So we're going to focus a little bit more this next lecture on harm reduction and low-threshold care. So kind of providing services to patients to improve their quality of life and reduce the risks to their health and life when they have severe substance use with other associated comorbidities and aren't succeeding in a traditional model of care. We're going to talk a little specifically about the intersection of opioid and stimulant use that we're seeing more and more commonly now. We're going to talk a little bit more about some treatment considerations when we're working with people with polysubstance use and talk about ways that we can reduce the risks to people's health and quality of life when they have these comorbid conditions. So in Alaska, in 2021, we had one of the highest nationwide increases in our overdose death rate. And what we saw is that Alaska Native people were suffering mortality rates that were about three times higher than white Alaskans, and that specifically both methamphetamine and fentanyl use were up by about 150 percent each. And what we've seen nationwide, a trend in this comorbid, co-occurring use of fentanyl with stimulants and in the West, particularly methamphetamine. So nationwide, it's like half or more significantly higher incidence in the West Coast of methamphetamine use for sure. What we saw in our practice in the last eight years or so is we've seen over tripling in the incidence of patients who, when they come in for treatment for their opioid use disorder, report that they're also using methamphetamine along with their opioids. And when you look at the patterns of overdose death rate statistics, what we see is that the deaths related to stimulant use have quadrupled over the last decade, and that over half of those stimulant related deaths are also involving fentanyl. And so they're really going hand in hand. And that, although, you know, sometimes there is a misconception among patients or even providers that, you know, when you combine, like, if you take a stimulant with an opioid, wouldn't that help to keep you awake and, like, reduce the chance that you're going to nod out or stop breathing? But actually, that's not the case. Actually, when you combine these two together, it actually increases the risk of overdose death. So the respiratory suppressive effects of fentanyl are so profound and so rapid that the stimulant essentially does nothing, doesn't help at all to combat that. You have the same respiratory depressive effects of fentanyl. And on top of that, you have, like, the cardiac arrhythmia risk of the methamphetamine. And so that increased cardiovascular risk along with the respiratory suppressive risk actually increases the overdose death compared to using either of those drugs separately by themselves. So why do people do it? That's a really important question to ask. And so they asked, they did a study a couple years ago where they interviewed a bunch of patients and said, why? Why do you use these two drugs together? And it actually kind of makes a lot of sense. And really, the most common reason is that patients, they want to counteract the negative effect of the fentanyl. So they're trying to stay awake, to try to be more functional despite these, like, you know, the really heavy effects of the fentanyl. So, you know, it makes sense that as the fentanyl potency is becoming higher and higher and there's more and more of it around, why people are, you know, adding the methamphetamine to that often used together at the same time to kind of counteract those negative effects of the fentanyl and to help improve their experience. Again, it's really critical to try to help reduce mortality, to get people on their medications and try to help them stay on their medication. But what we see, if you look at kind of the some of the epidemiological data nationwide, is that it appears that patients who are using methamphetamine along with opioids, that they have a harder time staying in treatment. And there's lots of different reasons for that, and it's not always patient based. So they can have, you know, just related to the comorbid amphetamine use and complications and things related to that. They could have more sleep disruptions, issues with their schedule, more trouble keeping scheduled appointments. They may be certain programs may actually discharge people involuntarily because of that other ongoing substance use that they're experiencing. They might be refused admission completely to treatment programs because they're using multiple substances. So what it really comes down to is that these patients who are at the highest risk of death are the ones that are having the hardest time both accessing treatment and staying in treatment. And when we think about, you know, one of the major concerns about buprenorphine, the worry about patients about this medication being being diverted, or we have a patient who's coming into the office saying, you know, I, hey, I was using buprenorphine that I was getting from a friend and it helped me to feel better. It's important to understand what the typical usage is of non-prescribed buprenorphine. And what study after study has found is that when buprenorphine is used without a prescription, that it is almost always for the medically intended purposes. So they're using it for the same reason that they would if you're prescribing it to help deal with withdrawal symptoms, to help taper off, stop using other opioids, to prevent cravings, the same reason that we're prescribing it. But unfortunately, in the non-prescribed setting, you know, buprenorphine is very expensive on the street. It's much cheaper to just get fentanyl. So trying to afford to continue, like it's not a sustainable thing to be taking buprenorphine that's not prescribed because it's too expensive, they're going to be running