Hi, everyone. Welcome. Thanks for coming. We'll talk about all the good stuff for opioid use disorder for a good kind of intro here. And really informal, please interrupt me with any sort of questions, put in the chat any of those kind of questions. You're going to be like, I need to know that, or I've wasted my hour sort of thing. Please put those in the chat or just interrupt me. Today, I wanted to start with just, they told me about 30 or 45 minutes of content and then open discussion and we can be up to an hour and a half, they were saying. But I want to start with just kind of some of the like the foundational like medications for opioid use disorder and primary care, kind of what is it? And let's just share the perspective for that. And then introduce some of these core concepts that come up a lot, like tolerance, withdrawal, opioids, brain receptor biology, and like how you talk about that with patients. What are the three FDA approved medications for opioid use disorders? And then kind of integrated here is like how nurses and other care team members can support those getting primary care treatment for an opioid use disorder. And then just really informal questions. But I don't have to show you this slide. It's like, you're pretty aware of this trend that we've noticed. But there's a lot of stuff we can do about it. These are the sort of terms that come up a lot. And it's been kind of an evolution of what we call kind of giving, essentially giving buprenorphine for an opioid use disorder. And so the preferred term right now is medications for opioid use disorder. The medication assisted treatments fell out of favor because the medicines are the primary treatments rather than just assisting another treatment because they haven't shown a benefit to the kind of behavioral health abstinence only treatment, the same way that medicines show a big benefit. So really the medicines are the primary treatment. And then office-based opioid treatments was more of an East Coast thing. And then opioid substitution therapy kind of had this idea that you were substituting one drug for another and the kind of outcomes were equal, which is not the case. So that's why the MOUD is the preferred term now, although it was kind of funny when it was met for me anyway. And then more kind of like semantic stuff that may not matter, but an opioid is the whole drug class, including the synthetic ones. And opiate is really just referring to the three derivatives of the poppy, which is morphine, codeine, and heroin. And actually buprenorphine is, there's this compound called febane in the heroin poppy. And buprenorphine is a slightly modified one of those kind of like minor compounds that's in the poppy. But the kind of clinical side, right? So like if you look at like unintentional opioid overdoses per 100,000 population, like we always think about this as kind of an urban phenomenon, but the data shows us that it's both, and it's also a much higher risk for a rural phenomenon. And then these rates also inversely correlate with the number of providers offering treatment in their local zip code. So we see that the buprenorphine medicine is life-saving in preventing overdoses, as well as helping people achieve prolonged abstinence. And graphs like this, I think are just kind of like a stark, I guess, Valentine's Day-esque color scheme reminder for that. And then another kind of good introductory thing is this PBS documentary, Chasing Heroin. I just thought it was really, really well done. So I put that out there for anyone that's interested. But the typical experience is people are going in and out of withdrawal throughout the day, typically having to use anywhere from like four to 10 times a day to stay at a withdrawal, which is quite a kind of time occupying activity. Not infrequently, you'll have people in like the second or third follow-up and they're like, what do I do with my day now that I'm not using drugs? I'm trying to obtain drugs all day, which is a really fun kind of motivational interviewing segue to get into. But anyway, I just want to just kind of start with like, obviously, this is important to you if you wouldn't be here. And I want to just get the kind of sense of like, what are your kind of like big questions or goals here? What have you heard about the kind of medications? Are there any like worries or things that are kind of driving comfort with it? It's not a big group, so I won't go through like audience response one to fives on this. But I'd love to just hear from people kind of what they're thinking about this. For me, I was just wanting more information in general about, you know, opioids and I have zero exposure in from my previous job. So any information as well as much appreciated. I agree with that, Milan, I think as nurses, we'll be seeing more and more of these patients, we want to get really comfortable with being able to walk into the room and educate and give the right, you know, information regarding the treatment side effects, you know, what it can look like when they leave our clinic. So anything to us that you can provide would be beneficial in that sense. Yeah, totally. I think we'll definitely get that out of the material I have here. And then from my standpoint, it's more about the fear and prejudice about the patients that come in with these issues that and then the fear from the nurses about like having those patients in clinic and having to do this work. Those are the things that might make us worry. My hope is to remove some of those fears and prejudices from the patients that come in with these issues. In clinic and having to do this work. Those are the things that might make us worry. My hope is to remove some of the prejudice by getting some better understanding about what we do in order to get this from a primary care standpoint, delivering this treatment. Definitely. And I think Sarah was working with you with some front desk and MA training about stigma and implicit bias, which I think is a really high yield session for the just when people are coming in, checking in for their appointment, like those other touches that people get. Well, great. Yeah, I think we'll definitely do that. In bigger groups, I sort of go over like the, you know, what is at what is this actually? And so are we prescribing medicines for like in an office visit? Are we doing counseling? Are we watching people inject drugs for safety? Or we're not actually sure. And in big groups, many people are thinking that we're kind of like safe consumption site, which it's totally not. So this really just looks like treating depression, you're prescribing medicines for people, they pick them up at a pharmacy, and then they use it at home. And they call you with questions when things are going different ways. So that's essentially what this treatment is. And just like depression, people tend to do better when they see the integrated behavioral health provider. And we do cross coverage for that. So that's essentially kind of what we're looking at here. In many groups, there's some sort of concerns about about different things. We'll go through these kind of in the rest of the content. But I hope that showing you some of the data for effectiveness will help with some of these kind of concerns. A lot of people are worried about like a deluge of sort of like, chemically dependent people kind of descending on your clinic when you say you're going to offer this. I've never I do consulting across the state, I've never seen a clinic get overwhelmed. The uptake is always gradual and slow. And many patients are actually within your clinic right now, they're just not getting treatment. So that that kind of fear that you're going to be overwhelmed and not be able to treat diabetes and ingrown toenails is really not I've never seen it play out. No more ingrowns for you, Dr. Wardrop. That's right. But like, what are the patients actually look like here? So this is like an example patient of mine. She was a 33 year old nursing assistant, and she came and saw me asking for help. And so usually what I've asked people is like, you know, how did drugs