Good morning. My name is Emily Mossberg, and I am a tribal-specific technology transfer specialist with the Opioid Response Network. The Opioid Response Network is a national SAMHSA grant-funded program that provides free training and technical assistance on topics related to prevention, treatment, and recovery for opioid and stimulant use disorders. We have consultants in all 50 states who can respond to local needs. Anyone can submit a request for assistance on our website at opioidresponsenetwork.org. Today, I am happy to introduce our consultant and trainer, Dr. Sarah Spencer. She is a family practitioner and addiction medicine specialist who has been providing treatment of substance use disorders in rural Alaska for over a decade. She is the volunteer medical director and founding member of Megan's Place, the first rural thoroughbred access program in Alaska. She also partners with the State of Alaska's Project HOPE, and she currently works at Nanilchik Community Clinic as an addiction medicine physician. And with that, I will pass it over to Dr. Spencer. Okay. Good morning. Are you able to hear me okay? Okay. So, it's nice to talk with all you guys today. So, we have a number of lectures that we're going to go over today, and the first one we're going to start with is just a basic overview of the treatment of opioid use disorder. So, we're going to talk about some of the guidelines as well as some common misconceptions around the treatment of opioid use disorder, talk about the efficacy of medication for treating opioid use disorder and how that helps to reduce return to use and mortality, and we're going to talk a little bit about some of the nuts and bolts of office-based practice, including treatment agreements and drug testing. I don't have any disclosures. I work for a tribal clinic and then do consulting for non-profit agencies. So, I'm going to talk a little bit about the treatment of opioid use disorder. We all know that we're in an epidemic of overdose death in the United States, and the rates are continuing to rise, and it is the number one cause of death for people under age 50 in the United States. So, it's really very tragic loss of life of people in the prime of their lives. For diagnosing a substance use disorder, the DSM-5 has three major categories. One is that people may have a physical dependence to the drug, which is commonly seen in opioids with tolerance and withdrawal, but that's really not the most important part. The most important part is even if people are able to get through the withdrawal and past that, they still have cravings and loss of control and a compulsion to continue to use that drug, even though it's causing them significant consequences. It's damaging their work life, their home life. It's causing them to get into dangerous situations, like having DUIs. It might be causing medical problems and other interpersonal problems, and the more problems that it's causing someone, the more severe we diagnose a substance use disorder that they have. And so, addiction, it's not a moral failing. It's a treatable chronic medical disease. It involves interaction between the brain, the genetics, and the environment, and a person's individual life experiences, where people engage in these behaviors that become compulsive and continue despite harmful consequences. But the good news is that prevention and treatment efforts for addiction are generally as successful as those are for other chronic diseases. One of the root causes that contributes to the risk of developing addiction is a history of trauma, and the majority of people who have a substance use disorder have experienced trauma earlier in their life. And especially adverse childhood events are highly correlated with the risk for developing a substance use disorder. Patients who have six or more adverse childhood events are almost 50 times more likely to use IV drugs in their life. And I really like this way of thinking of that connection between trauma and addiction is that people are using substances as a coping mechanism, as a way to provide that comfort and relief of pain that they're experiencing, whether that's physical pain or emotional pain. And it really becomes a ritualized compulsive comfort seeking is really kind of the root of that connection between the trauma and the substance use. And the reason that people are using a substance changes over the trajectory and timeline of their use. So early on in use, people are using the substance, in this case, if we think about opioids, to experience that pleasure and that positive relief of the pain that they are experiencing. And that's a positive reinforcement. However, as people develop a both a physical dependence and a tolerance to that drug that they are using, it becomes that they have to use the drug to relieve withdrawal symptoms. And they develop a tolerance so much that they no longer necessarily experience pleasure when they use the drug. They're using the drug to relieve the pain of withdrawal, and that's called negative reinforcement. And that really drives that long-term use of the opioids or alcohol. And we see changes in the brain in the way that especially neurochemicals like dopamine are acting in a brain when someone has chronic opioid use. So some of the changes that we see that affect the frontal cortex can result in increasing trouble with impulse control, difficulty with future planning, and motivation to plan for the future. There is a reduction in dopamine binding in certain areas of the brain. And so that can really make it cause an anhedonia or really this lack of pleasure in the normal things that everyday life would allow us to get pleasure from and increase the risk of depression as well. And in the amygdala, the amygdala is really where the cravings, fear of withdrawal, and anxiety occur. And that gets really hyperactive in opioid dependence and other addictions. So that fear of withdrawal and cravings can really become very powerful and guide a person's actions. What we do know is that for most addictions, that when patients just try to not use, they just try to rely on their own willpower not to use, that almost