Okay, well, welcome to, I guess this is our third or fourth iteration here of our piece here. What we're going to be focusing on today is MOUD or medicated opiate use disorder. And sometimes you might know this as MAT or medicated assisted treatment. We're going to talk about, or medication for addiction treatment is another way that that's been referred to. And we'll talk about some of the difference and why we're splitting those terms up here. So let's, we've introduced you to the ORN before. Oh, actually I don't, do I even have, oh, I just went straight to the objectives here. That's right. So great. Okay. So you've been introduced to the ORN before. Let's go straight to the objectives. So what we're going to do is we're going to provide information. It's pretty straightforward. We're going to provide information about different medications used specifically for opiate use disorder. We will talk about medications that are used for other addiction or substance use disorders. But we're going to be predominantly focusing on opiate use disorder. Some pieces here, logistics wise, we'll probably take, yeah, we'll definitely take a break somewhere, probably about an hour in or somewhere around 10, based on how we're moving through the material. And then please give questions and comments as we go along, because you're all working with this, working with folks that are using these medications currently, and I'm sure there are lots of questions or maybe information, like there's going to be a topic about xylosine coming up. And I actually really love to hear what's kind of going on with xylosine. If you've even heard of it coming through, I'm guessing you have, but we're going to touch on xylosine a little bit here and there's other things as well. So why do we call it MOUD? Why have we split this off to medicated opiate use disorder? So this has been a few years in the making of trying to make sure that we shift this. Predominantly to largely to move away from stigma, but also to accurately name what these medications are doing and what their purpose is. So here it reflects how the medications, specifically like methadone, buprenorphine, and those are the two main opioid medications that are used, and how they're used to treat withdrawals for opioid use disorder. If you remember all the way back to the SUD 101, there was a discussion we had of talking about how someone can be dependent, physically dependent on opioids, but not addicted. So an example would be someone who went, and this actually happens regularly, someone who goes in and gets an opioid prescription for, say, a broken bone or for some kind of injury. They may take opioids long enough to actually get physically dependent on the opioids, but we wouldn't say that they're addicted because once they stop, once the medication runs out, they feel sick, but they're not looking to get more. And then they feel sick for a little bit, or not so great for a little bit, and then it's done. And that would be an example versus someone who's going out and putting themselves into risky situations to get, to buy, it's taking up all of their time of day, either to get high or to get their fix, or to secure their supply, or they're recovering from it. They're not seeing any of that kind of stuff. And so why this is important, talking about this, and we'll come back to this, of looking at how these medications really do specifically treat the withdrawal, so they address the dependency issue with the hope that people will be able to then work on addiction issues if those are what's, if that's what's happening. It also recognizes that many people look at opiate use disorder as a chronic, ongoing condition that they can manage, they have to manage over the long term. And so this, it's more accurately showing that many folks will need to stay on this for at least a very long time, but even a group of those folks are going to have to stay on it for the rest of their lives, because they're going to do better that way. And so there's, it's basically treating a chronic condition, it's medicating it so that they're able to go about their daily lives, as opposed to treatment, which we kind of give the idea that, okay, we give a little bit of treatment, and then they're cured. It's no, this is an ongoing management kind of situation. And then I want to circle back to stigma. I started this by saying this, really the main thrust behind switching to over to MLUD is to help reduce stigma. It's to help reduce a lot of the stigma around, and stigma can crop up in a number of different ways. And we'll discuss this again at different points, but like the idea that we're just swapping one opiate for another, like opiate, and even the clinical term, and I've used to use this, and I'm trying to stop, is opioid replacement. That's actually stigmatizing language. Because it's just, it's the undercurrent, the message underneath that is that we're just switching one drug for the other. Now yes, we're taking methadone and buprenorphine, which are opioids instead, but we're taking them for very specific reason, because there are some specific qualities about those two medications that make them a particularly good candidate to help people manage their opiate use disorder, or at least their dependence on opioids, or their withdrawals, and be really stable. And so it's better to talk about how we're medicating the condition. So that's just one example, we'll talk more about this, because there's a lot of stigma, especially around methadone, but both methadone and buprenorphine. So MAT, or medication for addiction treatment. So this is still a term that is used, because MAT was actually a much larger umbrella. It didn't just include medications for opioid use disorder. And some examples here, like medications such as naltrexone, or dasulfiram, which is antabuse, and Vivitrol even, are all medications that can be used for alcohol. And they would fall under the umbrella, and they're all FDA approved for alcohol use disorder. So looking at that, and actually that should say AUD, not OUD, sorry on that one, there's a little bit of a typo there. So there's, and then Vivitrol, actually we all know it's correct, because Vivitrol can be also used for OUD as well. So these are just medications that are there. The difference with these medications is they, like antabuse, antabuse, if you're not familiar with it, is the medication where it's taken by pill, and if someone drinks after they've taken the medication, they get violently ill. And so it's a real, it's a deterrent to using alcohol. Naltrexone for alcohol use disorder, or for alcohol use period, is used as a way to kind of curb cravings. And then even Vivitrol actually has been found to be useful in with alcohol use disorder, but Vivitrol tends to, Vivitrol is an injectable version of naltrexone, and so it's a long acting opioid antagonist. What it does is it prevents the opioids from working. So it works a bit differently than methadone or buprenorphine, because there is no opioid, but it blocks opioid use, or opioids effect, actually. So now, mainly these apply to medications that are temporarily used to enhance behavioral interventions, and that's the one piece there that's important, is that these tend to come in as a temporary stopgap. People are on this for a few months, maybe a little longer, until it's seen that they don't really need it anymore, and then they come off, whereas MOUD tends to be more long-term. So let's start looking at the medications that are actually a part of MOUD. So it's a little fuzzy here, but hopefully it's clear enough to see. So what this is trying to show you is we've got the two main medications, methadone and buprenorphine, but we also have naltrexone on there. And kind of how they work with the postsynaptic receptor is what this is supposed to be. So hopefully you're familiar enough with neurotransmitters and how there's a gap between one nerve and another nerve, and there's a chemical signal that goes across the two. And so there's one neuron that sends a chemical out, and then there's another neuron that has a receptor that it binds to, it's what we call lock and key. And so what this is trying to show you is how the atoms or molecules of methadone and buprenorphine bond with that receptor. And so methadone, methadone is what we call a full agonist. So that means that it completely binds with the receptor, so much so that it generates the effect. And so methadone is an opioid. It will give you full effect of an opioid. And so it basically, it handles the withdrawals because it's giving you an opioid, which is blocked by giving you the opioid that prevents the person from going into withdrawal. Then we've got buprenorphine. Buprenorphine is what we call a partial agonist. And so keep in mind, we're just talking about buprenorphine. If you're thinking of suboxone, suboxone has buprenorphine in it, but it also has another substance called naloxone, which you might be familiar with because it's similar to Narcan. So buprenorphine, the opioid component itself is what we call a partial agonist. And so that's what those dots are. It's