Hello, everyone. Thank you for joining us today. We'll get started in just a few moments. Okay, without any further ado, we'll go ahead and get started. So good afternoon, everyone, and welcome to today's webinar titled Addressing OUD and BIPOC Communities Part 3, Substance Use Disorder Care for Native Americans, hosted by the Providers Clinical Support System in partnership with the National Council for Mental Wellbeing. Thank you so much for joining us today. So before we begin, I'd like to cover a few housekeeping notes. Today's webinar is being recorded and all participants will be kept in listen-only mode. The recording and slides will be made available on the PCSS website within two weeks, and there will be an opportunity to ask questions at the end of the webinar, so we encourage you to submit your questions throughout the webinar in the Q&A box located at the bottom of your screen. So today's presenter is Dr. Anthony Decker. Dr. Decker is currently the CMO of the Division of Developmental Disabilities, State of Arizona, and a volunteer member of the primary care service line at the Gallup Indian Medical Center in the Indian Health Service. He provides services in addiction and pain medicine, and primary care, and he's also part of the team working on the COVID epidemic. Dr. Decker is board certified in family practice and osteopathic manipulative treatment, adolescent and youth adult medicine, addiction medicine, and pain medicine. So Dr. Decker does not have any disclosures, and not all harm reduction views are supported by the federal government or SAMHSA, though harm reduction approaches have demonstrated promising results. And the overarching goal of PCSS is to train a diverse range of healthcare professionals in the safe and effective prescribing of opioid medications for the treatment of pain, as well as the treatment of substance use disorders, particularly opioid abuse disorders with medication assisted treatments. So at this time, I'd like to turn it over to Dr. Decker, who will review the educational objectives and begin the presentation. Emma, thank you very much and welcome everyone. Good afternoon. I should say that even though I've spent my entire career working for the government, either the federal or the state, I do not represent any federal organizations. And specifically, I do not represent the Indian Health Service, US Department of Public Health Service, the Department of Defense, or the Veterans Administration. I just retired after 37 years of federal service, and I do not represent the state of Arizona or the Division of Economic Security, which I currently am employed at. Our objectives for today are to be aware of the comprehensive needs of American Indians and Alaska Natives in regard to substance use disorder care, to have an understanding of the pharmacology and the risks of controlled substances, to develop a basic awareness of the problems of abuse, addiction, and diversion in Indian Country, and to ensure multidisciplinary management of the evaluation and treatment of pain and substance use disorder, especially in American Indian and Alaska Natives. Next slide. So, when we look at the relationship that the European nations have had with American Indians, going back to 1492 and carrying on, there are four pillars of colonial matrix of power. And this understanding is something that Bonnie Duran, who was at the University of Washington, shared with me. First is a control of economy. Land is taken, labor is exploited, and the control of natural resources goes to the winners. History is also written by the winners, and so the historical documentation and experience of Aboriginal peoples many times is adulterated by the concept, especially the European concept. Much of American Indian and Alaska Native and First Nations in California, their ideology is more circular than it is linear, whereas European thought is very linear. Control of authority, development of government, social institutions, development of military, control of gender and sexuality, so family education and family structures are determined by the conquerors, and control of subjectivity and knowledge. So it becomes an issue of control of education, and then the formation of subjectivity, which is the truth and the facts, become again the property of those who are in control. Next slide. Next slide. When we look at what's been going on over the past 200 years, it's clear that there were significantly stable societies in the Americas that existed before the European invasions. And one way to look at this is how they have approached the concept of the medicine man and medicine women and traditional Indian medicine, that these were substandard, that these were, quote, spiritual, magical beliefs that were practiced at the detriment of the Native communities, when in reality, for millennia, it held these communities in a fairly tight and fairly controlled setting. Next slide. One of the things that I was able to show here is back in 1883, it's looking at the judgment that some of the physicians had when they went into Indian country, they said promiscuous sexual intercourse among unmarried Apache Indians was common. They practiced polygamy. The women were unclean and debased. The Navajos were a branch of the Apache tribe, which is untrue. The two tribes separated more than 1,000 years ago. They have a common language, but they separated for a lot of other reasons, and they separated, Apache separated from the Navajo, but each tribes have their own creation stories. Again, talking about living in huts, drunken, worthless lives, and women being prostituted. Syphilitic diseases were common back in those days. Sexually transmitted diseases were very common. Next slide. The other way that I should say the colonization process worked was it essentially created a double standard, that American Indians, Alaska Natives, First Nation people, that they were prejudiced against, that they were unequal. They were pushed to the point of sheer exhaustion. Many times, the resources that they used were taken away from them. Hopelessness and powerlessness became the common denominator in many American Indian communities. Disease destroyed over 90% of the population, most of them being diseases that were brought in by the Europeans, measles, tuberculosis, things like that. The inability to recognize signs of resiliency, which has held them together for eons, was wearing away. The structure that most American Indians, Alaska Natives, and First Nations people had, and this includes the island nations and the