everyone goes back to using. And this is particularly true of opioid use disorder. If people are not taking medications and just trying not to use, up to 90% of them will return to use before the year is out. So let's talk about medications that are used to treat opioid use disorder. So the most commonly prescribed medication for opioid use disorder is buprenorphine. And thankfully, the waiver restrictions around prescribing buprenorphine are now gone. So there is no special education required to prescribe buprenorphine. Any prescriber that has a DEA license that allows them to prescribe Schedule 3 drugs can prescribe buprenorphine. There's no limits on the number of patients. There's no requirement to track the patients that you're treating. There's no requirement to refer for counseling. It's just like it would be prescribing any other Schedule 3 medication. So there's three formulations of medications, three types of medications that are FDA approved to treat opioid use disorder, methadone, buprenorphine, and naltrexone. The methadone is a full agonist, means it binds to the opioid receptors and fully activates them. Buprenorphine is a full agonist, means it binds to the opioid receptors and fully activates them. Naltrexone is a partial agonist, so it only partially turns on the opioid receptor and also works to block it. And naltrexone is a pure opioid blocker. And when we look at the benefits of, and this is specific for buprenorphine or methadone, they are dramatically effective in reducing mortality. And this is really the most important reason that we use these medications. The most important thing in treating, the number one priority is to reduce the mortality risk for that patient. So patients who are taking buprenorphine or methadone can reduce their mortality risk between 60 to 80%. However, it's really critically important both for the prescriber and the patient to understand that this benefit of reduction in mortality only happens when people are taking their medication. And when people stop taking their medication, that mortality risk goes way up, especially the first month or so that they have stopped their medication. They have a dramatic increase in their risk of mortality. The medications are incredibly effective at reducing return to use. So if we look at, this graph is looking at buprenorphine at return to use or relapses, and the patients taking buprenorphine or methadone are in the blue and red lines on the bottom, and the green is patients who are not taking any medication and only engaging in behavioral health support. And the blue line is patients who are not taking any medication and only engaging in behavioral health support. So we see really in that first year, medications can reduce the return to use by tenfold. Two to three years out, people who are taking medications still have two-thirds less relapse rates than patients who are not. And there is data that even five years out, patients who remain on their medications have half the return to use race as patients who were not taking medications. So it's really dramatically effective, and it is really the key of why it is the standard of care and why non-medication-free treatment for opioid use disorder is not recommended. Unfortunately, the least effective treatments for opioid use disorder, not taking medications, or the blocker naltrexone tend to be the least stigmatized, and the medications that are the most effective, like buprenorphine and methadone, tend to be the most stigmatized. And that can be a really huge barrier to offering treatment or for patients being willing to accept and continue that treatment, the stigma that can surround the treatment. And a really common concern that patients and also other providers, even our community members, will bring up is that, you know, I feel like this is just switch trading one addiction for another or substituting one drug for another. That's a very common myth. And it's really important to understand that this is not a one-size-fits-all approach. It's not a one-size-fits-all approach. It's a very common myth. And it's really important to provide the education to patients and others about what the difference is between physical dependence and addiction. So when you think of a drug that a person is addicted to, that use of that drug becomes compulsive, and they lose control of the use of that drug, and they use that drug in ways in which it harms them, and they continue to use that drug despite the multiple and escalating harms that that drug is causing them, versus a medication that is treating addiction that is taken in a consistent way on a long-term basis as prescribed and monitored by a provider, and that medication is improving the quality of life. It's reducing mortality. It's improving a person's health. It is improving their function in day-to-day life. And despite the fact that it can cause a physical dependence, there are many medications we use in medicine that cause physical dependence, and they're not all narcotics. There are antidepressants. There are blood pressure medications. There are lots of medications which, when you stop them, cause withdrawal symptoms or other dangerous side effects. The physical dependence is not the factor in the medication that is causing the problem. Physical dependence is not the same as addiction. So let's briefly review the other two medications that we're not going to spend as much time focusing on in the rest of the lecture, but just to touch on them briefly. Methadone was the first medication that was licensed to treat opioid use disorder. Methadone is a full opioid agonist, meaning that it fully stimulates the opioid receptors. It does to reduce cravings and use. It does provide some amount of blunting or blockade of other opioids at highest doses. However, it is highly restricted by the federal government, so it's only available at an opioid treatment program or what you'd hear called a methadone clinic. Patients have to go to that clinic every day to get an observed daily dosing, and those clinics also require that patients engage in a very high level of support with counseling and other psychosocial support