Good afternoon, everyone. I'm Dr. John Renner. On behalf of the American Psychiatric Association, welcome to today's webinar, American Youth Intentional Drug Opioid Fatal Overdose, The Magnitude of the Problem, an Improved Assessment of Intentionality. Today's activity is presented on behalf of the SAMHSA-funded Providers Clinical Support System, a program operated collaboratively by 19 medical specialty organizations, including the APA. Please note that following today's presentation, you will receive a follow-up email within one hour of the webinar. This email will contain the instructions to claim credit for attending once CME credit is available for today's presentation. Next slide, please. Slides for the presentation today are available in the chat area of the attendee control panel. Please click the message bubble icon to open the chat function. Then select the link to download the PDF version of the slides. Slides will also be included in the follow-up email. Next slide, please. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendee control panel. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Next slide, please. Now I would like to introduce you and welcome back the faculty for today's webinar, Dr. Yefar Kaminer. Dr. Kaminer is a child and adolescent psychiatrist and a professor emeritus of psychiatry and pediatrics at the University of Connecticut Medical School. Dr. Kaminer's main clinical interests and research lie in the spectrum of adolescent high-risk behaviors, in particular, the assessment and treatment of substance use disorders, psychiatric comorbidity, and suicidal behavior. I welcome you today to the session. Dr. Kaminer, thank you for leading our webinar. Okay. Thank you, Dr. Renner. Thanks to the APA for inviting me again to discuss matters that matter about adolescent substance use issues. I'd like to thank some of my collaborators and colleagues, Rebecca Burke, Dr. James Gill, and some of his data will be presented here, and Dr. Jane Angermach as well. In terms of disclosure, this study that I'm addressing and some studies I'm conducting right now are funded by the University of Connecticut School of Medicine. Also, I have been receiving royalties for books on youth addictive disorders. This slide has been presented already. What are the educational objectives? In my view, this is a relatively new presentation, not one of my, as you call them, dog and pony shows, because this is a very serious matter that is still evolving and developing in terms of overdose. We need to be a little bit more innovative in ways that we should address this major public health concern. We will get familiarized with the association between substance use and suicidal behavior. We would like to understand the magnitude of fatal drug intoxication, which is a professional term for overdose. Overdose is a very general, inaccurate, subjective term that can be different from different if you compare different people. However, the term fatal drug intoxication is pretty clear. This is a medical examiner-initiated term. Also, we will recognize the limitations of the system responsible for determining matter of death, including intentionality as it pertains to the opioid polysubstance use epidemic. As I said, there's a lot of work ahead of us in order to solve this matter of a highly heterogeneous population. And I would like to focus to some degree, and this is really the beginning, probably, of the journey on those who might have suicidal motivation in terms of fatal drug intoxication. Here's some terminology that you may find useful. Fatal drug intoxication, a term that is inclusive of the term overdose, which is commonly used. Some people can overdose, but it's not necessarily fatal. How do you decide what is the quantitative or the qualitative aspect of overdose? Fatal is pretty clear what it is. That's why I would use both terms interchangeably based on the literature that I would cite. But my intention would be to try to use the term fatal drug intoxication whenever possible. In this case, youth is a term that is inclusive of adolescents, as well as emerging adults or young adults up to age 25, where allegedly the prefrontal cortex completes its development. The term intent is very important because when we discuss suicide, we need to define it as death in which decedents intended to die, which is comprising of cognitive and behavioral elements. And it's also an important issue in terms of trying to determine whether an overdose or fatal drug intoxication was accidental, intentional, which is definitely a challenge and we'll see it very soon, or remains some kind of undetermined, meaning we are not sure. Now, two very important terms that usually are not being used, especially the first one is manner of death. Manner of death depends on the circumstances for unnatural death, which includes, for example, it's an accident, it's suicide, it's homicide and undetermined. The cause of death is a disease of the injury that started the lethal train of event. What does it mean? You can say cause of death, heart failure, choking or anything else that is very specific in terms of the pathophysiological process that