and Substance Use Disorders in the Courtroom, presented by Dr. Ellen Edens. She's an Associate Professor of Psychiatry at the Yale School of Medicine and Substance Use Disorder Lead for the VA National Telemental Health Center, Associate Director of Yale's Addiction Psychiatry Fellowship, Co-Director of the Connecticut VA's Interprofessional Advanced Fellowship in Addiction Treatment, and Co-Director of the Opioid Reassessment Clinic. And she joined our faculty here at the NJC in 2020. Judge Sean R. Flerke is the President and CEO of the Duluth Superior Area Community Foundation in Minnesota. He was the District Judge of the 6th Judicial District in Duluth, Minnesota for 16 years, where he founded and presided over the South St. Louis County DWI Court, one of four National Center for DWI Courts, Academy Courts in the nation. And he and his team won the NADCP DWI Court Leadership Award in 2018, and he joined our faculty here at the college in 2019. We're very happy to have both Judge Flerke and Dr. Edens with us today. And I am moving it over to your slides. Network's a little slow here today. Really good to be here. All right. And Dr. Edens, I'm giving you the ball. You are muted, Dr. Edens, so you'll have to unmute yourself so we can hear you. That's great. I thought I'd hit unmute. Thank you so much. It's, I'm gonna go quickly, but it's really my pleasure to be here, to be among judges who care about this enough to show up. And I'm very passionate about this, as is Judge Flerke. And so thank you for being here, and thank you for inviting me. All right, let's get the ball rolling. I do have some disclosures. I'm on the advisory board for two companies that I think are doing some innovative things. It'd be great if ever there was any money generated, but there is not at all, but I am on the advisory board. You are our target audience, and our goal of PCSS is really to train healthcare professionals in evidence-based practices. Obviously, I don't think you would consider yourself healthcare professionals, but you interact very strongly with the healthcare system when it comes to substance use disorders. And so that is, that's PCSS, and you are our target audience. Going over our learning objectives, we have four of them. After this webinar, you will be able to conceptualize the range of treatment plans. So when you think about treatment plans, historically, there's been like two options for people. You can either go to a 12-step program at a church basement, or you can go to a 28-day program. And we want you to know that there's lots of treatment options, and not only that, but a little bit, peek behind the curtain to see how a healthcare provider might think about that. So we're gonna use a mnemonic called RIP Care. This is something that we use at the Yale School of Medicine to try and help medical students. So they've learned how to screen, they've identified that somebody has, say, an alcohol use disorder, an opiate use disorder, but now what? Now what do I need to know about that person in order to really use that information to use my clinical reasoning skills to try and figure out where that person should go? And so I'm gonna teach y'all RIP Care. It is a mnemonic, and we tell students that if they know this mnemonic, then substance use disorders do not have to RIP and tear people's lives apart. That's where RIP Care comes in. Second, we're gonna describe the role of medication. Hopefully by now you are aware that medications are quite effective in the treatment of opiate use disorder, and we will talk a little bit about that. Not only are they quite effective, they are first line for the treatment of opioid use disorder. But unlike many other healthcare treatments, not only is opiate use disorder, the disease itself is stigmatized, not only are patients who have the disorder stigmatized, but this is a unique case where actually the medications themselves are stigmatized. And given that it is so effective, it does save lives, we want you to know about it and make sure that you know a little bit about that evidence. We're gonna talk about how client-centered conversations are key to successful outcomes. I talk to my students. What we say and how we say it matters, matters a lot, both in a healthcare system and in a courtroom, and Judge Flurkey will talk some about that. And then we're gonna talk about, this is probably what's most relevant to you, the judge's roles and responsibilities when working with clients who use substances. This is gonna be a bit of a whirlwind tour, and Judge Flurkey, I'm gonna go as fast as I possibly can, so to be perfectly honest, I have timed myself to get through this. If you need me to stop and you wanna say something, if you will just say, stop, Ellen, all right? Jump in. Let me say one thing, Ellen, and I'm in a men's group post-retirement, there are five of us. Three of them will tell you they are alive because of medically-assisted treatment. Not doing better, not being successful, alive. Two are peer recovery professionals, one's working in the construction field. Literally save these guys' lives. Thank you. It's not an uncommon story. Right? So, when we start this conversation, I go through this every single time. If you've heard it before, it's worth hearing again, but many people in healthcare do not know the difference between dependence or addiction. Most laypeople do not know the difference between dependence or addiction, and it's an essential concept to understand. When we think about dependence, we are talking about physiologic dependence, meaning your body has gotten used to a substance. It has been given it exogenously from outside, and then our body, what we do very well is we try and return to homeostasis, or basically equilibrium. So, if I'm getting steroids from the outside, guess what? My body's gonna know it. It's gonna stop producing steroids. If you then take away those steroids, I'm gonna feel terrible. I am going to go into a withdrawal symptom. It actually could be life-threatening until my body gets up to speed in actually producing its own steroids. The same thing happens with opioids. If I give any of you oxycodone for two weeks, three times a day, if I stopped that in two weeks, very likely the majority of you would go into some type of withdrawal symptom because your body would have stopped producing its own opioids called endorphins, and you would have become kind of dependent upon exogenous opioids. It does not mean that you are addicted. You will go through a terrible weekend. You will get over it. You will move on. You will not have cravings. You will not have your life destroyed in many, many ways. You will simply have had physiologic dependence. You will have stomach aches during that weekend. You will have pupillary dilation. You will feel sick. That is not addiction. So, what is addiction then? Well, when we think about addiction, we actually, addiction is a specific term for a severe substance use disorder. So, let's talk about what substance use disorder is. 2013, the DSM-5, which is our manual that diagnoses or defines mental illness, said we're no longer gonna use this outdated term of substance dependence. We're gonna use substance use disorder in part because it was confusing people because of that previous slide. They also said we're gonna put it on a continuum. We no longer want to only identify people with addiction. We need healthcare providers to identify people when they're in their early stages of some type of loss of control. So, a substance use disorder is a constellation of symptoms and I've got a bunch of pictures here. It's hazardous use, like boating while using repeatedly. Many of us love reading or enjoying and gazing and things. So, instead of doing those activities, you're really isolated. You're by yourself. You're not in your tennis club. You're not going to church anymore. You're not spending time with your family as much as you used to because you're using substances. You're much more isolated. Substances can have an impact on your job. That's the you're fired. It can have an impact on interpersonal social relationships and then this last picture is it can really have an impact on our psychological health as our physical health. That's not all of the criteria. There are 11 criteria, but the bottom line is substance use disorders are a constellation of symptoms. Mild is only two symptoms and it goes up to 11 symptoms. Severe substance use disorder is six or more. I treat many, many people who have six, seven, eight symptoms of substance use disorder and they are still functioning at work. They are still owning their own business. Maybe they're getting into some real fights with their family, but they're still a great father or mother, my apologies. The bottom line is we want to be capturing people. You don't need to have lost everything for that to all