services. There is a lot of work on the patients. It can result when you include travel, waiting for medications, the programming they need to engage in. It could be hours every day that patients have to invest in order to stay on this medication, especially early in treatment. It does have more drug-drug interactions and a higher risk of overdose when mixed with other CNS depressant medications or drugs. It's also helpful for treating chronic pain, so sometimes patients who have really severe chronic pain can get more relief from this medication. Overall, because it's been around for so long, it has the most evidence behind its efficacy of any medication, although buprenorphine is quickly gaining similar levels of evidence for efficacy and effectiveness. Naltrexone, the brand of Naltrexone, there's only one brand of Naltrexone that is approved to treat opioid use disorder, which is the monthly injectable Vivitrol. It is strictly an opioid blocker or an antagonist, so it binds really strongly to those receptors and it blocks them to prevent opioids from binding. Oral Naltrexone is okay to use for alcohol use disorder, but it is not okay for opioid use disorder. It has no efficacy in the treatment of opioid use disorder and can really be dangerous because people don't continue to take it. It's not a controlled substance, and so there is no physical dependence. This has been kind of touted by the manufacturers as being a benefit to this medication, and it was really very strongly marketed, especially to the criminal justice system a number of years ago in ways that actually got the company in trouble, as well as marketing to politicians and that sort of thing. It is the most difficult medication to initiate. It requires between one to two weeks of abstinence before that first injection. It is a very safe medication. For some patients, if they're able to get on and continue it, some patients do have good success with staying on this medication. It has the least evidence of effectiveness. Also, a number of studies have come out in the last couple years that really demonstrate that there is very little evidence for this medication actually reducing mortality in opioid use disorder. For certain select patients, this medication might be a good fit, but it doesn't have the same kind of evidence that buprenorphine or methadone would have to reduce mortality. When we think of how the medication works, it blocks the opioid receptors, which can help to reduce the reinforcing effects if people use opioids. Another way it's felt to work is that by blocking those opioid receptors, it's somehow reducing the drug condition cues to help reduce cravings being triggered by those. We don't entirely understand how it's working to reduce cravings, but it can be helpful for cravings over time. The other important thing to remember is that it does not have any positive or negative reinforcing effects. Patients don't feel any better when they take the medication, especially in patients who have severe OUD can really result in a poor retention and treatment. The medication does not incentivize to continue to take it. For patients that really want to take this medication or seem to be a very good fit for this medication, rewards for medication compliance like contingency management, we'll talk about that a little bit more later, but it does help to increase the retention and treatment for patients who want to take this medication. Buprenorphine, which is the medication we're going to spend most of today talking about, is a little different from both of those two. It has a number of different actions at the opioid receptor. It is both a partial agonist, so it partially activates the receptor, and it also works as an antagonist to block some of the opioid receptors. So, when it binds to those receptors and activates them, that minimizes cravings and helps people to feel more normal, and that is really the positive reinforcing part of this medication. It has a number of features that help with the safety and to reduce the abuse liability of this medication. So, it has a plateau effect, meaning that with increasing doses, we don't see an increasing opioid effect of the medication. So, there is a ceiling effect in which there really is very little incentive for people to want to take very high doses, much more than prescribed, because they're not going to get intoxicating effects by taking extra. And for people who have an opioid tolerance, they're not going to feel intoxicated when they take buprenorphine. It's pretty difficult for them to feel intoxicated off it. People who have no opioid tolerance, who are opioid naive, or like especially we think of like young people, teenagers, they will feel intoxicated if they take buprenorphine. So, it is important to try to reduce diversion of this medication in the sense of keeping it out of the hands of people who are opioid naive or are youth. And buprenorphine also acts as a blocker of other opioids. So, it binds so tightly to that mu opioid receptor that nothing else can bind. And it also binds so tightly that if there is any other opioids in the system, it will actually knock all of those opioids off the receptor and it will bind. So, if someone takes buprenorphine when they have a high amount of especially fentanyl in their system, it will knock all their fentanyl off the receptors and you'll go from a high level of opioid activity down to a low level of opioid activity very quickly in less than an hour. And that is what causes what we call precipitated withdrawal symptoms where people sometimes if they take that first dose, the wrong dose of buprenorphine at the wrong time too early at their first dosing can experience severe symptoms of precipitated withdrawal. Another really unique effect that buprenorphine has on mu receptors is on the kappa receptor, it is also an antagonist or blocker at the kappa receptor. And that actually results in likely having an antidepressant effect as well from that effect on that receptor. So, it can help to regulate people's mood especially with the full opioid agonist having a can cause some depression over time. This can help to reverse