Perfect. Well, it's good to see you all again. My name is Chelsea. We've been here before, so I'll kind of skip over my introduction. But before I introduce our presenter for today, I would really like to open our session with a land acknowledgement. Our work intends to reach the addiction workforce in the Northwest TOR region. This includes Alaska, Idaho, Oregon, and Washington. This region rests on the ancestral homelands of Indigenous peoples who have lived on these lands since time immemorial. Please join us in support of efforts to affirm tribal sovereignty and in displaying respect and gratitude for our Indigenous neighbors. I am calling in from Portland, Oregon. I reside on the traditional homelands of the Clackamas, Cowlitz, Siletz, Grand Ronde, and Cayuse, Umatilla, and Walla Walla tribes. I want to recognize that Portland today is a community of many diverse Native peoples who continue to live and work here. We respectfully acknowledge and honor all Indigenous communities past, present, and future. And with that, I would like to reintroduce Dr. Sarah Spencer, our presenter for today's session. She's a family practitioner and addiction medicine specialist providing treatment of substance use disorders in rural Alaska for over a decade. She's the volunteer medical director and founding member of Megan's Place, the first rural syringe access program in Alaska. She also partners with the state of Alaska's Project Hope. She currently works at the Nilshak Community Clinic as an addiction medicine physician. And with that, I will pass it over to you, Dr. Spencer. Thank you for being here with us again. Yeah, great. It's great to see everyone again today. All right. So we're going to start today talking about long-acting injectable buprenorphine, and then we're going to kind of transition into talking about low threshold care and harm reduction. And these two, there's a lot of overlaps sometimes between these two here. And so I will take some questions in between the two about the buprenorphine here. And if you need to ask a question that can't wait till the end, you can come off mute and, you know, ask a question. Sometimes I tend not to see the questions in the chat box while I'm going, but we'll get to those at the end and go over everyone's questions so you can put them in and then we'll go over them at the end. So we're going to talk about some of the kind of unique pharmacology of long-acting injectable buprenorphine and some of the logistics about how to use this medication. And we're going to compare some of the different formulations that are available of this medication, some different strategies to get people started on it, and kind of troubleshooting some of the problems that can come up with utilizing this medication. And I started using long-acting injectable buprenorphine when the first product came out in the U.S. in 2018, so six years ago, which is sublocated. We now, just under a year ago now, a second brand, Brixadi, was released, which has been being used in kind of Europe and Australia for a while, but just recently here in the United States. So we're going to compare some of those different medications and way to use them. I haven't personally used Brixadi yet myself. I've done a lot of reading about it and talked to people. Some people have used it, but we'll kind of compare different ways to use the different medications. So in my practice right now, we find that the majority of patients who are coming to us, self-referred, asking to get on MOUD are specifically requesting this medication, like when they make their appointment or when they come through the door because their friends told them, you know, how great this medication is and how kind of easy it is and how well it works. So a lot of our practice now involves prescribing this medication. I don't have any financial disclosures. Let's skip that. So there are a number of advantages to utilizing this medication that are in some ways a little bit different from sublingual buprenorphine. So one is it can kind of simplify issues around monitoring for medication adherence. And so we don't, we know the patient is getting their medication because we're giving to them in the office. It never leaves the office. There's no issues around diversion. We don't have to kind of worry about things that sometimes we might worry about with sublingual buprenorphine with diversion or have to do things like counting medications, monitoring drug testing to see if someone's taking their medications for that purpose. So it can simplify some of the logistics of the management and from our perspective. Also, it can be really useful medication when patients are at risk for medication interruption of sublingual buprenorphine. So we know if patients are taking sublingual buprenorphine and they run out of their medication. And a lot of times in my situation is, you know, people, they can't get to their clinic appointments. They can't get to the pharmacy. They don't get their medication refilled. They run out of medication. And then shortly within 24 to 48 hours, people are going to be going through withdrawal and that tends to trigger cravings and can trigger a return to use. But with long-acting injectable buprenorphine, it wears off really slowly. And we'll talk more about those pharmacokinetics. So you don't have that abrupt onset of withdrawal symptoms. So it can help to help to provide more flexibility and kind of rescheduling appointments. And, you know, it doesn't have to, you know, especially if people kind of struggle with getting to those appointments and those refills done on time. And the effect builds the longer that you're on it. And when you're stabilized on this medication, you can get a really, it can offer a very good blockade of opioids, as well as like a really long-acting blockade that lasts for a long time. Even after, even if the medication is interrupted, people have an extended protection, which can be really helpful for people who are at high risk for overdose and also high risk of falling out of care or losing access to their medication that we can help people get some extended protection when using this medication. So the patients that might benefit from this medication as a choice of MOUD. So, again, people who struggle with medication adherence and continuity who have a lot of interruptions, you know, when you look in their past medication fills, a lot of interruptions in their medication continuity, which we know is risky. Patients who are at risk for medication interruption, they might be at risk for incarceration. And maybe they're worried that they're not going to have their medication continued there. Maybe they are remote workers in our areas. It's fishermen who are away for long periods of time. Does someone have a question? I can't, if someone's trying to ask a question, you sound very far away and I can't really hear what you're saying clearly. I think it was an accident. Okay. Okay. And so other considerations, this medication, if you stay on high doses of long-acting injectable buprenorphine, and you're able to stabilize on those high doses, you get serum drug levels that are higher than you can get with with typical doses of sublingual buprenorphine. So it can be good for patients that do better with those higher doses. Some people just hate taking the sublingual because it makes them nauseous and they hate the taste. They don't like, you know, they like the convenience of, you know, not having to take something every day. Some people might live in situations where they have a lot of difficulty keeping their medication secure. They might be, maybe they're houseless and they don't have a safe place to store their medication. Maybe they are living with other people who are using drugs. Maybe they're getting pressure from their friends, family, domestic partners to share their medications with them, kind of issues like that, that might come up and or maybe folks who, you know, have been kind of blacklisted or, you know, dropped out of programs in the past because they did have problems with diverting their buprenorphine or maybe being accused of that. And so, and when we think of places to utilize this medication, primary care is a great place to utilize this medication. But it's also really gaining a lot of popularity in places where people are at risk for kind of falling, you know, getting, falling through the cracks. So these transitions of care, discharging from the hospital, giving this in the emergency room, in the criminal justice system or upon release, places where people in the past have been, had a hard time accessing care and being able to kind of have that continuity of care. So this patient, this medication does have high levels of patient satisfaction, which is great. It, most of the studies kind of looking at patient satisfaction show that it is, scores a little bit better than sublingual buprenorphine does in satisfaction and kind of quality of life measures. They're both good. People like sublingual buprenorphine too, but this tends to store even a little bit higher in patient satisfaction and quality of life ratings and other measures of treatment effectiveness. So, so we know that this can be a good, good choice for people and people tend to like it. The things my patients say they really love, they love the convenience of just waking up feeling normal every day and not having to take something. That's not true of everyone. Some people really, especially if they've done really well on sublingual buprenorphine, some people really like that ritual and the routine and it's very therapeutic to them to take something every day or multiple times a day to feel better. And when they lose that routine, it's very anxiety provoking. So, but a lot of people like the simplified, not having to take something every day. The, some of the logistics of this medication, it is, you can't get this medication filled at your regular community pharmacy. That's not to say it might not be available in a nearby pharmacy to you, but it has to be a specialty pharmacy