caused death, but this is not the manner of death. And usually, medical examiner address both the manner of death, which also has some legal implication, as you might imagine, and also cause of death, meaning what disease or injury affected what kind of system in the body. Now, we're going to struggle a little bit here with the chicken and egg controversy, which is also very common in terms of dual diagnosis, when, for example, we address mental health issues and substance use disorders, which came first. And there are several, of course, theories and avenues that address this process. So let's start with suicide. Suicide has risen dramatically in the United States and in other developed countries. So, for example, as you can see, there have been a rise of almost actually more than 50% in the last two decades. The rise has been less in young adults. Nevertheless, the numbers of casualties, the prevalence per 100,000, increased to 17, which is at least about 50% more than it is for sheer adolescence. The majority of adults and youth with suicidal behavior exhibited a pre-existing diagnosable psychiatric disorder, which includes also substance use disorder. And finally, co-occurring substance use disorders and psychiatric disorders increase the likelihood of suicidal behavior. So either substance abuse or psychiatric disorders increase the likelihood of suicidal behavior. And if it's end, meaning substance use disorder and psychiatric disorder, the increase in prevalence is even higher. Now, MDD stands for medial depressive disorder and substance use disorder. What are some of the implications noted in the literature for suicidal behavior, which is a spectrum from suicidal ideation all the way to suicide attempt and completed suicide. So one conservative figure published by David Goldstone is increased by a ratio of 2.5. Other studies show that actually a combination of MDD and SUD may even increase it into the teens. A study conducted by the WHO in multiple countries concluded that about 40% had a mood disorder, 41% had substance use disorder, and at least a fifth, a disruptive disorder, which is ADHD or conduct disorder. And about 40% of suicide cases, again, we talk about the young people, are diagnosed with two or more disorders. Finally, looking at data from the National Poison Data System, the percentage of under 19 years old, sheer adolescent, with suicidal intent with opioid use increased from 13.9 to 21.2. And this leads us to the issue that will actually engage us for most of this presentation is opioid use and opioid use disorders with or without some other polysubstance use, how does it affect death rate? So there is a term that is relatively new, and it's called death of despair. There's some publications, especially in the last couple of years, and this is a term that probably will be new to most of you, but it has been new to me also until a few months ago when I did the literature review of fatal drug intoxication, trying to explain what is really happening in terms of the individual level. Why now? Because we are aware of the fact, as I mentioned, that our percentage of people with substance use disorder, opioid use disorder, have some history of psychiatric disorders, trauma. There are also some aspects that pertain to socioeconomic class. So the death of despair is a term used to describe the increases in premature mortality from suicide and drug overdose. And association of despair with suicidality and substance misuse among young adults is being found. Some of the studies started in the Appalachian area where there's unfortunately very high percentage of low socioeconomic class. A lot of people see no future in terms of the economy and other opportunities, and I think that led to coin this term that also includes in some of the studies factors or variables that are very common in suicide in terms of hopelessness, helplessness, feeling that you're not being liked, or having very narrow or not at all a social circle, and so forth that definitely exacerbated during the COVID epidemic. So what they found in the study is almost 20%, three-month weighted prevalence of any despair, which I would say is pretty high, and I'm sure that it's still a conservative figure. And despair scores were associated with more suicidal thoughts and behavior, odd ratio of 1.5, illicit drug use 1.7, and opioid use 1.9, just mind you, odd ratio. One is the normative number, so these are not huge numbers, but they are definitely meaningful numbers. Non-consistent pattern of moderation by social demographic factors such as poverty and education level was found in this study. Although, as I mentioned, the study started with the assumption that poverty and educational level have something to do with death or despair. So there is an empirical basis for despair and several precursors of death or despair, and I will refer you to the evolving literature that is just actually coming up right now, and I'm sure we're going to see more of it in the near future. Now, the issue of suicidal motivation, intentionality, and opioid OD. This is always a question that was hovering in the air for anyone who works with adolescents and young