All righty, I want to welcome everyone to this webinar. The title is Everything You Wanted to Know About Substance Use Disorders, But Were Afraid to Ask, and it's being brought to you on behalf of the Connecticut Department of Mental Health and Addiction Services and Whiting Forensic Hospital and sponsored by the New England Region Opioid Response Network. Next slide, please. I'm Kathy Whalen, Technology Transfer Specialist working for the New England Region ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Services Administration, and our grant prime is the American Academy of Addiction Psychiatry. We provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulant use disorders, and we cover the areas of prevention, treatment, recovery, and harm reduction. Next slide, please. This is provided at no cost, as is covered through the SAMHSA grant. Our organization covers the entire United States and the U.S. territories and is broken up into regions, who all have technology transfer specialists who can assist you with a request. And the next slide. If you wish to submit another request in the future, our contact information can be found in this slide. And today we're fortunate to have Dr. Jamie Meyer as our presenter for the topic. Dr. Meyer is an Associate Professor of Medicine and Public Health at Yale and the Associate Program Director for Research of the Infectious Disease Fellowship Training Program. She's a practicing physician who is board certified in internal medicine, infectious diseases, and addiction medicine. Her NIH-funded clinical research lab focuses on HIV prevention and treatment for women, addressing social and structural determinants of health. Her ongoing projects involve HIV prevention and treatment interventions for women involved in criminal legal systems, attending to reproductive health needs, intimate partner violence, substance use disorders, and homelessness. Her clinical work and research are motivated by her experience working as an HIV care provider at the only women's prison and jail in Connecticut. Before I turn the webinar over to her, I wanted to review a few of the Zoom controls that you'll be using. I enabled the live transcript feature if you wish to use it. Please drop your name in the chat, and you can also use the chat if you need any technical assistance or for any topic-related comments. The webinar will be recorded during the didactic portion, and you'll be muted and your cameras will be turned off. Your participation is highly encouraged, so please use the Q&A box for any questions that you have during the presentation. When the presentation is finished, I'll turn the recording off and we'll open up to the Q&A session, and at that time we'll address your questions. If you wish to speak with Dr. Meyer directly at the end to ask a question, you can use the raised hand feature. I'll be able to promote you as a panelist, and you'll be able to unmute and turn your camera on. The last slide in the presentation will include a link to our learning management system. Our PCSS learning management system is free, and if you do not already have a PCSS account, you'll see in the slide there's a link to create one. Once your account is created, you can use the second link to gain access to the course materials, including the slides and the recording. The recording will be uploaded to the account in about three to five days, so check back if you don't see it. Our ORN evaluation and survey can also be accessed here, and we ask that you please take a few minutes to complete it, as your feedback is very important to us and allows us to see how we can improve our services. Once completed, you'll be able to download your certificate of attendance, and I'll also put those links in the chat towards the end as well. So thank you for your time, and I'll now turn this over to Dr. Meyer. Thank you so much, Kathy, and it's good to be with you all today. I'm thrilled to be able to, you know, be invited and to talk to you today about substance use disorders. Let's see. Here are my disclosures, and I have no conflicts of interest to disclose. I have some borrowed slides here that I've noted. I really get tired of hearing myself talk, and, you know, here on Zoom, we, like, scream into the void for a long time, so I really do hope that you participate, as Kathy mentioned. That'll kind of involve putting questions in the Q&A, and towards the end, we've left some time for you to ask questions. Please feel free to raise your hand, no question too small, and really want to just engage in respectful dialogue, and that means being respectful of other opinions, being mindful of time and attention, and trying to use non-stigmatizing language, and what that looks like is really using person-centered terms to think about people with substance use disorder or people who use substances. Just a few things to point out here, you know, we don't talk about users or addicts or drug abusers, right? We want to talk about people with substance use disorder, people experiencing addiction. The terms abuse and dependence have really fallen out of favor. I'm going to tell you exactly what substance use disorder is, and so we're going to use a clinical term of substance use disorder. When we talk with our patients, we don't talk about clean or dirty urines. They might talk about it in that way, but we are talking about a clinical diagnosis, so