of a sudden become a problem. We want to catch people early. So substance use disorders are on a continuum. When we talk about addiction, it's a severe substance use disorder as defined by the National Institute of Drug Abuse. Anything you want to say? Yeah, let me weigh in just to touch that. That idea of catching people early in the process and engaging in treatment. We used to sit around tables back in the day asking, well, has Johnny hit rock bottom? As though that was measurable or necessary or preferred or anything we can do to be upstream, engaging with people early before some of the devastating consequences that come in. It helps change our whole approach as opposed to having this idea that somebody's got to have rock bottom in order to engage and grow and move forward. Thank you so much. That's an essential point. Honestly, if you take nothing else away, we would be happy with that one. Right. So I'm going to go through two questions. This was a headline that came out in a newspaper, 2017, but I'm sure you could find it today. Baby born addicted. Can a baby be born addicted? Is that true or false? You can put your pointer where you think it goes. We have someone saying false in the comment section. I'll vote to. So let's talk about this. So I hear a false. So I would actually say this is false. So remember an addiction is a constellation of symptoms. It means that somebody is having interpersonal or social consequences. They are having roles. They are unable to fulfill their role. They are having negative health consequences because of their use. They're putting themselves in hazardous situations. So a baby simply cannot have an addiction. They cannot have a substance use disorder. There's no cravings in a baby that we can detect. There's no way for a baby to be anything other than a baby. Like they're not not fulfilling their role. They're not causing problems with the family. And so babies that are born say dependent, physiologically dependent upon opioids because the mom has taken opioids throughout the pregnancy, yes, they will go into a very reproducible expected withdrawal syndrome. We call this neonatal abstinence syndrome. They're usually hospitalized for a few days. We give them typically morphine and or breast milk if the baby's mother is continuing on medications. And after about a few days to maybe two weeks, the baby is no longer dependent on opioids. They begin to make their own endogenous from themselves, their own endorphins, and then they move on through life, no longer physiologically dependent on opioids. So babies cannot be born addicted. That is false. Again, addiction is a constellation of symptoms that are associated with behaviors. Let me throw one more point in there. We kind of threw a curve ball at you and used the word addicted. Back when I started this work, we were working with addicts. And people were either clean or dirty. We've moved, we're gonna talk about trauma-informed care and trauma-informed court work. But I never in the last handful of years doing this work used the word addict. It's a person with a substance use disorder. They're moms and dads, brothers and sisters, community members who also have a substance use disorder. One of the principles of trauma-informed motivational interaction with folks is word choice. And I can say, you're intestine positive as opposed to you are dirty. Or the test came out negative instead of kind of the labels that can draw people into cycles of shame and kind of hurt their trajectory for engagement with Dr. Eden's inner treatment. What we say and how we say it matters. Thank you for saying that. This is another example. Somebody comes in and they have prescription opioid use that they say is a reason for the divorce. They've taken a maximum number of six days due to opioid use. Do you think this person is physiologically dependent? Yes, do they have an addiction? That was a terribly worded question. True or false, do they have a substance use disorder? Sorry. I'm going to go ahead. Thank you all. Thank you for taking a stab at this. So, a little bit of a curveball, and I appreciate that maybe there's also some hesitancy, because I've only given you two symptoms. And you might say, well, okay, they're having interpersonal and social difficulties. Maybe this is affecting their work. You know, they're out the max number of sick days. And so, I think it's fair to say, unsure, we need more information. But I just guess I want this group to understand that even two criteria is enough to make an opioid use disorder. So, my suspicion is, yes, this person does have an opioid use disorder. And I'm very curious to learn more and actually nail down a diagnosis. It might be a mild opioid use disorder. But nonetheless, it's going to need some treatment of some type. Okay. So, once we have a substance use disorder, and a healthcare professional has distinguished that this is the diagnosis, then the question is, what else do we need to know in order to formulate a treatment plan? And this is where ripped hair comes in. So, what I teach my students is to ask about risk, talk about that. The initiation of use, when did they first start? What is their pattern of use? This is where pattern is where students go immediately, because that's kind of what we think of. What's their treatment history? What have been the effects of their use? Any periods of abstinence, and what has that looked like, and how did they obtain it? And then, any periods of relapse, and what happened around that return to use. And I'm going to go into that a little bit more in depth. Okay. The first thing, when somebody comes into my office, is, what is their risk? People who use opioids are at high risk of death from overdose. Opioid withdrawal is extremely uncomfortable, generally not life-threatening. But overdose is life-threatening. Alcohol use disorder, alcohol withdrawal is life-threatening. But also, many people who come into my office are at risk for trauma. They're at high risk for suicidality and completed suicide. Many completed suicides occur in people who have co-occurring, who have substance use disorders. They're at risk for infectious diseases, that type of thing. So, the very first thing right off the bat is, I'm going to triage them. If I see that somebody has suicidality, then very likely, I'm going to do a full assessment of that. And if they need to go to the ER, I'm going to send them to a very high level of care, depending on what that risk assessment is. If their risk is relatively low, and usually it is, because they're coming into outpatient care, then I go on to the rest of my evaluation. And I ask people, when do they start? This matters because people who start early have a much higher risk of ultimately developing a substance use disorder. They also are at greater risk of, A, having a longer course. They're at greater risk of perhaps having other developmental issues. Many people who start early have actually mental illness that preceded the onset of the substance use. A lot of trauma is in that history. Maybe ADHD is actually a risk factor for early initiation of substance use. So I am interested in when they started. Also, many people will say substance use disorders are a disorder of adolescence and young adulthood. And that is a key period of brain development. So it allows me to know that risk. If I have somebody who started using at age 30, I'm going to be thinking pretty differently about them than I am somebody who started using when they were 13. Next thing, I do go into a full range of pattern of use. This is the who, what, when, where. Where do you buy your drugs from? Do you use the same dealer? Do you use by yourself or with other people? People, I'll use alcohol as an example. People who use alcohol only in social situations, that is less of a risk than if people are using alcohol by themselves, alone, and kind of a solitary activity. So I'm interested in that as well. I put the needle here because IV drug use is a big risk factor for A, overdose, for infectious diseases, also for death and for severity of addiction. So I am interested in pattern of use. Then I'm interested in a person's treatment history. This is where many of my students don't go into this. What have you tried? Where have you tried it? Have you tried all levels of care I will go into? Have you tried psychosocial treatments, psychotherapies? Have you tried behavioral treatments? Have you tried peer support treatments? And have you tried medication treatments? I want to know all about their treatment history. Have you tried to quit on your own? I'm going to go through all of that for each substance that I'm worried about. That was always a conversation I would have first day in court with my treatment court clients. Tell me about when it's gone well for you. Are there any periods where this really worked, where