showing that it mostly fits, whereas methadone completely fits. It's like hand and glove. Buprenorphine, it's like a glove missing a finger, but you're mostly there. Or maybe there's a little bit of a wrinkle, you can't get the glove completely over the fingers. Or another way is like if you've got like a glove that's too large for your hand, it's in there, but it's not a perfect fit. And this is important to note because it will generate some effect. It's enough of a bind to give some effect, but not as much effect. And so it's kind of has a dual purpose of giving you enough effect, hopefully, to diminish withdrawals, but also not giving you so much that you get extremely high. And in fact, there's an idea with this that it will bond to a point where, and there is actually proof of this, that the receptors have a greater affinity for the buprenorphine. And so all the receptors will get taken up and so nothing else can bind to it. And so you get stuck at this kind of ceiling effect. There's only so much effect you can get. And so there's some added benefit to that. And then we have naltrexone. So naltrexone is not an opioid. And so it's called an antagonist as opposed to an agonist. Antagonist means that it completely blocks the receptor. It prevents anything from bonding to it. And so it will prevent someone, if they use opioids on top of the naltrexone, it will prevent them from working. Any questions on this, because it's kind of science-y and I just want to see, make sure it makes sense that I'm explaining it well enough. I had a question for the buprenorphine. Buprenorphine, yep. You talked about how it's a partial blocker and it'll kind of like make it so that, I guess what I'm trying to ask is how long does it stay there? Good question. Yeah. So buprenorphine, it has what we call a half-life of 24 hours. So and this is one of the things that is going to come up in a moment of why methadone and buprenorphine are good candidates, is that they stay in the system a lot longer than other opioids. Like fentanyl, it's just a couple of hours and then it's out of the system. But buprenorphine, even less. This stuff hangs out for a lot longer. And then I didn't quite hear any, what you were saying about the naltrexone. Could you repeat what's the deal with that one? So that's, it's what we call an antagonist. So it kind of connects to the receptor, but it doesn't activate it. It's kind of like imagining a key that has like missing teeth. It goes into the lock, but it doesn't turn it. And that's kind of the idea there. Whereas like where buprenorphine is a key that, yeah, it's fitting enough that you could jiggle and get the lock to work. Where naltrexone will go into the lock, but it's not, it won't turn. And what it does is it prevents anything else from connecting to the lock. Gotcha. So then, sorry, I got all the questions. Oh, please. That's great. I feel like looking at naltrexone and methadone, they both look like they go into the lock and stop anything else from connecting. I'm assuming the difference is the effects it's going to have on you? Yes. They mostly connect. So the difference, so methadone, actually, let me actually segue into this here, because this is going to start explaining some of that. And Dwight, can we actually hold on to that question? Because it's a great one, and I'm about to go into that. But Madalia, you've got your hand up first. You're muted. Yeah. Anyway, so my question was, when you first started, you talked about some folks getting addicted to the pain medication, you know, with what I've heard. Yeah, they go to the doctor, yeah. And then you said that there's folks that they're not addicted, but the body is addicted. So I'm curious, because I have dealt with folks that that's what happened, they didn't do drugs, blah, blah, whatever, had a shoulder surgery, hip, whatever, and then they become addicted, and then it's just ongoing. Like, it looks like, even going out, you know, if they can't get it from their doctor, they go and seek it, and they're responsible folks, they've never done drugs, what? So that's not an addictive person? It's, there's some split, I mean, it's, it depends, there's usually something, whether it's, because the thing with opioids is that they can also impact emotions, they don't numb just physical pain, they can numb emotional pain. And so for folks that have had maybe past trauma or adverse childhood experiences, or past addiction, maybe they were addicted to something else, it puts them at risk, because that tendency to do that is already there, or the opioids help them with something beyond just their broken arm. And so that seems to be the thing that, there's some kind of switch, for some reason, and there's some folks that go, that just are, and the terms I would use are what might become a little bit dependent on it, and so they'll have withdrawal, but they just go through the withdrawal and they're done, they don't end up sticking with it. But then there's a, but there are some folks that for various reasons, like we talked about past trauma or other reasons, will continue on using, because it helps them with something. And then there's folks that we, for whatever reason, just go that route, we don't completely know, but yeah, this is our best information, yeah. Yeah, because I was gonna even say, would the addictive properties of the drug also come into play with a situation like that? They can, yes, because the thing is, is depending on how dependent the person gets, if they get bad enough withdrawals, because opioid withdrawals are horrendous, and they are, and especially the longer you go, the worse they get, the more intense they get, and the more, especially if, and I think one of the other cues is, if someone starts feeling the withdrawal and then takes opioid or somehow is given opioid and they realize that taking the opioid helps relieve that, that can start building the cycle in them of, oh, wait, I feel like crap, this makes me feel better. For some, they just don't, they don't make that connection or the connection doesn't mean much to them. And so that, but yeah, that can definitely happen, yeah, say like someone with fentanyl, because it's particularly potent, they could, the withdrawal itself could cause them to go seek more. Yeah, it's complex stuff, yeah. Yeah, for sure, thank you, Paul. Yeah. So coming back to, and this, I believe we'll get some of the information in Dwight's question, so methadone. So we already talked about methadone being a full opioid receptor activator. It's, methadone has been around a long time. And that, it's interesting, because we're in what's called the fourth wave of the opioid crisis. And the first one, did I, I don't, I may have, did I talk about the four waves before? Okay. Oh, well, if I repeat some, my apologies, but yeah, it's, I think it's helpful information here, and it comes, something comes up here that's important to it. So the first wave was back in like the early 1900s. If you remember, there were the, in fact, there was marketing of the Pope holding up a bottle of wine that had cocaine in it. And there's, there wasn't much regulation and things like morphine and other things were ending up in regular cough syrups or elixirs. And so a lot of people became dependent on those and didn't even know, because they didn't know what was in the elixir really. And so there was an epidemic, an opioid epidemic that occurred then. That's when they passed the first set of laws that made drugs illegal. And that's what tended to, it also forced companies and it made it illegal for companies to be able to put that stuff in. And so consumer protections essentially is what ended that first epidemic. The next epidemic, yeah. Really quick, excuse me. You said the Pope had cocaine in his, what kind? He was, there was the Pope at the time, was, there was an ad of him selling or marketing for wine that had cocaine in it. And cocaine was in Coca-Cola. And it is actually true that some of the original versions of it had Coca in it. So you said, we're talking about opiates. Yeah, tangent. Oh, okay. Yeah, that's a tangent, yeah. Okay, thank you. Yep. So the second wave was in the 1960s, and this is the important one for methadone. The second wave was the Vietnam War. And there was a lot of access to, because opioids or opiates at that point, because they were from the poppy plant, and there was a lot of access to morphine and heroin in Southeast Asia. And that was where a lot of that ended up started using heroin when they were in Vietnam to cope and because it was accessible. And many came, and interesting facts of it, majority of folks that used in Vietnam and came back just stopped on their own. Many didn't too. So there were, but there was a group that didn't. And believe it or not, it was methadone that was the saving grace that helped us get through and curtail the second wave opioid crisis. It's something that's not well marketed or known out there is that methadone was instrumental in that. The third wave is what we've experienced in like the 2000s, 2010s, when we had like Oxycontin and that all of the opioids being