Hawaiian communities, were destroyed, and so the leadership process was destroyed. There's a pattern of not speaking up, not advocating for themselves. A great sense of shame, of stigma, of blame started to occur because of their failures in achieving any sense of success. Next slide. Now, we do know that when we start talking about pain, and chronic pain specifically, not acute pain, chronic pain is highly, highly related to adverse childhood events. We know that the American Indian, African American, and many people of color have had epigenetic changes that have occurred. Genes were turned on several generations ago that placed them at higher risk for a wide variety of medical and psychiatric problems, and that process of epigenetics can be turned off, but takes significant interventions to actually do so. The Institute of Medicine identified that the financial burden of chronic pain exceeds that of cancer and heart disease combined. The National Health Interview Survey identified that one out of five adults in the U.S. have chronic pain, that high-impact pain is experienced by 7.4% of our adult population, and there's higher rates of chronic pain in women over 65, non-Hispanic white adults, those in rural areas, and as we'll see soon, American Indian populations. Next slide. So we started looking at this, we know that there's certain populations that have single-source services, such as the Veterans Administration, and we can study that population with better accuracy. I spent five years in the VA, five years in the Army, working with high-risk active-duty service members and veterans in regard to pain and substance use disorder. 31% of veterans compared to one out of five non-veterans have chronic pain syndrome in the past three months, and you can see that when you look at the veteran versus non-veteran population, veterans being the light blue lines, that the veteran populations exceed the percentage of chronic pain in all ages up until 65. Next slide. Now, the VA in 2018 developed a strategic plan which looked at pain management and opioid safety. We're going to talk about some of these things that have occurred, but we do know a few things. The co-occurrence of pain and mental health conditions were often the result of high-impact pain. The greater the pain, the more disabling that pain is, the greater the mental health complications. Pain, medical, and or mental health comorbidities are often related to military service and require veteran-specific expertise. For instance, the common denominator we see in the Iraq and Afghan theaters were chronic pain syndrome, psychiatric issues, PTSD. And so when those things came together, the likelihood of substance use disorder increased dramatically. Veterans were at higher risk for harm from opioid use and accidental poisonings than non-veterans. Pain was the most common factor that veterans who died by suicide, and there's a close correlation between pain intensity, suicide risk, and death rates. And we'll talk about some recent studies that have looked at the civilian population in the same area. Pain requires a systemic coordinated medical, psychological, social, biopsychosocial, integrated health plan. Now when we look at the death rates, and this only goes up through 2018-2019, we do know that with the event of COVID, the worldwide pandemic, in the U.S., we have seen a rise in opioid overdose deaths. 2021 was estimated to have 107,000 opioid overdose deaths, and with fentanyl, illicit acetyl fentanyl, being the major cause of that epidemic. As a matter of fact, if COVID had not been the main thrust and main source of our activities over the past two years, the opioid epidemic definitely should have been in that place. Now over the past several years, we've seen an increase in the number of prescribed opioids. We've seen the epidemic switch from prescribed opioids to illegal synthetic opioids, such as all the fentanyl congeners. Now in 2021 and 2022, polysubstance use, meaning an opioid and a stimulant like methamphetamine or cocaine. Cocaine is coming into this country at a rate higher than any time in the past right now. Next slide. Veterans are at higher risk for death due to overdose. American Indians were 2.7 times higher to die by an overdose in 2021 than Caucasians. In 2016, there were 1,271 deaths in the VA system, or 3.5 per day. That's one and a half times higher than the non-veteran general population. But you can see with our graph here, the top one being all opioids increasing again over time. And you'll see this several times as we go through this. Next slide. When we look at unintentional overdoses, we do know that there is a risk that is closely associated to the dose. So this is looking at the morphine milligram equivalent in daily doses. So from 1 to 20 milligrams per day compared to 20 to 50, compared to 50 to 100, compared to over 100. And you can see a slight increase with suicides. And these are people who are prescribed the opioid and are kept on the opioid. You're going to see some very different data when you see veterans who were forced to stop their opioid medications. But you can see the unintentional overdoses rose dramatically with a hazard ratio that goes up to 7, secondary to higher doses of prescribed opioids. This was some of the reasons of the 2016 CDC guidelines, which we'll critically analyze towards the end of this presentation. Next slide. Now when we're looking here, we have the comorbidities of substance use diagnosis in green, mental health disorder in orange, and no substance use or no mental health disorders in blue. And you start to see here that almost four out of five were prescribed greater than 90 MMEs who died by an overdose or a suicide. That's 80% of veterans who died at high doses of morphine milligram equivalents. Next slide. Now we have risk factors that are prescribing factors and risk factors that are patient factors. When we look at opioid prescribing, we can see that the dose and the duration are things that you as a provider can affect. The type, long acting, short acting, is something that you have an effect on. The delivery system, oral, sublingual, film, transdermal patches, these are all ways that people can deliver opioids to your system. Then we have the interaction with other drugs, such as benzodiazepines. We know that the combination of benzodiazepines, especially intermittent higher dose benzodiazepines, are more problematic and associated with overdose events. We also know that certain medications like gabapentin and the pentanoids may increase the likelihood