that and improve normalized patient's mood. So, we'll quickly talk about the some of the recent changes and the guidelines for treating opioid use disorder. ASAM came out with these guidelines in 2020 and there were a couple of significant changes that came out of those guidelines. One was that home initiation of buprenorphine is considered as safe and effective as in-office initiation. So, and I think many addiction specialists have been doing home initiation for many, many years and this really came out and specifically said that yes, this is a safe approach for most patients. Medication should be initiated as quickly as possible when a patient is ready to do that and we should not delay the start of medication due to requiring a full behavioral health assessment or a full medical assessment. Counseling, although it can be helpful to improve people's quality of life and address underlying psychosocial issues that a person has going on, it should not be required in order for a patient to obtain medication for opioid use disorder. Also, although we want to warn patients that there are risks in taking buprenorphine with other CNS depressants like alcohol or benzodiazepines, we do not want to withhold buprenorphine from patients that are taking these other CNS depressants because even in the context of patients using buprenorphine with these other CNS depressants, it still dramatically reduces the risk compared to the patient taking fentanyl or heroin with alcohol or benzodiazepines. So, we're still reducing mortality even if the patient continues to use these other CNS depressant medications or drugs. And higher doses of buprenorphine work better and so the minimum recommended dose in early treatment is 16 milligrams a day. We're going to talk more in the next talk about how higher doses can be required early in treatment. This medication is meant as a long-term chronic therapy, minimum of two to three years, and there is no time limit. And again, really people that stay on this medication the longest tend to be the people who have the most long-term success. Women who are pregnant should be treated with either buprenorphine or methadone during their pregnancy. Both are acceptable and considered equally effective. There are some benefits to buprenorphine as far as reduction in the severity of neonatal abstinence syndrome. And also in pregnancy, we used to say that we would only use the plain buprenorphine product in pregnancy, but now either the plain or the combination with naloxone product is considered to be safe in pregnancy. When patients are seen for issues related to opioid use disorder, withdrawal, overdose, injection-related infections, any of these things in the emergency room or the hospital, they should be started on buprenorphine or methadone there in the hospital before they leave and be given a prescription on discharge to bridge them to chronic care. Treatment engagement is dramatically increased when that medication is started in the emergency department before they leave. And we no longer recommend that people stop or generally reduce their dose of buprenorphine before they have surgery. We found that actually makes pain control more difficult for patients, so they should continue their buprenorphine even if they're going to have surgery. Another important legal change that has come up for patients with OUD is the new protections from the Department of Justice under the Americans with Disabilities Act. So, historically, we've had a lot of issues with patients being denied access to their medications when they're in different facilities. So, now, it is officially illegal to deny a patient access to their medications or to deny them access to treatment to facilities simply because they have opioid use disorder or are taking medications for opioid use disorder. So, that includes residential substance use treatment. That includes sober living or kind of halfway houses, skilled nursing facilities. They can't deny admission or not allow someone to take their medication. It's also true of jails and prisons now are supposed to allow patients to continue to take their medication when they're incarcerated. This isn't consistently happening in all the facilities nationwide, but it is the law. And also, clinics and hospital can't deny admission or care for a patient because they have opioid use disorder or they're taking medications to treat that. So, let's talk a little bit about treatment agreements and kind of the policies and procedures of operating outpatient buprenorphine clinic that need to be considered. So, treatment agreements, they can be really useful to help to improve communication between the provider and the patient. So, both the provider and the patient have a good understanding of what the expectations are from each person in that relationship and what happens when those expectations are not met and what everyone's role is. They also educate about how to take the medications, how to store the medications, risks associated with the medications or with other drug use. And so, they can provide some really important information for the patient. However, it's really important that when we're developing policies and procedures that all of those prioritize keeping the patient on buprenorphine whenever possible. Because again, when patients stop taking their medication, the risk of death increases greatly. The risk of return to use and death increases when people stop taking their medications. So, let's talk about some of the common issues that come up in taking care of patients who have opioid use disorder and how we can think about addressing those in our policies and procedures. So, a common problem that can arise is issues around scheduling. So, it's important to remember that people, especially when they're early in treatment or they're not stable in treatment, before they start, they have untreated substance use disorders. One of the main diagnostic criteria for that is people have a failure to fulfill their obligations and have persistent and recurring social and interpersonal problems. So, it is normal for patients to struggle with keeping their appointments and