negative or positive urine drug tests. The terms opioid substitution or opioid replacement therapy have really fallen out of favor. We're going to talk about opioid agonists today, and also just of interest, we don't talk about medication-assisted treatment. That term has really fallen away. You might see that abbreviated in some of the older slides, but we're going to talk about medications for opioid use disorder or medications for alcohol use disorder. Opioid use disorder meds are usually abbreviated MOUD, and that's because medication-assisted treatment is actually a redundant term, right? We don't use that term for anything else like hypertension management. Yeah, so, and this isn't to be politically correct or have you walk on eggshells. This is really so that we can be respectful of our patients and their clinical diagnosis. So, our goals today are really to try to address a few questions. We're going to talk about what substance use disorders are and who is affected by them. We're going to talk about how they're treated, and I'll try to focus a little bit, I have a few slides in here on treatment for people who are leaving institutions. A lot of the data on people leaving prisons or jails might be relevant to your patients discharging from Whiting. And we'll really try throughout to differentiate fact from fiction about opioids. I will note, when I had our initial planning meeting here, you did ask me to talk a little bit about stimulants. I will run out of time if we focus too much on stimulants here, but I'm happy to answer questions about them, and I'm happy to come back another time and talk more focused on stimulants, but today we're really focusing on opioids. Okay, so what are substance use disorders? Here's your neurobiology 101. Okay, so importantly, addiction is a disease of the brain. For those of us who are children of the 80s, you know, this is your brain, this is your brain on drugs. It was real. It wasn't just an ad campaign, right? So, addiction is not a matter of willpower. It is not a moral failing. It is a chronic, relapsing, preventable, and treatable disease of the brain. So, this is actually your brain on drugs. This is what happens. These are the different parts of the brain that are sort of activated when people are using substances. So, when people are anticipating substance use, anticipating intoxication, these green parts of their brain here light up. When they're actually using and experiencing intoxication or high, the blue parts light up. And then when they're withdrawing or experiencing this negative effect, the red parts light up, right? And as these cycles go on and on and on with repeated use, there's actually neuroadaptations that happen. So, people go, for example, from using drugs to feel high to just using drugs to feel good to actually using drugs to not feel bad, right? And as these neuroadaptations happen over time with chronic use, we see these behavioral changes where people's function starts being impaired by their substance use. And by that point, they'll start to meet criteria for a substance use disorder. So, this is also your brain on drugs. You see these different parts of the brains that are activated with dopamine neurotransmission. And this is why people use, right? So, here's the bottom box here. These are rat brains when they're given food. And you can see that they have a 150% increase of basal release of dopamine when they're given food, right? And when those same rats are given amphetamines, they have a 1000% increase in basal release of dopamine. And not only is it incredibly high, right, tenfold increase in this y-axis, but also it plummets really fast, which causes people to want to use again to, you know, to kind of chase that up, right? So, that's why and how people use and the changes that happen in the brain is because of it. There's a spectrum of substance use, right, where the majority of people might use substances rarely, right, the little or no use. So, these are people who might have a glass of wine, you know, with a Saturday night dinner or something like that, but they have, you know, rare use or infrequent use and it's not impeding their function at all. In the middle here, we have kind of the majority of people who use, sorry, the next chunk of people who use substances, which are those who have at-risk use. So, they might be using with increased frequency or increased quantity, but they're not necessarily impairing their function at all. And then kind of a smaller proportion of those people have a substance use disorder diagnosis and I'll talk a little bit about what those criteria are. But all of this, this at-risk use and substance use disorder constitutes unhealthy use, right, that warrants intervention. And it's really only the tip of the iceberg here who gets substance use disorder treatment, right. It's estimated that about one in 10 people who have a substance use disorder, whether or not it's diagnosed, actually get treated. So, tip of the iceberg. Okay. So, what is a substance use disorder? We can think about the framework of the three Cs, this is sort of to help you remember. Craving, control, and consequences. Okay. So, craving are these kind of physiologic criteria where people are needing more to get the desired effect or they're experiencing withdrawal, which is the syndrome of physiologic withdrawal that experiences when people