first become part of your life? And how did that get you to where you are right now? And usually that set open in a question is all I need to get the kind of introductory history. So she started with marijuana use in high school, and it escalated when she realized that it would help her anxiety. And then she broke her arm as a young adult and got prescribed oxycodone and found that that really helped her pain, but also helped her sleep and helped her anxiety. And she said the doctor prescribed me for way too long, and she got cut off and did okay after a week or two. She had some withdrawal from that. And then she had another accident, just kind of in a short term after that, and found that after she was using the pills, she used them after the prescription had ended, and she was buying them from people or getting them from other people's medicine cabinets. And then she discovered that if she crushed up the pills and snorted them, they would last for longer. And then smoking it was another thing that she had done a couple times. But then she got pregnant, right? And she got scared. And she went to a sober peer group, which is all she had known. And she was able to stop using opioids for that for the rest of the pregnancy, which is not always common. And then things went okay through the kind of immediate postpartum period. But a couple months after the baby had, or the month before after the delivery, postpartum depression hits, and she had relapsed with opioids. She was still just smoking them. And then when her pill supply ran out, she was getting sick, and that was really quite an imposition. So she, at that point, she had turned to buying pills from the streets, and then eventually used heroin, because it was cheaper to smoke. And then in about a year, she got pregnant a second time. And that point, she was like, you know, I just can't do this on my own. And she sought help at that point, and went to an opioid treatment program, and was on methadone maintenance for a period of time. And then it was hard to go to the methadone clinic after her father, who was living with them, got diagnosed with cancer. He was really failing for a period of time there. And then they found out that it was because he had metastatic cancer. And so she was caring for him, as well as the baby, and always had the two young kids. And things were really stressful at that point. And she, there was a lot of hospice opioids there. So she was dipping into that sometimes. And she was like, I just can't do this anymore. Came into the office, not knowing I was a buprenorphine prescriber, and said, like, you know, here's my problem. Like, I just really need help with that. And we were able to get her stable on buprenorphine. And she was one of my patients for many, many years, and was stable and sober pretty rapidly after starting treatment. And this is the kind of story that I get all the time with doing this. But I think it's an important, like, exercise here. So, like, reflecting just, like, how do you feel after hearing a story like that? And then as a reminder from my psychologist wife, feeling is an emotion word. So what are some, like, feelings you hear after this story of someone kind of using substances in pregnancy, kind of, and having that outlook? I feel sad and empathetic towards her. Actually, like, the way you told the story was a little bit chilling. And also, I opened to hear and see that it's, like, not a one-picture-fits-all, right? So she sings from a story like a normal person, possibly, like, kept together, and not maybe, like, the stereotype that comes to mind at times of people who abuse opioids. Yeah, thanks for that. What are the kind of, like, reflections people have? Yeah. For me, I have a lot of personal history with it. I'm married to my husband whose mom was not able to get the help for 46 years. And she just last year at 66 years old finally got put on suboxone. And for the first time in his 46 years of life is actually clean, and completely clean, meaning when she was on methadone, she would still drink alcohol, smoke cigarettes, smoke marijuana. But with the suboxone, she said it's been life-changing, where she has zero addiction, you know, feelings at all. So she doesn't smoke cigarettes anymore. She doesn't drink alcohol. She doesn't smoke marijuana. She doesn't do heroin. She literally is completely clean for the first time in 46 years. And she has five children who are all adults. So she's now getting the opportunity to start relationships with her five children and all of her grandchildren as well. And it's been, like, such a miracle, in a sense. That's powerful. Thanks for sharing. I feel happy because I have a dozen stories very similar to that myself. So for me, it's happy because I know how well she's doing. I think for me, as I'm thinking about it, just from different times that Dr. Wardrop has asked this specifically, was, like, just saying, like, we need to get something up in the clinic to actually make people aware that we are actually, we have the services available to help with these things. Because it sounds like, in most scenarios, people just don't say anything or they just don't know to say anything or to who. So, yeah, I definitely think we need to get those signs up and put them in our bathrooms and, like, all of that. So that's what I definitely take away from this is just, like, as you said, like, most of these people are high functioning and appear like nothing like this is happening behind closed doors. So we would have no idea. Yeah, it can be really hard to know. I feel kind of judgy, right? Like, you know, that's been like, how could you use drugs when you're pregnant? How could you, like, who's watching your baby when you're out shopping the street for heroin? Like, I think it's really normal to have those feelings, too. But I think it's complicated. And the point is that your feelings will affect your thoughts and vice versa. So when you're interacting with people with a substance use disorder, it's really important to have that awareness about where your implicit biases are. I have a bias against young parents and so, like, teen parents. And so that's a harder thing for me that I have to be really aware of when I'm interacting with patients in that situation. So I'm not giving them that bias through their health care. So everyone's got these kind of, like, blind spots or other spots. So you just have to be aware of them. Because then stigma is like that effect that patients and others will experience, like, oh, you're a Suboxone patient or kind of things like that. So, like, that's the, I think, the office culture and that kind of invisible part that really takes some time and energy to work on. But the punchline is that medications that the opioid treatment programs provide keep people alive. It reduces the relapse. Every time you have a lapse or a slip or a relapse back into a pattern of regular drugs, there's a chance that you die. And addiction is a treatable chronic illness. It's going to get worse and better at different times, just like hypertension, diabetes, depression, and the other things that we interact with. So I think that's an important takeaway for the staff education and modeling that I try to do when I'm working with people. I'm talking about some kind of, like, terminology here. We usually say, like, sober or in recovery when you're not using versus, and a lot of patients will say this, you know, I've been clean for three months. My urine's going to be dirty from meth. And just thinking about those kind of, like, clean, dirty terms, like, thinking about the corrosive effect that might have on someone's self-efficacy, you know, when I'm using drugs, I am a dirty person. And that I try to, like, get away from in a more kind of, like, neutral or kind of, like, self-efficacy and improving way. And then a lapse is usually, like, a slip, like, one or two times to using drugs, and a relapse is going back into, like, a daily pattern of substance use. And so these are little words that I try to kind of nudge people on in the office room, just to avoid some of that self-stigma that