of injury because of balance problems and poor gait. Alcohol, a strong sedative hypnotic, has been associated with complications. Then we look at the patient factors, medical comorbidities, chronic obstructive lung disease, sleep apnea will increase the likelihood of complications with chronic opioid therapy. Mental health comorbidities, depression, bipolar disorder, PTSD, and then obviously concurrent substance use disorder. Next slide. In summary, when we look at pain and opioid overdose epidemiology, we know that chronic pain is in veterans more commonly and more often severely. We also know that American Indians have a higher rate of physical injury for two reasons. One is that the very nature of the work that happens on reservation, which is typically going to be farming activities, ranching activities, and the reality that, for instance, on Navajo, the reservation is huge. It's bigger than Connecticut and Rhode Island combined. Many of the roads are very seldom traveled. Many of the roads are simply dry washes. A motor vehicle event may take hours before someone recognizes that someone's injured and extraction from that area may be very difficult. The Gallup Indian Medical Center is right on I-40, so we get lots of accidents from I-40. It's the trauma center for Gallup, but we also have injuries that occur many miles into the reservation that can take a significant amount of time for recognition and for transmission. One of the problems on the reservation is a very poor cell phone reception. So what most people take for granted, that you can just get your cell phone and call for help, doesn't occur on many reservation areas. Mental health comorbidities have a very high impact. Veterans and American Indians both have high rates of suicide, high rates of mental health disorders. We already talked about the higher doses, and we also know that risk factors for opioid use disorder include a variety of things, including not only the dose, but also the exposure to longer acting formulations. Many people drank the Kool-Aid when we were told by the pharmaceuticals years ago that MS content, which is morphine sulfate content formulation, or Oxycontin, which is a different formulation, was safer, that long actings were safer than short actings, when just the opposite was true. 70% of the people who were dying from overdoses in the early teens, 2010 through 2015, were secondary to long acting formulations. Next slide. Let's discuss what pain is. The old definition of pain was interesting. Unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage. Now we say, and it's a little bit more complicated, it's an unpleasant sensory and emotional experience resembling that associated with actual or potential tissue damage. So we know that it's a phenomena and that it's more than just nociception. It's influenced by bio-psychosocial factors. We know that chronic pain is very different than acute pain. A personal experience should be respected and there should be collegial relationship between the patient and the provider. Recently in Tulsa, at one of the Tulsa medical centers, a patient was angry because his orthopedic surgeon refused to provide him with adequate pain relief. The person bought a gun, came in. The first person to try to stop him was an osteopathic internist who worked in the office. She was shot and killed. Two nurses were shot and killed. The surgeon, who was an African-American, Harvard-trained surgeon, was shot and killed. It's clear now that patients who abruptly stop their opioids can do very, very damaging things, not only to themselves, but to those around them, including their providers. So it is something that we need to look at very closely. Next slide. We look at the old mentality, which was you put your foot on a fire and you pull back immediately because it burns. And this goes all the way back to the 1600s. And even Galen, the famous Roman army surgeon, talked about the pain reflex reaction. Then in the 1960s, we started looking at the gait control theory of pain, that you hit a certain threshold and then you start to feel pain. Now we have what's called the pain neural matrix, which has an input that's both cognitive, emotional, and sensory, and an output, which may include pain, motor activity, stress-related events, and an emotional response. Next slide. There does not seem to be significant benefit from starting people on opioids for certain types of pain. So there was a study done at the VA looking at 240 VA patients with long-term back, hip, or knee pain. They were treated for 12 months. They were randomized into non-opioid pain relief and opioid pain relief. And you can see on our slide here that both groups improved over the course of one year of the study, opioids and non-opioids. However, the medication side effects were twice as high for the opioid group versus the non-opioid group. I don't want anyone to think that the non-opioid pain relievers are innocuous. We'll talk about that in detail shortly. But the likelihood of getting into trouble with a medication is twice as high if you prescribe opioids for chronic pain. Now, a person comes in with a long bone fracture. Studies were done at the LA County and at Grady Hospital in Fulton County, Atlanta. If you were African-American at the Grady Hospital and you had a long bone fracture and you had the exact same insurance type as a Caucasian that came in, so you both have Blue Cross Blue Shield, you have a Collies fracture, a long bone fracture. If you were black, you had 50% less chance of being prescribed an opioid for that acute injury than if you were white. At LA County, similar study was done, long bone fracture, opioid versus non-opioid. If you were Hispanic, you had a 50% less chance of being prescribed an opioid than if you were Caucasian. So we have a disparity in separate but not equal, was described very clearly when they wrote that book about those studies. We still have an issue now, huge stigma in regard to pain treatment, huge stigma in regard to people with a history of substance use disorder. Why is that? I don't think we can call it anything other than bias. You can call it racism or you can call it other things, but the reality is, even at the Phoenix Indian Medical Center where I was a medical director for 12 years, we had doctors who refused to give opioids for fracture care, saying that American Indians are more likely to abuse their drugs, so we don't wanna give it to them. Now we know that inadequate pain treatment results in more complications than adequate pain treatment. That