you were living the life you wanted to live? And tell me about what was going on and who you were with and what you were doing. You could get amazing histories of real beautiful, beautiful stuff that people were living. And then you'd eventually get into the conversations about, you know, what got in your way? What tore that down or what broke apart? A good way to start is where have you been successful? Are there examples? I would love to have you on my treatment team. So you're getting at the rest of the evaluation really is getting at those outcomes of treatment, what has worked. The other thing we also evaluate is the effects of use. So many people use substances not just to feel high or to feel pleasure. Many, many people are using substances to feel normal. A lot of people say, I never felt comfortable in my own skin until as soon as I took my first oxycodone, I felt like I could be myself. There is positive effects to use. And I want to know those because how motivated is somebody going to be to stop something that they see as really beneficial to them walking through this life in any capacity, right? So I do need to know the positive effects. And then I also want to know the negative effects. And this is where I build my case in my head for what we call motivational interviewing. And motivational interviewing is a powerful therapy where I begin to help a patient resolve their own ambivalence for change, hopefully in the direction of change, for positive health outcomes. Sorry, I don't want to cough in y'all's ear. I might have to get a cough drop here. This gets back to what Judge Flurkey was saying. I want to know all about any periods of non-use abstinence or what I would call when they've been in remission. Some people can be in remission from a substance use disorder and still be using that substance. It's not all that common. We'll get to treatment goals in a bit. It's not the safest thing because you're always at risk of a return to a substance use. But sometimes people can be in remission from a substance use disorder and still be using a substance. And many healthcare professionals don't even know that either. So I say abstinence, but I mean also other periods of remission. I want to know all about it. What happened? What worked? What helped? How long was it? Were you only in a controlled environment? Many people say I was in prison during that period of time. That is great information for me. Because to be abstinent while you're incarcerated is not nothing. It's helpful. But it does mean that you need a controlled environment. And when you leave, it's not a controlled environment. So what are we going to do to put in place for that person? And then I'm also going to want to know what led to a return to use. Did you run into somebody? Did you develop depression? Did you lose your job? Were cravings really strong? I'm going to really want to understand what led to that return to use. And then I'm going to be able to put together a treatment course. One of the things we started noticing and learning in our process over time was that return to use could be associated with the calendar, with memories, with prior incidents. We had a client who determined that November was when she would tend to relapse. And so it's beautiful. She brought us a plan to come in and reengage with us every September a bit to escalate higher engagement with us in October and then be a kind of phase one engagement in November and then go back down. I think we mistakenly see recovery as kind of this, you know, it's like the stages of grief. Oh, you're going to get through and have closure. That's a load of crap. We see the stages of change in treatment and recovery as that sometimes too, where you've met this point, you're good to go. Well, that's not true. I mean, it all depends on life and what comes and what happens when and what gets thrown at you as you move through your day. Amen. The chronic illness, and we really do think about it as a chronic medical condition now that's going to require oversight and monitoring throughout a lifetime once somebody develops it. It doesn't mean you have to be in intensive therapy for your life, but just like you would be seeing your primary care doctor for high blood pressure for the rest of your life, at least a yearly check-in, the same is true for a substance use disorder. So based on that RIP care assessment, then I also am going to think about complexity on each one of these measures. And I'm not going to go into this, but the bottom line is if you've never had treatment, then that's a low complexity. I have all range of treatment options available to you. If you've tried a bunch of treatments, then I'm going to have to really be creative about what's new. How are we really going to support this person? And based on where I see the complexity landing is ultimately going to help me figure out where they're going to go into treatment. All right. So once I have RIP care, I have my assessment, I promise the wheels are turning up here and I have a good idea what this patient should do. I really have an idea of what's going to work. But here's the thing. Any health care relationship, and certainly when it comes to substance use and when it comes to behavior changes, it is a two-way street. And so I might be able to come up with the best, absolute best plan. It's foolproof, if you will. But if the patient doesn't want it, if that is not their goal, then we are just going to end up extremely frustrated. They're probably going to fire me or leave treatment, walk out. I'm going to end up blaming them. They didn't accept my great plan. And we're going to end up nowhere. It is extremely important that we clarify treatment goals. I give patients four goals. And I will be very clear that abstinence, complete abstinence, this one in the bottom right-hand corner, is going to be the safest course of action. And it's the one I recommend. But I am going to keep treating a patient no matter where they are on this treatment goal, because honestly, my goal, my good outcome, is if that person stays in treatment with me, no matter what their goal. If they're using, not using, if they keep coming back to see me, then I know, A, they're not dead, and B, I have a chance to impact their care and their future trajectory. So my goal is to keep them engaged in treatment at all costs, if I can do that. And making sure that I know their goal and I align with their goal and I help them achieve their goal is one thing that's really going to help them. I tell patients they can use with less harm, go to a needle exchange, use a condom, use with other people, have a Narcan kit, that's usually less harm. Controlled use would be, I'm going to go from 80 of oxycodone down to 10 milligrams. I'm going to taper down. Doesn't really work with opioids, but a lot of people with alcohol use disorder try this. Conditional abstinence, also opioid use disorder, you won't see this much because people don't want to go through detox, but many people with alcohol use disorder will choose this, which is a period of time where I'm going to be abstinent. I'm going to be abstinent during Lent. I got that one yesterday. I'm going to be abstinent dry January, as an example, and then complete abstinence. I give patients the choice, and then they choose. And then I'll follow up with, all right, you're going to choose controlled use, what is that going to look like, for how long, when are you going to know that it's not working? When would it be considered a failure, if they're consistently going above 10, and maybe now they're using 30 milligrams of oxycodone, for example? Well, let's name the conflict inherent in your conversation with most of judicial conversation. As a judge running a drug court, I kind of can't say, well, let's only use heroin on weekends. On the other hand, I firmly believe in harm reduction, and I want to see my clients engage and find life, and I know it's going to be a long, long haul. I think your example of the Narcan kits is a really awesome example. I can build supports for my clients. I can build accountability. I can build a thoughtful treatment plan on our side and your side, and I can also give you Narcan kits for you and your family and your friends and let you know that I want you alive, that you will not succeed in treatment or succeed in my court if you are dead. If I can find a way to work in that area where I try to keep people alive and moving forward without allowing or opening the door to anything goes, a real tough tension for a judge, real tough. But Judge Filippi, I'm so glad you brought that up because I don't have any kind of a stick the way the court system does, and when we can partner together, like really, honestly, magic can happen, and it reminds me of what happens for healthcare professionals when they're at risk of losing