out, they're not going to have a dose that's high enough for them. So they're going to continue to return to use over and over again. But having that experience of utilizing buprenorphine in the non-prescribed way first, when people have a positive experience with that, that's associated with a high likelihood that they're going to do well in treatment. So when you have that patient comes to you and says that they've tried buprenorphine, it wasn't prescribed for them, you know, that's a good sign that they probably will do well on prescribed buprenorphine. And when we think of the risks and harms of medication when it's not prescribed or, you know, it's just potentially out there on the street and kind of comparing those risks and harms between different medications. So this is a nice study that was done, you know, looking in the UK and in France and Europe, buprenorphine has been around for a much longer time and more widely available than it is in the United States. So when they compare these to kind of the potential harm to others versus the harm to themselves by misusing non-prescribed medications, you know, buprenorphine is at the kind of the absolute lowest risk of harm either to self or other when it is taken non-prescribed versus, you know, these other drugs, even the legal ones are much, much more harmful both to the individual and to society. So again, just kind of reiterating the safety of buprenorphine and the low risk of harm, even when it's not taken as prescribed. And with a couple interesting articles, you know, have come out this year kind of taking a new look of kind of what is the impact of diverted buprenorphine kind of on the population as a whole. And what a couple interesting things that were found is they looked at people who were using non-prescribed buprenorphine and they found that people who were using non-prescribed buprenorphine actually had a lower risk of overdose death. So again, it can be protective regardless of the context, you know, any use of buprenorphine can help to reduce mortality. And also some interesting kind of social epidemiological modeling in this other study that was looking at, you know, different models of care, models of care where we're going to very tightly regulate it, try to do everything we can to 100% reduce any diversion at all whatsoever versus kind of in between where we're going to try to some extent to reduce diversion, but we're also going to increase access to the medication versus a model in which, hey, we're going to just make sure everyone gets buprenorphine as much as they need. So they're not really going to worry about diversion at all, kind of modeling these different strategies. And what they saw is that the two more liberal strategies of trying to, you know, make sure people get the medication they need and not worry so much about diversion actually resulted in lower overdose death versus the modeling associated with the highest risk of overdose death was the trying to control the medication as tightly as possible and trying to completely prevent diversion. That actually had a worse outcome as far as the kind of risk, population-wide risk of overdose mortality. So when we think about, you know, trying to do our due diligence to reduce diversion or misuse of the medication, you know, thinking about the context of why we're doing that is important. So one thing is, again, we want our patient to take the medication. So when I think about buprenorphine, I'm not actually, and I think about person giving their buprenorphine to someone else, I'm not really nearly so worried about the danger that that poses to the other person, that non-prescribed person that's taking it. It actually probably is doing some amount of good to whoever is taking it. But I do worry that my patient is not taking their medication because I'm taking care of that patient and I want to make sure that they are getting the help that they need and getting the medication they need. So if they're not taking their medication, they're not getting the benefit that they could be getting from taking it. So that's really kind of the biggest concern is that we want to try to help that patient to take their medication and also misusing the medication. So, you know, people who inject drugs, IV, that behavior of injection, that ritual of injection is addicting by itself. So people, you know, become that behavioral addiction to the ritual of injecting can continue. And then some studies say like even one in four people who inject drugs kind of have an addiction to that behavior, that ritual. And so patients can sometimes inject their prescribed buprenorphine. And it doesn't, you know, the nice thing about buprenorphine is that no matter how it gets into your body, whether it's injected, whether it's put under your tongue, in the end, it all has exactly the same effect. It still lasts in your body, you know, the same amount of time. It still has the same effect when it's in your body. You know, the difference between injecting, you know, obviously with injecting, you have more bioavailability. So they'll get a higher total dose of the medication than if they're taking it sublingually. But the end result is the same pharmacological effect of the medication. So again, it's not generally that patients are trying to get high by injecting their buprenorphine. But it's generally, it's a kind of part of that ritual of addiction. Or if they're short on medication, they don't have a high enough dose of medication, injecting it allows for greater bioavailability. So they have a higher serum drug level of medication that's going to be more effective and more effective for them. But of course, we worry about the other risks of injecting, all of the infectious disease risks that are associated with injecting any substance at all whatsoever. And so that's really kind of what we