doesn't mean you give a person a 30-day supply of Vicodin, but it's clear that a three-day supply for a fracture, if needed, may be appropriate. Some people don't need it, they have minimal pain, so each person should be individualized. Next slide. So the biopsychosocial components of pain management means that you need to be able to diagnose a person, you need to be able to understand where they are from an age standpoint, injuries and past injuries, illnesses, neurologic, genetic, hormones, obesity, inactivity, lack of conditioning, all those things are biologic factors. Psychological factors, mood and affect, stress, coping skills, trauma, including adverse childhood events. When the studies were done with Letty and Anda in the Bay Area looking at ACE, adverse childhood event, they were looking at substance use disorders. But the reality is the studies have been repeated with over 100 peer-reviewed articles now that diabetes, obesity, chronic pain, obesity, chronic pain syndrome, asthma, they go down the list of complications of chronic illnesses are related to your childhood events. Social factors, obviously, if you're in a healthcare desert and it's difficult to get to a place that can provide you with services, and that can even be in an area lush with services where you have inadequate insurance. But cultural factors, economic factors, support spirituality, which we de-emphasize, and that's a huge mistake by doing so. And then we start looking at ethnicity issues. So we need to improve the experience of pain. We need to enhance physical functioning. I'm often asked, what's the difference between MD and DO training? I said, and I'm very proud of my training, but I'm on faculty at MD schools and DO schools. In general, allopathic physicians are trained to prevent, recognize, and treat diseases. And osteopathic physicians are trained to prevent, recognize, and treat loss of function. So functionality becomes a critical part of this. Being able to get up out of bed and walking when appropriate becomes a critical part. Exercise is one of the most important factors in regard to treating chronic pain syndrome. Physical functioning, activities of daily living, being able to take care of yourself. A person who cannot bathroom themselves is at a severe disability. A person who cannot put their clothes on, cannot make their bed, cannot bathe themselves or clean themselves. Those are all catastrophic deficiencies that puts them in a very high risk. Next slide. The step fashion that we use in the VA system, I really feel is a good system. And so what happens is that you have foundational issues, primary care. So it's gonna be nutrition and weight management. Obesity is a major contributor to back pain. Exercising and conditioning become critical. On the VA side, we know everybody was in great shape at some point in time. But after you've been out of the military for several years, it's not unusual to gain weight or to have chronic illness from those injuries that occurred when you were active duty. American Indians, like I said, have a higher rate of injury because of where they live and what they do where they live. Family caregivers, learning and self-care all become very important. This is where we put mindfulness and engagement and spirituality, trying to make sure that a person has safe environments. You know, preventing injuries, preventing falls are all part of this. The second level is the patient-aligned care team or the patient-centered care. And what happens is that if a patient has pain, we evaluate the pain. Obviously, if they have a kidney stone, you treat the kidney stone. If they have back pain, you need to find out what's going on. That doesn't mean that we waste funds on diagnostic tests that are unnecessary. MRIs are very expensive and they're not really good at diagnosing pathology that needs to have interventional services. But we have all these other interventions that are available. And these are things where it becomes helpful for the physician, the pharmacist, the physical therapist, the mental health services to provide care. Specialty care becomes an area in which rehab services may be necessary, ongoing interventional services, mental health, combined multidisciplinary teams working with an individual, and pain management services. And advanced care would be surgery, radiofrequency ablations, spinal nerve stimulators. These are expensive interventions, but some people do need to have them, but you work into it. Similar to the way that we do hypertension care, you do step fashion, we can do the same thing with chronic pain management. Next slide. So what are the new principles for good pain care? Number one is, it's a complex personal experience. It's not the same for every person. So you need to take time to listen, not only to the psychological and social factors, but also the biologic issues that go along with it. Everyone is moving away from opioids. We've been able to decrease opioid use in the United States by over 60%. And during that time, we have quadrupled the number of overdose deaths, and we have doubled the number of suicides secondary to patients with pain. So we have to ask ourselves, we're using less opioids, what's going on? Well, it's obvious that the opioids that are being used to overdose, and it's not intentional, is the illicit fentanyl, is the illicit fentanyl, and the other synthetic opioids that are coming down the pipe. There are actually several other non-fentanyl, very strong opioids, that are coming down the pipe. Some of them can be inhaled and smoked, and vape, and this is gonna create a significant challenge for all of us. We need to promote self-care and self-management as much as possible. The multidisciplinary patient-centered teams is a standard that we're all going with right now. Next slide. So when we look at the five A's in pain evaluations, this is old, but it's still applicable. How much does it hurt? Analgesia. What is the activity the person can participate in? You don't need a sports club to go to. On the reservation, you have telephone poles. I'll find out. How far can you walk? I can walk to the telephone pole and back. That's great. I'd like to see if you can walk to two telephone poles and back by next month. Adverse reactions. Patients who take medications and then they just sleep in front of the TV set and lose their core strength. You are doing them a disservice. Even if the patient has the same amount of pain, but they've increased their activity, we're going in the right direction. Aberrant behaviors. Going