showing up on time. It is normal and expected for, you know, over half of the time for people to not show up for their intake appointment. So, kind of really making policies and procedures to address this issue, that this is normal and how can we help to make treatment more accessible knowing that this is a normal and expected behavior in uncontrolled substance use disorder. So, some things that we can do, scheduling appointments shortly in advance, so like no more than two days in advance, those have, you know, or having same-day appointments to really, when people right then are motivated, try to get them in right away, can help to reduce no-show rates. It can help with provider scheduling sometime to kind of have block scheduling where they have certain periods of time, maybe it's like a few afternoons a week, where those periods are set aside just for patients, you know, who are getting prescribed buprenorphine. So, there's more flexibility in the schedule in those afternoons. Afternoon times tend to be better for most people than morning times. Case management can be really helpful or having, you know, someone, an MA, a behavioral health aide, someone that's able to really make those frequent reminder calls and really help with rescheduling, arranging transportation, things like that that might be needed to actually get people to come into the clinic. And in some cases, patients, they're just, you know, despite many options, you know, that we offer them to try to get in, they still are, they're just not able to come in. They continue to frequently miss their appointments over and over again and can be kind of on and off and on and off and on and off their medication because they're not able to show up for those, you know, prescription refill visits. And again, we really, it's very important for people to stay on their medications. So, in some circumstances like that, it can really be a better fit for some of those patients to have monthly injectable medications that are much more forgiving in their timeline of, you know, when they're going to be given so that a lot, allows for much more flexibility in scheduling and rescheduling appointments. And we'll talk a little bit more about group visits later today. Group visits can be another way that can help to reduce burdens on scheduling and kind of simplify a recurring schedule for patients as well. Running out of medication and trouble with medication compliance. This is, can be a difficult problem to deal with in the clinic. So, if a patient is asking for an early refill, it's really important to dive into, you know, what, what happened? Did, were their cravings under control because their dose was too low and they're taking more than prescribed? In that case, maybe they need their dose increased. Are they're having cravings to take more because of other untreated problems like insomnia or anxiety or pain? Are they sharing their medication? Maybe their partner has opioid use disorder and, or their friend and they're sharing their medication with that family member, in which case we want to try to recruit that other loved one into treatment so, so that they get the medication that they need. Some things that we can do when we're seeing these patterns. One is, is to provide shorter prescriptions so that if patients are running short, that they have a shorter period of time in which they're without medication. Providing lock boxes or encouraging the use of those. If there are issues with security, if people are, maybe they're living with other people who are using drugs or maybe they're housing insecure and it's difficult for them to keep their medication safe, that could be helpful for patient. Helping patients to kind of ration, make a plan for rationing the medications they have left. If there's, if it's a short period of time before their refill is due, to reduce that dose for a couple of days to help them to get through. And again, when we see, sorry if I'm gonna say this, multiple, multiple episodes kind of recurring over and over again of patients, excuse me, running out of their medications early and despite addressing all of these other concerns, then there, you know, there are options. We could do directly observed dosing of the medication, which can be done over a video chat to check someone taking it, or there's programs that you can subscribe to that use apps on smartphones to help you directly observe therapy, although those can be expensive. And these are also, this is also time consuming for staff to have to, you know, evaluate the dosing. And again, if patients aren't able to successfully take their medications on a regular basis, despite trying to work with them with lots of other support, then again, they may be more successful and safer on a monthly injectable form of medication. Poly substance use is, is very common. It's really, it's normal in, in many forms of addiction and especially you see it a lot in opioid use disorder. Most patients who are using opioids are also using some other drugs along with that. And it's important to realize that, that patients who are using other substances can still be successful in stopping or reducing their opioid use and reducing their risk of overdose death and improving their quality of life, even if they don't stop using those other substances. Buprenorphine, it treats only the opioid use disorder. It's not going to treat the other substance use disorder. Each substance use disorder needs a treatment specifically targeted for that use disorder. So it's not reasonable to expect that just because we're treating an opioid use disorder that these other substance use disorders are just going to go away. Those all need to be treated individually. And again, all the federal guidelines say, including the FDA labeling of these medications along with the ASAM guidelines is that we should not withhold buprenorphine for patients who are taking other alcohol or other sedatives, but we do need to warn them about the risk of combining those medications and drugs together and make sure that patients have an overdose response training as well in naloxone. And for certain patients who are using