overprescribed and that piece coming in. And then that started to taper off as we started realizing that there was the opioid epidemic and prescribing habits changed. Unfortunately, like starting in like 2019, what's happened is methamphetamine and fentanyl have come together to create what we call the fourth wave, which is what all of you are seeing. Meth and fentanyl are king. And there's reasons why they're put together. But yeah, that's kind of the full spectrum of where we've been at with the opioid evolution. But yeah, methadone has been key ever since the Vietnam War. Now, coming back to the slide. So the treatment goal with methadone is to activate the opioid receptors to the point that they do not experience opioid cravings. It is not in withdrawal. And I almost actually just stopped there for a moment because yes, and is not experiencing euphoria is ideal. But the main treatment goal of methadone is to be able to not experience opioid cravings or withdrawal. And I say this because remember, it's a full agonist. And so there's gonna be some effect. And so you're gonna likely see folks that are nodding out. It doesn't actually mean that the medication is not hitting its target. My biggest question for someone on methadone is your dose letting you get all the way through the night? Are you getting a good night's sleep? Or are you waking up with withdrawal at like midnight or 2 a.m.? Are you waking up with sweats or really uncomfortable? Because that's more important than whether they're nodding out. And so I think that's the main goal. And this is challenging. And I know in my work, where it really comes up is with families is because that nodding out looks like the person's high. It's actually triggering for the family members because they see it and they're like, oh, this person's just high. They're just doing this to get high. It's like, it's a side effect. And the goal hopefully is to get it to a point where that's not happening. What I also say to families is just because they're nodding out doesn't actually mean they're high. It's actually just a sign that the methadone is working because it's one of the side effects of methadone. The part is, is like, are they fully, because I think, and I have to work with families frequently, are they falling over drooling? No, that's really what we're not wanting to see is that where they're just high beyond. And are you ever afraid that they're overdosing? No, then the methadone is working. But it is one of the challenging parts to it. I will say, well, let me go here. So the duration of methadone, it lasts up to two days, definitely about one. And in fact, that's where they'll go for dosing every 24 hours. And the goal of methadone is to be able to get it so that the dose lasts long enough to get all the way through the 24 hours. Now, methadone is extremely regulated. You probably encounter this. You have to go to a specific clinic, an opioid treatment program for this. And this is done that the person must dose in person and earn privileges. The privileges have been loosened quite a bit by SAMHSA recently. So folks are able to get carries. And carries are where they can take a dose home or multiple doses home. And they can do that pretty quickly. This is meant to make methadone a little bit more easy to work with. Now, the reason why methadone is given in a liquid form that you see in the picture here is that it helps prevent diversion. Also being given in these clinics, being given in these clinics in liquid form makes it harder for folks. You can't really cheat the liquid. And so that's the idea there behind using it in a liquid format. I already talked about how it's the oldest of the MOUD medications. And because of that, it's the most well-studied. And one of the things, and let's look at ideal candidates here. So some candidates that are looking at that, and especially if you're talking to someone about possibly starting an MOUD medication. And I wouldn't be surprised if many of the folks that you work with have exceptionally high levels and exceptionally high opioid use histories. Now, I'm gonna put this here and I'm gonna bring it back up when we talk about buprenorphine. Buprenorphine does work with fentanyl. There is a myth out there that it doesn't. And we'll talk about more in detail why, but I wanna note that even if folks have a really high opioid use history, buprenorphine still could be a better option because it will work. It takes some finagling and some different dosages and timing of dosages, but it does work. However, methadone can be a little bit more simplified for folks with especially high use histories. Now, folks that are having a hard time sticking with treatment, methadone tends to be better because it's that clinic, you go in person, there's just more checks and accountability. It tends to keep people engaged better. Now, it could be for folks that have not been able to tolerate buprenorphine for various reasons. So if they've tried buprenorphine and it doesn't work, one of the reasons why buprenorphine can be a little bit challenging is you have to go a little bit into withdrawal partly because it's that partial antagonist or partial agonist. And so you want actually pretty much all the opioid out of your system before you start buprenorphine, which can be really uncomfortable because unfortunately the person has to go and do a little bit of withdrawal before they can start. Whereas methadone, you don't necessarily have to do that. And then there's some other things that can make buprenorphine a little bit challenging to get onto, but there are also some really big advantages to buprenorphine. So that could be a reason there. And then the last one here, personal preference for medication needs to be taken into consideration. So yeah, if they like something more, if the methadone works for them, great. If something else works for them, better stick with that. We want them to work with the medication that they're going to take. One of the pieces to this, and this can go into some of this and I don't have a dot here, is I do a fair bit of work with various methadone clinics. And something I work with is when someone comes in, I'll frequently hear from case managers, a complaint of like, they're just using the methadone so that they can keep using opioids, but not have the ups and downs with it. Like it's more even. And so they're like, oh, this is something that people might say it's enabling. Some people might say it's a problem. We're just allowing them to continue with their addiction. I say that's a success because if there's less up and down, there's greater, first off, there's less chance for overdose because they're regulating things better. Their lives are going to be less chaotic. And so they're probably going to end up using less anyway. It could open a doorway to them talking about reducing use at some point, but above all else, they're alive. And if nothing else, that's the hope with these MOUD medications is that's going to help keep them alive. And so that can be, some of the stigma can be tied in there, this idea that like using methadone, it means you're supposed to stop using everything else. Especially other opioids. I actually think one of the greatest strengths of methadone is the fact that you can use opioids on top of it. And that I know can be like, what, what, what? But it's more, it's the fact that we can catch people that aren't ready to stop yet and start providing them something and start providing them help, which can then open the door to more things. And no matter what, even if they don't stop using opioids altogether, we're going to make their lives better and we're going to keep them alive. Questions or thoughts on that? Because I'm guessing there are some reactions to that. There usually is when I bring that in. Actually, just wanted to say, I appreciate that insight because it wasn't something that I was against. Like, you know, I wasn't against it, but just to hear your insight in that just gave me a new way of thinking. So I appreciate that. Great. Well, if there are questions as we go, please, please come in and comment. And did I get, I think I got to your question, Dwight, did I give you? Yes, you did. I was actually wanting to know a little bit more about the still being able to use while on methadone. Is it like, cause in my mind that screen is like partial blocking, but that's not the case. It's not. Yeah. Yeah, you methadone, because it's a full agonist, it fully bonds. If another opioid comes in, it, it will just bond. It's because it's a full agonist that it's kind of like, Oh yay, more here, more of us joining the party. We'll all bond with the receptors instead of kind of bouncing or preventing another one from joining. Now, some folks, yeah, we'll extend cause they're worried about like overdose and yeah, it's technically possible. You can have methadone and then take more opioid on top and overdose. It's there. Folks tend to be more mindful of how they use though, because they're again, they're, they're not going into that withdrawal. They're not in such a desperate state and it, they're using in