to different providers, getting their medication early, losing their medication over and over, mixing medications from other people or other providers. And then their overall affect. Recognize depression. Recognize hopelessness. Be able to talk about it in a non-pejorative, non-judgmental way. Next slide. So chronic pain treatment includes several things. And this is not the order that you go by, but this is how a lot of people think. You're supposed to see and document a visit every 15 minutes. It's impossible with chronic pain treatment. So you have medications, which may be oral, sublingual, topical, even intrafecal. The modalities include physical therapy, occupational therapy, acupuncture, microcurrent, transcutaneous nerve stimulators, osteopathic treatment, fascial distortion treatments, other types of body work therapies. Exercise, which I feel is the number one intervention that is not being adequately utilized. Rehabilitation services, weight loss intervention, dietician help, interventional services, whether it's either superficial, joint injections, selective nerve root treatments, some sympathetic chain, epidural spinal injections, radial frequency cryotherapy, spinal cord stimulators, intrathecal pumps. All these are, again, interventional services. And then you wanna make sure that in your team, you have someone who can give the behavioral health support to get through this process. Many doctors and providers think, well, I'm gonna decrease your opioids by 20% per week and we'll get you off these meds in a month and we'll see how you do. You better give them some other things because it's not gonna go well for that patient or for you. Psychiatric intervention services may be necessary for patients who get to the point that they feel helpless and hopeless or even consider suicide. Biofeedback, mindfulness, support groups all become part of this entire process. Comprehensive and alternative care. Traditional Indian medicines, critically important for American Indian populations. Many times we can tell them what's wrong with them. Well, you have a herniated disc, you have a iliotibial band, you have a herniated cervical injury, you have spinal stenosis, but you cannot tell them why they have that disorder. And so the spiritual part of this becomes a critical part of working with American Indians. Next slide. When you think of medications, you gotta be careful. NSAIDs, there were over 6,000 people who died last year from bowel perforations secondary to the non-steroidal anti-inflammatory agents. Acetaminophen, over 18,000 cases of liver failure secondary to acetaminophen. They don't really have overdoses from Tylenol in many countries because you can't buy more than 30 tablets in most countries. Here you can go down to Costco or Walgreens or Costco or Walmart, and you can get a bottle of 1,000. So we have the availability to cause significant damage. Anticonvulsant therapy with significant changes in your balance. The GAP pentanoids are famous for that. Topiramate also can cause significant changes in mentation. Your SSRIs have been used along with tricyclics for pain interventions. Corticosteroids, two-edged sword with a significant benefit for your inflammatory arthropathies but loss of calcium and other types of changes that go along with diabetic loss of control and things like that. Viscous supplements, anesthetic patches, muscle relaxants homeopathic agents, medication-assisted treatments naltrexone and opiates. Notice that it doesn't have to be the first. In the future, we may have non-opioid receptor agonist and antagonist, CB2, the cannabinoid receptors agonist and then the whole area of medical marijuana which has become very controversial but some people have benefited from this process. Next slide. So CBT is a non-opioid treatment. Exercise and activity therapy which I've said is the most important. First and second line options. We have all of our medications. We just discussed topical modalities, interventional treatments and then a multimodal or multidisciplinary approach appears to have more favorable responses than a single modality. Next slide. We've already talked about all the complications for these medications with the exception of the lidocaine analogs and people think that a lidocaine patch is no big deal and obviously patients come in with four or five patches on. You can cause significant cardiac abnormalities with an overdose lidocaine and people seem to forget about that. Next slide. So what are our goals? We want to improve the quality of life. We want to improve the quality of life, the person's ability to do the things that they want to do, the activities of daily living, to not depend on someone to put your clothes on or make your food or to help you toilet. We want to ensure safe and reasonable treatment so people don't have complications of their medications, a clear rationale for using any type of intervention and looking at the risk factors and the response. And we want patients to be autonomous, to be able to cope and to identify healthier lifestyles and long-term outcomes. Next slide. So will patients be able to reasonably perform the routine work and family obligations? Can they transfer, walk, routinely exercise or will they stay sedentary? Are they able to perform ADLs? What types of commitment can a patient make in regard to behavioral health services or interventions when they're needed? Next slide. Documentation becomes an important part because that's how you're essentially monitored. And you should assume that someone who doesn't like you will be looking at your charts. So you want to assess and document the signs and symptoms consistent with pain and dysfunction. You want to describe the setting and the provocative activities that make things worse. You want to talk about the things that make things better. What kind of pain is it? Myofascial, joint, facet, radicular, spastic, neuritic. And you want to correlate them on your exam with range of motion, strength evaluation and any special testing. And you want to tailor your objectives with the patient. Next slide. Now, when we look at the neuroceptive pathway on the distal nerve endings, you can see local anesthetics such as lidocaine patch and non-steroidal anti-inflammatory agents work in those areas. Local anesthetics also work on the primary afferent nerve at the dorsal root ganglion. That's where your local anesthetics, your alpha-2 agonists and acupuncture seem to have significant benefit. In the ending tracts, you have opioids, the alpha-2 agonists, tricyclics and the