multiple substances, if there is a concern with medication compliance or like a very high diversion risk and the provider doesn't feel comfortable with that, there may be times again where either we do very short prescriptions with very close monitoring of their sublingual medications or may benefit from a switch to monthly injectable medications in which we don't have to worry about monitoring for diversion in that case. Not participating in behavioral health. So there are a number of patients, you know, patients, first of all, behavioral health care isn't always accessible. There's a huge shortage of behavioral health preventionals nationwide. And so even if sometimes if a patient wants to get into behavioral health support, it's just not realistic. Sometimes there's insurance barriers, transportation barriers. Sometimes people have had really traumatic experiences or very unhelpful experiences in the past when they've participated with psychosocial support. So although psychosocial support can be helpful to improve a patient's quality of life in many ways, it is not really proven to reduce the most important factors, which are return to use, retention and treatment and mortality. Those are not very affected by whether a person engages in psychosocial support or not. So we should never withhold medications simply because a patient is either unable or unwilling to engage in psychosocial support. And we'll talk more at the end about, you know, other forms of psychosocial support that can be helpful that are not the traditional one-to-one counseling. We'll talk about that at the end. Special considerations for patients who have involvement in the criminal justice or child welfare system. This is a really important, when we're doing intake and getting a social history, this is a really important thing to ask about. Patients with these legal issues, they may be legally required to engage in treatment. They may be required to do random drug testing with child welfare or with the probation officer for these patients, because there are really significant long-term risks to them, either legally or custody-wise, they should be offered a highly structured plan with more frequent visits and more frequent testing and more behavioral health support. Not that those things necessarily should be required, but they should be offered because those things are required generally in the overseeing legal agency for them to be considered to be successful in treatment from their standpoint. Having regular communication between these agencies, getting connected to the local probation officers and to the local child welfare system so they understand how your clinic operates, they understand how to refer patients to your clinic, and why it's important for people to stay in treatment. Generally, what is important is that we not share any information with these agencies without the patient's very specific written informed consent. There can be really severe legal implications, for example, for releasing drug testing results. It's important to remember that these agencies, they perform their own drug testing and that's not our job to do that for them. Our drug testing is for taking care of the patient from a medical standpoint and shouldn't be shared with them without that patient-specific consent. Even if patients are court-ordered for treatment, they should still be offered low-threshold harm reduction care if they're not able to participate in the level at which the court or overseeing agency wants them to. Paying in collection, luckily for many of our folks in the IHS system, we don't always have to consider these concerns, but certainly uninsured patients sometimes can have issues with payment or bills. The important thing is that if at all possible, we should always prioritize keeping patients on their medication because withholding their medication because they have an unpaid bill or something like that has really severe consequences. There are many sample treatment agreements online. This is one that ASAM put out a number of years ago. It hasn't been updated recently, but again, making a treatment agreement that's specific for your circumstances is always recommended, but that can help to start with a basic one and change it to your needs. I'm going to briefly review the basics of drug testing, which from my understanding is not something that has been available in the behavioral health offices, but can be a tool that can help your practice. So why do we do drug testing? First of all, we're not the police. We are not trying to catch them in the act of doing something so that we can punish them. That absolutely is not the reason why we're doing drug testing. We're using it as just one tool in our arsenal to help to collect information that can help to guide our treatment conversations and to provide better treatment to the patient. So if we think for an example of a patient who's on buprenorphine for OUD and they have a urine drug screen that tests positive for buprenorphine, but also tests positive for non-prescribed benzodiazepines and THC. So how do we react to that kind of a drug test result? First of all, we don't stop prescribing buprenorphine to someone because they're using those other drugs. That is not the reason why we're doing this drug testing. What we do want to do is to use that information and then to guide the conversation with the patient to talk with them about why they are using the other drugs. There is an underlying reason and if we don't get to the root of that reason and address it, that use is likely to continue. So if someone is using benzodiazepines or marijuana, talking about them about why. Do they have an underlying use disorder of that other drug or are they using it to treat other comorbid conditions like insomnia, anxiety and depression, chronic pain, medicating other substance use disorders, really kind of getting to the root of why that other use is going on and then working on what those other triggers are and trying to specifically address those other comorbid conditions to reduce other risky drug use. There are two main types of drug tests. One is a screening test and that is