their license because of substances, and all of a sudden the choice is I lose my license or I submit to this very intensive, like three to five-year, very intensive monitoring and treatment and all this stuff, but guess what? Healthcare professionals and airline pilots who engage in health profession assistance programs or professional assistance programs, they have the best outcomes. They have the best outcomes, but sometimes that stick of the court system can save lives. I can't do that. I just told you that. Like I can't do that, but in certain situations, when I have a court that I'm working with or a professional assistance program, we get the best outcomes in that case. That's exactly right, and we would start a beautiful probation officer in the drug court context, probation officers in the field, testing, engaged, working with treatment and therapy and supports and housing. I mean, we were wrapping around, but I'm also having conversations with my clients that, you know, you've got some hard choices to make here between prison and living. I would say, you know, you get to decide prison or living life happy ever after, and we will support you all the way down the line, but it's not going to be easy, so I think you're exactly right, but we also have to remember that that compliance that I can bring only lasts until the compliance is gone. If they don't find adherence to their recovery, their treatment, their life, their path, their future, their hope, their place in the world, all the compliance in the world won't get it done, so I love the coordination between us and you and moving people into those places where it's about my recovery, my sobriety, my parenting, my life, not because Flurky said so or Edens is expecting it, you know, so we, yeah, you're right, we kind of seek to corral people in safe ways towards beautiful outcomes, yeah. Great, and I think one key ingredient is time. Yeah. You have to have long enough time, and I would say, you know, I've heard somebody, George Valiant is a, he's passed away, but he was a thought, kind of a, anyway, he led the field. He would talk about substance use outcomes kind of like, or remission kind of like cancer patients. He would talk about five-year survival, and I really think that's important that we've historically thought 28 days was enough and then people could just be okay, and it's not. It's years, and so when we can really work together for years, that's going to also be an important part to give our clients or patients the best chances possible. Right, right. We promised we'd talk a little bit about medications. I'm going to go through these three because there are only these three. They all work on the opioid receptor, which is found throughout the body, but a lot in the brain, and they work on the opioid receptor very differently. The first one is in, look at the red lines here. It's called methadone, and you can see here on the y-axis is opioid effect, and the x-axis is dose. So as your dose goes, oh, and by the way, I want you all to think about the opioid receptor in your brain as a light bulb. So as the dose goes higher, as you go up, you can see the effect for methadone goes up and up and up and up, and if, honestly, I would go up to here until the person stops breathing, and then they're dead, right? The light gets brighter and brighter and brighter and brighter and brighter, all right? There's really no ceiling to the opioid effect or how bright that light can become. The brighter that light becomes, the more respiratory depression you get, and that's how people die. That is methadone. The thing about methadone, yes, it's an opioid, but we'll talk about it. It's a long-acting opioid, and it's delivered in specific opioid treatment programs, and it is the oldest medication we have that's very effective. That is methadone. The next medication I'm going to talk about is buprenorphine, and you'll probably heard of Suboxone. That's the trade name. I don't like to use trade names because most things are going generic. Buprenorphine or bupe is what I call it, and this is here, I don't know, little diamond things that are in orange. As your dose goes up, you can see your opioid effect. Your light bulb is getting brighter and brighter until you get here, and guess what happens? It's a ceiling effect. Even though my dose is getting greater, I'm going higher and higher and higher and higher on my dose, I never go higher and higher on how bright that light gets. What that means is pretty much, I'm overstating this a little bit, but pretty much you cannot overdose on buprenorphine unless you're also using alcohol, other sedatives, or you have pretty severe pulmonary disease, or maybe you're an infant. We do try and tell people to lock. It is a controlled substance, but it is something that's quite, I mean, it is really a darn safe medication, all things considered. Then the third medication, IM stands for intramuscular, which means it is an injection that's given once a month, and it is naltrexone, and it's these diamonds down here. You can see here that there is no opioid effect at all. It's a blocker, actually, and as the dose goes up, the light bulb just stays off. Let's talk about these three medications and some knowledge about them. I want you to tell me if you think these are true or false. Don't be afraid to guess. Go ahead and guess if you want to. Yeah, just guess. Go for it. I don't expect you all to be, you're not medical students. I just want you to try. Medications for opioid use disorder can decrease or stop opioid withdrawal. In some ways, all of you are correct, because there is one that actually the naltrexone would put someone into withdrawal, because they would go from an opioid effect to no opioid effect with a blocker, and they would go into withdrawal. But it turns out that the other two, buprenorphine and methadone, do actually stop opioid withdrawal. And this is something that people often are continuing to use opioids, not because it gets them high anymore, but simply because they cannot go through opioid withdrawal. It is so uncomfortable. People can become suicidal when they're in withdrawal. It's just a miserable, people say it is the worst feeling you can imagine. And so they do not want to go into this, and so that's why they keep using opioids, because they can't stand withdrawal. Buprenorphine and methadone really will immediately address opioid withdrawal. I have had dozens and dozens of conversations with folks struggling with an opioid use disorder who say that very thing. All it was at the end was a no-holds-barred attempt to get the substance before withdrawal started. Nothing else mattered. It was just to avoid withdrawal. There's a wonderful TED talk by a bioethicist at Johns Hopkins who has prescribed opioids after acute pain syndrome, and he was given high-dose opioids. It was a bad accident. And then he tried to come off, and he became very suicidal, and really, it's a very interesting TED talk. Anyway, he describes the experience quite beautifully. Medications for opioid use disorder reduce infectious disease transmission. What do you think? Hmm. All right, so it turns out how in the world does infectious disease transmission have anything to do with opioid use and opioid use disorder and medications to treat it? Well, it turns out it absolutely does. This is a true statement. Medications for opioid use disorder have been shown over data over 50 years to decrease infectious disease. So what happens is people stop using IV drugs. They stop having risky sex. They stop, I want to say, how do I put this, they stop trading perhaps sexual favors for drugs. They stop engaging in those kinds of risky behaviors. And you see, and they're in treatment. So now you can treat people with HIV and get them to low viral loads. You can treat people with hepatitis C so that it's no longer there. And so they're not actually infecting somebody else. Medications for opioid use disorder has a powerful public health benefit. Medications for opioid use disorder reduces the risk of death. What do y'all think? Perfect, yes, it does. It reduces the risk of death. Mortality from opioid use disorder is extremely high. It's reduced mortality rates. Medications for opioid use disorder reduce or stop craving. That's an intense desire or urge to use substances. Perfect. Y'all are getting a trend. They do, they stop cravings. Don't get too, don't get too, we have a couple, or at least one false in here, so. Medications for opioid use disorder are just substituting one drug for another. Sorry. Oh, look at that. I went too long. Judge Flurkey, do you want to talk about this? I do. This is how I learned. I feel like this is confessional day. This is what I was taught early days, that especially methadone was a terrible drug, and people were zombies, and they couldn't do anything. You had