to your child's birthday make you happy. It's not happening. The things that normally make us feel happy start to pale in comparison. This is because the brain is built to survive. In fact, we know that this is a survival issue for the brain, mainly because dopamine is what drives us to procreate, to get food, to get water, like we talked about. And we know so much about addiction and all of these things that are going on in that part of the brain that we actually know the parts of the brain responsible for this motivation and this dopamine release. It's places like the anterior cingulate gyrus, the lateral bed nuclei of the amygdala, the nucleus accumbens, the ventral tegmental area, the periaqueductal gray. We know this. And by the end of all of these videos on this site, you're going to know exactly what each of those parts do. But for now, you should understand that this area of the brain called the limbic system, which includes, but it's not limited to, the ventral tegmental area and the nucleus accumbens are responsible for reward. And the fact that we can look on an MRI and see these parts of the brain working and we can see them working in a patient who is not on any drugs and those that have been on illicit substances for a long time and see major differences in how these structures work is really important because it allows us to start to understand things like behavior. We can see that all of the focus is on the dopamine part of the brain. Remember that I wanted to touch a little bit on like the neurobiology of addiction and just remembering that it's kind of something really important to remember in the early stages of recovery for patients. Those who can't make appointments on time. Some of them are learning how to communicate with different community members than what they're typically used to. I mean, they're coming, some of them have to learn how to not swear every other word. So I think it's just one of those important things to remember that people are coming from all kinds of different backgrounds and the brain just takes some time to heal. And I think patients really get really frustrated with thinking that I have to remind patients constantly that addiction doesn't happen overnight. It kind of took maybe like three or four months. So for that onset of thinking that they're just magically going to get better and their cravings are going to actually magically dissipate overnight and their hep C is going to be cured magically tomorrow doesn't necessarily happen. It's kind of a process. All right. So the CDC reports that last year overdose fatalities decreased. Some of that has to do with the availability of pipes and the change in the way that people used drugs. This was a hot topic of a SAMHSA meeting last week. North Carolina overdose fatalities went down last year. A lot of this probably has to do with the availability of drug testing and sending in drug samples. We continue to see overdose fatalities rise in Alaska, Oregon, and Washington. This is probably with the rise in xylosine availability that has just hit. I can tell you that it just hit Alaska. So it probably has just hit you guys as well. And those of us not being a hundred percent familiar with, you know, I think most of us are familiar with wound care treatment. And I think it's, you know, again, the frustration a little bit with the reoccurring use just, you know, there's some promising States out there that fatalities are going down. So let's talk about some stigma. So this is a pretty great slide. And these were some things that as I was putting together this presentation and kind of thinking like, how can I talk with you guys about stigma? I found myself having these thoughts on a Friday at 445, a patient has been out of their meds for a week and they just now realized that. And I was getting frustrated about that. So I've, you know, kind of thought really like, like really? And I thought I should put this in this presentation because if I'm feeling that I'm sure there's providers who are feeling that as we're trying to get off work at right on Friday at five. One of the other common things that I feel a lot is I have myself as a case manager fought with my clinic about trying to make appointments for people who are using drugs more available. And I mean, like you guys, we have a mobile clinic that we run twice a month. I send out text messages, our local syringe exchange text sends out text messages. We have made it very available, but people still can't get to our mobile clinic. And our mobile clinic was made to also cut down barriers. We get it closer. So I feel that I am in the same boat with you guys. But for me, and my perception is for me, stigma, stigma affects patients when my negative attitude towards people, when I'm kind of saying like, well, you didn't make the mobile clinic. So too bad. You're not going to get into the clinic at all this week as the scheduler as the case manager. Nope. You get no access to the medical provider. Too bad. So sad. Sorry about your luck. That negatively impacts patients instead of having a conversation with them about like, hey, you know, let's let's let's work to get you in. I know that you guys, you know, have done a fantastic job in making healthcare accessible to people. And it can be extremely frustrating, but know that stigma definitely affects patients. And so when we are shortchanging them and blocking them from accessing services because they were five minutes late for their appointment, it does not sit well. It wouldn't sit well with you if you were five minutes late for, I don't know, any kind of appointment that you were having with a medical provider. One thing that I want to point out is that a lot of healthcare workers are affected by substance use, whether that's active use or maybe they're in recovery. And so be aware that maybe the language that you're using may be affecting somebody that's near you. As well, maybe they have a family member who is affected by substance use. So I found this pretty interesting and I think a lot of us also probably deal with anxiety. So maybe we might be on anti-anxiety medications. Again, the definition of addiction is kind of