happens. And then in primary care, we really need to be doing it. If you think about, like, how many patients are managed by a psychiatrist for depression, it's not very many. It's basically the same thing for addiction medicine. Like, there's just startlingly few addiction docs out there. I am not one myself. So really, primary care is doing the heavy lifting for treating the broad population. And you don't have to have a special waiver or training for your prescribers to use buprenorphine anymore. So previously, there was an eight-hour requirement or a 24-hour requirement, depending on if you're a physician or advanced practice provider. So now anyone with a DEA license can prescribe this life-saving medicine, buprenorphine, with the asterisk that methadone can only be prescribed for pain. It can't be prescribed for an opioid use disorder in outpatient clinics. That is an exception to this kind of federal rule. So what's some general information about this? I've talked a lot about buprenorphine. Like, what are some of these things? So basically, the punchline is that buprenorphine and methadone are going to decrease or eliminate the death rates, complications like infections or blood clots, cravings to use drugs, withdrawal symptoms, rates of overall drug use, and relapses to drugs in the future. So if you've got an opioid use disorder and you're taking one of these two medicines, all of this stuff gets better. But how effective is it, right? There's a lot of kind of skepticism about how effective addiction treatment is in real life. So it's an interesting exercise to look at these three kind of categories of things and then rank which one is number one, effectiveness, two, and number three. So an opioid use disorder, medications to prevent infections or death, like the endocarditis, it's kind of like serious infections, high cholesterol medicines to prevent people from having their very first heart attack or stroke, or antibiotics for preventing, for strep throat to prevent rheumatic heart disease, which is the serious cardiac complication that we kind of treat that for. In healthcare, we talk about a number needed to treat, and it's basically like how many people do you have to give the treatment to for one person to benefit as like a prevented kind of illness. So thinking about like where you'd rank these, the number one one is the opioid use disorder medicines. So there's almost no treatments in medicine that are as effective as giving these medicines for people with OUD. So the number needed to treat is like four to 10 people, depending on the study to prevent one kind of death or a serious kind of hospitalization level of complication. Whereas giving cholesterol medicines to people with high cholesterol, I do all day because it's great, but I'm having to treat between 100, 150 people to get that for 10 years to get that benefit of that event. And then antibiotics for strep throat is almost laughable in this country, but we spend like over a million dollars to prevent kind of like one kind of case of rheumatic heart disease. It takes over a thousand people to prevent that complication. So it's just a different level here. If we look at the benefits of mortality, this is a standardized mortality index. So if you look at the green one, so that's like the general population death rates, and it's by age. And then if you compare people of similar age with an opioid use disorder and how, what their death rate is, this is what this bar graph is showing. So if you have untreated opioid use disorder or you're getting abstinence only treatment, which is just like counseling or groups, you have an over six times increased risk of dying. And if you're taking medications like buprenorphine or methadone, your risk of dying is like 1.8 times as high. So it really is a staggering benefit. So if like one out of a thousand people died in the general population, your age match peers with OUD have like a six out of a thousand of them will die. And if we look at randomized control trials, like this was one that had everyone going to daily counseling, and then they had a medical detox from opioids. And then they switched people to buprenorphine or a placebo control medicine, but they still could come for counseling. This is the number of time, a number of people that were remaining in the treatment program after a year. And so you can see in the buprenorphine group, 75% of people were still in the treatment group after a year, whereas there was a pretty precipitous decline after just like a week or two in that control group. And in this small study of like 40 people, four people died in the control group by the end of the year. So this has just been so many studies like this now, showing that these medicines really have just a staggering difference for the outcomes and mortality relapse rates for patients with an opioid use disorder. Here's what they look like. So like the buprenorphine naloxone under the brand name Suboxone tablets, traditionally had that little like dagger kind of mark on the back. Have you ever had those kind of like Listerine breath films? It's like the one that's dry, but when it touches your anything wet, it like turns into that like gum. So that's essentially what the Suboxone films are like. So you have to tell people to, you know, don't hit your tooth first cause then it'll gum on your tooth. So put it under your tongue, behind your bottom teeth with dry hands. And then opioid treatment programs traditionally called a methadone treatment program will mix liquid methadone in like a juice or other substance. And then you drink it in front of them. Usually go to that center about five or six days a week. And then you get these carry doses, which are like a take-home liquid dose in a locked box, depending on how long you've been with the treatment program. And then extended release naltrexone, also under the brand name Vivitrol, is a monthly injection that you get in the gluteal muscles. That one is a full antagonist, so it doesn't help prevent withdrawal. And we can talk about it, but basically like the punchline is that it's the least effective treatment for an opioid use disorder. It's a slam dunk for alcohol. So people with alcohol use disorder, best medicine, highly, highly recommend. But if you also have an opioid problem, I would steer people towards the other two medicines. Here's a picture or a diagram of what the film will look like. It usually dissolves within about five minutes. And during that time, you want to tell people not to swallow or talk because then that saliva that's pooled gets swallowed. The bioavailability, the amount of drug that gets into your system after you take it, of buprenorphine is not very high if you swallow it in the stomach through the GI tract, but the more of it is dissolved in the mucous membranes. So kind of think like a nicotine lozenge. The absorption is really in that buccal mucosa. The tablet can take like 20 minutes to dissolve. So that is something to warn people about if they're switching formulations or they have a preference of it. The naloxone does not meaningfully absorb unless you kind of dissolve the pill in liquid and inject it intravenously. It's meant as a deterrent for diversion to injection use. The naloxone is also destroyed in first pass metabolism through the liver. So what little naloxone is absorbed through GI tract, most of it's thought to be just eliminated when it filters through the liver. Some people will kind of worry about withdrawal symptoms from the tablet or the film with the combination products. I try to reassure them that that isn't really a documented thing, but I really don't care about giving people the buprenorphine monoproduct, which is only available as a tablet under the brand name Subutex. I don't think the diversion risk is that high to intravenous use for buprenorphine plain product. It sometimes is not covered by insurance. It used to be for pregnancy, they recommended the monoproduct just because the safety of naloxone wasn't known, but many people use the combination product in pregnancy now. And I've had these kind of like