that's been authorized to distribute this medication. For us in Alaska, that mainly means ordering from out of state and having it shipped in, but you probably have a pharmacy in state that will ship it to you or courier it to you. But essentially the most common way that this medication is ordered and reimbursed is what we call patient's own medication, meaning that we are ordering, sending, they're writing the prescription for the long-acting injectable buprenorphine. We're sending that prescription to the specialty pharmacy. The specialty pharmacy is then going to courier or FedEx us the shipment of medication that is paid for, arrives already paid for by the insurance company. It is, has the patient's name on it and it's only to be used for that specific medication. It is also possible for the clinic to just buy stock of medication directly from the medical supply specialty pharmacies to keep on stock. Then that's called buy and bill where it's just bulk medication you keep in your clinic. You can use for any patient at any time, but then you are in charge, your clinic is in charge of billing for that medication, the insurance and getting reimbursed for that medication. There's a little bit more financial risk in that, but it's a lot more flexible because you have medication on hand to use for any patient at any time versus the patient's own medication can only be used for that particular patient. It can't be transferred to another clinic. It can't be given to another patient. If it's not used, it actually has to be disposed of in 45 days or six weeks. That can lead to waste of medication for sure. If people don't come in and get their medication, that can be problematic. To be DEA compliant with this medication, it has to be stored in a locked box, in a locked refrigerator, in a locked room. The Brixadi doesn't have to be kept in the refrigerator. That's just a locked box in a locked room. It's a schedule three, so it doesn't need a double lock. You have to keep a log of all of the inventory. When it comes in, you have to put it on the log. You have to then note the date that it was either administered or disposed of and keep those records for potential DEA inspection. The DEA is not worried about this medication. It would be highly unlikely for you to have any kind of DEA inspection regarding your records, but it's a very simple log. It's really all that they're looking for for records for this. This is just a link to the buying bill information for reimbursement reasons. The pharmacy can also deliver the medication to another clinic for you. This is helpful in cases of telemedicine. If you have satellite clinics, that sort of thing, if I'm seeing a patient who's in the next town over, rather than having them deliver the medication to my clinic, I can have them deliver it to the clinic that the patient is closer to their home. I have to have an accepting provider who is registered at that clinic to accept the shipment. Of course, they have to agree to administer it on their end as well. Although generally this medication is not allowed to leave the clinic or be transported someplace else, they do have an exception called the black bag exception. This allows the provider to take that dose of medication to a different location within the same state in order to administer that elsewhere as needed on a random basis. This might be, for example, doing a home visit, maybe someone that's in homebound, maybe someone's in residential treatment, or in some kind of living situation where it's very difficult for them to leave and you're going to be going there to see them, that patient. This is something that is allowed as long as it's not on a regularly scheduled basis at the same location. Again, this Brixadi came out last year as the second brand in addition to the Sublocade. Some comparison of these two medications. So, Brixadi does not need to be refrigerated. Sublocade currently does. They are changing the packaging of that medication to allow it to stay out of the refrigerator for 12 weeks. So, in theory, especially if you're doing patient's own medication that we can only keep for six weeks anyway, then you actually won't have to keep that in the refrigerator. But certainly if you have clinic purchase medication that you own, you're going to want to have a refrigerator place to store that so that you can keep it until it expires rather than having to throw it away in 12 weeks. But the sublocate can only be given in the abdomen. Bruxadi can be given in ultrasound sites after the fourth injection. It can be given in places like the upper arm as well. They're all subcutaneous injections. The Bruxadi is a smaller volume and so it tends to be, I've heard that it's a less painful administration and it doesn't actually leave a palpable lump. The depot doesn't leave a palpable lump like it does with sublocate. There's a palpable subcutaneous lump that you can feel that slowly shrinks down as the medication is absorbed. The sublocate is only a monthly formulation with two strengths, the 300 milligram and the 100 milligram. The trend tends to be more and more, I think, people staying on the higher dose of medication, but they're both available. The Bruxadi has many different strengths and I'll show you briefly the table for that. It has a weekly formulation and it also has a monthly formulation. The weekly formulation can be good if, especially if you're starting someone that you really don't know what they need, you can actually repeat doses of the weekly formulation up to three times that first week to load people up when you're not really sure or they want to start a low dose and then go up because their tolerance is low. The weekly formulation is also going to be the one that is likely preferred in pregnancy. ACOG, no one has came out and made any specific statements about this, but there's going to be some research coming out about utilizing that formulation in pregnancy in the next year or two probably. The difference between the weekly and the monthly formulation, the weekly Bruxadi has a different substrate, kind of the inert substrate in it is different than what's in the monthly formulations. Both of Bruxadi and sublocate have the same substrate. That substrate is felt to possibly cause some teratogenic effects in rats. We haven't seen that in humans yet and it's highest after the first few days that the medication is administered. In our clinic, I have used sublocate in pregnant women. I try to avoid it in the first trimester if I'm able to, but there are some women who that's really the only medication that they're able to stabilize on. It's all a risk versus benefit conversation with the person. The dose comparisons, the highest dose of Bruxadi is 128. The monthly, it's a little bit higher than serum bred levels you get with 100 milligram sublocate, but it's not as high as the 300 milligram sublocate. The highest, strongest of all of them would be the 300 milligram sublocate and then the 128 Bruxadi monthly and then the 100 milligram sublocate as far as the strengths of those. Also, the half-life of Bruxadi is a little bit shorter, so we expect it's going to wear off a little bit faster than the sublocate does the monthly formulation. Otherwise, all the procedures, all the DEA regulations around both medications are exactly the same. The costs are very similar, although, of course, the weekly formulation is prorating cost rates, about a quarter of the cost is the monthly formulation. It's a good choice to use in places like the emergency room. They just need to give an injection, but maybe they don't want to have a huge investment in a very expensive medication to keep on hand that is less expensive. I'm not going to go over everything in this table, but I want to put this in here for your reference. This compares the serum drug levels that you get from typical doses of sublingual buprenorphine to comparing these various doses and strengths of long-acting injectable buprenorphine. As far as just highlighting, if we just look at the steady state average, we're going to see that someone who's taking 24 milligrams of sublingual buprenorphine is going to be close to 3 nanograms per milliliter. The 100 milligram, similar to what someone would stabilize at 100 milligram sublocade, but the 300 milligram sublocade actually provides a steady state of about 6 nanograms per milliliter, and then the 128 monthly, the Bruxade is around 4 nanograms per milliliter. But it takes time for those doses to stabilize, and we'll talk more about that. This table is provided for people who are currently stable on sublingual buprenorphine, and we want to make that transition over, so this is just kind of a direct comparison of what doses are equivalent for. This is the sublocade on the upper table, and then this is the Bruxade on the lower table. Bruxade, the generic before it was called Bruxade, is CAM2038, so you'll see that sometimes in some of the research papers. An interesting off-label way to use extended-release buprenorphine is actually to assist in the process of people who have been stable on buprenorphine for a long time, they're in long-term recovery, and they're interested in discontinuing their buprenorphine. There have been some case studies that look at administering extended-release buprenorphine as a taper strategy because it wears off very slowly, so it's kind of like a natural taper that you don't really have to think about. The more doses you get before discontinuing, the longer that the natural taper will be as it very slowly wears off over months to up to a year, depending on how many injections people have gotten. It's really important to remember, though, that it takes time to stabilize on this medication, and the first month of treatment for many people, especially people who have high levels of opioid tolerance or are needing high doses of buprenorphine to stabilize, those serum drug levels may not be therapeutic that first month on the Sublocade or the Bruxade. For example, if we look at the average first month is lower, serum drug