a different way. And so, I mean, yes, it's technically possible and I'm sure there are cases where it happens. My hunch is, and again, I don't have specific data, but is that because they're using in a different way, they would be using in a, it would be, might, might be less likely. I just wanted to piggyback off that. I have personally experienced where clients have, they would go to, I've taken to their methadone and then they would still go use and then they'll get into a state of drowsiness and, you know, kind of still looking like they're lounging over, not able to communicate properly. So yeah, I definitely experienced, they were using more opioid, like they were going to get the methadone and then getting more. Yeah, exactly. Yeah. Yes. I've seen it happen. And I've experienced where somebody would take the methadone and then go take another substance and then they would overdose right then and there in front of the, from the property. It happens. Yeah. Thanks, Mina. Yeah. Yeah. It doesn't, this doesn't prevent overdose, unfortunately, so. So before you continue, I did want to ask one more question. I think you alluded to it being harder to overdose, but not impossible. Let me know if that was wrong. And I heard that. I don't know if it's harder. I mean, if you really went for it, it could, yeah, because there, there's no, whereas with buprenorphine, there's some blocking effect. There's no blocking effect with methadone. Gotcha. Okay. Yeah, they could. There isn't any, yeah, there's no real guardrail there other than them being in a different state of mind when they're going to use Medallia. So really quick, does, I know that Suboxone has the blocker in it, but does methadone have the blocker too? Nope. It does not. That's what I thought. Huh. I'm wondering why. It doesn't matter. I'm just saying, I'm wondering why. That's the same thing I was thinking, Medallia. Which is a great segue into let's talk about buprenorphine because yeah, I'm going to get to exactly what you're asking here. So, so buprenorphine, so buprenorphine is the, is the opioid that's in Suboxone, but it's important. We're calling it buprenorphine here because there are several products that are just buprenorphine and with no Naloxone cap. And so let's kind of go into this and well, to discuss why we sometimes have the cap, sometimes we don't. And that also explained methadone a little bit too. So treatment initiation for buprenorphine, it's generally eight to 16 hours since the last opioid use. That's the piece there. And they, they need that at least eight, eight hours, preferably a little bit longer to get a good gauge of how much withdrawal you have, but also to make sure that you're the opioids enough opioid is out of your system, that it's not going to cause problems. And so the initial dose typically starts at four to eight milligrams and tends to go up to 16 milligrams. Technically it's approved to go up to 32 milligrams. Coming back to that myth about fentanyl, and I found one study where they actually brought the person up to, I believe it was like 138 milligrams and they, that's what they finally needed in order for buprenorphine to work for fentanyl, the amount that this person was taking. And so that the reason I'm bringing this dosage up is that they were taking 138 milligrams, but they were also taking it like one every two hours, like a certain amount every two or four, two to four hours. And so they were spreading the doses out throughout the day. It's one of the advantages to buprenorphine because it can be prescribed by, and it is prescribed and you can just get it at a regular pharmacy. And so you don't need to worry about going to a clinic. It's not as heavily regulated as methadone. And so you can play around with the dosing. You can do that, like do doses throughout the day or do one dose or however that works best for you. Now typically going back to treatment initiation, it's a three to four day follow-up. And then they titrate dose up or down based on where you're at, and then they, Lavelle, are you, sorry, there was an echo coming through. Okay. It looks like it's, no, it's still going, Lavelle, are you able to mute because I can't for some reason, mute your, mute her, I wasn't sure if she was trying to say something. Or now it's not letting me. For some reason, you're not, yeah, there's a delay. Oh, thank you. Oh, there we go. Okay. If you were trying to say something, Lavelle, if you can put it in chat maybe or figure out, because somehow there's an echo, yeah. Okay. So yeah, they titrate the dose either up or down. Now the goal with buprenorphine is the exact same as it is for methadone is again, to get it to the point where the person is not feeling cravings or withdrawals, ideally again, to get them to a point where they're not feeling euphoria, but that's kind of a secondary goal there. And I bring this up because with both buprenorphine and methadone, in my experience, when I'm working with folks that are getting on these, I'm regularly having a conversation of, because they'll frequently say, I want the minimum dose that will work. It's like, I hear that. And that's great that you really want to work on this and you're looking to come and not be dependent on this. Here's the challenge is they need to find the dose that's most effective. And that's probably going to be higher than you think it will. And so what I've seen is I share my, the success folks have had is work with them and go with the dose, even though it seems if they're recommending it, go with the dose that they recommend, even if it's, it might seem a bit high. And then once you're in a stable enough place and things are going well, then you can start possibly talking about coming down. But the goal really first is to find the dose that gets rid of all the withdrawals. And so it's really kind of listening to your doctor. And even though it might be like, oh, this feels like I'm, I'm, I'm using more than maybe I want to. That's also for family members. I, as I mentioned to folks, because again, you might see some of the nodding out. You're going to see things that look like they're high granted. They're not usually they, they shouldn't be as high as they were. They shouldn't be fully passed out. Like you would see if someone was using a lot. But you still might have them be a little bit distracted and doing other things that would look like they're high. So treatment course, now someone, the minimum someone can be on this is 12 months. It's rare that someone's only on it for 12 months. And the reason for the 12 months is to get them as stable as they can. And frequently it takes longer than 12 months to get that full stability. And then what they'll do is if they'll, at that, whatever point that makes sense is I'll encourage folks, start talking to your doctor and letting them know that you would like to come off and then putting together a plan for that. So with it, I'll always give that caveat. Just remember the doctor is going to be tracking you. And if problems start emerging or you relapse and start using opioids again, other opioids again, we're going to go, they're probably going to go back up and you may stay on it for the rest of your life. Or it may take a longer time at least to come back in to make another attempt. That's the purpose here is that we would really only want to work with folks coming off of it as long as they can do okay. If they have problems or it causes hiccups, it's better to just stay on it. Of course, continued reassessment and constantly like gauging if someone's having cravings or not and adjusting the dose. If someone comes off of the medication, something to note, if you're working and talking with them, they'll titrate down by like two milligram or so distances, sometimes a little bit less than two milligrams, depending on how the person's tolerating it. But usually it gets to two milligrams and then after two milligrams, they have to completely stop. That is a terrifying cliff for folks when they reach that. I don't know of anyone I've worked with that's come off of Suboxone that hasn't found that last two milligrams really challenging. Folks can get through it and I've worked with folks that have successfully come off. It is a thing and people can, but yeah, generally it's there. The hope is, is that they've been on this long enough and the rest of their lives are so fulfilling and stable that even though they feel awful, the likelihood of them going back out to use it is really low. That's the advantage to buprenorphine there, or at least coming off of it. Now let's talk about naloxone and why it's put in. Often buprenorphine is combined with naloxone and there's a couple of products. There's Suboxone, Subsolve are the two primary ones that have naloxone attached to it. Subutex is buprenorphine sublingual tablet and then Sublicate and Brixadi are also injectables. They are buprenorphine without the naloxone cap. The reason for the naloxone cap is buprenorphine itself has that partial agonist piece. There's kind of a ceiling to how high you can get with it. There's a point of diminishing returns for use. But