crossing that threshold and using and regardless of the consequences, but alcohol is pretty prevalent amongst our healthcare community as well. And I also want to point out that there are substances that do not come across, urine drug screens, and there are medical providers that may participate in some of those. And so it is very important to be acutely aware of our language when talking because we may have people who are sitting right next to us who may be using and have shame around that when people are talking about each other in negative attitudes. So as a person who's in recovery, who accessed treatment through my medical provider, I will tell you that the cycle of stigma within the healthcare system is alive and well. And I also continue to see this as a case manager when coordinating care with other medical providers. And I will tell you that nothing sucks more than being somebody who is using substances and maybe needs an antidepressant or just again wants to try one more time taking that medication to stop using substances and being looked at by your provider with absolute disgust of, well, we've already tried that. And so when you're kind of already dealing with a situation of, yeah, I know I've already tried that and it wasn't super successful, but maybe I could try it again. I'm coming to you as somebody who is struggling in my life to ask you for help. And so I'm trying to form kind of a relationship with you, a team membership. So kind of the same as if I'm coming to my medical provider for birth control and it's kind of like, hey, I'm coming to you so that I don't get pregnant. I'm coming to you so that I don't die of an overdose. Yes, I know that these are my choices, but you're here to help me. So remember those things. This is just the same slide kind of written a little bit different. The impact of substance use disorder is, again, it's far reaching. It can continue to keep people untreated from their substance use disorder. It can keep people untreated from hep C, HIV. It can create barriers to housing, barriers to accessing. I once had a patient who we had to kind of figure out how she could attend her mother's day brunch with her mother when she was well, because her mother did not want her showing up high and she wasn't really sure how she could do that. When all we ever hear is, those people are making those choices. We don't really get to see the benefits of people getting better or well. We are consistently defining the treatment of addiction based on abstinence instead of people getting access to housing or getting employment. And we are basing the concept of treatment and recovery on a urine drug screen instead of on their happiness. So that continues to perpetuate the stigma of addiction treatment. The two main factors that affect the burden of, perceived control that a person has over the condition and the perceived fault in acquiring the condition. And so I remember like working in, it's kind of like somebody who has a treatment resistant depression and treating them. Right now, ketamine is one of the big treatments for that. What if somebody doesn't wanna take that? Are we just gonna continue to say, well, that's their fault for wanting to lay in bed forever because they don't wanna take ketamine for that. And I think that when we just continue to say that, I think those of us going back to kind of that stigma slide, yes, I know that when I'm before and I have not taken anything. And I know that when I have made that choice to take something, I know that I have made that choice. However, please know that I am sick and I am unwell, whether that's mentally or physically or spiritually or anything like that. We gotta get down to that root cause. And so having those behavioral health specialists or those spiritual advisors or medical providers were coming to you for help. So I wanna talk with you guys a little bit about the most stigmatizing situation that I ever experienced in healthcare that motivated me to get my blood into school to become a nurse practitioner. So we all know that most people are secretive about their healthcare and what they're experiencing with new medical providers because they don't really want people to know what they have going on because they have their own shame. So we had this patient who she was a volunteer at our local syringe exchange as a peer distributor. She was a low threshold MAP patient, which means that she was still injecting drugs and she was on long acting injectable buprenorphine. She also lived at a drug house and she was a nurse by training, by education. She did a lot of community education with people who used drugs. She took care of a lot of them with wound care. She just like, that was just kind of what she did. She called me one day and said, I'm really, really sick. And I could just tell by the sound of her voice that she needed to get to the hospital. And I said, you need to go to the hospital. And she goes, I don't wanna go because they're not gonna treat me. And I said, you have to go. Like, there's just no other option. I can just tell. And so she called a mutual person that we both knew and he took her to the hospital and he called me and he said, she is not well. She is white and she is pale. And I went and visit her at the hospital the next day. And that nurse told me straight to my face. She said, she's drug seeking. And I looked that nurse in the face. This is the only issue that you're gonna have with her is trying to find a way to manage her withdrawal. That patient ended up having severe endocarditis. She needed heart valve replacements. She ended up in the hospital for three months. She ended up septic, medevaced, almost died. She now has been sober for 23 months. Probably one of, again, I live in a rural town. So let's keep this in mind. And she is actually a friend of a sister, or she's the sister of a dear friend of mine. She is somebody who watches my 19 month old son. And like for a nurse at the hospital to look me in the face and say she is drug seeking and to come out, like this is, I was floored. And I'm just gonna leave it at that. So we just continue to, this cycle of stigma just continues to perpetuate. And