level is lower than it would be when people are taking 24 milligrams a day, so if you have someone who's on 24 milligrams or 32 milligrams and then you're giving them that shot, that there's a high likelihood that they're going to say, this doesn't feel strong enough, this is not controlling my cravings. The other really important thing is that the NADER, the low level at the end of the month is dropping well down below two nanograms per milliliter, which that kind of two nanograms per milliliter is kind of a magic number because that is kind of the tipping point at which you see a more or less effective blockade of fentanyl-induced respiratory depression. So ideally, people that are at risk for continued exposure to fentanyl, we want to have those serum buprenorphine levels over two, so it will help to be more protective against overdose. At the end of the first month, those levels are dropping down well below that, so if someone has uncontrolled cravings and they're using, they're also probably going to report that they don't have an adequate blockade of the fentanyl effects. Also, Brixadi as well, when you kind of read the five prints, actually the trough, that first month could even go down to like one nanogram per milliliter. So, the long and short of it is people may need to have supplemental sublingual buprenorphine, especially during the end of the first month of therapy, but sometimes it's the entire first month, sometimes they need some for a couple of months in. So, it's important to have the flexibility to work with your patients, listen to your patients, and kind of follow up with your patients during the course of those first couple months to check in with them about how their symptoms are controlled. The administration technique is really straightforward and the instructions are right in the packaging when you get it. It's a subcutaneous injection. So, you pinch the skin with the Brixadi. It's a shorter needle, so you go straight down. The sublicate is a little bit longer needle, so you go in at a 45-degree angle. The sublicate has a, as you can see, it's a big fat needle. It's a 19-gauge needle with like honey-thick viscous liquid. It hurts. The Brixadi is less uncomfortable, I've heard, but I haven't personally given it myself. But I think that I've given probably like, I've given for sure more than a thousand of these injections myself, hands-on, and I can tell you that adequate anesthesia is really important to a good patient experience, especially early in treatment when, you know, people, especially if someone's in withdrawal already, they're in pain, they're uncomfortable, and they're very anxious about, you know, this very vulnerable area, you know, your abdomen, someone poking a needle in it. And so, trying to make that experience as painless and as possible, I think, is important. So, there's different options for anesthesia. The one that we do in our office, we have these little mini kind of reusable ice packs. We actually have the patient apply an ice pack for at least five minutes prior to the procedure until the skin feels, you know, put it right on your stomach. We want it to get really cold and go numb. Not everyone likes the feeling of ice, but it does a really great job at anesthetizing the skin. And then some people just use ice and that's it, especially if, you know, if you have, you know, a nurse is having to give the injection, they are probably not allowed to give injectable anesthetics. I also administer, after the ice, I administer one milliliter of lidocaine into the subcutaneous space, the same angle that I'm going to administer the shot at. And some places also, you know, if you have the ability to plan before for someone to put amyla cream on before, but, you know, that takes like an hour to work. I haven't had patients be very successful with remembering to do that at home and bring that with them, but I have a couple of patients that did it. And we've used that a little bit kind of in the bush, the roadless villages when during COVID when chaps had to help administer that they weren't allowed to give lidocaine. So, they would put some amyla on the hour before. So, there's lots of different options for local anesthetic, but you can find out what works for you. But I think it's important to offer that to try to reduce the discomfort of the, at least for the sublucate injection. This is those clinical studies looking at the ability of buprenorphine to block the respiratory effects, depressive effects of fentanyl. So, this was a study where they gave, you know, progressively higher doses of fentanyl up to 800 mics of fentanyl in a single dose. When the patient was not taking, did not have any buprenorphine in their system, they stop, they become apneic and stop breathing. However, when people, they studied high serum drug levels of buprenorphine, five nanograms per milliliter, they showed essentially no respiratory depression with those high doses of fentanyl. It is dose dependent. So, as the serum drug level went down, especially when it got under two nanograms per milliliter, it really started to significantly lose that effect against, the protective effect against fentanyl. So, again, it's dose dependent. It depends how much fentanyl the patient is exposed to and it depends on how much buprenorphine is in the system. So, the higher levels of buprenorphine are more protective, but there is no such thing, and I warn my patients, like, there is no such thing as 100% blockade of fentanyl, especially when you're dealing with, like, you know, the more unusual, even more potent forms like carfentanil and things like that. You know, there's no such thing as 100% blockade right now. This is the closest that we have. So, it's really helpful for those patients that continue to risk for fentanyl exposure. And this is looking at the pharmacokinetics of sublocade. We don't have a graph like this yet for bruxality or this. I haven't found it yet, but the, when we look, when people stabilize, so if this lower graph, this upper graph is looking at someone who's stabilized on 100 milligram sublocade, and so that takes, that's by the third month that they're stable on the 100 milligram. If that gets interrupted, they will maintain serum drug levels above two nanograms per milliliter for about two months after their last injection in theory. If people, it takes about four to five months to stabilize on the 300 milligram injection. If you keep people on the 300 milligram to reach those levels of like five to six nanograms per milliliter, and then if that is discontinued after stabilization, they can actually maintain serum drug levels above two nanograms per milliliter for up to five months since the last injection. So, we definitely try to get people on this medication when we know that they're at risk for losing access to their medication or kind of falling through the cracks, so they have that extended protection, extended elevated buprenorphine levels. Blocking the, we don't have a lot of information about what happens if people only get one or two shots and how quickly it wears off. This is in the package insert for sublocades, so it shows people getting two injections here of sublocade and then not getting the third injection at eight weeks, and there still appears to be good suppression of the liking effect of hydromorphone. So, even after a couple shots, we're getting some protective effect. One thing that I counsel my patients on, especially if they have involvement in the criminal justice system or they're on probation, that they're subject to kind of drug testing monitoring that lyontanegethylbuprenorphine can cause a positive urine drug test for buprenorphine for up to a year after cessation, especially if they've reached stable levels. I'm actually monitoring a patient right now who has some legal issues in being monitored, and we're actually kind of monitoring his urine drug concentrations of buprenorphine over time, and he is a year out. He had stabilized on the 100 milligram, and he is a year out now and is still having detectable levels in his urine. It's very slowly coming down, so that is an important thing for people to know, and we are often dealing with writing letters and talking to the probation officers for people who have unfortunately fallen out of treatment, so they're no longer getting their injections of buprenorphine, but they are still being monitored, and they keep getting accused of taking non-prescribed buprenorphine because their urine is continuing to be positive. We're continually re-educating people about how to properly interpret the drug testing when people have discontinued this medication. The package insert for sublocade says that you need to—the patient needs to be tolerating sublingual buprenorphine of at least eight milligrams per day for at least a week before you administer this medication. The—in reality, people who are using this medication a lot have found that in kind of real-life practice that patients are able to start this medication much sooner than that. They don't have to take the sublingual buprenorphine for the week before that. And most of our patients choose to stay on 300 milligrams. The package insert for Sublocade recommends two doses of 300 milligrams as the loading dose and then transitioning to 100 milligram as the maintenance dose. But we find that many of our patients do better at the higher dose. There's been some studies that show, especially people who have, who are using IV drugs, they have better retention and treatment when they're kept on the higher dose. And again, they're gonna have possibly an improved blockade of fentanyl if they stay on the higher dose. So you don't need to switch to the 100 milligram. The only advantage is switching to the 100 milligram. If people are having persistent side effects that they can't, were not able to be managed on the 300 milligrams, sometimes those are less than the 100 milligram. Sometimes it's a smaller injection, so it's slightly less injection site pain, but the insurance doesn't care which one you