SSRIs. In the dorsal horn, you have opioids, ketamine and the gabapentinoids. And these are all areas that they work, but opioids can work in all of these areas. You can decrease the sensation of burning in your fingertips. But the thing is, is that the best treatment when there's so many complications that can occur using opioids? Next slide. We know the CDC 2016 guidelines were set up because of the overdoses in response to prescribed opioids. There was insufficient evidence, long-term benefits of opioids was there. We showed you the study from the VA earlier. And we also saw that the decision-making process was based on a relationship between the clinician and the patient. Unfortunately, people uniformly applied the 2016 guidelines to their patient population. In other words, taking patients who were doing very well and then just decreasing their doses. Next slide. So in 2017, they came out with a practice guideline from the VA and the Department of Defense. When prescribing opioids, use the shortest duration and the lowest dosage. No dosage was absolutely safe, but strong recommendation was to stay lower than 90. Avoid long-acting opioids for chronic, I mean, for acute pain, use as needed. And opioid dose reduction should be individualized, not given uniformly. In acute pain, fractures being a good example, kidney stones being another example. In pain that is essentially prevents the patient from functioning, the use of opioids should be less than three days, three to five days, depending on the weekend. So if you have a 4th of July weekend, you're seeing a patient on Thursday, you know they're not gonna be able to see anybody on Saturday or Sunday. You could give them enough to last till the following Tuesday, but not more than that. Next slide. Opioid prescribing. First off, there's very poor empiric evidence that long-term relief occurs with chronic pain therapy. And we were prescribing 400% more opioids based on the instructions from all kinds of pharmaceutically-based training programs. We know that all prescribers are now being followed. The CSPMP or the Pharmacy Drug Monitoring Programs, they exist in all states, Missouri being the last state to activate the process in 2020. The DEA dropped the training requirement to obtain an ex-DEA to use buprenorphine or medication-assisted therapies. And I don't think the DEA is hiding behind bushes waiting to pounce on the first person to walk by, but I can tell you that they can see everything that's occurring on the Pharmacy Drug Monitoring Program. And if they see someone who is doing things outside of the range of practice, they will intervene. Next slide. Long-term adverse effects. We do know that addiction, tolerance, and dependence, depending on the individual, there is a risk. We know there's all kinds of endocrinopathies that can occur, and the sex hormones are just one, but vitamin D25, hydroxy 25, is also one that has significant changes. And I'm a big believer in vitamin D. Hyperalgesia syndrome, which means that the nerves become more sensitive to pain stimuli with continued use of opioids. And this is seen extensively with fibromyalgia. We have significant respiratory suppression with patients who have chronic obstructive lung disease, sleep apnea, things like that. And we have issues of anxiety, sleep disorders, and depression. Secondary to chronic opioid use. Next slide. We do know that non-medical prescription opioid use was greatest among Caucasians and American Indian men. This was especially true in the Midwest and the West with incomes of less than $70,000 a year and with a high school education or less. That's a risk pattern. That doesn't mean that a person who's a doctor can't get into trouble with opioids. I treat them all the time. And opioid use disorder is linked to a variety of mental health disorders, PTSD, borderline disorders, antisocial personality disorders, major depressive disorders, and bipolar one. Next slide. Safety issues are significant. We've talked about this. American Indians and Alaska Natives have a higher risk ratio in regard to opioid use, opioid dependence, and opioid diversion. Next slide. So number one, is it clinically reasonable to initiate or continue the current regimen? You have to ask that of all your patients. If so, how long and at what dose? Is it safe? What are the long-term concerns? Is there evidence of aberrant drug-related behaviors? Are there supportive or evidence-based interventions that should be trialed? Next slide. So opioids should not be your first line of choice for chronic pain. If they are used, they should be combined with non-pharmacologic therapy, exercise, weight loss, body work. You should make sure that you also have a non-opioid pharmacologic intervention. You want to make sure you can track accountability and progress, including drug screens, medication counts. You want to prescribe at the lowest effective dose, preferably less than 50 mmE. And if you're going above 90 mmE, you really, really, really want to know what's going on. And prescribe no more as needed than for the acute pain syndrome. Next slide. The 2016 recommendations were problematic. I've already said that before. Decreasing opioid loads, especially with methadone, you want to be very careful converting to methadone or rapidly decreasing methadone because you're going to have difficulty with overdoses with methadone because the high variability in half-life and the use of methadone in chronic pain is successful, like with cancer pain. However, you can't make a conversion from a non-methadone to a methadone with any sense of accuracy. You're going to have to be very careful in that process. Be very careful about the use of benzodiazepines or other sedative hypnotics. Next slide. Now, the purpose of the guideline was to improve safety. 2019, the CDC followed up and said, do not apply these guidelines to all because there were way too many problems that occurred when they uniformly were applied. In 2022, they have decreased the recommendation, individualized the intervention, and it was public comment just closed two months ago on April 10th. So that's going to be coming out from the CDC very soon with the 2022 guidelines. Next slide. So number one, we want to improve our communication skills and the risk of opioids for chronic pain. We want to improve the safety and effectiveness of pain treatment, both non-pharmacologic, non-opioid pharmacologic, and opioid pharmacologic. We want to decrease the morbidity and the mortality of long-term opioid therapy. And we want to recognize the appropriate referrals and the appropriate recommendation for medication-assisted treatment, buprenorphine. Next slide. So taper strategies, 10% per week is a pretty significant drop in treatment. Now, that's not true, by the way, if the person has overdosed or if they've been selling the medications or they've been using all the medication up too rapidly. 