want to work on too with patients is trying to reduce those risks of injecting, no matter what it is, if anything that they're injecting is going to pose health risks to them, just based on the fact that they're injecting it. So things that we can do to try when we're concerned about medication, people not taking their medication or misusing their medication, you know, we don't want them automatically discharged from the practice. We want to try to again, increase that level of support around that patient. So seeing them more frequently, doing shorter supplies, shorter prescriptions of medication, maybe doing some occasional supervised dosing, which doesn't have to be every dose, it could be like randomly once or twice a week, doing it over a phone chat on the video, can you show me taking your medication? So the, you know, if we're able to give them, you know, increased psychosocial support, and in situations, again, in situations when we try all of these things, but patients still are not able to take their medication on a regular basis, they, you know, then those may be cases where the patient would be more successful with a long-acting injectable form of medication. And then when we think about referral to a higher level of care, there are definitely patients who, you know, despite all of our best attempts at trying to help them, are not able to stop using opioids when they're on buprenorphine, or they're, or they're, maybe they are able to stop using, using opioids, but, but they, you know, they're dealing with really significant other substance use disorder that's having big impacts on their quality of life. And their health, and they're not able to stop those despite us trying to help them. And so we always want to continue to offer people a higher level of care, and like through motivational interviewing, try to gradually work with them, if we think that that's what they really need, gradually work with them with coming to a place where they're accepting and motivated to engage in a higher level of care. But what we want to avoid is, you know, saying, hey, I can't take care of you, you need a higher level of care, and then just, you know, and, and then not allowing people to have a choice in that and what level of care they want. Because, you know, a higher level of care is more, that's more intensive commitment from the patient. You know, having to like, leave their home, they have kids to take care of, they have family here, they have pets to take care of, you know, they may have had very, very unpleasant experiences with residential treatment in the past. You know, there's many reasons why patients are either unable or unwilling to engage in something like intensive outpatient or residential treatment. And so when we force that on someone saying like, that is your only option, then essentially, that higher level of care can mean no care at all, because that may not be realistic for a patient to engage at that higher level of care at that time. So it's important to also offer when people, even though we know that that would be provide them with the most important services, it may not be realistic for that patient. So we also need to make sure that we're offering a lower level of care if people aren't able to participate in like the standard care that we're able to offer kind of an entry level, low threshold harm reduction level of care for patients who that is what they want or need at this time. So, low threshold here can be a potential strategy to help to keep folks in treatment who are really struggling the most with polysubstance use and other comorbid conditions is making that entry level of care as low barrier as possible that we're asking very little from the patients and making things and making it as easy as possible to get them at that level of care. As possible to get the medication that they need. So, reducing, you know, increasing access to care, there's many different ways in which we can do it and there's not, you know, no one clinic can do everything. And, and different patients have different needs that they have but there but there are different ways that we can work on to reduce reduce those barriers. So the number one common thing that kind of all low barrier harm reduction programs share in common is that not discharging patients for ongoing drug use, which also can mean ongoing opioid use, you know, some patients are, you know, they're able to reduce their use, but they're not able to completely stop their use, which is still a very valid goal. Reducing use and reducing mortality related to overdose is a very valid outcome and goal, even if it doesn't result in complete abstinence. So we really want to focus on, you know, what is your goal as a patient? What are you looking to do? And that should be the focus of our care for the patients. Now, we may have a very different idea about what would be best for that patient. You know, it would be best for you to stop using all substances. It would be best for you to, you know, take this dose of medication every day. But that may be very different from the patient's goal for themselves. And that's something that, you know, that the patient's goals for themselves can can change over time throughout that, you know, treatment journey, especially when we're offering motivational interviewing with them. We're developing a healthy therapeutic relationship with that patient so that they're trusting us. It can take, you know, months and months of, you know, working with people to gradually, slowly get them on board to, you know, get more engaged in treatment, be more motivated to reduce or stop their use, more motivated to accept more support. It's something, it's a process and it's a spectrum and it can take time for those to happen. And we shouldn't expect all patients to be able to, you know, fit into our box