use, they're the same cost. There's no issues with prior authorization. So we tend to encourage a lot of our patients to stay on the 300 milligram, but we allow them to kind of choose at any point in time what dose they want to be on. Reasons, when we think about starting this medication more quickly than a week of sublingual buprenorphine, there've been a number of studies that have looked at this. The Bruxade is, if you read the Bruxade instructions, those instructions, especially for the weekly formulation is that you don't have to, people don't have to be stabilized on buprenorphine ahead of time. You can give a test dose of sublingual buprenorphine before you give it, that when, we'll talk about that more later, I guess, that in the emergency room studies that they've done, they've not given any sublingual buprenorphine before giving the weekly Bruxade, they just give it and had very low rates of precipitated withdrawal. The studies that have been looking at sublocade, they have had like a one in three day protocols and the drug company did one where they essentially did a similar thing where they gave them one test dose of sublingual buprenorphine and then gave them the injection, the monthly injection. Again, the test dose of sublingual buprenorphine is actually, we don't do that in our clinic. It's more likely than a shot to actually trigger precipitated withdrawal symptoms. And if you look at the studies, they note that it was the patients who did have precipitated withdrawal, it was due to the sublingual dose of buprenorphine they had received, not the monthly injection. So the reasons to administer buprenorphine, sublingual buprenorphine before you give a long-acting injectable, there's a few different, there's a few different reasons for that. So one would be a patient is currently abstinent from opioids and they do not have any opioid tolerance. So in that kind of situation, if a person, they might be coming out of rehab, they might be coming out of incarceration, they haven't used in at least a couple of weeks or more and they've lost their tolerance. If we just administer this high dose of injectable buprenorphine, we are gonna cause a lot of side effects. It's not a safety issue. High dose buprenorphine generally is not a safety issue, but it can cause side effects in someone who doesn't have a tolerance and they can get very nauseous and just feel overly medicated, feel dizzy, just feel like they're gonna sleep for days. It's unpleasant. We want people to feel well when they start their medication. We don't wanna cause unpleasant side effects. So getting people kind of ramped up on sublingual when they've lost their tolerance before giving the injection is with the goal of reducing medication side effects. Another reason to give someone sublingual buprenorphine before they take their injection is if they've never tried buprenorphine before or have never had a positive experience with buprenorphine before. Maybe they've only tried it for a few times with their friends and every time they tried it, it made them feel super sick and they don't really know if they like it or not. Once you give the shot, you can't take it out, you can't take it back. And so we'd hate to give it to someone who has never had a positive experience with buprenorphine and then they feel horrible and they hate it. So it's pretty rare in my practice that I come across people who haven't had an experience, a positive experience with buprenorphine before, but in those people, I really encourage them to kind of try, make sure that they like the sublingual first, that it helps them to feel better before the injection. And another can just be like timing their withdrawal appropriately. There's lots of different ways to initiate buprenorphine. So some people, they might wanna do a microdosing, a low dose overlapping start of sublingual buprenorphine because that really allows them to kind of gently get started on it. Some people, they may wanna stop using a couple of days before they come in to get their shot. Great, we want them to have that sublingual buprenorphine at home so that they have the ability to start it whenever they feel ready. But when I have a patient show up at my office and I gave them their prescription of sublingual buprenorphine to start taking before they come in and they show up and say, hey, I haven't started it yet, I didn't take it yet. We're never gonna turn someone away. So if someone wants to get the shot on that day, we're gonna give it to them. And we explain kind of those risks and benefits of it is possible. Anytime you start any formulation of buprenorphine, there's always the possibility of precipitated withdrawal. And so we teach people how to recognize precipitated withdrawal if they haven't experienced it before, and we teach them about how to treat precipitated withdrawal. We make sure that people have sublingual buprenorphine, clonidine, Zofran, or other comfort medications that they may need on hand to treat withdrawal symptoms in the first couple of days after they get their shot. Almost all the studies that have looked at initiating this medication has shown that essentially once people get 24 hours out, for most people, we're gonna be reaching peak serum drug levels that are quite high of buprenorphine. And for most patients, that is going to be enough to resolve their withdrawal symptoms. So most people, 24 hours after they get their shot are feeling way better. I've had a couple of patients that had persistent withdrawal symptoms that last for a few more days after that as the fentanyl is kind of still limiting from their system. But for most patients, if they can kind of get through that first day, by the next day, they're feeling way better. This is a study, if you wanna read the study of using this medication in the emergency room. So they used the 24 milligram dose of Brixadi. They gave it in the emergency room to people who had low COWS scores, some of them. I think it was anything with the COWS scores that was above three. They didn't give any sublingual buprenorphine before that. And they monitored the patients and showed that almost no one got precipitated withdrawal, which is great. Especially when we think of people who really struggle with, they've had a lot of negative experience with taking sublingual buprenorphine, people who are using really high amounts of fentanyl. Sometimes they'll say, hey, every time I try to take Suboxone, I just get so sick. Even when we're offering things like a high dose start or a low dose overlapping start, they still can't kind of manage with it. So some people, I've had people that come in like, hey, I hate taking sublingual, I'm not gonna take it. I know that I might get sick after I get this injection, but I wanna get it anyway. And it's a lot easier for them. It's easier for them for, if I do it to them, I'm giving them the injection and they're consenting to that. They know that they might feel sick for the next 24 hours, but then they're gonna feel much better. It's very hard when you're taking a medication by mouth and that medication makes you violently ill. And then to keep forcing yourself to take that medication is incredibly difficult. So for some people who just really struggle with that initiation, this really allows them to kind of get over that hump and without having to struggle with the medication adherence issues. So in a lot of ways, this medication, it really lends itself to low threshold, kind of easy access for patients who have severe substance use disorders. Some of the way that we're gonna talk more, expand more on low threshold access to care here in this next talk, but some of the ways we make this medication easy to access, we do not require any drug testing in order to get this medication. We always offer it. We offer it. Some patients are happy. They like to do it. They like the accountability. It can help us during our conversation to talk about the results and what's going on in their life, but we absolutely do not require it. It's always optional to get this medication. We always tell people, it doesn't matter what drugs you've been using. You're always welcome to get your medication, no matter what. We would love to talk with you about your drug and alcohol use, but you don't have to be afraid to talk with us about that. You're always gonna be able to get your injection no matter what other drugs that you're using. We try, we offer a lot of flexibility. When people come in, they don't have to come in right at the one week mark. They come in at six weeks, eight weeks, whatever. We're still gonna give them their medication. We do try to always keep a little bit of room in our schedule to squeeze in walk-in appointments. If a patient, they missed their appointment, it's two hours later, I'm in doing a physical with another patient, I'm not available to see that patient, I can have my nurse give that injection to that patient, or another provider who has a minute can run in and give that injection. We try as much as possible to allow for that kind of flexibility for people. Even if I don't have time to do a full visit, at least they can come and get their injection at the minimum. And we always make sure to offer supplemental, sublingual buprenorphine supplementation, especially in the first month or two. So general counseling for our patients to kind of summarize the things we already talked about. We tell people, hey, it's normal to not feel like 100% the first month, that it's normal to feel like, hey, it's not strong enough, it's not working well enough, it's wearing off, it is, it is wearing off, it isn't strong enough, it's okay. Some people feel great, some people feel amazing the first month, and they're like, this is a miracle. Other people are like, eh, I don't know, it kind of helped the first week or so, and then I just went back to using again. So that's kind of really, we're touching base that first month to kind of give people that support and be like, I'm gonna be here for you, I'm gonna keep prescribing you, I want you to take sublingual