experience when they reduce or stop their substance use. The second C is control. People have a loss of control, so they're using more larger quantities, unsuccessful attempts to cut back, right. And then, really importantly for this disorder diagnosis, they're experiencing consequences. So, it can be continued use despite threats to their physical safety, to their relationships, right. So, for instance, you're seeing people starting to have, you know, get arrested for DUIs or they're failing to, you know, failing to show up at work, fulfill their major role obligations, things like that. And for an individual to be diagnosed with a substance use disorder, they have to have at least two of these 11 listed criteria within the past 12 months. And obviously, the more criteria you meet, the more severe your substance use disorder is. So, who is affected by substance use disorders? So, this is data from the SAMHSA National Survey of Drug Use and Health that asks everyone age 12 or older who's surveyed about their substance use in the past 12 months and potential effects of their substance use. And they found that 17.1% of people who were surveyed actually met criteria for a substance use disorder. So, that's 48.5 million people. Of those, about half have a drug use disorder and about half have an alcohol use disorder. And a small proportion, well, relatively small proportion of people with a drug use disorder have an opioid use disorder. And I say small, like in quotes, right, because it's still 5.7 million people. This kind of trend has been flat from 2023 to 2022, but the rates of substance use disorder overall have been going up over the past few years. People are using more. Importantly for the population that you serve, co-occurring substance use disorders and any mental illness are incredibly common. So, it's estimated in the most recent survey, about 20.4 million people had co-occurring disorders. And any mental illness could, you know, it was mostly depression, but it could be of any severity. Kind of also relevant potentially to the population you serve, you see there's an incredibly disproportionate number of, a disproportionately high prevalence of substance use disorders among people who are incarcerated or institutionalized. So, incarcerated in state and federal prisons, arrested at least once. You know, this was the survey from 2016, right, it's only gone up since then, but a prevalence of in the 40th, 40% or so compared to 8% of the U.S. population at the time. So, very disproportionate concentration of people with substance use disorders in prisons and jails. Some of you may remember that it was for the first time in about 2010 that drug and alcohol poisoning or overdose became the leading cause of death for U.S. non-Hispanic white adults ages 45 to 54. This exceeded their rates of death due to lung cancer, suicide, chronic liver disease, diabetes, anything else. For the first time, this was sort of monumental. And even though in the beginning of sort of the opioid epidemic, people who were non-Hispanic white were disproportionately represented in terms of overdose mortality, this demographic has certainly shifted and the disparities are quite different now and I'll show you that in a minute. Age-adjusted overdose death rates differ by state, so even though in Connecticut, you know, we think that we have quite progressive policies and, you know, we're really attuned to meeting the needs of people with opioid use disorder and preventing overdose, we have one of the highest overdose death rates in the country. This is sort of the 95 corridor. This is the drug trafficking group. So, here's what I was mentioning. There are significant racial and ethnic disparities in terms of age-adjusted overdose deaths, so that in 2022, for the first time, the highest prevalence of overdose mortality was among people who are American Indian and Alaska Native, and then increasing rates of overdose mortality among people who are black and non-Hispanic as well. The other racial and ethnic groups are essentially flat from year to year, but this is incredibly high, just contributing to health disparities. To add to the, this is a good news, bad news, good news slide. So, to add to the depressing news, is that in 2023, there were 107,432 drug overdose deaths in the United States, the majority due to opioids and synthetic opioids. That's the bad news. But the good news is that for the first time, we saw a decrease in overall drug overdose rates. So, maybe the tide is starting to turn a little bit, right? This is starting in 2021, where we started to see the rise of fentanyl. Okay. So, I'm going to zone in on fentanyl and xylosine and management of overdose, because I think these are sort of the newer kids on the block that just disproportionately contribute to overdose deaths, and I'll talk about why. Okay. So, let's start with fentanyl. Over 150 people die per day from overdoses related to synthetic opioids like fentanyl. So, this on the left, 30 milligrams, this is a lethal dose of heroin. This is a lethal dose of fentanyl. So, basically, think about some table salt, like a few grains of table salt in your hand. That is enough to be a lethal dose of fentanyl. It's incredibly potent. So, how do we know that someone's having an opioid overdose? You're going to look for someone, obviously, when you find someone who's not conscious or not responsive, they