of what we expect from them, you know, right away from day one. So, you know, we can help to make care more accessible if we have ways, if we have some more accessibility in our scheduling, which could be maybe we have certain hours during the week that we have some walk-in availability, or maybe we have a, you know, a same day time slot available a couple days a week. Again, telemedicine appointments can make it easier both for the patient and the provider to have more flexibility in their schedule. If you have someone like, I think you mentioned earlier, behavioral health aides, if you have a peer support workers or behavioral health aides who are in your community, they can help to, you know, work to support people and contact them, especially through texting. we found that that's a big thing. Patients, a lot of people don't really like talking on the phone or maybe even seeing someone in person, but they're willing to reach out via text when they're struggling or they need help or they need support. And so that has been really helpful for us in like case management for people and just kind of providing that support from that they might need outside of the clinic setting. Making sure, contingency management, we'll talk a little bit more about here, a little bit later about how that can help people to meet their goals. And finding a source of support for case management, which doesn't always have to be within your organization, but it can allow you, it can be by utilizing a peer support person or a behavioral health aid or maybe someone that works with you, even if they don't work in your clinic to kind of have that person to help people navigate the system, help them with doing the other things they need in their life, like filling out insurance applications, helping them figure out the transportation to get there and providing as many kind of one-stop shop services as possible, which is especially true, maybe not in your clinic, but like in a primary care clinic to be able to, when a person comes in, let's say to get their once a month shot or to get their sublingual buprenorphine refilled at that same time, offering them contraception, offering them hepatitis C testing and can really help them to get those other health needs net when they wouldn't normally seek medical care for their other problems, talking with them about their mood and prescribing an antidepressant or other medications like that. The more that we can do to help people, this is the only care a lot of times people are seeking or getting, and so being able to try to reduce, offer them as many services as we can and including harm reduction supplies that we can keep harm reduction supplies in our office to hand out to patients is probably more effective in a lower barrier than saying, oh, this is where the harm reduction program is. This is the hours you can go there and get those things, which is good. It's good to know that it's good to give patients information, but also having some samples of supplies that you can actually hand out to patients when they're right there, being able to hand out an ARCAN kit, fentanyl testing strips, or even injection supplies, that really shows that you're a safe and nonjudgmental environment and that people can feel safe talking with you about their ongoing drug use and not feel like you're having to hide it, that you understand that addiction is like a chronic recurring relapsing disease and that the comorbid use may also be continuing to go on and that people feel safe talking with you about that. So some specific ways in which long-acting injectable buprenorphine can be utilized in a low threshold manner, which is pretty straightforward and easy both for the provider and the patient to offer, is for one thing, we can give it regardless of what other drug use is going on. So we don't require people do any kind of drug testing to get their injections of long-acting injectable buprenorphine there's nothing that we're gonna see in that test that's gonna make us withhold that shot. It doesn't matter what other drugs they're using, their urine, and we already know it's gonna test positive for buprenorphine, we don't need to do testing for medication compliance purposes. So that makes it easier for the patients who are hesitant or don't want to do the drug testing that they don't have to do it for that. It allows us more flexibility both in our schedule and in the patient's schedule. Again, even though the shot is due in four weeks, they could come in three and a half weeks, they can come in five or six weeks, even later than that and we can still do their injections. So it's not gonna immediately wear off at the end of the month, it's gonna slowly wear off. So we have much more flexibility to reschedule patients and if they're missing their appointment, it doesn't become a crisis situation that day. It's easy to move things around, it gives us more flexibility in our schedule. We also being able to do walk-in appointments for injections in some offices if you have an ancillary person who's medically trained, who's able to give those injections. Sometimes those injections can be done under the order of the prescriber, be done by another medical staff person in your office to allow that even if you're not able to have a full visit with that patient and not able to address all the other issues at the bare minimum, at least that they can get their injection of medication and because that is the most important thing to keep them safe. So it gives a lot more flexibility with that as far as provider schedule and whatnot. And there's a lot of flexibility with the dosing to increase or reduce the dose, depending on what is effective for the patient. And it can be utilized also in pregnancy second line to sublingual therapy. So if a patient is not able to succeed on sublingual therapy, it