buprenorphine at the end of the month, every month that you keep getting that shot, you're gonna feel better and better and better as the medication levels continue to rise. And even people that are just kind of continuously using or a lot the first month or two, if they stay on it, most people are going to get control, you know, control of their cavings and extinguish most of their use or dramatically reduce their use. Also, if people experience side effects that first injection, that's generally when people have a lower tolerance to either buprenorphine or opioids in general, you know, that, hey, it's normal also to feel like you're a little bit overly medicated that first injection. And sometimes some of those symptoms like nausea and sweating can actually be confused with withdrawal symptoms when there can actually be, you know, actually side effects of the high dose of the medication. So it's important to tell people, you know, that that's only gonna be the first shot that they're gonna experience that, it's not gonna be recurring, and that we're gonna help them through that with the anti-nausea medication and that sort of thing. Also that once they get a couple of injections that they probably, they very might well not feel the medication wearing off and that can be dangerous. Because, you know, they feel so good, they feel normal every day, they miss their appointment, they don't really feel the medication wearing off, they don't feel those withdrawal symptoms setting in. And, you know, they say, oh, I'm doing so good, you know, I don't even really need to go back for another injection, I feel great. But it is wearing off, even though they can't feel it wearing off and then a couple of months down the road, something's gonna happen, a stressful event, they're gonna run into someone that offers them drugs, and that tends to be when the craving comes back there's a return to use and then realize that they don't have that blockade anymore and, you know, could be at a risk of overdose as well if they've lost their tolerance. So we warn people about that, that if they return to use that, you know, harm reduction, don't use alone, use with someone else that has naloxone. So I'm gonna stop there for about five minutes and take any questions that you might have. About the long-acting injectables before we dig into the harm reduction and low threshold care a little bit more. I have one question. I'm sorry. Yes. So when you start patients on these regimes, do you have like a checklist or a sheet or information that we can give patients? Because this is a lot of information to give to a patient that's, you know, just starting out on this so that they know what to expect, they can remember what to do and when to do it, they have some kind of reference. Yeah. So we do, so I do have a handout about, I have a couple of different handouts, you know, I have a handout like on how to start taking sublingual buprenorphine in the different options. For that, I have a handout for patients on how to treat precipitated withdrawal. You know, if that happens, we have like a, not a specific handout, but a consent form when people come into treatment that describes the kind of issues around, you know, the fact that the medication, you know, is gonna be wearing off and the need to stabilize on it and that sort of thing. And the Bridge to Treatment Program does have a patient handout. I'll get, I'll try to, I'll find some, I can find some resources for you and try to send those out. But I think it is a good idea to have a patient handout and there are some that pre-exist and, but you might, you know, wanna make your own for your, because it is very hard for people to remember. And we have patients, we always encourage people, we always give patients, our case managers, she has a work cell phone number. So we basically say if anything happens, cause it's really hard to remember, you know, what happened in that appointment or, and so like, hey, if you're struggling, if you're feeling sick, if you don't know what to do, if you're having side effects, you know, text, you know, text or call and, you know, so we can give them advice, you know, as it's happening. And I guess the next question I would have is, do you start patients on the medication immediately at the first visit, or do you educate them at the first visit and have them come back to start treatment? So the most common way we do it, most of the time we do a telemedicine visit. Ideally we do our intakes via telemedicine, and then we plan for them to come back in a week to get their injection. That is so that if the patient wants to take sublingual buprenorphine the week before, they're able to do that and get on it. It also allows us time to order their injection because we do not entirely, but almost all of our, we do patients on medication that comes already prepaid from the specialty pharmacy for that patient. And that takes us a little while to get that in. You may be able to get that delivered to your office the next day or two days from now. So that has a little bit to do with it is, you know, how you're gonna store, you know, what you're gonna have available for medication. We do have a few doses of Biome Build medication that we have in stock that we can use kind of for emergencies, because we do get patients that just walk in or they come with their friend that day, right? They're just gonna shut and say, hey, my friend wants to get a shot too. Like, okay, I've never met your friend. So let's talk about that. And sometimes like they just drove from 40 miles away and that was the only day that they have a ride there. And so like, yeah, we're gonna make it work and we're gonna give them their injection that first day when we meet them. But the routine kind of way we do it most of the time in our office is a telemedicine visit the week before and then come back the next week to get their injection. And sometimes they have to reschedule that appointment multiple times before they eventually show up for their injection. And hopefully it's before, you know, sometimes they don't show up and we have to throw their shot away and then start over again next month when they decide they're ready to start treatment. So that's usually how we do it. All right, are you guys able to see that next slide show now? Yep. We're good. All right. So, we're going to spend about a half an hour now talking about low-threshold access to care and harm reduction, and hopefully I don't go over by too much on this. So we're going to talk a little bit, we're going to bring up stimulant use disorder a little bit in this talk, and kind of talk about taking care of patients who have more severe substance use disorders with co-occurring issues, and especially co-occurring polysubstance use, and talk about some ways that we can help to improve people's quality of life and kind of reduce the harms to their health even when they're not currently abstinent or maybe don't have the goal of being abstinent from drugs. The use of stimulants with opioids has been dramatically increasing in over the last five to ten years. These are older statistics, but if we look kind of on the west coast now, especially in most regions, over half of people who are using opioids are using it with methamphetamine. In my practice, it's the vast majority of patients, like 80 to 90 percent of my patients who are coming to see me for treatment of their opioid use disorder are also using methamphetamine with fentanyl, sometimes consistently, sometimes intermittently, but it's something that we see on a daily basis, and there's been a dramatic increase in methamphetamine-related overdoses. They've more than quadrupled in the last ten years, and Native populations have the highest rate of stimulant-related overdose deaths. The combination of stimulants with opioids is more dangerous than using either drugs alone. You get the potent respiratory depressant effect of fentanyl, and then you get the cardiac arrhythmias that happen because of the stimulants, and that kind of combines to create an increased risk of overdose death. So why do people use these drugs together? When they've done surveys to ask people why, the main thing is to reduce the side effects of the fentanyl. They don't want to be nodding out. They want to be able to function, do the things that they need to do during the day, and it can also just give them kind of the energy, and as a fabulous antidepressant, it makes people feel like they can do what they need to do to get on with their lives. So as the fentanyl gets more and more potent, then people are adding in the stimulant to counteract the effects of the fentanyl. Now unfortunately, when you look at these patient populations that are using methamphetamine with opioids, a lot of studies show that they tend not to stay in treatment longer. They're more at risk for falling out of care. However, if we are able to keep them in care, many of them are able to reduce their stimulant use. There are a lot of barriers to care for people who are using stimulants with opioids. So some of those can be, some programs say, hey, I don't want to keep prescribing buprenorphine to you when you're continuing to use methamphetamine. People can be struggling with their sleep cycles. They might be having some, you know, binging for a couple days on methamphetamine, and then they're sleeping for a couple days, and they sleep through their appointment. You know, they're just kind of struggling with a more complex condition, and it can be more difficult for them to access care kind of in the traditional way that we've been offering it. So when we have low threshold care, the goal of that is that we're going to make care as accessible as possible. So we're going to make minimal demands on the patient. We're going to offer services without attempting to control their intake of drugs, and we're going to provide any support services that a patient is willing to accept, but we're not going to require people to engage in any of our particular treatment services. And this can really