might have pinpoint or very small pupils. They may gurgle or kind of snore, have irregular breathing or not be breathing, and they look hypoxic, right? They might be foaming, they might be grayish, and perhaps you'll see some drug use paraphernalia around. So, just like any person that you would come upon, you're going to want to check for consciousness, you know, shake them, call their names, try to, you know, give them a good sternal rub. If no response, the first thing you should do, like you should do among anyone who you've come across who's not conscious, is to call 911. Check for a pulse. This is just basic, you know, CPR, right? If there's no pulse, start CPR. And then, if they're still, if they have a pulse, but they're not breathing, we're going to give Narcan. So, Narcan comes as a nasal spray. I'll show you some pictures in a second. Tilt their neck, put the Narcan spray right in and spray it in. And then, watch them for two to three minutes in their recovery position, and if they still don't respond, you can give them another dose. And usually, for fentanyl, we say it requires at least two doses. Hopefully, that will buy you enough time to have an emergency response come. So, in 2023, the FDA approved the first over-the-counter naloxone nasal spray in a 4-milligram dose, which means that anyone can have access to it. We should all be carrying it. And for our patients, you know, you can give them a prescription for it, and I'll talk a little bit about that towards the end. But we often give them a prescription for two of these, because with fentanyl, you want to be able to give a 4-milligram dose and then another 4-milligram dose if there's no response. Okay. What about xylosine? So, xylosine is also called Trank or Trank-Dope when it's mixed with fentanyl. If any of you are on, you know, social media, you might see these images of people kind of walking around. They're known as Trank-Zombies. And they're a little bit more walking around. They're known as Trank-Zombies. They literally look like people risen from the dead, you know, like walking around like zombies. And that's sort of the telltale sign of xylosine. So, it's usually injected, and it can be mixed with opioids, but it can be swallowed or sniffed too. It lasts one to four hours, and people mix it with opioids because it increases the duration of sedation or it gives it legs. So, as people have been using more and more higher doses of opioids, including with fentanyl, they need the xylosine to get the longer effect. The 23% of all fentanyl powder that was seized by the DEA in 2022 had xylosine in it. And I'll show you data just showing how much more there is now. Just in terms of how it works, it is not an opioid. It is a sedative. It is a tranquilizer. It is basically like a clonidine analog. So, it is not approved for use in humans, but problematically, it is not a controlled substance. It's a veterinary drug that's a horse anesthetic called anesthesia de caballo. So, a lot of people, you know, will call up vets' offices and say, you know, my dog is sick or whatever, and basically get a prescription for xylosine. Naloxone will not reverse the effects because it does not work on that opioid receptor, but you should give it anyway because a lot of people are mixing their xylosine with opioids. And think about it like if someone had a clonidine overdose, right? So, the effects are sedation, low blood pressure, low heart rate, overdose, death. And it's really known for having these very complicated skin and soft tissue infections. So, if you're eating right now, like just pause for a sec because in a couple slides, I'll show you some pictures of some of the skin and soft tissue infections related to xylosine. Okay. So, it was actually in Connecticut where an MMWR came out in 2021 just showing the increasing proportion of overdose deaths related to xylosine. This number has only basically doubled in subsequent years so that in 2021, xylosine was found in 20% of all overdose deaths. And almost all of these are also positive for fentanyl. So, there's lots of mixing happening. And fentanyl is kind of ubiquitous in the supply. Like there's almost no, there's very little pure heroin in the New Haven area anyway. Almost everything is fentanyl. So, these are xylosine induced skin ulcers. This happens for lots of reasons. It's not necessarily at the site of injection, but these horrible ulcers that can be quite debilitating, horribly painful, and often get infected. So, it's often the reason why people aren't presenting to the hospital. So, if you find someone who has a xylosine overdose, we want to take those exact same steps we just talked about, including giving naloxone because of the mixing of xylosine and opioids, right? But importantly, there is no commercially available antidote for xylosine. So, you want to make sure someone's in the recovery position. You're going to check for pulse and breathing. You're going to give them supportive management. Like basically, it's just a matter of time. You know, it's one to four hours until the xylosine wears off. But always, you know, check for pulse. Start CPR if there's no pulse. Give rescue breathing with an ambu bag if you have one and give naloxone. So, just a little myth busting here because there's, you know, a lot in the public media anyway about xylosine and fentanyl. So, importantly, xylosine is not naloxone