adults who have been suicidal and or use opioids and or were OD, which means basically it ended up in medical care, and hopefully they survived. Some of them just got naloxone and decided not to get care, but there is a research group at McLean Hospital near Boston that published a couple of papers, and they raised the question, is there a suicidal motivation? And I will get back to this towards the end when I will summarize, but I just wanted to bring it to you right now so you will have some food for thought. So first of all, which is really interesting, 40 percent of people who OD have no perception of fatal OD, meaning they did not think they are going to die, and there's a similar finding in another study, which is more of a qualitative study of youth. However, a very high percentage had the desire to die, and about 20 percent had an intention to die, and the correlation between the desire and the intention was quite high, which means that we definitely need to look at suicidal intentionality in order to break down the heterogeneity of the population we are working with and target those who might be suicidal in order to prevent an intentional overdose as compared to just accidental, which means, you know, in a patient's world, I just want to get high, and well, if something's going to happen, so be it, but I really want to get my high. As compared to people who say, I want to get high, but let's say on a scale of zero to seven days in the study, I'm also hoping to die, which is, of course, more of a concern to us, and it raises the question that I've read a couple of years ago in the Journal of Substance Abuse, and it was a very interesting discussion on whether we should hospitalize people who all did, even against their will, because many of them just get out and leave the emergency department. And the idea was that this is very similar to people who are suicidal or repeated OD events in their history. And probably we should treat them in a way that we treat suicidal behavior and say, well, we will need to hospitalize them against their will. Again, food for thought to address this matter. Now, in terms of opioids, let's go very quickly. You know, this is a long list of available opioids and let's focus on fentanyl, which is from 2016, the relatively new kid in the block and in environmental perspective, the invading species is pretty much overwhelmed everything else. So what is fentanyl? This is a synthetic opioid pain medication with rapid onset and short duration of action. It is much more potent and much more lethal than other opioids. And it's even been called in the street with its names and they're also different kind of analogs. So even weed, even cannabis, cocaine and other drugs of abuse can be laced with opioids and definitely with fentanyl and some of the victims, some of the casualties don't even know that they've been exposed to fentanyl. That's to put it aside as compared to people who know that they're using fentanyl. So fentanyl, which was produced mostly in the Far East and was imported to the United States illegally, but now a lot of crime establishment that has been cutting the middleman and they're producing fentanyl by themselves here. And fentanyl is much more profitable than heroin in terms of how much you can charge if you compare, let's say heroin and fentanyl by weight. I remember in the mid eighties and it used to be called China White because it was produced in China. Now, some information that I retrieved and it's as different years in it, but it can show you the trends. So as you can see that the Northeast, particularly at a higher rates of drug overdose or fatal drug intoxication as compared to most of the other States, that's particularly pertain by the way to opioids. Interestingly enough, you see New Mexico, everybody's been watching Breaking Bad or you better call Saul, although they have a methamphetamine problem in that area that is definitely more serious, but you can see that the majority of States, the chunk of them is in the Northeast, but you can see Florida, Louisiana, and New Mexico as well, even a touch of Hawaii. Now, in terms of specific drugs in accidental fatalities, as you can see, fentanyl started very low, but since 2016, it is pretty much trumped all the other drugs. It's responsible for a half a cent that you will see in some coming slides of fatalities. Now, in terms of use with just the paper that came out a very short time ago, what about fentanyl in use? Well, fatal overdose rose sharply from 2020 in teens. After being stable for about 10 years, it was about 2.4%. Suddenly it skyrocketed and probably we can associate it with the fact that young people find fentanyl, I'm talking about very young people like adolescents. So in 2020, you can see that the rate was almost double of 2019, 94% increase. 