to either ban them from it or get them cutting off it right away because it was substituting one drug for another. I deeply regret the conversations I had with people early days before I started to learn something. Yeah, not substituting since medication were taken on board that can help people. Well, Dr. Edens will talk about it. Adhere to treatment. Be safer. Not suffer lots and lots of consequences. Yeah, the thinking has changed. The other thing that I think this is kind of getting at is that you're still, and I'm going to use a word that I never use, but I think it's endemic in this kind of thinking, is you're still an addict. It means that if I go from using heroin to using buprenorphine, I still have an opioid use disorder. The truth is that's not true. Remember, opioid use disorder is a constellation of symptoms that has psychological effects, physical effects, and behavioral effects. Well, if I was using heroin, and I was spending all my time looking for heroin, and I was not able to keep a job, and I was headed towards a divorce, and I had contracted hepatitis C or whatever, and then now I'm on buprenorphine, and I don't have cravings, and I'm going to work every day, and I'm not divorced, and I'm able to take care of my family, and I've treated my hepatitis C, and I no longer have risky behaviors, I no longer have an opioid use disorder. Most of my patients, actually, on buprenorphine, this is the diagnosis I write. Opioid use disorder in full sustained remission on partial agonist therapy. The bottom line is they are in full remission from opioid use disorder. Yes, it was there, and I'm always going to follow them, and I'm going to watch them, but they do not meet criteria anymore. They're in remission, and that's what we're looking for. Those are the guys in my men's group. Yeah. Spot on. Dads, peer recovery specialists, workers, yeah, living beautiful lives. A couple of them still on dose abuse. Yeah. Hopefully, by now, medications treat the opioid use disorder. What do you think? So medications, including methadone, buprenorphine, and naltrexone are the treatment of choice for opioid use disorder. Their first line, to not provide medications is not standard of care. To not have access for patients with opioid use disorder to not have access to medications is not standard of care, and people are at very high risk, actually, of death. Well, and you know that one of the, and give me the name of the gentleman who did the TED talk, will you? Brooke's going to get it and share it out for folks. Do you remember? I will do that. I can't remember his name right now, he's a bioethicist from Hopkins. If you search it, you'd find it. They just, anyway, it was just shown at the APGME, which is our Graduate Medical Education National Meeting. But, you know, the, oh no, I lost my train of thought. Keep going, sorry. Okay. We are, I am aware of time, and I want to get to the case discussion. So I want to go through the pros and cons of these various medications. Hopefully I've, you know, at least gotten you to think about the fact that these medications reduce infectious diseases, they reduce death, they take care of withdrawal, they reduce cravings, and they successfully treat an opioid use disorder. And then how do we think about which one to use then in patients, and how do we talk to them about it? So methadone is the oldest. It's been around since the 1960s. It is the best for treatment retention. And I think I've already said, like, that's one of my main goals. I just want to keep you in treatment. If I can keep you in treatment, then again, you're alive, and we can continue to make some progress. Methadone is the best. It is the oldest. It is highly regulated, which is good. So yes, it's an opioid. It's a controlled substance. You can only get it at opioid treatment programs, and you have to go. The other thing is intense monitoring. So this little blue line, purple line down here, you're going six days a week for the first 90 days, and then you kind of slowly progress down. And even at the end of the year, you're going once a week, if you've completely done perfect, if you've never used anything, no positive urines, nothing. Then you can get methadone a week's supply at a time. I wonder if we could get folks to give us either a red yes or a green yes or a red no if you have methadone capacity in your community. While you're doing that, a question did come in. What are the percentages of success of medications in treatment of opioid use disorder? Yeah, so the success is about the same. And this, again, comes from the National Institute of Drug Abuse materials. But it's on par with the success we have with, say, hypertension. It's better than asthma treatment, perhaps not quite as good as type 2 diabetes treatment. But it's around 60% in a primary care clinic. Buprenorphine can work. And it also depends on how you measure success. But we typically measure it by percent consecutive negative urines, things like that. That's how we define success. And so we're talking about around two-thirds of people really can go into remission using these medications. It is on par with what we see with chronic medical conditions. It looks like some people do have capacity. And I'm assuming the current administration is working really hard to increase access to methadone. I know full states, there are one or two states that do not have a methadone clinic at all in the entire state. Some states only have one. We're trying to be creative about perhaps moving to, like, say, methadone mobile vans. That's not yet. We don't have capacity for that. But because it is an effective treatment, because opioid use disorder and opioid overdoses this past year with over 90,000 deaths from overdoses, we really are trying to expand this very effective and very well-studied, long-studied medication. I would argue that methadone is one of the most effective medications for such a deadly illness. And so it's a tragedy, honestly, that it's so underutilized and difficult for some patients to get. Buprenorphine, it's very safe, less opioid effects, it's less restrictive. You can get it in a primary care office. You don't have to go to one of these specialized clinics. But that's also a con. It is less intensive. And so when people are not doing well on buprenorphine, that is when I might say maybe we do need to kind of step up your care to methadone. Methadone, by the way, is super cheap. So if you're near a methadone clinic, sometimes that actually is more accessible than buprenorphine. It kind of depends on where you are, and that's just something for you all to be aware of. And then last but not least is iamnaltrexone. It's a great medication. It will stop physiologic dependence, but you have to go through withdrawal to get there, which I've already said is extremely uncomfortable, and most patients don't want it. It's also a really, really risky period in people's lives. So right now the healthcare system does not pay for inpatient care of opioid withdrawal. It's not an indication. Opioid withdrawal is not life-threatening. It's not an indication for admission to a hospital. But what happens then is we are forced to actually have our patients withdraw on an outpatient basis, and that's very dangerous because withdrawal is very uncomfortable. Then you're losing tolerance, and people go out to try and treat their symptoms, and they take something, and it's got fentanyl in it, and they're dead. So it would be great if the healthcare system could catch up, admit people, and over a course of a week we could get them on to iamnaltrexone. But I'll tell you, in the meantime, or in a residential care, I mean, there are certain settings we can do this. Great use of this is people coming out of prison or the incarceration system, you know, the carceral system. Many times people are given iamnaltrexone because they've already lost their tolerance. But the real con is how do we get people on it? But I would say if somebody's goal is to come off of medications altogether, like come off of opioids altogether, I still am going to want them on this. I do not want them on nothing. At a minimum, I want them on iamnaltrexone. Well, and you talk about inducing in an outpatient capacity what has happened historically in our jail. I'll speak for our county jail as people went through withdrawal on a cot in a jail cell. And then, like you said, most of our jail admissions are pretty short-term. They're released and they're at substantial risk of overdose and death afterwards. So we worked with our jail to establish a methadone buprenorphine process where we can put people up immediately, get them on medications, get them in a treatment relationship while they're in our jail. That's awesome. So let's move to a hypothetical. I call it a hypothetical. Dr. Edens calls it a case study. I think it's two different