resistant. It's just not an opioid. It just doesn't work on the same receptor at all. So, there is no known available antidote for xylosine. For both xylosine and fentanyl, there is no known risk to first responders from xylosine exposure. There's no known risk of accidentally touching it unless you're ingesting it. Xylosine does not cause flesh-eating wounds like the ones I just showed you. Those aren't flesh-eating wounds. Those are just skin and soft tissue infections. And these wounds are not contagious to officers or first responders. However, importantly, you know, sedation from xylosine will make people who use it less able to respond, less able to follow direction. Even though there is no known risk to first responders from handling fentanyl and xylosine, we do want to take universal precautions for lots of reasons. Just things like wearing gloves when you are working with someone with an overdose. I always have an extra pair of latex gloves in my purse. You never know what you're going to come upon. You just want to practice sharp safety. Be aware of sort of what's around someone. And, you know, consider using masks and eye protection really more because of COVID than anything else. And I don't think any of us are resuscitating people necessarily in the field with a bag valve mask. But, you know, if you have one, to use that instead of rescue breathing. Okay. So this might seem like really obvious, but just starting with the 30,000-foot view, why do we treat substance use disorders? Okay. We treat because symptoms like craving, withdrawal are really uncomfortable, right? And so we treat to reduce those symptoms for our patients. We treat to reduce morbidity. We know that with treatment of substance use disorders, people have reduced hospitalizations, ED visits, transmission of HIV and hep C and other bloodborne pathogens. They have reduced psychiatric substance use disorders, psychiatric disorders related to their substance use. They have reduced unemployment, reduced homelessness, reduced poverty. They have fewer interactions with the criminal legal system as well. Perhaps most importantly, we treat to reduce mortality and fatal overdose. And frankly, just treating reduces costs to the healthcare system, to society overall. And, you know, what I've seen in my own practice is that treatment has other benefits as well in that people are interacting and engaging with healthcare. When they're going in to get treatment for their substance use disorder, you know, maybe once in a while someone's checking a weight or a blood pressure, or they're getting some basic labs, or they're getting tested for pregnancy, or, you know, they're, you know, talking about HIV prevention or hep C treatment or whatever it is. So it's really one way to, for people to kind of enter into the healthcare system. Okay. So how do we treat? Evidence-based treatment for substance use disorders in general, and I'll focus on opioid use in particular, but in general, combination therapy. So we need behavioral therapies. We need pharmacological management. We need to treat the medical and psychiatric complications of addiction. And we need to address people's social and structural determinants of health, really meet their basic subsistence needs. We want to do all of these things all together. So I'm going to zone in a little bit on the pharmacological management, but that alone is insufficient, right? People need all of these things all together to treat substance use disorders. They don't just exist in a vacuum. Okay. So what are our options for medications for opioid use disorder? There are basically three buckets. We got methadone. So methadone is a full agonist. So you see the little mu opioid receptor here, and methadone fits nice and snugly into the full receptor, but does not cause any euphoria. So it fits in the same way that heroin does, but doesn't cause euphoria. So it's a daily oral medication, comes as a liquid usually. It's a full agonist, but it can only be given in a licensed drug treatment program. And maybe, I'm not sure if Whiting has a license, but you might be able to give that to your patients as well. Then we have buprenorphine, which also is an opioid agonist, but it's a partial agonist. So it like fills and sort of tickles the opioid receptor, but doesn't completely fill it the same way that methadone does. So what you have here is you're filling the receptor, so you're getting all the benefits of not having craving or withdrawal symptoms, and you still don't have euphoria with it, but you're not having the sedating effects that methadone does. Buprenorphine comes in lots of different formulations. I'll show you some pictures in a second, but it comes as a fill, as a sublingual film, as an injectable, and in a long-acting implantable rod. So these are the brand names here. And it can be given by any medical provider, a physician or APP, and we no longer need a DEA waiver to do it. So y'all should do it. And then we have naltrexone, which is an opioid antagonist. So unlike the other ones, right, it's fully blocking the opioid receptor. It comes as both a pill and a long-acting injectable. That's brand name is Vivitrol. And it also can be given by any medical provider, but it does have to be given in a clinic setting when you're doing the injectable. Okay. So the pros and cons are sort of like what I think are pros and cons, but it's also