really annoying situations where someone's pregnant and I switch them from the combo product to the monoproduct and then it requires a prior authorization, which is delayed for like a couple of months. So then I just end up prescribing them the combo product anyway. I don't really care which one to give, but the combo product is what most of your prescriptions will be for. People are concerned about the kind of like precipitated withdrawal parts. And you have to explain that that's the buprenorphine part that's doing that. We'll get to that more later, but people ask a lot of questions about naloxone and I have to reassure them that the absorption is just really not meaningful. The buprenorphine molecule is incredibly safe. There's no adjustments for kidney function, someone's on dialysis, end-stage renal disease, unmodified doses of buprenorphine. It's excreted through the biliary system as well as through the kidneys. That's why you can get away with that. And it's just really hard to kill yourself or get into trouble with buprenorphine. There's really rifampin when you're treating like latent tuberculosis is really the only time that I have to run into like a drug-drug interaction with it. Atazanavir is another listed drug interaction, but most people with HIV are not taking that medicine anymore. And then I had a story of someone that was taking half of a Suboxone film and she left like a open wrapper in a place that her 18-month-old ingested the film. He was a little bit altered, a little bit stumbly. She realized what happened, brought him to the emergency room. They just observed him for a few hours and then he was fine without even needing Narcan. CPS had some involvements and there are some other things that happens, ultimately ended up fine. But I think it just underscores the safety of this medicine. If that was like a morphine pill or an OxyContin pill, that might've been a different outcome for this kid ingesting it. But it's just very, very safe, even for people with like an oxygen requirement. So it's just a very good, very easy to use medicine. If you don't have an opioid use disorder, it's an opioid, don't take it. But if you do, it's lucky that it's so well tolerated. There's some new Depo formulations of it, which are really good. Sublocade is available as the monthly one and then Brixadi is available as a weekly or a monthly injection. It's a gel that's gonna slowly dissolve and release the medicine in your system over a month. It's incredibly expensive. It's about $1,200 per dose, but they've been really great for some of my patients that their medicines get lost or stolen, or they can't reliably take their medicine every day like teenagers or young adults. So I think this is a really great, or those with serious chronic mental health conditions like schizophrenia or bipolar illness. I think this is a really good medicine, but still like over 95% of my patients are using the sublingual form. But I think this is a really good thing to have in your back pocket. Getting it implemented in your clinic is a little bit of a chore because there's that risk evaluation mitigation system kind of requirements from the DEA about how it's stored and dispensed and documented. So we can talk about that offline if that's something you're looking at, but it is a bit of a chore. Already done for our clinic. Hey, that took someone a lot of work. Thank that person. So if you look at what these things actually do, so like in the brain, you have these mu receptors, which are going to interact with morphine, heroin, oxycodone, buprenorphine, all those molecules. So if you look at like a graph by like increasing dose on the X-axis and then mu receptor activation on the Y-axis, you're gonna get three different patterns. And so for buprenorphine, the blue one, there's a ceiling effect. So if you keep taking more and more of the medicine, you're not gonna get up past about 40%. That's why it's such a safe medicine for like a respiratory depression, which is the problem with another opioid. So if you're taking more and more fentanyl or oxycodone, at a certain point, you're gonna stop breathing and you will probably die unless you get treatment. So that's where there's like that threshold where your breathing stops for the full agonist as they're called opioids, which is dangerous. And then the orange line at the bottom is the Narcan or naloxone. Naltrexone is the pill that your body metabolizes into naloxone. And that one gets you 0% receptor activation at any concentration. So when we think about these concepts, there's that thing about tolerance. And so tolerance is when you take a substance for a longer period of time and your brain is going to adapt to that new level and the effects are gonna be decreased. So when I explain it to patients, I kind of say like tolerance is like a joke. It gets less funny every time that you hear the joke and then you're gonna need a funnier joke from that same person to get the same kind of laughter response that you used to have. And so when anyone uses opioids for any reason, your brain is gonna adjust to it. And then the oxycodone five milligrams that used to last for six hours, now it lasts for five, now it lasts for four, now it lasts for three and you get a little bit less pain relief every time you take it. And now you have to take an oxycodone 10 milligrams to get the same kind of level of pain relief that you were used to. And then you can draw those kind of like diminishing hill graphs for people to make it visual. And so this is not addiction, this is just a physiologic body thing that happens to everyone. And so when you have tolerance, like your threshold for stopping breathing is going to increase to a higher level. So it takes a higher dose of fentanyl or something to get you to stop breathing than it would for someone that was naive to taking opioids. And so withdrawal is the other side of that coin. And so when your brain needs a certain level of substance to function normally after it's had continued exposure to that, if you don't have that same level of substance that you needed to feel normal, now you're going to feel withdrawal symptoms, which are usually the opposite of what the substance gives to you. So for opioids, they're going to kind of relax you, they're going to constrict your pupils. When you have withdrawal, it's going to feel the opposite. You're like an adrenaline kind of autonomic mess. And so you've heard about kind of like kicking the habit, that's the muscle jerks from opioid. Withdrawal is where that comes from. Goosebumps is the other kind of part of that. But basically it's like a really bad flu that is not going to kill you, but it's going to feel like you're going to die. So you're sweating, vomiting, your heart's beating really fast, you're sweating, your nose is running, you're sneezing, your muscles are up in knots. And this will last for a certain number of days or weeks, depending on the opioid that you're sort of coming off of. But it's just really hard for people to complete this process, knowing that if I just took a dose of opioid, I would feel totally fine. So that's why a lot of people come in and he's like, you know, if I could be sober for a week or two, I wouldn't be here. It's just really hard to do that. People will call this like, you know, dopesick, super flu. And it's due to that increased kind of like adrenaline and other kind of neurotransmitters for it. And so when you're thinking about how these medicines work, we have that kind of like Y-shaped orange receptor, and then drugs are going to bind to that receptor and cause that little like starburst effect for what it does. So methadone is going to be that full agonist. It's going to give you 100% effect. Buprenorphine is going to get you those kind of like partial effects. And then the naltrexone is going to be that full antagonist. And so if you're using heroin or fentanyl and you're feeling normal with that, your receptor is kind of 100% active. If you use buprenorphine, it's going to have a higher affinity for that receptor, and it's going to knock it off. And so you're going to