usually a rapid test that we get in the office. We get instant results and then there is a confirmatory test and those are send out tests that go to a lab and those actually measure the exact amounts of each drug or medication that is present in the urine. Drug testing is not just urine. You can also do oral fluid testing and that can actually be done if you're doing telemedicine. It can be done from a patient's home, witness collection or video and can be mailed in to the lab. Oral fluid collection has a very short, oral fluid really shows you what's in the person's system right then, right that day. It doesn't tell you what they did three or four days ago. Urine drug tests are, the rapid ones are very inexpensive. They're easy to perform and then that sample can also be sent off to the lab for confirmatory testing. When we're performing a urine drug test, it's important to train the person who's going to be collecting that sample on how to do it. This is just some recommendations on that procedure of collecting the specimen and interpreting the results and all different tests, they always have instructions about how to interpret those results or read them. Typically, with drug test results, there is a line present when the drug is not there and then the line is absent when the drug is there. So it's a little reverse of what we would think with like a strep test or a pregnancy test. So it's important for people to be trained on how to read the test and every test is a little different. So it's important to read the instructions in the package. With oral fluid testing, oral fluid testing is send out only testing. You don't get any instant rapid results from that. But it can be helpful when we're a patient, maybe they can't provide a urine sample. They're not able to go. We have concerns with the sample alteration or tampering, and we want to get that observed sample collection. That's nice because you know for sure that it has come from that person without having to do kind of invasive or embarrassing witness urine collection. Every oral fluid test also has instructions in there on how to use it. Typically, they need to be left in the mouth for about five minutes until there's an indicator that shows enough saliva has been absorbed. And then they get mailed into the lab and labs sometimes will even be able to mail testing supplies directly to patients or sometimes we'll give them to patients to take home with them with a prepaid envelope. We can observe the collection over video and then they can mail it in. This was very helpful for us at our clinic during COVID times when patients were doing a lot more telemedicine and patients weren't able necessarily to come into the clinic, but we still wanted to have some testing results for those patients. Probably the most important reason, one of the most important reasons that we do drug testing is actually just checking that the patient is taking the medication we prescribed to them, that they're taking their buprenorphine. So drug testing can help us with confirming medication compliance. So this is particularly true with confirmatory or send out testing for buprenorphine. Buprenorphine is metabolized into norbuprenorphine. So when you send a urine sample out on a patient who's taking buprenorphine for confirmatory testing, you will always see the presence both of buprenorphine and norbuprenorphine together. What you will sometimes see, probably one of the more common ways in which people kind of tamper or alter their samples would be to take a urine sample that is not theirs or maybe that is theirs, but doesn't have any buprenorphine in it. And to actually put medication into the urine sample, like a tablet of buprenorphine or a film of buprenorphine naloxone, actually dissolved in the urine to make it appear as though the medication is taken. But when you send that sample out for confirmation, what we'll see is that there's a very high level of buprenorphine present and sometimes also a very high level of naloxone present if it's a combination product, but we see no or very little norbuprenorphine present. So that is an indication that that sample was altered and, you know, wasn't either their sample or that they're trying to alter the result of the sample. So some clinics will send out samples for all patients one to two times a year for this buprenorphine norbuprenorphine confirmation to kind of help us document that patients are taking their medication. And if we see a sample that has been tampered with, or maybe that doesn't have buprenorphine present, then again, we need to investigate what is going on. So if they're not taking their medications, then why? You know, what happened? When did they run out? And it's important. Buprenorphine stays in the urine for a long time, and so people have to be off it generally for more than a week for their urine to test negative. Another thing is that, you know, if a patient is substituting their urine, it may be to cover up other non-prescribed drug use that they're embarrassed about or they may be scared about the legal implications of having a drug test result on their chart that is positive for non-prescribed substances. So you know, kind of again talking with them about what's going on with their other substance use and why, you know, why they might be scared to admit that or have that on their record. And much less common is that a patient isn't taking medications and on diverting it. That's very uncommon. There's usually another underlying reason why that sample has been tampered with. So this is an example of a drug test in which the sample has been tampered with. So in this sample, we see that there are very, very high levels of buprenorphine. However, there is no norebuprenorphine and no naloxone. This means that a plain buprenorphine tablet was dipped into or dissolved in the urine sample. If it was a buprenorphine naloxone strip or tablet, we would also see very high levels of naloxone. And so with this particular patient, when we kind of talked to them about this and he came back to give a sample that was actually was his sample, we see kind of what the actual result should have