be a great way for people who are really struggling with severe substance use disorders to kind of get that foot in the door to get treatment. And when we think of, you know, is this effective, does this actually help people to stay into treatment, the data we have shows that it does. And so some aspects of low threshold care that can help people to engage and retain in treatment, allowing people to start treatment right away, ideally in the same day, whenever that's possible, when someone's ready, getting them started on the medication right then when they're ready in whatever formulation of medication that they're ready to accept, that can really help. Not requiring people to be absent from drugs, you know, offering treatment regardless of what drugs that people are using. Offering people telemedicine whenever that's possible, because, again, it can be really hard for people to get into that face-to-face appointment when they're struggling with all the other issues that are going on in their lives, offering, you know, offering optional support but not requiring counseling or behavioral interventions, but making it flexible and accessible for people. So when they are ready, that it's accessible to them. And really kind of reaching out and connecting with some settings where these patients might be interacting with, like at the syringe access program, in a mobile clinic setting, kind of reaching out, street medicine, that kind of thing, to make medication, make treatment as accessible as possible. And making sure that we are talking about harm reduction strategies and providing people access to supplies and education that they need to help to care for themselves. So allowing people to get into treatment quickly, having a harm reduction approach, having as much flexibility as possible and kind of allowing people to access care kind of wherever they are at, really meeting the patient where they are at is kind of the key philosophy behind this low-threshold treatment. So in our clinic, the most important thing is to not discharge patients for ongoing drug use and to make sure they feel safe to talk with you about what drugs they're using and that they're not going to be judged for talking with you about their drug use. We're going to focus the care plan on what that patient's goal is, and that goal may not always be abstinence-based, or they may want to stop using fentanyl, but they may not be sure if they may not really want to stop using methamphetamine or drinking alcohol. Maybe they feel like that's not causing them a problem right now, and they're not really interested in focusing on that. So we're going to build those care plans around the patient and then adjust those plans as time goes on as the patient's goals can change. And motivational interviewing, as we create that safe space where people can come in every month and talk with us about going on, over time we can offer things like motivational interviewing that can help people to kind of identify that internal drive for change to meet their goals. When we do offer behavioral health support, we make it as accessible as possible. Peer support via texting is one of the most utilized formulations of support that our patients choose to utilize in our clinic. They really rave about how helpful the peer support was for them to navigate the system and to feel safe and comfortable in care. My case manager and peer support people, every day patients talk about how helpful it is that they're there for them. And peer support people that are, you know, willing to, you know, work with people who are still using drugs and may not, you know, be able to be abstinent right now. We'll talk a little bit more about contingency management for stimulant use disorder in a minute. Any time that you, if you have access to harm reduction on site, I think it's great. Not all clinics keep harm reduction supplies on hand, but any of them that you can keep on hand, I think the patients find that to be, you know, very helpful. In our situation, there's very few syringe access programs and they may only be open on limited schedules. The patients can't get to them. And so I think that it really helps patients to feel safe and to, when, you know, you offer them, it's like, hey, are you still injecting or injecting methamphetamine? Do you have access to clean syringes? You know, can I get you some here today? And you know, that patients are really surprised by that a lot of times, but that can really help them to feel safe to know that this is a judgment-free zone and we're here to try to help them to be healthy in any way that we can. And when my patients are coming in for their monthly, you know, injections or their occasional visits, a lot of times I'm the only doctor that they're seeing. And so I'm going to try to do anything I can for them during that visit when I have them in front of me or over the telephone too. So we're going to try to get them tested for hepatitis C, get them treated for hepatitis C, even if they're still using drugs, you know, get them on contraception if they want to prevent pregnancy, you know, get them connected with any, you know, with PrEP for HIV treatment if they're interested in that. So try and work on their mental health, you know, addressing their anxiety and their depression. And we just kind of chip away at things at each visit that they come in. We talked about telemedicine. And more and more, we're seeing a lot more in the research and in the media really talking about the importance of having programs that allow patients who are not currently abstinence or abstinence may not be their goal to still allow them to access treatment. And we can see significant improvements in quality of life and reductions, you know, in disease burden. You can reduce their risk of overdose, even if they're not able to achieve abstinence from all substances. So in harm reduction, we are trying to reduce the harmful consequences that are associated with high-risk activities. And that there's all kinds of things in life that are harm reduction. You know, driving is one of the most dangerous. You know, if you don't use drugs, probably the most dangerous thing you do in your daily day life is driving your car. And very high risk of accidental death associated with that. So we have airbags, and we have seatbelts, and we have speed limits to try to reduce the harms associated with that dangerous activity. But it doesn't eliminate the harm, but it reduces it. We're not, you know, the kind of myth around harm reduction is that it's enabling. We're encouraging people to use drugs. We're enabling to use drugs. But you know, people, they're going to engage in those activities regardless of whether we give them the tools that they need to stay safe or not. They're already engaging those activities. They're not, you know, whether we offer them the tools they need to stay safe is going to have no effect on whether or not they engage in those activities. But we can enable people to reduce the risks they're taking, to keep themselves safer, to be healthier, to make those connections, develop those therapeutic relationships with the providers and with the healthcare system. We can enable them to take charge of their health and to reduce the risks in their health. And harm reduction, too, is really, you know, it's an essential part of healthcare. It really is focused on treating all people with dignity, compassion, and respect regardless of whether they are using drugs or not, that we are going to focus on the quality of life improvements no matter where that person is at. There's always something that we can offer people to try to improve their quality of life and reduce their risk to their health, reduce their morbidity and mortality. There's almost always someone we can offer to people even when they are not ready to stop using drugs yet. And that can really empower people to make those changes. It can really empower people to help and educate their peers. And people, when they get, you know, educated in how to keep themselves safer, they use that information, they share it with others, and they tend to reduce their risk-taking behaviors. And we know that people who engage in, specifically in syringe access programs, they are five times more likely to then engage in substance use treatment if they've engaged in the syringe access program. So it's really a foot that, it's that door into treatment for the people who haven't been able to access treatment from other ways. So it's, you know, really a critically important way to engage people who are at the highest risk. And harm reduction, we can apply these, you know, harm reduction principles to everyday treatment and all the chronic disease, you know, treatments that we're offering people, you know. Just like, you know, we are adjusting, we have sliding scale insulin, right? If someone's going to eat their, you know, their ice cream, right, they're going to calculate how much insulin, that's harm reduction. You know, people, they're continuing, you know, to smoke and they have COPD, but we're going to kind of adjust, you know, their rescue inhalers and everything they need to try to like help improve their quality of life. So we're going to meet people where they're at and see what we can do to help reduce those risks and improve their quality of life, regardless of the behaviors that they're engaging in. As far as harm reduction supplies, fentanyl test strips can be a nice thing to hand out in your office. So we encourage people to use fentanyl test strips not to test opioids, because all opioids have fentanyl in them. That's a waste of a fentanyl test strip. We encourage people to use their fentanyl test strip to test any non-opioid drugs. So especially powdered drugs, powdered or liquid drugs are more likely to be contaminated with fentanyl than are like solid or crystallized drugs. So, but any form of methamphetamine, cocaine, can be contaminated with fentanyl, especially if people are trying not to use opioids, they're only wanting to use a stimulant or what