2021, it kept on going up 20%. I don't have the figures of 2022. Let's see what's gonna happen. And fentanyl was identified in three quarters of deaths, which by the way, is less than in adults, but I'm concerned that this would increase into the 80. So definitely there is a concern. I can tell you Connecticut is a relatively small state, 3.6 million people, but we already had a couple of cases of death by fentanyl for young people under the age of 16. And this is relatively new to us to see this accidental death. And again, it's not a large number and we don't even, you know, can analyze it given the small numbers, but it's an alarming phenomenon that fentanyl has been available to young people. Now in terms of methamphetamine, as I mentioned before, you can see the changes from 2015 to 2019. And as you can see, let's say New Mexico and Nevada were pretty high in 2015. In 2019, you'll see that methamphetamine really spread dramatically in the West, Southwest and Northwest, even in the central areas around the Appalachians and also into Maine. And you know, in order to get methamphetamine, you need to have the laboratories to conduct it. And so we are getting to a point and you see in one of the very coming slides of defining what kind of way or set of drug intoxication we are in in terms of chronological waves. So some people term this wave as the opioids and stimulants oriented wave, polysubstances, this is the fourth wave. And the previous wave were opioids only. And then, you know, the fentanyl wave, which was the third wave, and now we are moving to another wave. So this is a very dynamic change in terms of the epidemiology. And I know that you're all aware that we unfortunately face the 100,000 casualties, meaning deaths in the United States due to fatal drug intoxication. But at least in about a quarter of them, we see involvement of cocaine and stimulants. So this is in the neighborhood of 20 to 25,000 deceased individuals. So a few more numbers here, as you can see, this is up to 2019, but the numbers keep on climbing. You see the breakup, and which is pretty clear, the synthetic opioids are moving up quite quickly and overtaking all the other drugs. Even though we can underestimate other drugs, for example, you know, even benzos, for example, claim a large number of people. It's less than 100,000, of course, but we talk about in the thousands. Now, let's see what's happening with our neighbors in the North. And this is also a study that just came out from Ontario province in Canada. And you can see the ratio between males and females is two to one. I personally am more interested in the 15 to 24 years, this formative years of young people, but the numbers keep on climbing, particularly at the age groups between 25 and 54. And they're almost similar. And even some senior citizens, as you can see, are using these drugs. And you can see the increase from early 2000 into where we are right now. And definitely these are very disturbing numbers. Now, in terms of the triple ways of opioid mortality rates, let's say a period of almost 20 years, again, you can see that opioids are pretty much marshaling the numbers. And whether you talk about any opioids or other synthetic opioids, and this is a slide that covers 2017, but new slide that I'm hoping to get access to because it's an official one from the CDC, probably will show a continuation of this trend. Now, what about gender issues in the United States and Connecticut? So again, as you can see in the United States, the ratio is almost two to one in favor, favor meaning it's worse among males. In Connecticut, I guess every state has its own statistic. It's almost males are more likely than females at the rate of four times actually to overdose. And you can see the very steep increase as compared to females. Now, I don't have the slides about ethnic and racial breakdown, but I think three or four years ago, people used to say, oh, you know, certain drugs is more by white people or black people or by Hispanic, and heroin overdose and methamphetamine, basically the white people disease. However, in the last several years, it's clear that drugs are equal opportunity offenders that are not into justice issues. And in the last several years, you see a very sharp increase in fatal drug intoxication among Native Americans and among black people. So unfortunately, bad stuff catch up. There are all kinds of psychosocial variables that might affect different populations, but the availability of drugs is a major issue. And when drugs are available, people are using them. And in one way or another, it's almost by osmosis. Anybody who might be using it is using it. And this is why we're paying this price in the United States that is way, way much higher of what's happening in Europe. And this is another wonder, why are we in such bad shape compared to Europe when we don't have a higher rate of psychiatric issues, but that's probably more a subject for a talk about epidemiology and health disparities and health policies. So probably I'm starting to bore you with the slides, but again, you can just see the continued increase in numbers and where we are, where are we compared to 2012. Now, this is a slide I just got last week from the chief medical examiner of Connecticut, because finally we have the number of 2021. And as you can see, Connecticut, unfortunately, is one of the top four states in fatal drug intoxication prevalence. And these numbers are numbing for such a small state. So the last 10 years, we started with 357, and