10% per month will be more better tolerated. Rapid tapers are associated with overdoses and a higher rate of aberrant behaviors. In Arizona in 2016, a rapid taper, in other words, going into jail, over 50% of the people who died from overdoses were recently released from jail. And they were using opioids before they went into jail. And when they got out, they started using again. The problem was is they went to the same dose they took before in the overdose because they lost their habituation. Consider medication-assisted therapy if the tapers are intolerable or if the patient is pregnant. Next slide. Now, PDMP monitoring, like I said, I check with every one of my prescriptions for a controlled substance, but at minimum, at least once every three months. You can check out of state. Right now, the PDMP through the APRIST software will let you check 37 states. So when I work in Gallup, which is New Mexico, I can check New Mexico, Colorado, Utah, and Arizona with the same check. Keep in mind that the pharmacy drug monitoring programs do not include opioid treatment programs, which include methadone clinics, or dispense medications in the emergency room or the urgent care. So a person could get a shot of fentanyl and that would not be in the report if it was given in an emergency room. Next slide. Okay, patient discussion. You wanna make sure the patient gives informed consent. That's the biggest part of that. And make sure they understand the risks, the benefits, and the alternatives. Next slide. Behavioral health supports are a critical part of all this. Stress reduction techniques, exercise, and behavioral health are critical parts of this whole entire process. Next slide. Practice pitfalls. Number one, make sure that you establish your ground rules. Have a agreement from the beginning, what they can expect from you and what you expect from them. Do not clone your charts. In other words, cut and paste, that works a little bit, but you've gotta have some individual comment and examination on each visit. Do not blindly continue high-risk regimens. You have to have a very transparent plan and review. Do not allow frequent early refills. Minimize management of high-risk patients without coordination with pain management, psychiatry, and or addiction services. And do not have erroneous delays in mail-outs. Most of us are in a mail-out process, so you don't want the mail-outs to be five days late when they're on chronic opioid therapy. Next slide. So how did we get here? Well, if you remember the Institute for Healthcare Improvement Joint Commission, they said we had to have a policy for pain, and they all promoted this. They said pain is the next vital sign. Well, when we all drank that Kool-Aid, we increased prescribing of opioids by 400%. Purdue Pharma, other manufacturers and distributors played a big role in this process. Provider education was actually, the water was contaminated and we still drank it. We had people that were going around telling us that this was a safe process. The PDMP and the Controlled Substance Pharmacy Monitoring Programs all got us into trouble. Bomex, the number one reason in Arizona for you to get in trouble with the Board of Medical Examiners, you were on a prescription for an opioid and something happened to a patient. The number two reason that you get in trouble in Bomex is you stop prescribing an opioid to a patient who is receiving them. You're damned if you do, you're damned if you don't. You've gotta be able to realize what is the right way to pursue this. Next slide. I wanna go over these slides pretty quickly because I'm at the end of the talk. The BMJ had an article in January, 2020. Oliva, who's at the VA Menlo Park facility and Yale University looked at 1.4 million veterans with an outpatient prescription in 2012 and 2013 for an opioid. 800,000 of them stopped. In other words, their opioids were stopped. There were 2,887 deaths that occurred and they stratified it for how long you're on opioids and how much opioid you're on. Next slide. You can see here, it's about a third of the people were on 30 days or less. A third of the people were on 400 days or more and the middle third, 31 to 90 or 91 to 400. Next slide. Dosing wise or the odds ratio, if you were on an opioid and you had your opioids terminated the likelihood that you would overdose was 1.67 times greater, 67% greater if you were on opioids for 30 days or less. But look at that if you're on for a year or more for 400 days, you're almost seven times greater to overdose and die if your opioids were stopped. Next slide. If you were looking at suicide events, if you're on 30 days or less of opioids and had them stopped you're twice as likely to complete a suicide. If you're on 400 days or greater, you were eight times likely to die by suicide if your opioids were stopped and you were on those opioids for more than 400 days. Next slide. So we looked at 1,851 overdoses, 1,249 suicides, 13 cases were excluded for missing data. It's clear that those individuals, those vets who were on tramadol, those that were on increased morphine milligram equivalents, those who had a medical diagnosis, a mental health diagnosis, a substance use disorder, younger and male, they were more likely to die by overdose or suicide. Next slide. Agnoli in August of 21 published in JAMA that when they looked at a large population of civilians that the likelihood of a mental health crisis at an incidence of 7.6 per 100% years compared with 3.3 of non-tapered periods. In other words, when you try to taper a patient, you double the likelihood that they would have a significant mental health crisis. And then when you looked at the reduction velocity of 10% was associated with an increased risk also, not that much greater, but enough to say a 9% increase and an 18% increase. So we did know that there were significant changes of increased risk when you tapered a patient down. Next slide. So what are our controversies? Limits in morphine milligram equivalents. Is it really the best thing for a patient who's been stable on a regular dose to be cut back, especially if they're less than 30 milligrams per day? I have patients who take five milligrams of Vicodin at bedtime to help