what is nice with the naloxone cap is when you add that in, what happens is if the person uses any, and it talks about injectable, but it's really any opioid on top of it, the naloxone will kick in and put them into withdrawal immediately. And so, yeah, essentially they're Narcanning themselves by using more. And that's a really nice protective feature to kind of it's built in accountability. Yeah, and they have that in the back of their mind of like, if I use more, I'm going to actually I won't feel better. I'm going to feel way worse. Now, the problem with naloxone and that cap is it's kind of sensitive and the naloxone works at a certain concentration of opioid. And so if depending on dosages and if the person is using other substances or they're having a hard time coming in and out of things, it might not be the best to have naloxone. So let me give an example. Anecdotally, and I've had this so many times with folks that are trying to stay, get on suboxone, but then they get in there and they're like, okay, I know that they'll start calculating how many days it takes for the naloxone to come out. And they try to guess at when they can use their opiate and they'll time themselves. And and they almost always get it wrong. In fact, they kind of need to get it wrong a couple of times to actually start getting an idea of when this works. And so that's a person that's not a great candidate for suboxone because they're kind of unfortunately their addiction and their thinking based on the coming from their addiction is causing them to kind of game and figure out and scheme how to get around this. And so it's it's not good that they would do better on something like subutex, sublucate or methadone. And in fact, frequently, if I start encountering that or I hear that someone has done that, I am talking a lot more about methadone because it's their bet. It's a better route for them because this the cap, they keep kind of playing a game with the cap. But then you get folks that have been solid and they're just like, you know what, I'm really on this. I need to take care of this. It's just nice to have that backup and they don't scheme or they're not scheming anymore to do that. And then the suboxone is a really nice, nice piece of quality to it. So subutex and suboxone are both sublingual tablets or actually the suboxone is a sublingual film. So what sublingual means is it's actually under the tongue. And it's what they have to do is they can't eat for like 15 minutes before or after. And they have to let the film sit long enough that it absorbs. The reason is, is that if any of it goes and they swallow any of it, the gastric acids will actually destroy and make it inactive. And so in order for the suboxone or subutex to work, it really does need to sit there and, and actually the subzone as well and dissolve under the tongue. This is a little bit challenging because it, it requires again, making sure, timing it, making sure you're able to sit still enough and not lose it. And dealing with the fact that it's kind of wonky, it tastes kind of weird. So it's, it's one of the little bit of a challenges there with this. But yeah, it does need to be taken this way. And then our last one is, and this is a newer one. I'm starting to see, cause I just heard last week, I may have been going for a little longer that Medicaid is actually starting to pay for sublicate because it's a newer one. It's tends to be expensive. Brixadi, I haven't encountered as much, but it is another one that's out there. These are extended long-term injectable. And so it'd be buprenorphine that you would get once a month, which is actually a game changer. So for a lot of the folks that you're working with, I, my hunch is, is that there, this is going to be an important piece because it, it removes needing to get to an appointment, get to a clinic on time and every day, and needing to be organized and be able to think ahead and plan and, and do that kind of thing. And for a lot of the folks you're working with, that's going to remove a significant barrier. So our last point here is buprenorphine is more effective than low-dose, high-dose buprenorphine is more effective than low-dose. What the image on the right is showing is buprenorphine working at different levels. So the first line, you see the MRI is just a standard brain. The one below it, BUP0, that's someone that's not taking buprenorphine and that's in withdrawal. And you've got the green and the, especially the red sections show the active parts of the brain, basically the inflamed parts of the brain that are happening, that are causing withdrawal. Buprenorphine 2, that's at 2 milligrams. You can see there's a lot more blue. 16, it's almost entirely blue. There's a tiny bit of red right at the base. And then at 32, there's no red. There's a little bit of yellow, but yeah, it's, it's very inactive. In fact, there's a couple of black sections that are showing complete, like fully settled. And so that's that idea there of just recognizing that generally, yeah, we want to find the dose that gets us to that full blue. This is where we want to get. And so for this person, the 32 is going to be the one that is going to be most effective. I talked about buprenorphine being a partial receptor activator. Again, the treatment goal is the same as methadone. So getting them to the point where they're not experiencing withdrawals or cravings. Duration is a little, technically a little bit shorter than methadone because it's, it's about 24 hours. Whereas methadone can kind of stay in almost up to two days. But it's still a lot longer acting. And this is again, why buprenorphine, a big reason why buprenorphine and methadone are good candidates because they stay in the body a long time and they can continue to suppress withdrawals for a much longer period of time. Talked about the sublingual tablet, dissolves in five minutes, onsets about 30 minutes. So I think I've alluded to this, but buprenorphine has a very high affinity for the receptor sites. So, so much so that it kicks off existing opioids. So that's part of why you want opioids out of the system is because it can make the person feel not so great if they've got opioid and then they take Suboxone on top of it because it actually kind of bumps them down a little bit. And then the ceiling effect. So the ceiling effect creates an amount of safety for overdose because you can't really overdose easily with it, whether it's because of the ceiling effect, again, it's binding to those receptors. And so you'll get, feel the effect, feel the effect. And then all the receptors are connected and you kind of, it tapers off because there's just, it's giving you as much effect as it can. And so this is kind of talking about buprenorphine, it'll just become kind of, it caps off at a point. There's this ceiling to how high you can get. Now the morphine here, it shows that you can use more, there's a little, it kind of tapers off at the ceiling, but then you can use more on top of it and get even higher. So a couple of things here. There was a fear a long time ago, and one of the myths around buprenorphine was that if you used enough buprenorphine, at some point it would start actually knocking opioid off the receptors and cause you to not be able to, you would go into withdrawal, or a better way to explain this, well, there was a fear that you could use too much and that eventually it would just cancel itself out, which is actually not true. There was also a fear, the bigger one, the bigger myth, and that I even actually, and I have a book that still has it in there, and it's actually a peer reviewed book from about 10 years ago, and talking about how people with, on buprenorphine, that ceiling, if that ceiling is below their level of use, in other words, their use of opioids was so high that where this ceiling cuts off is still too low for them to not experience withdrawals, that it would be a problem. And in fact, they kind of went in and they were trying to talk about volumes of opioid use that could cause that, and it's actually not true. It's a complete myth. What happens, there's a ceiling effect for the amount of high that you can get, but there's no ceiling for capping withdrawal. The difference, so what that means is as, even though they may not be feeling higher, if they keep taking more suboxone and could be, or they hit that ceiling and they're still feeling withdrawals, if they keep taking more suboxone eventually, or buprenorphine, they will eventually be able to hit a dose that gets rid of the withdrawal. So it will continue to suppress withdrawals. They just won't feel the high as much. And so that's an important one out there, because that is a big myth that's out there that, oh, I can't use suboxone because it doesn't work for fentanyl. That's absolutely not true. If there aren't questions, let's take a few-minute break. It's a good time, we're at about the top of the hour. Let's take five minutes, that will put us at like what, 10.06. Let's just take a quick five-minute break, and then we'll start up again. Welcome back. I'm wondering, what are folks seeing in your