now we're standing at 1523. And I'm not sure that 2022 will be much better. This is an increase of at least four times more. As you can see opioids in any death, the numbers are going high so quickly, and they're truly like in the 90s in terms of percents. And then you can see what's happening with fentanyl that the numbers are also skyrocketing in 2012, 2016 when fentanyl really hit the street with a stride, and now it's overwhelmingly all over the place. You see intoxication by fentanyl went up to 80%. You can see also this combination, this cocaine and other issues. And as we mentioned to you, one other new agent that is very little published about it, but it will come out very quickly. I don't have it in the slide. It's called xylazine. Xylazine is spelled X-Y-L-A-Z-I-N-E, xylazine. It's an non-opioid veterinary anesthetic. It has been found in Connecticut almost in 300 cases. It was associated as part of the polysubstance abuse. It's an alpha-2 agonist, so it causes bradycardia, vasodilatation, and so forth. And it can also increase the potential for fetal expiratory depression. So xylazine is the new bad kid in the block. There is no antidote to xylazine. I mean, there is one in veterinarian work, but studies are still going on to find out if this would work with humans. So intoxication by xylazine is very, very dangerous. And of course, if you mix it with one of the other agents, 50 or more, fatality is quite likely. So another slide, we just finished analyzing some of our data because we focus on people under age 25, and actually next time that we give this presentation, hopefully in a year from now, we will have data for 2021, and hopefully we'll keep on doing it because we've done it since 2016, looking at adolescents. And as you can see, the numbers are small, but there are a concern. As you can see, in 2019, we didn't have any deaths under age 15. In 2020, we had two, and unfortunately in 2022, we already had more than two, and we are still only seven months after the beginning of the year. The number among older adolescents doubled, and the number among young adults kind of remained the same, roughly speaking. Now, why adolescents are so important? Because of all this impulsive behavior and the fact that the prefrontal cortex area responsible for abstract thinking or for inhibitory functions in order to block or to screen and filter the stimulation that come from the striatum, that we also know as the limbic system, where the dopamine is found in the prefrontal cortex, and the prefrontal cortex is supposed to send feedback, don't do it or don't do it now. So definitely adolescents are at vulnerable period because the brain is under construction, and even normative adolescents don't have enough breaking power to avoid using these drugs and think about what is in the best interest because they feel very impulsive and sensation seeking due to the brain development. Here you can see some comparisons in terms of children, adolescents and adults. Now, we also know that adolescents are adolescent brain is the plasticity is much higher because it's work in progress. And here's just an example, it's an old slide of nicotine, but it shows you how exposure to nicotine by very adolescents is much more meaningful in terms of its consequences than in post-adolescent. So the younger is the age of using drugs, the higher is the likelihood that the brain will get addicted to the drug. Now, what we have found in Connecticut is that in a study of more than 5,000 high schoolers, it was like an internal study conducted in Connecticut, not by our team, it shows that teen cannabis users report 14 times more abuse of pain meds, four times more of heroin and five more times of other drugs. So when people say marijuana does not kill, this is a very general and very, if you will, superficial approach because adolescents don't wake up one morning and use opioids, they start with marijuana, alcohol and nicotine. And those who would like to have more sensation seeking and more, if you will, impact may roam into more lethal, more immediately fatal or lethal drugs. And as you can see, this is definitely very alarming. Now, I'm not saying that anything abusing cannabis gonna shift into pain killers, heroin and so forth, but those who will definitely have a poor prognosis. Also, we know by other studies that early range of initiation, including psychopathology and use of drugs is consistent with the fact that it predicts opioid use disorder. So that's another reason to provide high level education and prevention for young kids because we see a very disturbing phenomenon that the age of first use of drugs is decreasing, which increased the likelihood of developing what we used to call dependence and now it's drug use disorder. You know, for example, if people use alcohol before age 14, the prevalence and likelihood of having alcohol use disorder by age 21 increases seven times. And also in terms of cannabis, when adults use cannabis for the first time, about 11% will develop cannabis use disorder. With adolescents, the risk is double, is one out of five. So here is another slide that shows that indeed cannabis should be included