they think is a Xanax pill, what they think is an Adderall pill, right? Those are the things that we want people to test with the fentanyl test strips, because to see if they are unknowingly being exposed to fentanyl. And if you're not already handing out naloxone in your office, I would encourage you to connect, you know, with your state opioid response program to see how you can access naloxone to hand out. If you're not able to keep it in your office, we're definitely going to be prescribing it for every patient that we see, even if they're only using stimulants and not opioids, because there's significant risk of fentanyl exposure due to contaminated stimulants. So we want everyone who's using drugs to have access to a naloxone kit. Another resource that we can share with our patients who use drugs alone is this hotline, Never Use Alone. So this, the most overdoses happen when people use alone. If people, if an overdose is witnessed, there's a high likelihood that that person is going to be rescued. But when people are alone, there's no one to rescue them. So they can call this hotline. They're going to be connected immediately with a volunteer somewhere maybe a thousand miles away. That volunteer is going to find out where they're calling from, where they'll, you know, how to access the local EMS in that area. And they're going to stay on the phone with that person while they're using and make sure that person's staying responsive. If at any point that person becomes unresponsive, then they're going to reach out to the local EMS and have them come and do a wellness check on the person. And this has been effective in reversing a number of overdoses nationwide. If you don't have, you probably do have local access to harm reduction services, but there is, if you have people that live in an area where it's hard for them to get to the harm reduction program this is a free mail order harm reduction supply that people can order from online. I've also written prescription for syringes for people who have a hard time getting to the syringe access program and they can fill those at a local pharmacy or they can fill them online and have that kind of anonymity that especially if they're afraid to go to the syringe access program. I'm going to just really quickly review a few highlights about treating stimulant use disorder because it's such a common comorbidity we're running into. This guide was just released last year by ASAM. The new guidelines to treating stimulant use disorders. The number one treatment for stimulant use disorder is contingency management, which we'll touch on here for a minute. Contingency management is rewarding people for meeting their goals. However, there is, you might start to see people talking a little bit about the possibility of using prescription stimulants to treat stimulant use disorder. So this is included in the guidelines. This is an area they recommend is only done by board certified addiction medicine providers. There's a lot of debate about, there's conflicting research about whether this is effective or not and what the right approach is to do this. So it's something that is recommended to be reserved only for specialists at this time. And this really nice paper came out, that talked about the fact that in people who do use stimulant use disorders, that if they had a goal to reduce their use and they were able to reduce their use, even though they weren't able to achieve abstinence, they did have significant improvement of measures, improvement in their quality of health and life and recovery. So we're seeing a lot more about this, about the fact that reducing drug use is a meaningful and a goal that can affect people, improve people's quality of life. There are no medications that are approved to treat stimulant use disorders. The most common ones that you're going to see are naltrexone can help to reduce cravings. Most people who are using opioids are gonna have difficulty getting on naltrexone. So I'm usually gonna use that in the patients who are only using stimulants and not opioids with it, unless they want to go through withdrawal management to get on that medication. The combination of wellbutrin, bupropion, bupropion by itself can be helpful to reduce cravings. If people take it every day, the combination of that medication with naltrexone can help to reduce cravings. So we're looking at like about 15% of people that this is helpful for, that are able to have abstinence with this. We see similar effect in using mirtazapine, can help about 15, 20% of people increase their number of days of abstinence. Topiramate is another one that you'll see talked about that can help to reduce cravings and increase abstinence rates. But again, we're talking about the minority of people that will be able to abstinent on these medications. Contingency management is absolutely the gold standard, number one treatment for stimulant use disorder. So in contingency management, we are going to provide immediate rewards for people meeting objective goals. The most common objective goals that you will see in the papers is a goal of abstinence, meaning, and that would be monitored by drug testing generally, or a goal of engaging in treatment. So a patient coming to their medical appointment or more commonly coming to their behavioral health, you know, their therapy appointments, or another one is encouraging medication adherence. So people may get rewarded for getting their monthly medication injection, for example. The most common rewards that you're gonna see are monetary, typically with values of approximately 100 to $200 per month. However, there are other things, you know, non-monetary prizes, you know, other reward systems that also show evidence of effectiveness. This is an old study, but there are lots and lots and lots of studies that kind of show the same thing that when you utilize contingency management versus standard treatment, just counseling, behavioral health treatment, especially if you combine it with community reinforcement therapy, which is helping people find a job, helping them get marriage counseling, helping them find recreational activities, just things to help their quality of life be better. We see about four times as many people are able to be abstinent and with some continued effect, even after treatment is completed with contingency management, especially combined with community reinforcement therapy. I'm not gonna talk too much more about stimulant use disorders here in general, other than the fact when we're, it's important to address people's mental health. And so many of our patients are gonna have with substance use disorder are gonna be struggling with their mental health, especially issues like anxiety, depression, PTSD. And a lot of times they just have never really gotten the treatment that they needed for that. So once we get people engaged in treatment, you know, people are oftentimes thrilled to hear like, oh, you can help treat my anxiety too, or my insomnia too, my pain too. You know, people are thrilled and that can help them also to improve their quality of life and engage in treatment. So we're focusing on non-narcotic medications. So I don't prescribe benzodiazepines or controlled substances for sleeping. But a lot of times we are able to find medications that can help people to feel better. And specifically related to psychostimulant use, there are some resources. There's a couple of resources here linked to that are harm reduction more targeted for people who are using stimulants, which can be a little bit different, different supplies and different approaches than with opioids. So it can be helpful to have some patient educational handouts that are, and also for providers to read a little bit about how to reduce harm associated with that. So I'm gonna go over this case here and we can talk, and then that might bring up a couple of questions about how we could help this person. So this is a 25 year old female. She's about four months pregnant. She has been seeing a couple of local buprenorphine prescribers in the area, but she keeps moving around to different places. She frequently no shows for her visit and she is really struggling to take her sublingual buprenorphine. And she told her doc last week that, it helps me when I take it, but I just, I'm having a really hard time taking it every day, still continuing to use fentanyl pills and then kind of brings to our knowledge that she's been using a non-prescribed high dose, non-prescribed benzodiazepines, as well as methamphetamine. And she doesn't have any recovery support. She doesn't have any friends who are sober. She doesn't really have any family supports. She, the doctors who saw her before did have help her. She made two attempts to inpatient withdrawal at the local critical access hospital. And both times she left on the first day against medical advice and she's refusing. We don't have a methadone clinic nearby us and she's refusing to go into residential treatment at this time. So when we think about this patient, how can we help her to reduce some of the most immediate risks to both herself and the health of her fetus, including overdose, withdrawal and infection? And then what can we offer her to, and what kind of approach to help to her to engage in care and develop a stable therapeutic relationship with this patient? What do people have ideas for some things that we might offer this lady? Long-acting injectable? Yeah, absolutely. Long-acting injectable. And if it's a person that's able to come in every week then the weekly one might be a good choice. If not, then the monthly one. This patient actually did get started on the long-acting injectable and it worked very well for her. And hopefully some therapy sessions if she's willing. Yeah, offer her, is she interested in getting connected with behavioral health support? And what form of support is she interested in or willing to accept? And if she's not ready to go to counselor yet, is she willing to meet with the peer support person or have an online support group