work? Are you seeing more folks using methadone? Are you seeing more folks use suboxone or buprenorphine products? What's more common at your sites? Yeah, Paul. Yeah. Mostly the fentanyl. So they're just continuing to use fentanyl, they're not worrying about any MOUD stuff? No. I don't know if they're thinking it in their head, but their actions of using fentanyl and then meth, they do both. I don't remember what Dwight asked. The question was, how long does that last for buprenorphine? Then turn left onto East Coast. So would it continue on? Yes, but it's more fentanyl. Okay. Do you have anyone that's taking MOUD? We have one person that's doing methadone. Sorry about that, that's my phone. I'm on my way into work. Got it. No worries. Thanks, Kelvin. They got one person. Okay. So it's not the most common. It's interesting because there's that question of whether, like, do you have an entry point for discussing it? And some of the things that I can say, if you get a window, like, I can ask them, like, what do you know about those medications? And see if they're curious. If there's someone who's not wanting to stop using, I sometimes can ask, like, well, what do you think about, like, your use? And, like, because there's times where the gaps in between the fentanyl. How is that? What's happening with the withdrawal? Or, like, how bad does it get? And if there was something that could help make that less, would you be interested in that? And so, but some, like, and that then can potentially see whether they're aware. Because a lot of folks are not aware that, yeah, you can continue using on methadone. Or you can, if you take Subutex, you technically could continue using some of these medications that you can continue to do. That's a little easier to do with methadone. But, and then, because that can sometimes be our doorway of, again, of, like, if we could make things a little less up and down, would you like that? So, I don't know. As I say that, though, and, Madalia, you were the one that brought that in, but I'd love to hear from any of you. Is that even too far? Do you imagine, would you get shut out from folks because that's too close to treatment? Honestly, I don't think it's too far. I can speak for myself. Sometimes I just haven't even brought it up. But it's, for me, like, it's a good talking point. Bring it up, because we've been having clients that have talked about other things that it's a natural segue to even, you know, approach the topic about, you know, what does that look like for them. So. Great. Yeah, because it is one that's a real concern sometimes, because, yeah, again, if you come in and are, like, espousing treatment and all that, they're going to shut you off. But, yeah, hopefully we can kind of come in a way of, like, it's up to you. Just going to give you information. You can do with it what you will. That can be enough to be, like, okay, well, I'll at least look at it. I don't need to do anything with it. It's really quick. Paul. Sure. Do you think it's the reason that a lot of our folks that are addicted to opiates or, you know, fentanyl, the fear of the sickness that comes with that quitting, you think that's a prevention why they, like, they could want it to be clean or whatever, but they don't because they're fearful of the. Oh, yes. It's one of the most important, and for some it's the only thing that keeps them stuck to it. That fear, it's really hard to underestimate that fear of withdrawal because it's horrendous. It's like having a flu, like, the worst possible flu, so. Thank you. Yep. Well, hopefully, yeah, that, yeah, there's some tools here, kind of some information that might be useful for you. So, we talked about, okay, thanks, Calvin. We talked a bit about this, but let's look a little bit more in the myth regarding fentanyl and buprenorphine. So, the fear is somewhat based in older knowledge. Like I mentioned, I've got a book from about 10 years ago that actually talks about how suboxone might not be, might not work for people with, that have used really high amounts of opioid. There was also in there that fear of precipitated withdrawal, and so that was the thing I was trying to describe before where if the person, in other words, there was a fear that there ceiling of high, there was another ceiling where all the, somehow all the buprenorphine would cancel itself out and the person would go into withdrawal, even without the naloxone. And so that was there. It's based some, yes, there's a point where there's a cap where the naloxone can't get And then if that's the case, then you just don't use one of the buprenorphine medications with naloxone. So there's a clear solution built in. And so that's the piece there. Plus that precipitated withdrawal just from the buprenorphine itself is not true. It does not happen there. Or at least we have not found that limit yet. There's the, and kind of connected to this is buprenorphine would overwhelm the mu receptor. So the mu receptor, that's what that mu is. It's not a misspelling. Mu receptor is the primary receptor that opioids attach to that causes the effect. And the thought is that it would overwhelm the receptor before withdrawal is alleviated. And so I was alluding to this before, essentially there would be that ceiling effect of high would mean that folks couldn't act. There was a ceiling to the amount of opioids they could be dependent on. And beyond that ceiling, suboxone wouldn't work anymore. And then there's also the, here is distinguishing buprenorphine monoproduct versus combination product. And so that's that recognizing that a lot of the fears are more connected to the naloxone and what that might do. And recognizing that there are buprenorphine products that don't have the naloxone in it, like subutex, sublucate, and brixoti. Expanding on this a little bit further, buprenorphine can be prescribed in higher doses and spread out over time. So you can take doses throughout the day. It's one of the nice advantages of it, again, is that you can, there's a little bit more flexibility in how you can dose, whereas with methadone, you really have to go when the clinic is open. The previous believed upper limit of effectiveness has been disproven. We don't, we haven't found an upper limit. It doesn't exist at the moment that we're aware of. It comes in several versions without the naloxone cap, so you can just get straight buprenorphine. And overall, the buprenorphine has been shown to be effective in treating the dependence on fentanyl. So there, yeah, again, it's a myth that's out there. It's a pretty persistent myth that's out there. And that's why I'm kind of hammering that home, is that if you, whether or not you've had these discussions with folks, there's a good chance that they've heard this myth that buprenorphine or suboxone specifically, if they're using the commercial name, doesn't work for fentanyl. I don't know how much you're running into this, but it is important information to realize that there was the Consolidation Appropriations Act of 2023. And so what, this is a lot of words here, but what this did was this made it so that any provider can, or any prescriber, anyone who has prescribing authority for medications is able to prescribe buprenorphine. That wasn't the case before 2023. People needed to get this waiver and you needed to go, there was some extra steps that were needed to be taken in order to be able to prescribe it. That is all gone. Why I mention this, and it still could come up, is that their regular doctor can prescribe it. And so the purpose behind this is to reduce barriers, to get it so that more and more people have access to this. And that's also set in of like, you don't necessarily need to go to a whole new prescriber. You don't need to go to someone that specializes in this. Anyone can prescribe it. And you as case managers, if you have contact with their physician, you're within your right to bring this up. So the fact that, yeah, it sounds like you may not be aware of the Consolidation Appropriations Act of 2023 that allowed you, in section 1262, it did away with the requirements, the federal requirements needing a waiver. In other words, you can prescribe. Branching off a little bit here to MAT, it's still helpful to look at these. We're going to move, to some extent, a little bit away from opioids here. We're going to talk about amphetamines and alcohol as well, and talk about MAT. Yeah, Madalia. Really quick, you said that case managers can access what again? As case managers, if you're in communication with a physician and the physician is refusing to prescribe Suboxone, you can bring up that Consolidation Appropriations Act of 2023 and let them know, I run into this. I'm like, well, you can just go to your regular GP or PCP or internist, however you're referring to them, and technically, they can prescribe Suboxone. Yeah. It's more than technically, they can. They just flat out can. It's within their scope. Right. Okay. All right. Thank you. Yep. Hey, Paul. Yeah. I also wanted to ask a question. Sure. First of all, my phone died, and then I got into a bunch of work calls, so sorry I