incidental prescription opioid use disorder and the risk for developing opioid use disorders as well in adults. Now, it's important to understand, remember the slide on the chicken and the egg, it's how the occurrence of dual diagnosis, meaning substance use disorders and let's say major depressive disorder basically feeds each other. And there is some kind of a vicious circle. Let's say people are depressed, they are self-medicating, they're gonna take higher doses of drugs or more frequently or more powerful drugs. And then it doesn't let them anymore to self-medication, they get more depressed and then they're gonna take more drugs. So this is a vicious circle that can end with set negative consequences, including morbidity and mortality. Now, let's shift into the chief medical examiner office to explain and to understand what is really happening in the system. And the bad news, I think to some degree epidemiologically that I will provide you is that as much as we see this numbing, huge numbers of casualties in the United States of more than 100,000 people who lost their life to fatal drug intoxication, this is a relatively conservative approach because the process of generating the manner of death, not the cause of death, but the manner of death, whether it's accidental, intentional and so forth is flawed. So first of all, there is a chief medical examiner in many states. However, there's even the politics, what I call the politics of death certificate, quite chilling term, because in some states they use the term coroner, which is common, let's say in the old UK system. But here's a problem, a coroner is an administrative appointee. It's a political figure that's being appointed. So the medical examiner is usually a pathologist, an MD, whose decisions are mostly professional that are evidence-based. With coroners, it's not the same. And because sometimes there's pressure, for example, family does not want the son or daughter to death to be defined as suicide or as overdose because of the stigma associated with it. And they can put some pressure and they're usually pathologists that are working for the coroner. So this is where we are in terms of several states that in the coroner system, which is a much more problematic system in terms of providing you the accurate information as compared to the medical examiner, because this is not a professional person who knows how to conduct pathological assessment of many of them. So reportable deaths by statuettes, they all need to be reported, as you can see. And they need to be conducted within 24 hours after death, which definitely is very challenging, given the number of casualties that we're experiencing in the United States. And as I mentioned before, only the medical examiner can certify the manner of death, something a coroner cannot do. So there's definitely a discrepancy if you are probably, I mean, the audience represent most of the states in the United States. I think it would be interesting for you to find out what's happening in your state. And if you do have a coroner-based system, the chances of detection of, for example, intentional deaths are 50% less than they are in the medical examiner-based system. So what do we do in terms of what is the process of determining manner of death, cause of death? So it's the autopsy, the toxicology, and the history and circumstances on the scene of the death. It could be a crime scene, or it could be a home, accidental scene, or even a hospital. Then the medical examiner need to provide a death certificate and again, as I mentioned, sometimes people are putting pressure and arguing over the death certificate and what does it imply. So that's another issue we need to understand. Anyway, as you can see from this publication, which is relatively old, it just shows you how much people were aware many years ago already that this system is definitely flawed and it needs to be remedied. And I'm not sure how much of it has been done. Now, this is based on 2017, and now the needs are much higher. And as you can see, the United States is a major, major shortage of board certified forensic pathologists, which means that not all cases arrive to a good evidence-based practice analysis. And there are probably shortcuts being done. And if you check very carefully, speak with medical examiner, you realize how much pressure there is in order to do it and how they need somehow to detour what is considered to be a good practice. Now, in terms of Connecticut, again, to show you how bad the situation is now, and this is 2019, I'm gonna see what's happening in 2021. Accidental drug intoxication. Past 1,000, and this is more than suicide, homicide, and motor vehicle collision. Total is 842. So definitely the number one public health issue, let's put COVID aside, but it has been growing, is fatal drug intoxication. I've got all kinds of numbers here, but I don't want to get you more fatigued in terms of them. But again, we covered accident, suicide, and undetermined. The percentage of suicide among adolescents have been relatively small, but these numbers are still meaningful. The numbers are higher. I don't have the figures right now. And