school systems. This comes from my experience, and so I will try and talk it through with a steady voice. Amanda is the mother of two children. They're six and nine years old. She's divorced from her husband, the dad of the two kids. She's seeking sole custody. Mom has an OUD and recently overdosed. The kids found her unresponsive on the bathroom floor and called their grandmother for help. Kids have been with dad exclusively since. Dad asserts that mom should have no contact whatsoever. Dad has been incarcerated for criminal drug-related activity in the past and been through treatment, and now asserts he's abstinent and in recovery. There's no reason to question that. We're going to do a conversation between Dr. Edens and I, and we're going to hypothetically have Amanda as a shared client. Amanda's in court with us either on a custody question or maybe on a DWI court question, She's come in to Dr. Edens to seek treatment. She discloses a history of alcohol and cannabis use before and within the marriage, domestic violence in the marriage and after, and then childhood trauma that she's not going to discuss with you. Her opioid use began with prescribed medications, followed surgery after a bad car accident. She was charged with a felony DWI and is still on probation under that accident, too. She's developed psychological dependence to prescription medication and an inability to cut down along with cravings. And when the prescription opioids were discontinued, she started buying prescription opioids from a friend. When this became too expensive, she switched to buying heroin. And, of course, in our community, when you're buying heroin, there's a substantial risk. You're also buying fentanyl in it. So, Doctor, what are the conversations you're going to have with Amanda, given her history, this really brief history, about her treatment options and medication? Yeah, so I think you've already kind of seen what I will do. I'll take a really good history. I'll do that RIP care history. And then I'll want to find out what her goals are. I want to find out what she's wanting out of treatment, what she knows about treatment, if she has any experience with any of these medications at all. And then I'll want to make sure that she knows what options are available to her. And while I want every single patient to have all three medications available to them, that's not always true. If somebody's working, maybe they have to take four bus lines to get to a methadone clinic, if it's there at all. You know, methadone might not really be something, you know, somebody can't spend four hours. And I've had that. People in Indiana who are driving two hours every morning just to get to a methadone clinic, right? I need to know some of those things. But mostly I'm going to be also finding out from her. I'm going to be developing rapport. What are her goals? Again, I want her to know that I'm going to be her treatment provider, really engage her. And then we'll get to this in a bit, but I'm really curious about that history of trauma. So I'll be thinking about that as well. So I have a question for you. What are the conversations you're having with Amanda? They're a little different, right? First off, we're covering, you know, I have both parents in front of me arguing. Each of them is frankly arguing that the other shouldn't see the kids at all. She's arguing dad's history. He's arguing the current overdose and situation. So I'm trying to sort out safety for the kids and what I should do in the interim. But I'm also, if we're in the treatment court context, I'm having that initial conversation about what's your plan, who you see in for care, and I'm trying to do everything I can to, and I would never have her in the same court, so I'm not saying that. I could not have the child protection case and the treatment court case at the same time. No way. I'm having conversations about trying. You mentioned motivational interviewing earlier. I'm trying to offer hope and future and connection with treatment and assurances that, you know, I'll have folks look around the room and say, put your hand up if you've been sober this long, et cetera, and I'm trying to engage with a person and encourage them towards therapy. They may not be there. I understand that. I have to deal with reluctance or refusal just like you do, but I'm having those initial conversations, trying to plant the seeds to a treatment outcome that will sustain her life and her plans. And then both of us are getting releases. Yeah. If possible, right, so that we can talk to one another. Yeah, back and forth. So this question I think was for both of us. How are you thinking about trauma-informed care? What I will say is many, many people who come into substance abuse, and I am mindful of time, but many people who come into substance abuse treatment do have a history of trauma that precedes their substance use. And we know that people who have untreated trauma have a harder, more complex course for substance use. Treatment is harder. And there is a real misconception among my colleagues that I cannot treat the trauma unless the substance use is completely stopped. But the truth is, if somebody is using substances, this is the way the conversation goes. I cannot treat you if you come in intoxicated. And if you're actively using substance, there's a good chance that this won't work as well. But all people who use substances should be getting trauma, if they also have PTSD or trauma, should be getting treatment for that. And so that's just something to note. Now I'm going to turn that over to you. Yeah, and Dr. Edens and I have created a judicial bench card on this topic, which I'm told won't be available through the National Judicial College until late next year. I wish we could hand it out. But one of the pieces we cover is trauma-informed court and care. My working assumption is that everybody I see has trauma history. That's what I do. There's a vast representation of traumatized individuals in the criminal justice system, and it doesn't hurt to treat anybody with a trauma-informed approach, which to me boils down to ideas of transparency. I need to be super transparent with you about what my obligations are, what my role is, what your role is, what the path is, what happens if this happens, what happens if it doesn't. I need to be really transparent so that folks can hear and understand and onboard what's happening. I need to honor voice and choice. Back in the day, certainly I was guilty of this. I know Dr. Edens would have known treatment providers who were guilty of this, who had a one-size-fits-all, welcome to the shop, honey, you're going to do this. It didn't work. It doesn't work. It won't work. So I'm trying very, very, very hard to listen to clients and honor their voice. That doesn't mean I agree with everybody, but it means that I listen. One of the men in my men's group stood up. He was 31 years old back in my court years ago. He's graduated. He's long out. He's off probation. He turned to our treatment provider and broke down and said, you are the first person who ever listened to me. And that was literally the start of what saved that young man's life, was somebody listened to him. And if I have any ability to give people choices within what I'm doing, I'm going to try and do it. I will create two or three choices that are acceptable to me, and then the court process and allow them to choose, giving them some agency. How much of it is like being pushed along and told you have no choices, you're going to go here, you know, do you want to spend the rest of your life in a TSA line telling you go there, go there, take your belt off, take your shoes off. Think of the anxiety you have going through TSA. Maybe that's just me. So I'm giving people choice whenever I can with transparency and with voice. And then lastly, I think of it as an idea of, you know, we tend to say that persons with substance abuse disorders lie. They're untrustworthy. They have all these moral character judgments about them. That's not been my experience by and large. I tell my folks that I am going to prove myself trustworthy to you, and then you can trust me. I'm going to follow my word. I'm going to do what I say so that you can learn to trust me. And I told my teams anywhere I was, we're going to lead with trust, and that means we're going to behave in trustworthy ways so that folks can understand that we're safe people to be around. So those are some of the things I'm thinking about. I don't know if I answered the next question too for me, but that's my approach to trauma-informed care. SAMHSA has really great resources on judicial trauma-informed practice that are brilliant, beautiful. You can download them and put them into your work. Mindful of time, are we okay? Yeah, we've got 13 minutes. We're good. Awesome. We've got lots of