them sleep because their DJD and bone-on-bone is so severe. They're not taking any benzodiazepines and they have no maladaptive behaviors. I'm not that worried. Many MAT providers, we've got loads and loads of people who can prescribe buprenorphine, have XDA, but only one out of 20 prescribe on a regular basis. What is the effectiveness of residential treatment care? We send people off to drug treatment all the time. It's highly questionable. The effectiveness of sober living homes, highly questionable. Naloxone, the Narcan sprays need to be given to every person who's on chronic opioid therapy. Buprenorphine is given out to many, many patients now. There is a market for Suboxone strips in Phoenix right now. $30 a strip. So diversion is a challenge, but we wanna make sure we're monitoring that. The DEA has dropped the requirement for training for the XDEA. And some states require a board certified pain specialist for any opiates over 90 MME. That's just an unreasonable expect. Okay, let me go ahead and stop here. I think our next slide should say, where do we go from here? I think we got all that there. Next slide. And that's mine there. So I'll take any comments or questions on the slide series here. I know we're getting towards the end, but I wanna make sure we have a chance to discuss some things. Sure, I don't know if you had a chance to look through the chat, Dr. Decker, but there's a lot of compliments. 63, okay, well, I'm going from the bottom up. We do only have like a couple of minutes for questions, but I think one of them we can combine, two questions we'll combine into one related to Indian Health Services. Do Indian Health Services clinic physicians participate in the PDMP and are dentists also participants of the PDMP? Yes, yes and yes. Now tribes may make a decision that doesn't do that, but the Indian Health Service routinely shares their prescribing information. Now keep in mind, these are for prescribed opioids and prescribed controlled substances. What's given in the emergency room or what's given in the OR does not show up in the PDMP. So you have to understand that it's only those medications that are prescribed. Keep in mind that opioid treatment programs, whether they're native or not, there's only four native OTPs, but whether they're native or not, that is not prescribed, that is dispensed. And so that may not be in there. So if you're running a tox screen and you find out a person has methadone in their system, you should be asking them, do they go to a methadone clinic? Well, why are they getting opioids from you if they're getting methadone from someone else? That's where you sit down with a patient and really work with them from a standpoint of what's best for them. Another question? Sure, we'll do one more. And I think afterwards, we'll just collect all the questions and send out a document to everyone. Is the higher rate of chronic pain in veterans due to physical wounds, emotional factors, or something else? Well, the reality is that many of these injuries are secondary to their active duty activities. War wounds are horrible. And this particular war that we just, that we're still engaged in to a minor degree, explosive events was a common denominator. So brain injury was very common. And brain injury is associated with chronic pain syndrome, PTSD, and loss of filter. So a lot of times your vets will tell you things that just flies out of their mouth. And we know that if whatever's in your head flies out of your mouth, nothing good happens. And so these brain injured veterans, and we see this also with car accidents and falls and fights, that traumatic brain injury is a major contributor to psychiatric illness and to chronic pain syndrome. American Indians, like I said, 2.7 times greater overdose deaths than the majority population in 2021. So the parallel line, American Indians volunteer for military service higher than all other ethnicities combined. So there's a warrior ethos for many American Indians, but the damages that occur in the battlefield or while you're active duty, many times don't get addressed when you leave. And so they go back to their homes and there's a process that they need to go through. The value of traditional Indian medicine for that population is clearly, clearly a fantastic need. You want to encourage and help people access those services. Many of the Indian health service sites have traditional Indian medicine services. COVID slammed the door shut for a long time, but we're opening up again at Gallup. And across all these nations that we have, encourage your veterans especially to participate in traditional Indian care, but also see that for your civilian population. That's an amazing asset to have in regard to chronic pain syndromes. Thank you very much. I have my email there. You're welcome to either call me or email me. Take care. Thank you. Well, thank you so much for presenting today, Dr. Decker. We truly appreciate your willingness to share your knowledge and expertise with everyone. As a reminder, the recording and slides will be posted on on the PCSS website within two weeks from today. I'd also like to make you aware of two resources offered through PCSS that may be of interest to you. First, the PCSS Mentor Program is designed to offer mentoring assistance to those in need of more one-on-one interactions with our colleagues to address clinical questions. You also have the option of requesting a mentor from the Mentor Directory, or PCSS can pair you up with one. For more information, please visit the PCSS website noted on the slide. Secondly, PCSS offers a discussion forum comprised of PCSS mentors and other experts in the field to help provide prompt responses to clinical cases and questions. There's a mentor on call each month who is available to address any submitted questions through the discussion forum. You can also create a new login account by clicking the image on the slide to access the registration page. This slide lists the consortium of lead partner organizations that are part of the PCSS project. And finally, the PCSS website, contact info, and social media handles are listed here if you would like to find out more about the resources and trainings offered. So thank you all again for joining our webinar today, and we hope you all have a great rest of your day and week.

Substance use disorder care

American Indians

Alaska Natives

Pain management

Health disparities

Chronic pain

Mental health comorbidities

Multidisciplinary support

Opioid prescribing controversies

Transparent treatment plans