what our patients often think of as pros and cons. So when you're deciding which option to give people, you want to weigh these things out with them. Hopefully you're doing some shared decision making that people are able to participate. Some pros of methadone are that it's highly structured, directly observed therapy, right? So some of our patients, especially people who have been in a system for a long time, whether incarcerated or in other institutions, they're very used to these highly structured settings. And so that can help them, that it is a highly structured outpatient setting. It's time tested, right? Methadone's been around since the 60s. So because of that, it has the best evidence, especially for people with very severe opioid use disorders. It's super cheap. It's a treatment of choice in pregnancy since the 1960s because it's been around forever. And someone asked me in advance about allergies to methadone, just to say that true allergies, like IgE mediated allergies to opioids in general and methadone specifically are exceedingly rare. So your patients might tell you they have allergies to methadone, but it might just be that they have reasons for not liking it, or it might be that they had experienced withdrawal because their dose was too low or something like that. So you want to tease that out a little bit. On the downside, it is highly regulated, right? So it doesn't work for everyone. Like if you're trying to work a job or like it can be hard to do that. And there's a culture, right, that comes along with standing in line, maybe with other people who you used to use with. So that can be hard for people. There are drug-drug interactions that one should be aware of when you're starting methadone, these pharmacokinetic interactions. The biggest ones are the risk of prolonged QT, and that happens especially when you have someone who's on another QT prolonging agent, like a lot of your patients may be on antipsychotics. I have literally seen someone go into Torsades because they were on methadone and got Cipro for a UTI. So these are things you just want to be aware of, like checking an EKG, checking the QT interval before starting methadone, especially if you're going to go for a higher dose. It can be highly sedating if you're not tolerant, right, so people get the methadone nod, and it is a pregnancy class C. Okay, what about buprenorphine? So this is a take-home medication, which really works great for a lot of our patients. It's less stigmatizing, right, because they just get a prescription from a regular pharmacy and go home and take it. It's available from any physician or APP. There are a number of trainings available if you want to learn more about how to prescribe, how to safely prescribe, but essentially we all should be prescribing it. It is not as sedating, so people don't get the nod. It is superior to methadone in preventing neonatal abstinence syndrome, so for your patients who are pregnant, and it can be used for pain management at higher doses. I really like it for my patients who have opioid use disorder and chronic pain because it sort of treats both. It is less structured. There is a risk of diversion, you know, basically if people are diverting, they're essentially treating other people. The only real risk with that is to people who are naive to opioids, and traditionally, the traditional initiation of buprenorphine, you had to be in mild withdrawal to start. So, you know, back when buprenorphine started to become available, a lot of people had this idea, oh, my gosh, they're going to have everyone sitting in my waiting room, like, withdrawing. They're going to be miserable. I don't want to prescribe that. But a lot of what we do now is to initiate buprenorphine without withdrawal, so this might be particularly relevant to your patient. I'm showing one example here of overlapping initiation on microdose, the Oxlane effect, but it might be particularly relevant to your patients who may not have used opioids for a long time, but they're at high risk of returning to use after discharge, and so they're at very high risk of overdose, right? If you've been institutionalized for a long time, and you go back to using what you used before, but now all of your receptors are almost like naive again, and, you know, there's no heroin anymore, it's all fentanyl, that's extraordinarily high risk of overdose, so we want people to be able to start buprenorphine, even if they're not in withdrawal. So this microdosing or overlapping initiation, there's lots of protocols, this is just one that I particularly love, where basically people are continuing to use their full agonist, whether this is, you know, they're on methadone, we're transitioning over to bup, or they're still using their oxycodone, or they're still using heroin, but they don't want to go into withdrawal. So we basically tell them, like, to start very low doses of buprenorphine, and as they're escalating the dose over the course of the week, they're also tapering off their full agonist. So by the end of day seven, they're on a full dose of eight milligrams BID of bup, and they're off their full agonist, or maybe they weren't on an agonist at all to start, and that's okay. There is another protocol to initiate without withdrawal that involves a transdermal patch called Butrans. I don't show that here, but it looks pretty similar, so you have overlapping