was awake. No worries. Do you run into providers not knowing versus knowing, and then for the ones who don't know after you tell them, do you still run into opposition for prescribing that? Great questions. Yes. A lot of them don't know. It's really common that they don't know or they know, but they still don't want to do it, and this gets to some of the myths and the stigma around MOUD. It's really common. I mean, you can't force someone to, but you can gently and nicely remind them that it is something that they're able to do because, yeah, there are going to still be doctors that don't. Because there's a lot of myths around folks that use MOUD. It's like, oh, they're going to just be like criminals or they're going to make my practice worse or something like that, or they're going to try to get one over on me, and you're just going in for treatment. I mean, you're already probably, this is probably, hopefully someone they're already seeing for treatment and it's like, this is just something being added. Okay, cool. Thank you. Yeah. So, coming back to, great questions, thank you. So, coming back to MAT, and so we're going to look at some FDA-approved medications that are out there. I mean, they're all meant to kind of either help with craving, relapse prevention, and also can be helped to deal with what we call protracted withdrawal symptom reduction. And so protracted withdrawal is, so we have acute withdrawal, which happens within three to seven days, can go on, depending on the drug of use, can go on for sometimes up to a month. And then we have this protracted withdrawal syndrome or symptoms that can start whenever acute withdrawal stops and can go on for months, in some cases, years. And so there's gonna be medications that can help with some of those symptoms. So for alcohol use disorder specifically, there's antabuse, which we talked about already. It appears that antabuse may also help with cocaine use disorder. I'm not totally certain of the mechanism there. Cocaine and alcohol frequently go hand in hand. It's rare that I run into someone that uses cocaine that doesn't drink. So I don't know, and I've actually had it. It's not unusual for folks to only use cocaine when they're drinking. So that might be it. But there is some evidence to support, but strong evidence to support with alcohol use disorder. There's oral naltrexone, also helps with cravings. Injectable naltrexone also helps with cravings, as a longer acting piece. And acamprostate and topiramate, they are FDA approved. They do seem to help with cravings. And the mechanisms are a little bit different, but they're mainly around cravings. Then we got nicotine use disorder, which you might be more familiar with, because a lot of these are more common knowledge. We've got nicotine replacement, which I know is stigmatizing, but we still use that term. And then we might have the nicotine gum, nicotine patches, lozenges. But it's basically giving you a steady dose of nicotine. And then the purpose of that is to help you, titrate you down and off of that. And then there's Chantix, where there's interesting, Chantix, it does work to help reduce cravings. It's been around for a little bit, but it seems to be very effective for folks. There was also another one that's, I'm surprised it's not on here, but Welbutrin, I'm forgetting the name, they gave it, but it's an antidepressant that also has been shown to reduce some cravings for nicotine. That's another one that can be in there as well. Yeah, excuse me. So she said Welbutrin and that's it. Because it made me think of my father. He quit smoking after 25 years, but he used the Welbutrin for six months, and then he was okay with that. Yeah, it works. Yeah, it's been, it's one that's been around, Zyban is what I think they, Zyban is what they call it, but it's actually, it's Welbutrin, just under a different name, yeah. Oh, okay. So opioid use disorder here. So injectable naltrexone, the withdrawal is there, and then there's also FDA approved for managing depression and anxiety that can come, especially with protracted withdrawals, because it is really common for folks with an opioid use disorder to go into a state of depression and have really high anxiety even after their acute withdrawal from opioids has stopped. And it's one of the things that makes quitting really challenging is that they, even though the withdrawal might be over, they still don't feel great. And so there can be medications. Now those can be prescribed even if the person is on MOUD. There are some concerns about certain anti-anxiety medications and how they might combine or interact with, especially methadone. But working with a doctor, you should be able to find some combination that works. And then methamphetamine. We had this, there is currently no FDA approved medications for meth, meth use disorder. The only approved one that we know of is contingency management, which is something that's done in, tends to be done in treatment centers, but it can be done, you could actually set up contingency management if you're interested in it. It essentially, it's something they actually took from sales when you think about, if you ever think of like membership programs where they give you like rewards for like, like I fly Alaska because I have a membership awards program with them. And I pretty much stay with Alaska because they work. And you probably have certain memberships or things that you stay with. It's the same idea. And they took it and implemented it of basically giving rewards for certain milestones. Like if they had a UA that was free from substances or came up negative or certain number of negative UAs or, and there's much more that you can do with that of, but that is been shown to be incredibly effective with amphetamines across the board, but especially methamphetamine use disorder. So stigma. So the following slides are gonna include some stigmatizing language, and we're gonna try to see why each statement is stigmatizing and ask questions as you have them. So I already brought this one up, opioid replacement. In fact, I already described why it was. So opioid replacement, it's this, the message kind of behind it is you're just swapping one drug for another, which is actually not accurate. It's you're swapping a drug that has, or has certain qualities that will help you with managing withdrawals better. You're not supposed to be on it forever. This is a common one. Again, we kind of talked about this, but this is something we see a lot, and it is actually stigmatizing because there are many folks that do need to be on it forever. And an extension of this, and you can see this sometimes in recovery halls of if they go to AA or NA or something like that, people saying, oh, you're not really in recovery until you're off of these medications. And luckily, thankfully, it's that softening and changing, and they're recognizing that there are many different paths to recovery and that this is, for some, this is what's needed in order to be able to live life to its fullest. This one, it's one I've fallen prey to until recently. So methadone is hard on the body. You'll gain weight if you stay on it. Has anyone heard this? That, yeah, people that stay on methadone tend to get really sick, tend to get very overweight. Yeah, I've known some clients, or people that have gained weight from the methadone treatment, mm-hmm. Same here. In fact, it used to even say that it was bad for the bones. Mm-hmm, so what are- No, no, that's true. Okay. The piece, now, Medalia, you're bringing up, and I have the same experience. I've worked with a number of folks that have gotten on methadone, and it's really common for them to put weight on. They're putting weight on because they're healthy. They're actually eating nutritious food, and their body is able to put weight on because of that. It's not the methadone. It's actually the stability in their life that's actually allowing that to happen. So it's, yeah, it's an important one. And it tends to be a really important stigma one to get, because it can be, and with all of the stigma, when people take this on and believe this, it can give them a reason to not use it, not try it. And that's what we want to remove, is remove all of the barriers and the reasons why someone may not try it, because they may self-select and say, oh, that's not for me, because I don't want to gain weight. So, which gets into some of this here of why it's stigma. Sorry to mention how MOUD is just replacing opioid, perpetuates the idea that these medications are continuing the addiction, and it prevents people from trying them out of shame. And that is, this is also an important part of the discussion of, when I bring me up these medications, how do you feel about them? How do you feel about people that use them, is another one. To see whether there's shame there, and whether they're falling into some of the stigma. So, the second statement, best results are seen when they're taken over consistently over a long period of time, and it may be for life. And there's nothing wrong with that, it's you figuring out what's the best treatment for