that she could sign onto? What about preventing other ways to help her prevent overdose and infection and issues like that? Harm reduction kit? Yeah, so if she's injecting, ask her, are you smoking or injecting? And if she's injecting, offering her supplies for that or offering smoking supplies, sometimes say, hey, if people are able to switch from injecting to smoking that may, it's not going to prevent overdose, but it can definitely help to reduce those risk of injection-related infections. So that can reduce that risk both to herself and her fetus as well. Go ahead, I was gonna say not to use alone, but to be in the company of others. Yeah, talk about some safer use strategies for overdose prevention. So she is using alone right now. Actually, she's living with her mom. They have a relationship where they're not supportive of each other. She's hiding in her bedroom using alone. So maybe she could call the never use alone line when she's gonna use to have someone there with her on the other end of the phone. Some other things, just in general, offering that this is a safe space, especially for pregnant and parenting people. It can be terrifying for them to seek treatment. And they can be very rightly scared that if they engage in, seek treatment, admit that they are struggling with drug use, that they are going to be separated from their baby. Their baby's gonna be taken away. That's a very legitimate fear. And it's very important to start talking to people about those fears and what to expect. You can't start too soon in that, to talk with people like, I want to be your advocate. I want to help make sure that you are not separated from your child and that you get all the support you need to be a happy and successful parent for your child. So it's never too early in pregnancy to start having those conversations about what does it look like when you go to the hospital? What does the drug testing look like in the local hospital? What's their procedure for getting child welfare involvement? Talking about things this whole time and trying to figure out what is the patient's goals? What are their resources? What kind of help do they need to be successful in their parenting? And every time you engage this person, see her, you're gonna have another opportunity to get resources. The, you know, offering. To a place where she was willing to go to a higher level of care to residential treatment that a place that is specifically for moms and babies to help them stay together and was successful in not being separated from her her baby. So so that's the end of the presentation. My contact information, you can reach out to me if you want connection to kind of some more of these resources and you can get all the slides for the links on there. This is a survey code. I would encourage people to fill out a survey about the education today to help us improve our educational opportunities. And I know we're at the end of time now, but I'm happy to take questions for a few more minutes. If people have a few more questions. I, so I see someone had a question about prescribing stimulants to stimulate use disorder patients. So, yeah, there, you know, there's not a ton of research. Some of the things, you know, that come up, like, there, like, I don't think there is much of any research that's really looking at patients like that have, you know, other core morbid. Other core morbid, you know, people who are also have opioid use disorder and that kind of thing. Some of the themes that are seen in that is that it can require very, very high doses of psycho stimulants to be effective, and it can help to keep people in treatment. There's kind of conflicting reports as far as, like, the kind of number needed to treat to actually achieve abstinence and whether it's kind of only effective in the long term, in the short term, or whether there are long term improvements there can be in my practice, we're starting to kind of explore this a little bit. And I think a lot of what you'll see a lot of folks really kind of limiting the prescribing of psycho stimulants to people who have comorbid ADHD. So we're really, like, we're prescribing the psycho stimulants to treat the ADHD with, like, the very close monitoring to also with the goal, the secondary goal of kind of reducing or preventing stimulant use. The, you know, it's a very hot topic, but there's a lot of people who feel rightly very uncomfortable with it, and they're worried, you know, am I going to get legal trouble for prescribing this? And, you know, so I think it needs a lot of caution around it. But, you know, it's I think we're gonna hear a lot more about it in the next five years. Dr. Spencer, just to kind of piggyback off that question. So you were saying that in the literature, it doesn't actually show that prescribing stimulants helps people recover from a stimulant use disorder. Is that correct? So there are some, yeah, and I encourage you, like, if you're interested to check, you know, to look at the guide and check out some of the references, you know, that are linked in there. So there are studies that show that it can help to reduce use and can help some patients to be abstinent. You know, I would say, like, the outcomes at this point in time don't appear to be any more effective than the non-narcotic options are, like the mirtazapine and the topiramate and the, you know, buproprion and that sort of thing. So, and they have, you know, their, like, results are conflicting. I would read about it if you're interested in learning more about it. You know, it's, there's not consistent evidence that it is, you know, widely effective, but I think that for some select patients, it appears to be helpful with, like, close, careful monitoring of the treatment. Okay, thank you. Yeah, I'll definitely look into that. And part two of my question, do you think the reason that we don't have good medication-assisted treatment for stimulant use disorder, is this, like, the science is lacking? Is it stigma? I'm just curious, like, why we've been so successful with it? Yeah, I think, you know, I think part of it is just, like, the biology of the receptors, you know, like, if you block opiate receptors, nothing bad happens to you. Maybe you get a little depressed. If you block, you know, dopamine, you get Parkinson's disease, right? So, it's not, like, there's not a straightforward treatment, like, you know, the medications we have for opiate use disorder, I mean, they're amazing, especially even when you compare them to medications to treat diabetes and blood pressure, like, they are amazingly effective. We just don't, you know, people are trying really hard. There's a ton of studies on it. There's a really nice review article, like, that reviews all, like, everything that's been tried for stimulant treatment, and kind of the effectiveness or ineffectiveness. There have been a lot, it's not for a lot, I mean, I think there could always be better funding and research, 100%. It's not for a lack of people doing the research, but it has been, it's just been clinically very challenging to find something that works. But, you know, I don't know if in your state yet if they have any state-sponsored contingency management programs. There's only a couple states that have them, California, and I can't remember whether it was Washington or Oregon was getting ready to start it, but so that you could actually build contingency management through Medicaid. It's an 1115 waiver that the state has to file with the federal government, but to get reimbursed through Medicaid, but you can use tribal opiate response funds. You can use opioid settlement funds. There are a number of funds that are not restricted that can be used for contingency management. Contingency management is by far the most effective treatment. Like, it's, so if you're thinking of treating stimulant use disorder, and you want to take that seriously, you should seriously consider, you know, at some point, you know, looking into what, you know, what your organization could offer, or if there is a local organization already offering that treatment to help connect your patients to that, because that is by far the most effective treatment. Okay, awesome. Yeah, I'm excited for us to discuss that as a team, because I'm sure you're familiar about Coos Bay, Oregon, and particularly the neighborhood that we're in is like a huge meth hotspot, even more than opioids, although they're both problematic. And I really, you know, it's been clinically really challenging because people come in and we just have nothing to offer them. And so I'm excited for us to talk as a team later about maybe bringing that on board if that's possible. Yeah, and the ORN does have some trainings, like, in contingency management, like, they have teams of people, too, that are, like, trained in contingency management, and there's some, there are pre-existing kind of curriculums out there for, like, implementing contingency management, like, within the healthcare setting. That's so great. Thank you, Dr. Spencer. That's really helpful. And feel free to reach out to me via email if you have questions, you know, down the road that you want to ask or to get connected to more of those resources and I can help out with that. Oh yeah, I'm sure we will. And do we have one more training scheduled with you or did I make that up? We do. We have one more. It'll be next Wednesday, June 5th, and it will be on buprenorphine prescribing for chronic pain. Oh, that's really exciting. This has been fun. I want this series to go on forever. I'm sure you have other things to do. Yeah, well, great. Thanks to everyone for attending. That's great. And yeah, we will talk again next week. Thank you. Thank you, Dr. Spencer. Thank you all. Thanks, everyone. Thank you, Dr. Nod. Bye, please.

Chelsea

indigenous lands

Dr. Sarah Spencer

long-acting injectable buprenorphine

addiction treatment

Alaska

medication benefits

logistical aspects

patient satisfaction

transitioning

patient counseling

flexibility in care provision

low-threshold approach