go from like 100% effect to like 40% effect. And then your brain is going to really feel that distance, that difference, and you're going to feel really, really sick. So that's the precipitated withdrawal. Same thing happens with naloxone. You know, if I use too much and I'm not breathing anymore, and then I have that Narcan naloxone get in there, it's going to bump that off the receptor. I'm going to start breathing again, but I'm going to be hopping mad because I've got full withdrawal symptoms right now. And so the goal is really going to be having people ideally metabolize the opioid away a little bit, and then start the medicine. And then there's a number of kind of special techniques now with fentanyl that we'll talk about. But it used to be, you know, you could just wait eight to 18 hours after you were using your heroin or your oxycodone, and then you could take little bits of buprenorphine and then feel better. So fentanyl is a fat-soluble compound, just like marijuana. So after you stop using it, if you're using it chronically, it's going to continue to come out of your fat cells and seed your kind of bloodstream. And so we think about it like this cute little PACU drug that you use for colonoscopies that's only there for labor, that's only there for a couple hours, which is true, but if you're using it chronically, that's when it's going to build up in your system and become a much different problem. So it's challenging to start people because after they stop using fentanyl, it's still kind of like coming out at a high level, and it's such a potent opioid that it can be a barrier to starting people on buprenorphine. And so from 10 years ago, we used to tell people, hey, just stop for under a day, take meclonidine, gabapentin, Benadryl, like these kinds of medicines to manage your withdrawal symptoms and then take half of a film of suboxone. And then after two hours, take another half film. And then if you're still feeling sick four to eight hours later, take another buprenorphine film and you should be fine. And then just take that twice a day afterwards. But for fentanyl, there's a bunch of different like lower dose inductions. There's not an evidence-based kind of like best method for doing this. So you kind of just make something up, but essentially it's like taking fractions of a film. So like an eighth of a two milligram buprenorphine film, and then you're still using opioids during that time. And then over like three to five days, you're building up to higher fractions of the film. And you're sort of like slowly getting your buprenorphine level up as the fentanyl level is kind of like then coming down. And so you have this like cushion of buprenorphine when the fentanyl goes down low enough that you don't feel sick. That's the theory of doing this. And there's a lot of different protocols out there. If someone's on long-term like prescribed opioids, you can use a transdermal buprenorphine patch to help transition them. But for people taking like illicit opioids, typically it's like smaller doses of the film that you're gonna gradually cross over for. And I've had follow-ups like a week afterwards where I was like, so how did it go? And it was like, well, here's what I did. I just did this random stuff. And I was like, oh, I just spent 20 minutes like explaining all these like complicated fraction things. And it's like, I'm glad that worked out. Don't stress about the exact details because some people are just gonna do what they're gonna do. And then if you feel sick when you're doing this and you might get a call about this, I'm doing this complicated microinduction and I'm really, really sick right now. In that case, you can just take like three, eight milligram films all at once. And that usually is a high enough dose to kind of overwhelm that kind of precipitated withdrawal and people will feel better after that. So like I tell people, like try for the low dose one and we're gonna try and kind of like ease it up. But if we get into trouble, just take a whole bunch of buprenorphine and most people feel okay. And again, not a carefully evidence-based thing, but it usually is enough if you trip that precipitated withdrawal to not feel really sick. So another kind of anecdote about a patient is he came to me in his young 20s and he said that his parents gave him methamphetamines for the first time on his 12th birthday. And he kind of drew up in a drug household like that and was using cocaine and heroin and cannabis problematically. And the second visit, he was like, wow, bup takes my cravings away. I feel normal now. And that was actually a little distressing for him as he started to reflect on his kind of like PTSD late in childhood. And I was like, well, we've got behavioral health in the room, like a real office. Would you like to chat with them? And he never quit using cannabis, but he did stop using opioids pretty readily. And then on the urine drug screen, kind of like a couple of months in, it was the morphine in his urine, which is a metabolite of heroin, codeine and morphine. So I was like, oh, so what's that about? And then he's like, well, I used and I didn't get high. These friends came over and they brought drugs. I knew I shouldn't have done it, but I did it anyway. And then he had a pause and he was like, yeah, that was dumb. I shouldn't hang out with them anymore. And I was like, hmm. So urine drug testing ideally is a tool for a conversation. It's not to like catch people or get like an aha moment, but I think it can lead to some good structured conversations. Although after COVID, I'm not urine drug testing every visits. I think much of us are doing it far less often than just kind of asking people. Most people will disclose kind of lapses or slips when they're asked in a nice way. So again, like if you're using buprenorphine, you're not gonna get that euphoria or high when you use illicit opioids. So it's really good at like getting people or protecting people from getting back and do like a pattern of daily use when they're like, oh, that felt really good. I should start using that drug again. It really does block that euphoria for people. And then he started missing appointments and outreach is unsuccessful and he relapsed to opioids and he was kind of lost to contact. So when people come off the medicines, my experience is they tend to have a relapse events. A few people are able to be successful long-term if we kind of gradually taper them off over like a year or two, but most people that stop abruptly will have a relapse. And just again, that kind of, this has been validated in the data too. So opioid treatment programs, we talked about that. There's kind of like daily monitoring and there's counseling and groups and other resources available. So people that are not doing well or wanting that really like extra accountability or wraparound supports, an opioid treatment program really is a good option for them. This was a study in Massachusetts that took 52,000 treatment episodes of people with an opioid use disorder and followed them over three years. And you can just see the green is abstinence-only treatments of people that weren't taking medicines, therapy groups alone. And just the relapse events per patient months is how they measured it is just incredibly high in the abstinence-only group compared to the medication group. So again, there's just like no contest for what you would recommend to someone if they're thinking about medicines or new medicines. Medicines is the right answer. It's also cost-effective. So if you look at the per member per month kind of cost to the insurer in Massachusetts, this was the breakdown. So if you think about preventing endocarditis, ER visits, ambulance kind of utilization, like the buprenorphine method and there's much more cost-effective. A couple of times when I was at NeighborCare, I kind of saw how many patients I had, after doing it for several years, I had 63 patients, which was like half the number of my diabetics and other things. So like you definitely get, you can build up a practice, but I never experienced that it took over my primary