we would like to find out, especially in terms of undetermined, what else can be done to reduce the number can be done to make things more accurate. And again, as you can see, exposure to fentanyl at early age, the numbers are small, but they're definitely disturbing. So in terms of summary, the opiate crisis in Connecticut is greater than the national average. Urban and minority populations are being infected by overdose mortality, and the numbers are probably growing as well. As I said, until five or six years ago, this was not the case. Overdose mortality in Connecticut, as it is in the United States, is driven primarily by fentanyl and polysubstance use, which also includes stimulants and the introduction of a new drug. And they're always gonna be more and more, unfortunately, but beware of this new kid in the blood, oxalazine. It looks like this is a very helpful drug. FDI has been underdiagnosed by limitations inherent in the standard medical examination investigation. And I think that every state should reassess what's going on and how to meet the need for accurate assessments and determination. One of them is perhaps also use some of the psychological autopsy procedure we used to use them more often in the 80s and the 90s to close the gap, meaning anything we can do to get more accurate determination of accidental or intentional in order to reduce the undetermined numbers. And there are variation on complexities and limitations of the system, again, that in my opinion, probably should be a very good reason to push some politicians to get into improving the medical examiner system. They're very good people who work in the system, but they're totally overwhelmed and it affects the quality of their findings. And if we don't have accurate findings that are reliable, the message to public health is that this is a very conservative estimate of the numbers that are probably higher. There's no pathological training. It's not really integral into the preparation, which is I think is important as well. If you want to have a more accurate investigation or examination or assessment with the family of the disease and the case load, I mentioned it several times. So getting back to the study that I mentioned to you before, it is truly important to understand and assess people with opioid overdose, what is their suicidal motivation? Because we are saving a lot of people by naloxone, but naloxone is a mean and it's not an objective because there's a lot of cases of repeated overdose. And we also are aware of neurocognitive damages that happen because of compromised breathing physiology during the time until these people are being resuscitated. And it's important to take it into consideration in terms of psychological and psychiatric treatment, what damage has been caused to people who overdose and suffer only morbidity, not mortality, but how much would it affect future potential accidental overdose, not to mention intentional overdose, which are not clear one-on-one in terms of intention. But as I mentioned about the study from McLean Hospital, it's more like a dimensional approach. We have a range here of suicidal behavior, which decreases the likelihood of prevention of suicidal motivation and suicidal intentionality. So we have, this is a very new slide that looked at the fact that even those who OD, young people have difficulty identifying OD, difficulty perceiving risk when understanding all the intentionality, similar to the study that I just mentioned before from McLean by Conner and Weiss, difficulty to interpret even personal OD events. And what really was more effective or effective in terms of getting the message about OD was when people observed other people OD, and this witnessing process as being more of an opportunity for intervention and window of opportunity and educational moment to intervene in order to reduce the risk of suicidal behavior and OD. So anyone who has any further questions, this is my email. And I think that there are several more slides here, but there are 10 more for the educational perspective. So either Dr. Renner or Mr. Buchholz, we'll take it from there. Are you going to coordinate the chat or the Q&A or how is this going to work, Dr. Renner or Ben? Dr. Renner, are you there to lead the Q&A? Okay, can you hear me now? Thank you very much, Dr. Kaminer. It was very informative and provocative presentation. Remind people can ask more questions in the Q&A portion of the page. I wanted to start out with one thing. Do you have any idea when you look at the data from around the country, how much data on suicides is generated by coroners versus how much data is really generated by medical examiners? Because I think the quality of the data is a problem, if you will. There's no question of the large increase of deaths, but I think we need to understand what's going on. So I'm curious about the quality of the data that we're getting or what the percentages are around the country in terms of the availability of medical examiners versus coroners. I think there's a recent paper, I think I saw it in the ASAM weekly news, I think it's in drug and alcohol dependence that shows, again, I just mentioned