you. And then, like I mentioned already, there's no evidence that methadone or any other medication can cause weight gain or health problems. It's misinformation about methadone use. Yeah, so here, a doctor or pharmacy believing that MOUD patients are just always trying to get one by on them. I already mentioned this, and how that, yeah, definitely is a major component there. Then this is a common one with telling folks how the waiver is no longer there. There's a fear doctors or pharmacies will have that if they dispense suboxone specifically, or buprenorphine, that it will bring in a bad element into their practice that will actually harm them in some way. This, again, it's not true. That, yeah, it's an important piece there. Believing that MOUD patients are just addicts who are not in recovery yet. Yeah, we've already discussed this. This is really harmful, because it's discrediting work that they're doing and recognizing that everyone's recovery looks different. You can't take your recovery, and if you have a recovery, and say, oh, well, that's how everyone else's goes, or you can't take the recovery that you say, a family member do, or someone you know do. No two recoveries look the same. Yeah, and so medical providers believe that they'll lie, cheat, and steal, which is really stigmatizing. And providers will also believe that working with MOUD patients is time-consuming, can damage their practice. I haven't mentioned the time-consuming piece. There's this belief that, oh, they just take up too much time, there's too much chaos. That's not true. That's not true. Again, yeah, hopefully they're getting some supports and other things in other places that can make it so that the provider doesn't have to take up as much time for case management type things. But they also, it's just providing the medication for MOUD, and these folks tend to get really stable really fast. And lastly, again, it just prevents people from trying it, and also it can even cause people to be refused from treatment. Now we're getting to some stuff that can come up a little bit closer to home, stuff that we might encounter either at treatment programs or sometimes in our own work environments. So removing someone from methadone because they're continuing to use other substances. This is still a common practice in a lot of places, and it's really unfortunate. In fact, yeah, it's still weeding itself out in Washington. It's strange because we're refusing, we're preventing someone from receiving treatment just because they're showing symptoms of their disorder. And I'm sure many of you can, and I would just use these slides just last week, and someone brought up a counterpoint to what I'm about to say, because the idea here is hopefully with something like diabetes, you're not gonna be refused treatment or insulin if you've eaten too much sugar. And yes, there are definitely places where folks with diabetes are shamed and can do it, but you generally would think that that wouldn't hopefully happen. Whereas with something like opiate use disorder, this is kind of the same thing, of we're refusing them, we're refusing to give them a medication because they're having symptoms of the disorder that we're giving them the medication for. And so it's one of the, it's a weird punitive piece here. Plus I know it's going into other substances here of recognizing that we might just be treating the opioid use disorder and then dealing with the other ones later when we get a chance. You probably run into this, because I don't know how many folks go to sober housing. I know you do a lot of work with getting folks to supportive housing and more and more in fact, you started a lot of supportive housing just because there was such a shortage of it. And it's great, you've gotten a lot more access to it. But yeah, we still run into this folks that are on something like suboxone or methadone and are not allowed to live in housing, especially sober housing. Because again, there's that stigma of that they're not really in recovery. So many addictions counselors work with MOUD and will taper and discharge people that continue to use other substances. So this is, it's still really common. And this is a way of refusing treatment as a punitive. So it's punishment. And we know that punitive approaches don't work. They just create more problems. And there's no other medical condition where someone can be removed from treatment for having symptoms. No question for me. Yeah, so, yeah, looking at stigma further, so it's. Stigma is still a major barrier to. Um, and so it is something that we really want to work to remove. Um, and there's this also the self stigma. That can come into this if they internalize it and I wouldn't be surprised because you're saying you've only got a couple of folks, or maybe 1 foot 1 person that's on. Uh, there's a good chance that a lot of them are having the self. Stigma that they're self selecting out of it for whatever reason. Um, something I would even say, and kind of tying back to ways to have conversations with folks. And there's been a lot of work within methadone and other settings to reduce the stigma over the last few years. So, if it's someone that's tried, maybe methadone years ago. I would encourage you to, you know, it might be worth going back because there's a good chance things are going to be very different. Um. In fact, they pretty much will be, um, because Sam says really kind of getting in there and setting some guidelines and really trying to help programs be maintain access. Though there still is a lot of work that needs to be done chain hearts and minds about and especially also about the people who need it. I don't know if this is how useful this 2 resources for you, but I always like to make sure folks are aware of it. Just in case you're not is the never use alone. Um, it's an 800 number, um. There it what it is essentially, yeah, there's no judgment, no shaming or preaching. This is just someone you. You can call if you're going to use and not have anyone around you. I don't. Your settings, I don't think that usually folks are around, but if for any reason, they have just being aware of this, essentially, they do is they just stay on the phone with you while you're using. And if you go completely silent, and there's a fear that you may be overdosing, they'll call for help. So, uh, yeah, it's a great resource that's out there, but yeah, it's just they just. When it pick up the phone, they know you're about to use opiate opiates or opioids, and they'll just stay with you. So, come into an end here class questions comments thoughts. Especially if you feel like you're going to be having these discussions with folks. Anything that you're wondering about, and possibly going into having those questions, discussions. Concerns that you might have. Yeah, I think 1 thing I'm still. Trying to work through, and I think, um, I know we talked about it just to reiterate somebody on methadone. Can still use will still use, but how they go about getting, um. Getting, uh. Their substance is going to be different. Is that correct? Um, I don't know if it would be, I mean, they can still go to the same dealers. Um. It's they're going to use, they're going to be thinking differently about it. Yeah. There, because the hope is, is that the methadone is going to keep them even. And so they're not in withdrawal when they're going to use. Um, which right away that takes 1 of the reasons to use away. So, if they, um. There's going to be less times that I feel like they need it. And in fact, they're just using to get high at that point. As long as the methadone is working properly. And so right away that takes 1 of the reasons to use away. 2nd, they're also going to be like, okay, I just need to get a little bump. I don't need to go all the way up. I mean, yes. And you have that. There's definitely going to be folks that overdo it, um, and overshoot. Um. But, yeah, that they're the way they use will be different in the sense of the pattern. Um, it won't be so frantic. It will probably be less often. I know it'll probably be in probably be in lower dose. Gotcha. Okay. Thank you for that. Yep. Or they may just give up on the opiates. And decide to just use math and I know there can be. Sometimes spent on the map. They could use the test strips then the way they're supposed to be, which is to tell whether or not is, even though I know most of them are just using the test strips to make sure the fentanyl's in there. So, yeah, make sure they didn't get. If not, that actually wraps us up for today. And so we have one more of these coming up next week. So that will be Introduction to Motivational Interviewing. And so that will be, get ready. That's a lot more interactive. We have exercises and stuff to do with that. So just be ready for that. And you also hopefully learn a lot with that. It's kind of, it's working with how to talk with folks. And yeah. If there aren't any other questions, we.

Medicines for Opioid Use Disorder

MOUD

Medication-Assisted Treatment

MAT

methadone

buprenorphine

opioid use disorder

OUD

stigma

naloxone

fentanyl

naltrexone

antabuse