time. Here's a question from Berk sent up. Do you feel that going to a methadone clinic alone is sufficient for court to consider that drug treatment? My answer is going to be I have not experienced a methadone clinic alone, which I think you're meaning you're just getting the medication and going. That's not the model I'm accustomed to. The model I see for our methadone clinic is you're engaged in the medication. You're also engaged in therapy, support groups. They've got art. They've got trauma-informed. They've got a whole wraparound offering that when somebody, quote, goes to the methadone clinic, end quote, they're getting the full shebang. Now, if you told me that there was a client who was getting nothing but methadone and doing fine, being a mom, being a dad, working, living, they were not experiencing any of the negative side effects that Dr. Edens so beautifully described, I would say, yeah, that's probably enough. If I had somebody who is 100% or beautifully successful on just picking up and incorporating methadone, why would I add more? That's my take. And, Dr. Edens, you can do a better job on that one than I can. I think you said it beautifully. What I think you're saying is that not all methadone clinics are the same, and so it really is a bit of a, I don't want to hedge on that answer, but you'd have to tell me the methadone clinics. There are some methadone clinics that are for profit that might have 5,000 clients and really do not provide much co-occurring mental health treatment or other services, and then there are methadone clinics that have lots of groups, and if you're engaged, you should be going to some group, and they have counselors on site, and you're getting mental health care, and you're seeing a psychiatrist, and you're getting your searcher lane there, and so I hate to kind of, again, hedge on that one, but I think it's important to know that methadone clinics are not all equal. That's perfect. I hate to describe mine because I'm spoiled, and I know them people, and I know the work they're doing. I think the majority are like what you're describing, and VA methadone clinics, which is where I work, are really amazing because we have 70 patients, not 5,000, and if you do have a veteran, you have really good substance use services. Well, and I, as a judge, I knocked on doors. Treatment providers, I've been to every incarceration, I've been to all the juvenile facilities, I've been to our visitation center, I've been to every treatment facility. I go look. I want to know because these are my people I'm sending to you, so I want to know if you're doing the work that your brochures say you're doing. No offense, Doc. I know yours are better than your brochures, but I think that as a community judge, I want to be in those places, and I want to know. My clients can say to me, oh, jeez, I went to Dr. Eden's, she's a quack, and her place is a bunch of crap, and I'm like, stop, I've been there. I know that work. Him in the back, he's alive because of Dr. Eden's work. We're going to stop that conversation now. It might be that it's a bad fit, but it's not that they're doing bad work, so I can even be part of holding the line for the treatment facility and provider. That's wonderful. Is that standard for judges to go out and meet their... I don't know. I think it's standard for some. It's standard for me. I just... It sounds like it benefited you greatly. Oh, yeah. And then you're always asked to go during lunchtime so you can have lunch. Well, it's interesting that you say that because that's exactly what I tell my students to do. If you're in a community, wherever you go, you can't just land in a hospital. You need to find out what's out there, and you need to go and visit places, and I think it's super important for healthcare providers, and I can see that being important for judges as well. Yeah, and the connected relationships lead to better outcomes. They just... Do you feel like you've answered this other question, how might you present Amanda's choices? I think I have. The one example that's easy to come up is that if Amanda takes off for a weekend and is unaccountable for probation, I can, with my team, come up with two or three different sanctions and present them to Amanda, and she can choose her sanctions. I'm totally fine with that. I've had clients who could go to jail... Loved going to jail because it was nap and food. I had a client who had been sexually assaulted by her stepdad, who was a deputy, who did it in uniform. Sending her to jail is way different than sending my 6'6 gang member guy to jail. So to have a one-size-fits-all is maybe doing harm, and it doesn't honor the choice conversation. There's some things I'm going to decide. You can't tell me Dr. Edens is a bad provider, and that ain't on the choice option. But other things, I can find ways to give people space to make some choices. So back to you, Doc, and I think this is one we deal with quite a bit. I want to dig in, we want to dig in to kind of off-script use of medication. What if you learn Amanda's using buprenorphine occasionally from a friend without medication? That means she shouldn't receive medication at all because she's used it illegally. How do you think about it? We bump into it a lot. I've bumped into it daily. Yeah. So honestly, I would say most people who come into my... Well, I work in a pain clinic, so that's different. But in my addiction recovery clinic, I would say most people with opioid use disorder have tried buprenorphine that was not prescribed to them. Some of our kind of ethnographic studies that have been done indicate that buprenorphine that's used in a non-prescribed manner, right, or illegally, people are using it the way we would use it. They're using it to stave off withdrawal, to get them through to the next heroin, or because it's what's available to them, it's long-acting. So they'll try things, and that's not uncommon. Honestly, when I see this, I'm thinking a couple of things. All right, so she's tried buprenorphine, and did it send her into... We won't talk about this too much, but did it cause withdrawal? How did she get onto it? How did she feel about it? How long did she wait? You know, how long were her withdrawals before she got onto it? Because when people start buprenorphine, generally, they need to be in some kind of withdrawal. So she already knows about this. So there's a lot of education in that I'm not going to have to do. She also probably has some preferences about it. She either liked it, or she hated it, and that's going to be helpful. And then the other thing I'm really thinking is, wow, her best friend's on buprenorphine. So does that mean her best friend's in treatment? Does that mean her best friend might be encouraging her to get into treatment? Does she have a support that's actually trying recovery? I actually am... Most people are not getting it from their best friends, but when I hear that, I'm actually fairly positive about that. She's going to know things, and I can have a more informed conversation with Amanda now. And absolutely, it does not mean she doesn't get a medication for opioid use disorder. She has an opioid use disorder, and I actually am practicing below standard of care if I do not provide her those options. So I just answered that. I think, yeah. Does that mean she should be prescribed buprenorphine? Not necessarily. Not necessarily. It means that she gets the choice, but it doesn't mean that methadone might not be... Or naltrexone. She might not want it, right? So I'll go with what she wants. Yeah. Yeah. A couple more on this one. You want to click the slide? Yeah. Methadone, you'd consider that? I would absolutely consider methadone, and again, I would be thinking about why. Has she tried buprenorphine? Does she know that it requires more intensive monitoring? It might be what I think she needs, because she's tried buprenorphine multiple times. It might be that her friend is on meth... Not this friend, but another friend is on methadone, and she's heard good things about... I'm going to want to know what she wants and why. I will say most people who come in do have preferences, and in general, if you have a preference, I just want you on something, so I'll do what I can to get you on that medication, unless it really has failed multiple times, and then I'm going to work to try and see if maybe we could consider another plan. I think the bottom line about her options is I'm going to educate her the way I've talked to you all. I'm going to tell her about the three medications, about the pros and the cons. Most people with opioid use disorder come in in opioid withdrawal, and they're looking for opioids immediately, but in general, when I think about education for substance use disorders, I often will give people their options, and then in many cases, I'm giving them so much