care access or anything like that. And then when I measured people that I had started and were still engaged in care, like several months later, it was about two out of three people that I had seen for initial visits that stayed engaged in care, which I thought was pretty good compared to like our engagement with hypertension and other things. So even in the real community health level where 5, 10% of my patients were homeless, it really is effective. Extended release naltrexone, we kind of talked a little bit about this, but I would basically never recommend it for opioids because I've just never had it work. Again, alcohol, slam dunk, do it all the time, but for opioids, I've never had anyone do well after like the second or third dose with it. So I don't think it's quite ready for prime time. And then just an example of a patient that sought care from a local clinic, and they said you'd have to stop marijuana in order to be a patient here, and she didn't want to do that. And then her boyfriend got discouraged from seeking care at that point, and then she sought care from our clinic, and we're like, yeah, I mean, using marijuana all day isn't great, but let's get you off opioids first. Here's some buprenorphine, and then she ended up following up long-term with us. And so her ex-boyfriend got incarcerated and then discharged from prison or jail and then relapsed and died at 22, where she was able to be very successful. And we get those like next-gen messages at the time, and she sent us a message when she had graduated from her community college program and was very thankful to everyone. But it can have a really high impact for people, and so I think really carefully about kind of like what your initial kind of impressions are really like don't require abstinence from methamphetamines, marijuana, those kinds of other drugs. Usually they go away with time when you're starting it, but the opioids are the first thing to kind of manage. And so just thinking about that, kind of like the different ways that those kind of like lack of exposure or personal prejudices can come up with people. And what our old kind of public health service general said is that the first step in this is understanding it's a chronic but treatable brain disease and not a moral failing or a character flaw. And I really feel like our primary care toolkit works really well. It's just different medicine. The nouns are different, but the content, the motivational interviewing, the patient-centered plan, the engagement with our other kind of members in clinic, I think is really similar for when we're treating OUD. So that's the kind of overview here. Again, happy to go into a lot more detail, but what questions do people have or what other things are coming up for you right now? I think for me, just because you're in a clinic similar to ours, how, I guess, what are your nurses doing as part of your process? What does that look like at your site? Yeah, great question. I think our nurses are usually engaging with people over the phone when there's a crisis or a problem. So I try to like shadow some buprenorphine visits so you can see that it's not always sort of a scramble. So yeah, like my medicine got lost or stolen or I'm having a surgery and the surgeon says I can't get pain medicines or I'm worried that I'm going to have a stroke or something like that. Or I'm worried that I'm going to have a surgery and then be in pain. They said the anesthesia doesn't work if I'm taking buprenorphine, which is not true. I need a prior authorization for it because my insurance changed. I'm trying to get an appointment, but I can't get an appointment. I think those are probably like the top three things that our RNs are having to feel. I would say for the proceduralists, I just have a letter now that I can give to people that for the surgeons like buprenorphine, they should continue taking it. It's don't stop it. Use higher doses of opioids for the same duration as you would a regular patient. If they need prolonged pain medicines after surgery, I'm happy to manage that. For example, if you're giving, usually give two days of opioids for someone with a hernia surgery and usually give five milligrams of oxycodone. I would give 10 to 15 milligrams of oxycodone per four to six hour dose because they have a tolerance for opioids. Or if it's a really serious surgery, hydromorphone, which is Dilaudid. I had someone with like an esophageal cancer and they were just taking liquid oxycodone, 10 to 15 milligrams every four to six hours for the week. And they did totally fine. If it's like a dental procedure or something kind of minor that can't be managed with NSAIDs, then you can just temporarily increase the dose of buprenorphine for a couple of days instead of two times a day, take it three times a day. And that will get you some extra pain relief. And that will get you some extra pain relief with it. Using regional anesthesia, patient-centered or patient-controlled anesthesia in the hospital. Those are kind of like details that I'll just tell the proceduralist about. For the concerns about, you know, my medicine was lost or stolen. It's pretty easy to kind of phone in, talk to the provider and then like, they're like, yeah, give them a week's worth of medicine, tell them to come get appointment with me in the next week. You can send that in to people. It's a schedule three medication, so it can be called in. And then thinking about like how you wanna manage my medicine was lost or stolen. There's different ways to manage that. But I think those are the main kind of ways that our RNs are kind of having this kind of stuff come up. And what, I guess, for questions are, what is like the next meeting? What is it that point to be? Like, can we look at reviewing at the next meeting? The next meeting with me? Yeah. Oh, I'm available for whatever you need, but I didn't have anything scheduled right now. Oh, okay. I don't think there was anything scheduled. I don't think it's like a series. I think it was more based off of like what we feel like we could possibly benefit from. Okay. Here's the basics. So then what areas do we come up with that we would want more training in? Is kind of what the next level would be. Is there something more that we want as a group after doing this? Oh, okay. Yeah, I really like the slides over, where we went over the receptors and kind of how the medications work. Those are some of the questions that I know I had, but after going like over those slides and you're reviewing them, like I feel comfortable now, like going into a patient rooms and like confidently being able to explain these things if I had to. Yeah. Okay. I can't hear Renee. Renee has a question, but she's muted. Oh, I am? Oh. Now we can barely hear you. Talk louder. Can you hear me, Matt? Okay. So my question is, is because I'm a new nurse, do we dose Suboxone to patients at Farm Workers Clinic and pregnant patients? We're just the same outpatient as every other primary care. So there are any prescriptions going home and doing their own dosing. And yes, we do take care of pregnant patients as well. Okay. Okay. We also have Naltrexone and we have Sublocaine now as well. We have a pharmacy in our, part of our clinic, like in the building with us. And so it was, our pharmacists are very on board with us as far as MOUD goes. And so they've been really helpful with making sure that we always have Suboxone in-house. We always have Narcan in-house. We always have Naltrexone in-house and now we have Sublocaine. Okay. Thank you. There's a couple of things with pregnancy that we should probably talk about briefly. Breastfeeding, totally safe, not passed in the breast milk. Same thing with methadone, very little to no excretion. And this is like the conversation for withdrawal of the newborn is probably one that you should punt to the prescriber. Just cause it's so loaded and everything. But if you take buprenorphine or methadone during pregnancy, which you definitely should, because there was a big mother's study, they called it, that basically showed no one did well or was able to parent in the