when we continue to see, patients have like, again, going back to her story, she had her own stigma. She's a healthcare worker by trade. She knew that the hospital wasn't gonna treat her. Like, why would she go get help? She almost died. And so when we have people who are thinking those kinds of things and they're on the brink of death, I mean, to get Narcan'd, you have to die to get Narcan'd. So these are the things that people are dealing with. Why would they wanna come to a clinic where they're just gonna kind of get the side eye for being 10 minutes late for their appointment? So we still have medical provider. So some believe that some people will not get treatment because they believe that medical providers specifically emergency rooms, but that they believe that medical providers send law enforcement data upon discharge. And so that can definitely be a reason. So we still have emergency services that underdose, don't dose ER doctors. I wanna know, is your location labeled? There's some clinics that only do MOUD treatment and they only advertise it as such. Like there's just this big billboard on the outside of their building that says, we treat opiate use disorder. And so every time anybody walks into that front door, everybody knows what they're going in for. That's a little stigmatizing, I think. Like everybody knows who goes in and everybody knows who goes out instead of just being kind of a primary care clinic. I myself, having a mobile clinic, like that's all that we do. I get that. Sometimes you're a little limited, but it's just something to keep in mind. So this is kind of the tree of liberation. This is from the National Harm Reduction Coalition on Undoing Stigma. And it just kind of talks about creating a team with your patient. And so some of the things that you can do is to change your language and your terminology, educate people. I myself, right, like being in school right now, guess what? All of my papers are on drug treatment, buprenorphine treatment, methadone, working with people who use drugs, whether it's in speech, all across the board, there's always opportunities to do stigma education. And I think my favorite though is definitely telling positive stories. And I try to incorporate that everywhere I go. This, definitely, you know, working on changing your language. I work with people who use drugs. That just could mean anything. It could be coke. It could be alcohol. It could be benzodiazepines. It could be ketamine. It could be LSD, anything. People use drugs across the spectrum. It doesn't necessarily mean that they're, you know, living in addiction, but language really changes things. Terms to avoid, clean dirties, talking with people about the results of their urine drug screens. One of the things that I really try to do is match their language. That also comes based upon a relationship and built on trust. So I don't just kind of right out of the gate, start using slang terms. That really comes with over time. And building street cred. I am gonna talk about compassion fatigue. I hate talking about compassion fatigue. I really, really hate the term compassion fatigue, but we gotta talk about it. So unfortunately, it is just kind of one of those things that I feel like kind of happens. And I feel like we just, over time, we don't pay attention to it because maybe you just get into a group. I feel like it's inevitable. I, myself, have resorted to compartmentalization kind of naturally. And maybe that just has to do with a longstanding history of life trauma. I'm not sure. But, you know, we deal with people who die every day or put themselves at risk of dying every day. So maintaining, you know, healthy, positive boundaries and relationships with them, boundaries and relationships with them is extremely important. But I will say that it is sadly part of the job, but we definitely have these tools to work through that, right? Like they all teach us about self-care again. But, you know, that's kind of one of those, I can't imagine doing anything different. And I can't imagine working with any other different demographic. Staff turnover is really one of those things. I think stigma and thinking negatively about patients is probably one of the biggest things. And we have definitely talked about, and we talked about this kind of when we were planning this too, you know, what are some things that you guys do within your organization that help to minimize some of that stigma? Here, we kind of chat and we do a little debriefing sometimes after a very difficult situation and sticking pretty close. Sometimes we hang out outside of work together to help build that team membership. Again, remember that addiction is a chronic disease and it needs a long-term plan. One of the things I also love to remember is that sometimes we are all patients have and we are sometimes the only support that they have. So again, we may be people's rock bottoms, we may be people's last resort, we may be all that they have for support. And so they may be living double lives and there may be people in their lives that don't know that they are in a treatment service program or services. And I try to tell people like that's not really everybody's business. Your healthcare is private. So what you do here is with us. I have a case presentation I just kind of wanted to talk about. This is something that we see pretty common ish. And I think you guys might be a little bit more urban. So I thought that this might be a little bit appropriate and I think I have a little bit of time. So you have a patient who has been with your clinic for a couple of months and he calls in Monday at 9 a.m. and says that he missed his appointment the previous Wednesday and needs to be seen urgently because he is out of a medication and experiencing withdrawal symptoms. So the front desk makes an appointment for him to be seen at 11 a.m. with his usual provider. And Joe calls at 1045 to say he's on his way. Who knows why? But Joe doesn't show up to the clinic till 145 and his provider is booked. So there was somebody who had an opening. Joe went in and saw that provider and Joe got a prescription. He's on 24 milligrams of buprenorphine and he