it briefly, that in terms of accuracy of manner of death, coroners-based counties are at 50% less, if you will, accuracy than medical examiner, meaning that medical examiner maybe accuracy is not the right term. Medical examiners are more definitive, so they have less undetermined, which is kind of a no-man's land, but it's kind of, to some degree, maybe it's not the only reason, it could be multifactorial, is that the coroner is not a professional, it's an administrative person and sometimes they make decisions that are not professional, and that's a reason for concern. No, it certainly is, and any pressure that we can exert professionally across the country to increase the quality of medical examiners' work, I think would be very helpful. We've had a question from one member of the audience about their patients' use of fentanyl and alcohol every few weeks, and their concern about whether it's risky to increase their dose of buprenorphine from, I think they're saying now they're getting 21 milligrams per day. We can't, of course, give specific advice on any one patient, but I think there's been some tendency to increase buprenorphine doses as the more common use of fentanyl around the country, and I'm curious from other people in the audience whether there are any other experiences. I think a lot of people are concerned that buprenorphine at too high a dose may be dangerous, but my concern is that it may be more effective to prevent fatal overdoses with fentanyl if you've raised the patient's level of tolerance high enough to make it a safer environment. Do you have any thoughts on that or any comments? Let me respond to that by saying, again, the twist and turn of medications, I'm not a toxicologist, or a pharmacologist, but I think we need to look at it more from a motivational perspective. When we intervene with adolescents or with young people, with anybody, first of all, we like to improve their motivation to engage in treatment and understand where we're heading with this, doing motivational interviewing, something of this sort. Later on, that will enable us to improve their ability to adopt the right coping skills. It's not about we're going to be hiding just behind medication. The issue is how to engage the patient in the therapeutic alliance of walking through the addictive behavior, because otherwise, just playing with the medication per se, it's not going to help. Another quick comment is Andrew Geller mentioned something about a paper released last week on self-harm with medications. I'm afraid I'm going to lose this link, so Andrew, please be kind and send me your paper. I would love to read it and maybe incorporate it in a future presentation. I'm wondering if anyone has any suggestions, though, about how we can improve the education for young people and adults as to curb their enthusiasm, if you will, for experimenting with drugs or taking things that may otherwise be very risky and dangerous. Well, you know, you just opened the Pandora box because this is what prevention is all about. I will make only one quick comment. Drug education and drug prevention should start in the early years of elementary school. Middle school is too late. Another probably political issue is when you identify high-risk communities or high-risk families and you want to intervene, people say you're stigmatizing us. Well, we need to make a choice. We have got to the point that we have broken the genome and we know so much about genetics and yet we find it very difficult to work with high-risk populations and high-risk families. So this is, again, a decision of public health policy that needs to be addressed. But as I said, we should start at least general prevention education at the elementary school because we see kids who use weed already at sixth or seventh grade and I even heard about kids who do it before that. Well, I think we've run out of our time for today and I think that's a very important point to end our discussion where we can begin doing preventive work. Can I have the next slide, Ben, please? I want to thank everyone for participating in today's session. Please visit www.pcssnow.org and see the variety of helpful resources that are offered, including the free PCSS mentor program, which offers general information to clinicians about evidence-based clinical practices in prescribing medications for opioid use disorders. Next slide, please. PCSS mentors have expertise in medication for substance use treatment and clinical education. You can also find the PCSS discussion forum, a simple and direct way to receive an answer related to medication for substance use treatment. Next slide, please. The PCSS partner, today's activity was presented on behalf of the SAMHSA-funded providers clinical support system, a program operated collaboratively by 19 medical specialty organizations, including the APA. Again, I wish to thank you all for joining us today and I hope that you will see us soon.

webinar

intentional drug opioid fatal overdose

SAMHSA-funded Providers Clinical Support System

substance use

suicidal behavior

fatal drug intoxication

opioid crisis

fentanyl

prevention efforts

medical examiner system