non-medication group was the main outcome of the study. So the standard of care in pregnancy is really, really encouraging people to be on medicines through pregnancy and in the postpartum period. But the infant will be born with a neonatal abstinence syndrome, which lasts, it's an unclear amount of time and it doesn't correlate to the dose that you took. So like if you take 30 milligrams of methadone and 100 milligrams of methadone, there's no correlation for how long the newborn experiences withdrawal form, which is really frustrating. But that's something that you can reassure patients that there's no value in decreasing your dose during pregnancy because it doesn't matter for what the newborn experience is. Babies born to buprenorphine moms in general have a milder and shorter period of withdrawal compared to methadone. When they look at the long-term kind of developmental outcomes, it's a lot of challenge from like doing that by socioeconomic status, but there's not thought to be any long-term detriment to the newborn for that period of opioid kind of tolerance, apart from the neonatal withdrawal. It can look anything from like being in the hospital for three days and getting some extra like pats and swaddles to getting a little bit of like morphine over two weeks to be kind of like weaned off the opioids. Hospitals have specific protocols for that, but that is one kind of like nuance in pregnancy care. But reassuring that there's no birth defects, no problems with breastfeeding, I think would be like the initial like RN level reassurance. And then, you know, I would talk to your prescriber about some of these other advanced questions. Thank you. And I also want to say I really appreciated real case patient scenarios. I think that brought some light to me and I hope that it did to everybody else. So thank you for that. Well, thanks. Yeah, it's such a spectrum of people and you really don't see the, it's less visible to see the people that just look like the regular patients in the clinic, right? What other questions or thoughts are coming up for people? I do have a question. For the suboxone films, is there such a thing as taking too much? Like, I guess when we're triaging, is there, you know, like, oh my God, they took, you know, way too many films instead of, you know, like if there is such a thing as taking too much, what would be kind of like what we would, the symptoms we would be looking for, or? Yeah, great question. In my experience, usually nausea is a symptom that you'll get either when you're first starting and it usually goes away if it's when you first start, or if your dose is too high, nausea can be one. This actually is probably a good thing to, as like an RN level kind of question for people. So like, how long, or how are you taking your medicine? So like getting through like, oh, I just, you know, throw a pill in and then I take a drink, or like, you don't wanna smoke 15 minutes before or after your dose, because when you smoke tobacco or nicotine products, it's gonna, or vape, it's gonna constrict the blood vessels and then you're thought to get less absorption. And then you still get absorption, you know, in the 15 minutes after you finish your dose. So avoiding smoking for that time can get you more of your real dose. Some people, the pooled saliva is a lot, and if they swallow that right afterwards, then they can get some nausea. So we could, you could tell them like, after your dose is dissolved, you could spit out that collected saliva instead of swallowing it. Sometimes that will help with nausea too. Other times it's their other medicines. Talk to your prescriber about the kind of six other medicines you're taking, or cannabis use is another thing that I find commonly, actually is the cause of the nausea and it's not the buprenorphine. But nausea, you'll probably hear about. Are there some like key symptoms? I guess I'll start like, I had a patient that I triaged last week who was previously on Dilaudid and then started on Suboxone. And so all the symptoms that she was reporting to me, you know, I'm thinking, could they be withdrawals or could it be, you know, like she was possibly concerned that maybe she had a UTI, but didn't really have any signs and symptoms of a UTI. So I actually ended up talking to Dr. Wardrobe about her. So if I hadn't had Dr. Wardrobe there, is there, what is like some guidance for like the RNs that I could try to really pinpoint like, yeah, this patient could possibly be having withdrawals? Yeah, I think it can be hard to tell. So you might just say like, you know, what, describe to me the symptoms you're having and kind of like just get a good kind of S-bar to the prescriber about like, here's what they're reporting. Does that kind of run into any algorithm for you? But typically withdrawal is gonna be kind of nausea, vomiting, sweating, sneezing, runny nose, goosebumps, kind of restlessness, feeling anxious, tachycardia, muscle aches. Usually those are the kind of symptoms you get. If someone has clonidine or any like PRN withdrawal medicines on their list, you could certainly encourage them to take those medicines. I find that sometimes people have the medicines, but they don't actually use them at all. And you're like, well, take the medicine that I gave you for the sweats, tremors, anxiety, fast heart rates, and then you should feel better. You can encourage a same day visit or a walk-in or get back to them on MyChart. I don't know what your system is, but yeah, sometimes it can be hard to tell. So I would just take like a careful S-bar for it or encourage them to take their PRNs. Is it? Oh, sorry, go ahead. I have a dot phrase for those withdrawal meds too. So I know what I give when I give those withdrawal meds and I can make that available to you all. Oh, yeah, that would be great. Thank you. Is there, are you seeing, or do you see in your practice that the patients who actually are addicted to fentanyl are the ones who have more of a withdrawal when they start Suboxone or it can be anybody? It can be anyone, but I think the fentanyl ones are the most challenging and it really does take like sometimes three or four weeks before we're in a kind of good place. So it's a lot of like, you know, trust us, this should get a little bit better every day, every week. Keep at it. It's kind of like swimming lessons, you know, like you're gonna be anxious at first, tiptoe in the water, kids are splashing around, having fun. How about you climb into the rung down? The water is still kind of cold, you're getting used to it, but let's keep going. Would you like to talk to your prescriber to see if your dose is right, see if there's any adjustments in the plan? But I think it'd be hard to give you like a, if this, always do that kind of answer for that. Okay, so just encouraging them to continue with the plan and obviously communication with the prescriber as well so that they're aware of what the patient's calling us about. Yeah, and if you remember like the half-life of, the half-life of buprenorphine is about 30 hours, the terminal half-life. So it takes about five half-lives to get to a steady state. So that's like, what, 150 hours or so. So a lot of people expect when they take a medicine, they're immediately kind of with the light thing. So you can tell people, you know, it takes about a week of taking the same dose of a medicine for it to build up enough in your system. You know, I see you were just changed from this to that, you know, let's give it some more time to kind of get your body to adapt to it. So just waiting a couple of days is a totally reasonable response in a lot of cases. Okay. That's awesome, thank you. Yeah. Yeah, my pleasure, it's new stuff. One more question, because we do a lot of triaging over the phone. What are some good like home care measures you would have, you know, your nurse recommend when they're going through withdrawals? Like what are things that can help the symptoms of withdrawal? Or is there nothing really like, it's like, is it the same, like if we get the same home care measures as you would for someone that has the flu or COVID? Like