also can be potentially used in pregnancy as well with a risk benefit discussion with the patient. Telemedicine, we've had a lot of studies that have come up about telemedicine for treating opioid use disorder since the pandemic and they've all been had positive outcomes. Essentially all of the data and we have like a lot of data now for nationwide has shown consistently that telemedicine is an effective way to deliver care for opioid use disorder. It reduces mortality risk, it increases engagement in treatments and retention in treatment. And so the concerns that we had that you have to see a person in person, you have to do drug screening, all these things in order for treatment to be effective has turned out to not be true. So we have good evidence now that telemedicine is effective, safe and effective in treating opioid use disorder. This is another article sharing the same thing. So for telemedicine, we again in our office, we do almost all of our intake visits via telemedicine. It can allow for kind of easier scheduling or moving things around since we don't have to worry about the patient, physically waiting in the office to be squeezed in. And what we're gonna have essentially the same conversation over the phone as we would have if we were seeing patients in person. Giving those instructions, it can help to have ways to send people information and instructions, whether that's via texting that information over the phone to them, with the medication instructions, having an online portal they can sign on to or even emailing or mailing the instructions to them in the mail. So those kind of paper things that you might be giving people in the office, you can transmit to them electronically to use at home. And when we're talking with people about, often we're doing a telemedicine visit, talking with people about initiating, if they're asking to initiate monthly injectable buprenorphine, we tell them to come into their in-person visit, even if they haven't taken their subliminal buprenorphine as prescribed, we're gonna talk with them anyway. And if they want to get their shot, regardless that we're still gonna make sure that they, if they show up and they wanna get their shot, they're gonna get their shot no matter what. When you are ordering injectable buprenorphine, depending on where in the country you're ordering it from and how long it needs to be shipped to, some places have it right there in the state and they can courier it to you the same day or the next day. Other times it can take up to a week to ship to the office. So we generally plan on doing our visit, a telemedicine visit the week before the patient wants to get their first injection. And utilizing this medication, monthly injectable buprenorphine is something that it's much simpler than a lot of people think it is. And it can be really reduced the burden, both to the providers and the patient. And that's something that it's kinda, it's a little bit of a big topic, but it's something that in the future we could do another just brief training on just kind of the details and logistics about how to actually utilize that formulation of medication. But it is really pretty easy to do. And there have been a number of studies that have looked at this rapid starts of this medication and have shown, they've all shown that you don't need to take buprenorphine, sublingual buprenorphine for a week before the injection, you know, taking it, you know, that day or the day before, or even not at all appears to be well tolerated for most patients. Again, just ensuring that they have had at least some positive experience, that they know that they like buprenorphine and they tolerate it before doing an injection. When we looked at our patient population over the last five years or so, six years, we looked at this group of patients who use methamphetamine with opioids and looked at, you know, how long they were able to take buprenorphine for comparing, you know, whether they were taking a sublingual or extended release formulations of that medication. And what we found in our clinic is that patients were able to accumulate almost three more months of buprenorphine therapy when they were on the extended release formulations versus the daily formulations. So I think there's a lot of factors with this medication that make it easier for the patient to stay, to continue to take the medication. And so it can really help to improve that length of therapy of being exposed to buprenorphine, which again, that's the most important thing. Every day, extra day of buprenorphine therapy that we can have someone on is going to be helpful and longer is better. So this is, you know, really the biggest challenge in treating patients with this medication is helping them to stay on it. That is the biggest challenge that we face in day-to-day. And I wanna talk a little bit about, specifically about stimulant use disorder because it is so common now as a comorbid substance use disorder with opioids. There is no FDA approved medication to treat stimulant use disorder, it doesn't exist. There have been many studies looking at many different kinds of medication to see if it would be helpful to treat stimulant use disorder. There have been a few that have been somewhat helpful for a small number of the patients. So a couple medications that used off-label that seem to be helpful, bupropion by itself is somewhat helpful and in combination with naltrexone appears to be more effective and that combination can help about 10 to 15% of patients to stop using amphetamines. And mirtazapine has also had kind of a similar effect similar outcomes in helping to reduce or stop use for about 15% of people. Topiramate is another one that has some efficacy with it as well. So there are some medications that can help. And I think when we think about these medications like bupropion