been. We're seeing buprenorphine, norebuprenorphine, and naloxone because he was taking the combo product. So this is the normal urine result. And then we see here methamphetamine. So this was a patient who was having legal problems. He was on probation. He was very scared about having... He was taking his medication as prescribed. He wasn't using opioids, but he was using the methamphetamine. So that is what he was trying to cover up was the use of methamphetamine. It wasn't that he wasn't taking his buprenorphine. So again, really getting that information. It's also important to understand that the concentrations of drugs, these numbers in the urine are not... There's no formula to determine what dose a person has taken a medication or when they took their medication dose based on these numbers, like the amount of concentration of buprenorphine in the urine. That is not correlated with the serum drug concentration. So we can see those numbers go up and down, and that's normal, that urine drug concentration. There's many things that can affect that from timing of the dose, the amount that they took, their other things going on in their metabolism and their hydration status, other drugs that they're taking. So we can't use these numbers to say if a patient is taking the prescribed dose of medication, but we can tell if they are taking the medication, period. False positive drug tests are very, very, very common. And so we see there's a lot of false positives for amphetamines from over-the-counter like energy supplements and decongestants and things. Poppy seeds can cause a true positive for generally low levels of morphine with codeine combined. If you're seeing something like that in a patient and they're denying use, especially if you have a patient who is on some kind of legal monitoring, it's important to encourage them to avoid the ingestion of poppy seeds because it will cause a true positive for morphine and also generally codeine. One thing we see in patients who are taking either naltrexone or even naloxone with the combination product of buprenorphine is that you can see a false positive for oxycodone. I think I've seen this like three times. And again, this can cause major problems for someone if they're having legal monitoring. So anytime we see a result, either a positive or a negative that doesn't align with the patient's report and it could have effects on them legally or it's important and it's going to change, possibly change your treatment of that patient, we have to send those out for confirmation because the rapid tests they have, they are not very accurate. And so we don't want to make any significant changes in a patient's treatment based on the results of a rapid in-office test. We want to send out and get that confirmatory test, especially if a patient has legal involvement. So we see false negatives for other certain prescribed drugs. For surfazol, fentanyl, tramadol, and kratom, those are not going to show up on any rapid tests. They just released a rapid urine dip test for fentanyl that's CLIA-waived, just came out in November. It's hard to get, but that will be an option now. But it's not included on any of the standard cups. But other prescribed, often clonazepam will not show up in a rapid test. And clonazepam and clovenidate often will not show up on a rapid test. It's just another chart that shows the very common and many false positives that can occur. And different medications and drugs stay in urine and saliva for different periods of time. So with, and buprenorphine is not on this list, but buprenorphine can stay in the urine for one to two weeks with chronic heavy doses. Buprenorphine from sublocate, long-acting buprenorphine injection can stay in the urine for over a year. Benzodiazepines can stay in there for weeks. So understanding how long a drug is likely to stay in the urine or oral fluid is important when you're trying to interpret these drug testing times. Again, buprenorphine has a long detection in the urine. So when their urine tests positive, it means, you know, it doesn't necessarily mean that they took their buprenorphine that day, but it means, you know, they've certainly taken it within the past week. And when you do confirmatory testing, you, a great resource to utilize is the lab's medical review officer. So a medical review officer is a doctor who has a special certification to interpret drug testing results. And every confirmatory lab you send out for has a medical review officer that you can talk with that will help you understand how to interpret those results. So you want to utilize that service anytime a result is confusing for you, that's what they're there for, is to answer your questions and help you interpret those tests. And we really need to outline what the expectations are for patients with drug testing ahead of time. We need to talk to them about why we're doing the test. Again, you're like, we're doing this test to see that you're taking your medications. We need for them to understand what the expectations are, you know, if they are other non-prescribed medications. People are, again, they're very scared sometimes to provide a sample. They're worried that if they test positive for a non-prescribed medication that their medication will be stopped or they'll be kept out of treatment. They might have experienced that in the past. So in order to, for the patient to be willing to provide a sample, they need to feel safe in doing so. And they need to understand what the implications are for providing a sample or for not providing that sample. And again, this is the things that we really already talked about is that, you know, all of our drug testing policies should always prioritize keeping patients on the medication whenever possible. And we really, we want this to be, you know, an additional tool to help improve our therapeutic relationship with the patient. We don't want it to be a barrier to patients being able to access their medication. So that is the end of that presentation.

opioid use disorder

treatment

medication

addiction

chronic medical disease

prevention

trauma

neurochemical changes

buprenorphine

methadone