drinking, smoking, and you know. Yeah, totally. Those kinds of things will all work too. I would first make sure they're taking their medicines because the most effective withdrawal medicine is buprenorphine. So make sure that you're maximizing that first. But over-the-counter Benadryl basically makes everything better of the withdrawal symptoms. The medicines that are on that withdrawal phrase, dot phrase, I would pull that up and like, oh, they don't have clonidine on their med list. Like, well, let's see if we can prescribe you some of this medicine clonidine. That seems like it'll help the things you're feeling. Trazodone is for sleep, you know, at bedtime. If they have that on their med list, you know, that's a great way to do it. But yeah, all the, like the sort of like soda, rest, comfort food, like all that stuff helps too. Okay. The dot phrase is by its symptoms, which medication to take. Oh, perfect. I already stole it. Okay, good. What's it called? Oh, okay. So while you guys are thinking of your questions, there's actually a GPRA survey that we'd like you to do. If you give me just a second, I can pull that up. Well, we have access to these PowerPoints, like so we can reference. Yep. I can send you a PDF version. Yeah, that would be awesome. And you can see a QR code, right? Yes. Okay. Just making sure. Do you want us to scan it now or are you gonna send this out? If you can scan it now so you can have it, that would be great. I can send the link to when I send the PDF. Yeah, that would be great as well. But I think most of us are grabbing it now, but if you send it just in case we lose it after this. Yep. One more question, when you prescribe Suboxone and you know you do everything and you know on our end everything is done, patient is started but they only stay on it for a couple you know weeks or so and then you realize that they're non-compliant but then again they come a month later and now they want to be started again and then they're off again and then you know like, this is going to sound really bad but at what point do we or do we just keep on going, keep on trying and just over and over or is there anything that we are doing, I don't know, like wrong in a sense or I just, the cases that I've had any, like that I've come across, it feels like it's not really, I don't know, like they all just, they don't stick with it and I'm like, I do know that it must be hard right for them to stick to this but it just seems you're not having the cravings, you're not, you know, that is taken away so why are they not sticking to the plan, why and we just keep on trying and they don't want to stick to the plan, I don't know, am I making any sense? Yeah totally, I think that's a really real question, a really important one and then I would just say like, you know, I've got a kid, I bring them into clinic, we get the first shot of their vaccine at two months and then I come into clinic when they're nine months old, I'm like, oh I'm going to come in and get that booster, I'll get that second one and then I come back in when they're three years old, like do you give me shots at that point or you tell me I've used up all my opportunities for shots or like, you know, I've got my diabetes, I come in, I'm getting medicines for a couple months and then I come back a year later, I've been out of medicines for a long time, what do you tell me at that point, do I get another chance at medicines and I think this gets at that concept of harm reduction which feels really bad for us as healthcare providers because all of us like had to do a lot of stuff to get to where we are, we needed like our A's, we needed our stuff together and then this idea that people are struggling and like, you know, it's I'm doing something wrong, right, but I think this idea of harm reduction is that you do prescribe people refills when they're, when they lose their hypertension medicines or they haven't been in clinic for a year and a half and they want to refill metformin, you refill it before their visit because you're doing harm reduction, like if I'm still smoking cigarettes, do you still give me nicotine patches so I can smoke less, if I use condoms some of the time, do I still get the condoms or a seat belt, right, if I'm using the seat belt most of the time, that's harm reduction and so I think when we're applying that concept that we do kind of unconsciously to this really difficult stigmatized condition, it's, it can feel different, so I think that that kind of discomfort and those questions are really normal and I have them too and I think conceptualizing this in like a harm reduction, like any treatment you're getting is decreasing your risk of harm, it's not perfect because you're not doing it all the time but the more kind of good experiences I can give you with health care, the more chance that you're going to be engaged longer term with our services in the future and that's all I can do at this moment, I don't have full control of you like fully getting into daily adherence with the medicine but I could build a patient-centered plan, like you know it's hard for you to take your medicine every day, would you be interested in a monthly injectable version of this medicine that you didn't have to think about it every day and things like that, that you would do all the time for all our patients? Yeah, I used to think the same way when I first met my husband 23 years ago, I knew about his mom's story because I felt like oh my god, how could a mom ever choose drugs over her children but then over the years obviously knowing the whole situation and going through all these years with it, it's in my eyes the same as a diabetic or high blood pressure, like you're not going to give up treating the patient because they're eating cake when they shouldn't be eating cake or when they're you know eating salty foods when they shouldn't be eating salty foods, you're still going to treat them and you're still going to keep educating every single time as much as possible so I feel like it's just the same category as anybody else that's getting care. And then just like the diabetes, one day it clicks and then a couple years later you see you have a story like Dr. Perez's story of this patient whose life completely changed because of it. That's why people do this is because we know that if we keep giving this positive kind of model of treatment and we keep doing the harm reduction, we're going to catch some of those cases and then have stories like Dr. Perez had presented to us today. I've got dozens of those myself because it takes time and it takes how many diabetics have we had where that's the case where it's been why is this person with a BMI of 50 not taking their insulin and all of a sudden something clicks and a couple years later they're in great shape, their diabetes is well managed, what did that happen? Well it's because we were there when they were ready and that's part of it it's just for us to be available and ready when they're ready when they're ready to finally make that switch. I do want to acknowledge it's really hard and it feels bad. Like I had this guy that was a he was a grandfather taking care of his grandkids while his daughter was working and he would use methamphetamines most nights in the casino. He was sober from opioids right away but I was it took him like two and a half years he was doing this and I came home and I was like do I just suck? Like I thought I could do AMI but like this grandfather still using meth all the time but then eventually he stopped but yeah it can feel really bad for a long time. Hey these are great I think you're thinking about all the right kind of things here. Anything else guys? Thank you. Yeah thank you very much. Thank you. Thank you this is perfect. Hey my pleasure I'm so glad you guys are doing this work and please let me know if I can be useful for anything else you're working on.

opioid use disorder

OUD treatment

medication-assisted treatment

buprenorphine

methadone

naltrexone

primary care integration

stigma-free approach

overdose prevention

harm reduction

healthcare provider education