and mirtazapine, they're probably kind of helping to treat some of the underlying chemical imbalance that we're getting from the amphetamine use. Helping to replace some of those feel-good neurotransmitters that are being depleted by the amphetamine use to help with some of those triggering symptoms of depression and fatigue and that sort of thing that triggers them to continue to want to use stimulants. But when it really comes down to it, the most effective treatment for stimulant use disorder is contingency management, which we'll talk more about later. If you're going to prescribe an antidepressant for someone with stimulant use disorder, bupropion is the one that has the most efficacy behind that. Mirtazapine also can be helpful. It's interesting that SSRIs, when we think of amphetamines, it's dopamine mainly. Dopamine and norepinephrine that we're dealing with being depleted and studies looking at using SSRIs in patients with stimulant use disorder do not have as good of outcomes as the, even SNRIs, bupropion or mirtazapine. So contingency management is by far the most effective treatment for stimulant use disorder and it's actually effective treatment for pretty much all use disorders as well as for other health conditions. Yeah, I thought I had more information here about contingency management. So contingency management is offering rewards for patients who are struggling. If I don't have more information now, I have it's in the next slide. So we'll talk more about the contingency management when those slides come up. But generally, harm reduction, there are resources out there that kind of specifically give information about harm reduction for stimulant use, about avoiding over-ramping or over-stimulation and helping people to access dental care, smoking supplies instead of injecting with syringe. These kinds of things can be a little different for stimulant use in some ways than it is for opioid use. But these are some resources that give some specific information about harm reduction that is related to stimulant use that you can look up to help and to share with your patients about reducing some of those risks to their health. Fentanyl test strips can be helpful for patients when they're using other non-opioid drugs. We actually don't recommend that people use fentanyl test strips to test heroin because all heroin has fentanyl in it. It's kind of a waste of a test strip. We just assume that all opioids are fentanyl or have fentanyl in them. But what we use these, what we recommend people use these for is for testing other drugs. So anything that's a pill that they get from someplace else, there's lots of fake Xanax, fake Adderall that really it's just pressed fentanyl pills. There's a significant contamination of methamphetamine and cocaine with fentanyl. And that could be 15% or more depending on the geographic location. It's just very unpredictable. So that those things can be particularly deadly when a person is not intending to use opioids, they're intending to use a stimulant or they're intending to use the benzodiazepine and instead they're getting fentanyl, especially if they don't currently have a tolerance to opioids that can be particularly deadly. So that's really kind of where we recommend utilizing the fentanyl test strips is so that people who aren't intending to use opioids or fentanyl can test their drugs to see if they might be contaminated with fentanyl and then maybe choose a safer way of using or to not use that drug or change in other ways the way that they're using to reduce their fentanyl exposure. And naloxone kits are important for people to have even if the only drugs they're using are stimulants because of the unintentional exposure to fentanyl that can occur with these other drugs. So Narcan is for anyone using a non-prescribed drug. Or anyone taking any opioids. It's not just for people on opioids. Any non-prescribed drug use folks need to have Narcan kits on hand. And for harm reduction training specifically, the Alaska Native Tribal Health Consortium has this nice toolkit and a kind of indigenous-focused harm reduction toolkit that is well put together and well written. And they also have a list of harm reduction trainings online that are focused on tribal health. And they also offer mail-order harm reduction supplies for Alaska Native beneficiaries and clinics. And when you look at the principles of harm reduction, it really aligns well with Alaska Native and American Indian values. And that's something that is brought up in some of those trainings that these philosophies actually merge together and are not really in conflict with each other of really accepting that people's lives are complicated. People exist within their entire community. And that we wanna be there to support people and not judge them no matter where they are in their life journey. And so kind of reviewing of that low, kind of the entry-level harm reduction approach to healthcare is that to treat all patients with the same respect and dignity regardless of how severe their disease at, work with patients to set goals for their care and allowing them to guide and set those goals. Offering a broad range of support so people can have the choice between kind of very low level and no barrier basic harm reduction level of care all the way up to a very highly structured intense level of support depending on what their goals, accessibility and needs are. And that to acknowledge that patients have the right to determine what their level of care is and their level of participation is and that we should not be discharging patients for an active disease because they're returning to drug use or continuing drug use. That's the end of that talk about harm reduction.

harm reduction

low-threshold care

substance use

comorbidities

opioid use

stimulant use

fentanyl

overdose death