information that I think it's really nice to, number one, I have them teach back to me. What did you hear me say? So I can actually process that they understood or know what they understood, and then I often will give them written material, too, because it's just a lot, and then give them a follow-up time when I will call them so that they have time to think about their choices. Again, with opioid use disorder, people are often coming in in crisis, and it's such a lethal disease that I want to get people on something immediately if I possibly can, but in general, I like to give people time to think about what they want to do if that's appropriate clinically. That's awesome. Let me, I've got one comment I'll take out, and I think maybe we're out of time, and we're going to try, you and I are both trying to have ongoing connection with Amanda and find out how she's doing and checking in, and if I've got probation visiting, if we've got drug screenings, if we've got treatment reports, we are trying to stay engaged with her long term. The comment came in, maybe give mom some time with the kids, because this came in as a custody hypothetical, and this was a, I had the family case, and it came in as the custody dispute. I never had her in a treatment court. The judge suggests doing some type of monitored parenting for her, you know, whether you've got a service that can do that, or if there's a really, really thoughtful, mutually agreed on party who could watch those, those are scary, but ultimately I did order some monitored child care, or visitation. Ultimately, Amanda was reunited with her children for several years, and was in a 50-50 parenting time with dad. The sad end of this story is that Amanda went on to become a treatment counselor at one of our local inpatient places, was doing beautifully, and relapsed, and relapsed on fentanyl and died. And at the same time, the dad had been sent to prison for hauling an SUV full of drugs back from Portland, so there was nobody in play for these kids, except the grandparents who had been involved all along, so these kids are with their grandparents. This is a sad story and a tough story, but she lived many years of beautiful recovery, a beautiful contribution to the community, but ultimately some fentanyl and a relapse situation took her life. I would say, though, that you gave her, the court system gave her and her children many years of recovery that wouldn't have happened otherwise. So actually, even though it ends tragically with a death, there is an enormous amount of positive outcomes that wouldn't have been possible if she weren't provided treatment and probably evidence-based treatment. Totally agree. Totally agree. I agree. I think you gave her children some good memories. Yeah. Yeah. Mom who struggled. Does anyone have any questions? I know they've been answering them as they come in, but if you have any questions now, and you can actually raise your virtual hand and I can come out and unmute you as well. Judge Allen, I see your hand up, so I am going to unmute you. All right. Judge? In our court, we have, it's misdemeanor court. We don't have serious felony cases. But we do have individuals who come in who are addicted to various substances, and that's their lifestyle. They're homeless or whatever. And all we have the program is like 26 weeks of counseling that we require them to pay for. I used to say that it's not successful in completing very, very many times. Among the facilities that those complete is not very great. Robin, I was with you 26 weeks. You'll get some. That's great. And so it's almost like it's a push here, push there, and we don't see them anymore. And the problem doesn't go away. It's a resources issue with the budget keepers in the city here. So that's the issue. How do you, we have developed what is called a community court. And it's trying to work with people who have the homeless issues and so forth, the trespassing, the addiction drug paraphernalia, those kind of things. And we've tried to get some providers to come in and volunteer to assist. Some have, but I don't know that it's been to a great extent thus far. But they're hoping it will evolve into that kind of a circumstance. How have you, in your situation, obtained the necessary approval of the budget resource people where you are a judge? Right. Robin, I feel you big time. I was glad I didn't get our community court. I wanted the felons, man, because they had some tools and some, because you feel like you're just always coaxing people along and trying to ask them to come with you. You know, you don't have that coercive. The revolving door. Yeah. But on the other hand, Ellen doesn't have a jail either. Yeah. You know, and so I do look at our treatment facilities and they have beautiful outcomes that you and I are never aware of without a jail, without a police officer, without so it can be done without the coercion. But for your instance, I would continue, bless you for engaging with that level of client because it's super hard. It's long term and it's really challenging. I would be going out into my community and trying to shame people to the table. I'd be coming to me now. I run a community foundation. I got 100 million bucks in the bank to do good in the community. I'd be coming to Flurky and saying, can you help? Can you help? Can you help? That would be how I'd try and crack that. But yeah, to have a 26-week program they got to pay for, that's just, that's harming everybody. That's killing you. That's killing them. Yeah. But I love that you're getting some people in. So do a little less. Do a four-step or do something smaller to try and get people moving forward. 26 weeks is a pretty good barrier too. Maybe you can do a smaller start or maybe you can screen for kind of high-risk, low-risk and deal with the high-risk folks. I'm just making it up, but I feel for you, man. I really do. All right. And judges, we are at the 75-minute mark. So feel free to jump off. If there are any other questions, I'm happy to come out and unmute you. I don't see any hands. I think there was one question here that I saw about percent of change in deaths, transmission of disease. Oh, cool. And what I would say is there's been so many different studies in various populations. And so if you think about meta-analysis, what's coming into my mind is that if you look at mortality for people who don't have opioid use disorder as your reference point, it's about one. People who have an opioid use disorder that's untreated, it's six times the mortality. And people who are treated is two times mortality compared to your reference. So it really substantially reduces mortality. People still have a higher mortality than people who don't have opioid use disorder at all. But it does reduce the risk. Hey, Doc, is Jeffrey Kahn, K-H-A-N, maybe the gentleman who you were talking about? That's sounding familiar. Let me, I think probably he's the Andreas T. Drakopoulos, director of Johns Hopkins. Do it. Share it out, will you? You got the YouTube, Brooke? Thank you. And as I can ask my assistant, my course administrator, to include this in the email as well. Awesome. Awesome. So you'll miss it here. And I'll verify. If you want to actually, yeah, if you want to find it, Dr. Edens, and then email it to me. Oh, y'all, it was so good. Travis Reiter, R-I-E-D-E-R. Travis Reiter is the man. And he's written a book on his experience going through opioid withdrawal. He ended up off opioids. He's now no longer taking them. But it sounds like by the skin of his teeth. Is that right? What's that? That's how they said it back in the day. Do you have the book handy? What's the book name? I'll type it out. Let me look at that. Oh, pup. I just think I, in pain. Travis Reiter, that's his name. In pain. And he wrote, I think it's called In Pain. Yeah. Young guy. He was a beautiful speaker, actually. And he has a nice TED talk. Which reminds me of Gabor Maté's book. Don't Ask Why the Addiction. Ask Why the Addiction. And he's a wonderful speaker. the pain. That's been one of my guiding principles for trauma-informed interaction. And I just put the YouTube link for his talk on the agony of opioid withdrawal. You're the bomb, Brooke. That's awesome. All right, I'm not seeing any other questions. Thank you, everyone, or any other hand. Just lots of applauses and thank yous, I might add. Thank you, Judge Flurkey. I'm glad that while you're off the bench, I'm glad you're no longer on a drug court, but I know you're still doing good work and thank you for helping to educate our judges on this important topic. And Dr. Eden, same to you. Always a pleasure talking to you both, but I like doing this with you, Judge Flurkey.

Judge Allen

Dr. Eden

treatment options

opioid use disorder

medication-assisted treatments

methadone

buprenorphine

naltrexone

life-saving

dependence

addiction