use. There's some preliminary evidence on initiation of buprenorphine prior to release from jail, so this is data from the Rhode Island Department of Corrections, showing that when people are started on buprenorphine prior to release, as compared to people started post-release, they have a much higher rate of being retained in treatment following release, and that's up to, like, 25 weeks post-release. So just a nice proof of concept. We'll have more data on this soon, it's anticipated, but just a nice proof of concept that this kind of thing works for people leaving institutions. Okay, what about extended release naltrexone or Vivitrol? It's really, really good at reducing craving. It can treat both alcohol and opioid use disorders, so for patients who use both, it's helpful. I would say there's more data on it for alcohol use disorder, but it is a nice option for people who don't want a daily oral medication. You only need this once a month injection. You cannot be on opioids for pain or anything else because, remember, it's an antagonist, so you have a risk of sending someone into withdrawal, and they'll hate you, and they'll never want to come back. So you want them to be off all short-acting opioids for 7 to 10 days before starting, and off all long-acting opioids for at least 10 to 14 before starting. Sometimes we'll send a urine drug screen just to make sure that there's no more opioids in their system. Sometimes we'll give them a test dose of oral naltrexone before starting the long-acting. It does require a once-a-month nursing visit, so that doesn't work for everyone. There is some nice data from a large randomized clinical trial that Josh Lee did at Rikers that shows that you can give extended release naltrexone to people who are involved in the criminal legal system. I believe this was done among people who are on community supervision, but he has a trial that's ongoing for people leaving jail. And you can see that this is a significantly higher rate of relapse-free survival for people who are getting extended release naltrexone versus usual treatment. Okay. I was asked to talk a little bit about symptomatic management for opioid withdrawal symptoms. Maybe you have people when they're first being admitted who are experiencing withdrawal. I'll just start by saying when people are feeling really crummy, this is a great opportunity to initiate treatment with evidence-based medications for opioid use disorder, including buprenorphine and methadone. So if possible, don't do just this, but actually use it as an opportunity to think about longer-term treatment. However, if people aren't quite ready to start or there's other reasons why you're not starting medications for opioid use disorder, you can do a methadone taper. So your initial dose of methadone is based on basically the equivalent of whatever they were using as an outpatient. Try to get a rough sense of how much, what their morphine-equivalent dosing was and dose the methadone accordingly. And then you want to taper the methadone by 5 to 10 milligrams over 3 to 5 days, understanding that it'll last a long time. So you might want to even extend it a little bit longer. You want to treat their GI symptoms, nausea, vomiting, diarrhea, cramps, with loperamide or ondansetron. You can give them clonidine for their anxiety. You can treat their insomnia. You want to treat their headaches, muscle aches, bone pains. It means these flu-like symptoms are miserable. So yes, giving people ibuprofen or acetaminophen. And in the hospital, we often give people oxycodone as well, at least on a short-term basis. It helps with a lot of things, but on a short term, it's really good for some of their aches and pains. SAMHSA tip 45, it really goes through some more of the details on this. So if that's something you want to refer to, I would definitely recommend that. I just want to note that taper alone is not usually sufficient. This is one of many trials that have shown that medically managed withdrawal, including tapering after a short period of stabilization, does not retain patients in treatment. And it's unlikely to prevent a return to substance use, and it's more likely to lead to overdose. So this is just the taper condition over time compared to the maintenance condition. And I say that in part because in jail, the most effective treatment options are often the least accessible for people with opioid use disorder. So this is data from 2019, just showing only about 19% of all jails offered people treatment for opioid use disorder with medications, but about half of all jails just did the medical management of withdrawal symptoms. So least evidence-based, but that's what most people are getting. Okay. What about your patients who are getting ready to leave? You know, I just want to say we want to, you know, engage in shared decision-making. We want to offer medications for opioid use disorder. We don't offer treatment. Just recognize that in spite of treatment, it's like our little dose of reality, some people might continue to use, and absolute cessation might not be realistic for all people at all times. So we want to use these nonjudgmental approaches and talk to people about trying to minimize the negative health consequences of their use. So we want them to not share. If they're injecting, we want them to not share needle syringes or other injecting equipment. We want them