walks out the clinic door, says bye. Joe did not tell that fill-in provider that he had used fentanyl in between Wednesday and Monday because he was out of his medication and he was experiencing withdrawals. And I don't know if your guys' clinic tests, your drug screen cups test for fentanyl or if you guys do fentanyl dipsticks. We do now because our UDS cups don't test for fentanyl. But that night at 11 p.m., Joe goes to the emergency room because he's experiencing precipitative withdrawal after he took his buprenorphine films and he cannot walk due to pain in his leg from an old motorcycle injury. So I may be throwing some new information at you guys, but he is very irritable and he was demanding that the ER take care of his withdrawal symptoms. You know, like the kind of patient that's like pounding on the desk at 3 a.m. at the ER? That's Joe. So there's some kind of things about Joe that we need to pay attention to. That one is that he was five days late on his med refill and that he forgot to disclose to his provider, the fill-in provider. And remember, he's only been with your clinic for a couple of months. So he kind of may be new to some of this information and like new at the game. He goes to the ER at 11 p.m., which was a little complicated. And the ER hasn't really had buprenorphine training or any MOUD training. So they're not really sure about, you know, how to treat buprenorphine withdrawal or opiate withdrawal or really kind of like what's going on with Joe. And it's 11 o'clock at night, so they can't really call his provider, nothing. Joe's not being very nice. And the ER staff has a history with Joe. And so they're just not really having it. So there's, I don't know if you guys have heard about this. It's called withdrawal-associated injury site pain. It's called WISP. And it is kind of this referred pain that is coming out of people who are experiencing opiate withdrawals. And we see it a little bit kind of common where randomly people will just kind of be like, yeah, I had this, you know, when I was 16, I broke my ankle playing football and I'm 35 now, and I'm just having this random kind of body pain when they're going through opiate withdrawal. So there's some resources within this PowerPoint presentation, but you can look it up. It's called withdrawal-associated injury site pain, WISP. So just to kind of follow up a little bit about Joe, some things to think about with Joe. He's obviously dealing with some transportation issues. You know, does anybody call patients after they leave their appointments to follow up with them, check in with them, see how they're doing? Does the front desk call if they left and they didn't make an appointment? Did the fill-in provider do anything wrong by not asking him, you know, hey, did you use anything between then and there that wouldn't show up in your UDS screen? And what medications could the ER give him at 11 p.m. to help make him comfortable? And that is the end of my presentation. I don't think, were there questions in the chat? I didn't see any. I think there are people putting them in. Do you guys have questions? Comments? What is xylosine? Feedback? Can somebody ask what xylosine is? Yeah. Xylosine is a veterinary clonidine that is showing up in our opiate supply. People are having a really hard time. It's a beta blocker, and we're treating it with clonidine and benzodiazepines for withdrawal. People are really having a hard time. Right now, what we're seeing is the pressed pills, and we're seeing low amounts of fentanyl and high amounts of xylosine in it. It's kind of like tizanidine, and so we're just seeing a lot of that. Is that what is causing people to be on domer? Yes. I can kind of hear you. It is amplifying that, so people really don't know. You can procure xylosine. It's like the fentanyl testing strips. You can procure xylosine testing strips. I don't know if your state opiate treatment authority person can procure them. Our state does, but they are used in the same manner as the fentanyl testing strips. You can get them from BTNX. I don't know what your guys' opiate or your funding looks like. I think xylosine is a tranquilizer. It is, yes. They call it TrankDope, but xylosine is an animal beta blocker. It's what's in our drug supply right now. It is showing up in methamphetamine. It's showing up in everything right now. There's no reversal agent for it, correct? Nope. Narcan doesn't work on it? No, but it is, I mean, it is not being marketed as a standalone. It is in stuff. It is spelled X-Y-L-A-Z-I-N-E. Mostly, you're going to mostly see wound care. Your patients are going to start complaining about their drug supply, so ask them about their drug supply. I don't know if you guys already asked them about their drug supply. or how like MAT heavy you guys are or drug user health heavy you guys are how many people you have that use drugs that come into your clinic directly for that kind of stuff I kind of heard that. So she was saying that the here at the primary care clinic, they mostly see all the stable stable patients, and we only do Suboxone. And then the healing clinic is probably are the ones that do more of what you're talking about. Right? Yeah, like the rapid stuff and like the, yeah, more emergency acute care kind of stuff. Yeah. That's pretty much the end of it, unless you guys have any other questions or comments. Thank you. Thank you guys. Thank you so much, everybody. We will have the recording ready for you in about a week or so. So we'll make sure we get that over to Megan to share with you all. And you'll also be able to access your CEU credits once that recording is uploaded. So please let her know if you have any issues with any of those links, and we'll make sure that you guys have access to those credits. And thank you, Annette. There's a QR code that I forgot to share for this. Should I pull that slide up? Yeah, you want to go ahead and pull that up. I can also add it to the chat for everybody. And then we can. I will include it in the link as well that was sent out for the CEUs.

substance use disorders

stigma

healthcare

addiction treatment

neurobiology of addiction

compassion fatigue

empathy

case study