to practice sterile injecting and use safer injecting sites that have a lower risk of skin and soft tissue infections and other complications, right? So arms are safer than groin or neck. Between the toes is not so great, just the high risk of infection complications related to that. We want to prevent overdose, certainly, and we want to give people access to harm reduction programs like syringe service programs where they can get single-use sterile equipment and learn about appropriate sterilizing techniques. I'm focusing in here on people who are injecting opioids, but just to say a lot of people use opioids in lots of different ways, and still syringe service programs are an important way to access other harm reduction equipment. So these are, you know, examples of some things that are available through syringe service programs, including the one we have here in New Haven. So we give people things like alcohol wipes to kind of prep the site. We give them sterile cookers and cotton with which to inject. We give them insulin syringes that are sterile for one-time injecting, and they can mix the sterile water with their substance to inject it, and then there is bleach and rinsing water here as well that's sterile in case they need to reuse their own needle, although we don't recommend that. And then we give them Narcan as well as other equipment to practice safe sex. Overdose prevention also involves people sort of knowing, you know, certainly Naloxone, we talked about that, but also like knowing what you're using. So there are fentanyl test strips out there. Actually we have them available at New Haven syringe services, but I tell my patients just assume that it's in your supply. When people test their supply and it's positive for fentanyl, most people will use it anyway, right? But we want to tell them don't use alone, and use the smaller quantity that you would normally use and have Narcan nearby. And even that is still not a guaranteed, you know, protection against overdose, but we want people to be aware of what's in their supply. And xylosine test strips as well are just an important tool for people to understand what's in their supply. I interestingly had a patient who has used heroin for a very long time, and she tested her drugs for xylosine and was so scared by it because she had seen pictures of tranq zombies and everything else that she threw away her drugs, which was a lot for her. So just it's really important for people to be aware of what they're using and what the risks are. There's a large study in the UK that actually provided naloxone to everyone who was releasing from prison. And it's just sort of interesting that the study was very effective in that it prevented a lot of overdose. It trained everyone, gave everyone naloxone, trained them how to use it. It prevented a lot of overdose. But a third of the time, the naloxone was given to someone else. So it has these like, and actually because of that, the study was stopped early. So it has these like wider public health impacts. So yes, prescribe naloxone on release, but just know it might be for the greater good. It might not be for your patient, and that's okay. Near and dear to my heart as an infectious disease physician, I just want to point out that treatment for substance use disorders is a really important part of combination HIV prevention for people who inject drugs. So we treat people because for lots of reasons, right, including that it's effective HIV prevention. And service programs, condoms, we talked about as well in terms of preventing HIV. The other things to think about for your people who inject or people who are using substances is doing HIV testing. Treat them if they're positive. If they're negative, offer PrEP, Hep C, and STI testing and treatment as well. Just seeing tons of syphilis in Connecticut. So you really want to use the opportunity as you're treating people for their substance use disorder to like engage them and care about all these things. I think we could probably do an entire talk just on what trauma responsive care looks like and how we can give people person-centered, you know, patient-centered care. We could do a whole talk on that, but just in a slide to say that most people, many people, high proportion of people with substance use disorders have experienced trauma. Trauma is also incredibly prevalent, I'm sure, among the population of patients that you take care of and certainly people in the criminal legal system at large. And so when we deliver treatment for substance use disorders, which is like a highly stigmatizing disease, we want to think about how to build trust, how to present people with choice, right? I gave lots of options when I was talking about medications for opioid use disorder. Not everything is right for everyone at all times, right? Think about how we can collaborate with our patients, empower them to make some choices if they can, and really to integrate services. This is, you know, kind of more on a systems level. We want people to access care for all things and kind of have a one-stop shop as much as possible. And a lot of this is about understanding addiction to support recovery. With that, I want to thank you. I'm happy to take questions. And I think…

Substance Use Disorders

Opioid Use Disorder

Epidemiology

Fentanyl

Xylosine

Treatment Approaches

Harm Reduction

Trauma-Informed Care

SAMHSA