One world, one people, one tribe, one tribe What I know, what I know, we are one It all starts with the people One people we stand all together, one voice saying yes we can Each one reach one till we pull ourselves up cause we all one fam From the rest to the block to the prairie to the rock we connect that love Cause the people we're powerful, the power of the people whom we stand as one I got your milk off the realness, we be indigenous you heard of us Back stepping the murderous bread and the love with the water In front and the stand against, ain't gotta know what the purpose is We rise, the climate is changing, signs of the times, it's time to start praying For the world and community, rest, I'm more powerful when we're in unity What I know, what I know, we are one Woke up today, hugging for a change, new path to take, can't stay the same It's been too long, putting out, who's right or wrong, can you hear me out All we need is a little bit of love, take time to heal and it starts with us Hand in hand, I put my trust, here won't worry you, it's a must Hold on to hope, we can overload, we can break the code with a single note Sing out for the world to hear, that our time is now, no more for tears I look in the young's eyes, a new day and a new life Lift the bell and dwell so peaceful, come together one, one, one What I know, what I know, we are one It's who you are, it's who I am, we all bleed the same blood yeah I am one, we all bleed the same blood yeah We got beautiful differences, let me give you a peak, over 500 tribes, we're all unique And if we cannot compete to eat, nothing can beat us, jealousy is more dangerous than diabetes See this unity, imagine what it look like, you would think you would do whatever it took right I would do anything for this good life, we can do anything if we unite Young native, you are my savior, say a prayer for our inspiration From the block to your reservation, and in color, all my relations From the basement worldwide invasion, everyday we're painting our faces Fighting back but learning our language, dancing our dances, saving our brothers What I know, what I know, we are one All we got is one voice, one choice, one birth, one love, one birth, one life to live One life to live, yeah One people, we stand all together, one voice saying yes we can Each one, reach one till we pull ourselves up cause we all one fam From the rest to the block, to the parade, to the rock, we connect that love Cause the people with power, for the power of the people when we stand as one What I know, what I know, we are one Good afternoon, everyone. My name is Twyla Nalari. I'm a TTS specialist with the ORN, serving with the Tribal Southwest Region. My maternal clans are Red Towering House Clan, which is on my mother's side, and my paternal clans are Winder the Water. We'd like to begin this morning by opening in a good way and also sharing a land blessing from the areas that we are presenting from. Our morning begins with, and as we gather from various locations, we humbly acknowledge that we are meeting on traditional territories of many Indigenous Nations. The ORN and our partners are committed to upholding Tribal sovereignty through the dedication of increasing wellness among Indigenous communities. And as we also gather today, our words come from Article 24 of the Multicultural Indigenous Rights and Poetry. Indigenous peoples have the right to their traditional medicines and to maintain their health practices, including the conservation of vital medicinal plants, animals, and minerals. Indigenous individuals also have the right to access without any discrimination to all social and health services. Indigenous individuals have an equal right to the enjoyment of the highest obtainable standard of physical and mental health. We shall take all the necessary steps with a view to achieving progressively the full realization of this right. The songs of the people are entering our bodies, teaching each cell, each strand of DNA about beauty and wonder, and we arise at dawn once the ceremony is complete like newborns born of a womb. Thank you. Next slide please. And once again, we thank you all for joining and spending your afternoon with us. We would like to share a brief overview of logistics. We'll provide an overview of the opioid response network, transitioning into the presentation, and followed by questions and answers. We will also have the chat box open, and we'll aim to answer all of the questions at the end of the presentation. You're welcome to utilize the chat box. We will also leave at least 15 to 20 minutes that will be dedicated to the OTAP staff, where they'll provide updates applicable to TOR grantees and also to any participants with us today. At the end, we'll also have a brief two-minute survey. We kindly encourage your participation. And we want to acknowledge that today's webinar is also funded by SAMHSA. The opioid response network shares gratitude to both SAMHSA and our participants. We do have ORN staff on the webinar today, as well as leadership and our project officers. Next slide, please. Next slide, please. All right, Twyla, are you not seeing the working with community slide? Is that the one you want, or do you want the next one? I think there is a delay, yes. I think so, too. There we go, apologies. Okay, there it is. What SAMHSA, as I shared, is funding today's webinar, and we are sharing the overview that the SAMHSA – I'm sorry, there is a delay. Sorry. It is freezing a little bit on my end. Can you hear me now? Okay, and we want to acknowledge that the ORN is a national partner. We partner with 40 partner organizations providing experienced consultants in prevention, treatment, and recovery to communities and organizations to help address the opioid crisis and stimulant use. And we'll share a brief video of the ORN here. Next slide, please. Working across prevention, treatment, and recovery. For state agencies, organizations big and small, and individuals working to address local needs, we bring training and education to bear on your efforts. We're here to help you help others through evidence-based support, all at no cost to you. For instance, the Opioid Response Network helped a tribal college in New Mexico join forces with local organizations to develop a culturally appropriate prevention, treatment, and recovery training series for its students. In Rhode Island, we convened correction staff from 34 states to share how a program had reduced post-incarceration overdose deaths by more than 60 percent and supported them in their efforts to build similar programs in their home states. In West Virginia, we mobilized to help a clinic incorporate substance use disorder services into their practice, serving a faith-based community. We helped healthcare providers in South Dakota address barriers they face providing treatment services for their patients. We're here to help those on the front lines. So, what are your needs and how can we help? Visit theopioidresponsenetwork.org to learn more and to submit a request for support. The Opioid Response Network, funded by the Substance Abuse and Mental Health Services Administration. Communities across the nation. Once more, the Opioid Response Network's vision is to enhance prevention, treatment, and recovery. And with that, we aim to streamline our services that are tailored toward tribal communities. Next slide, please. With the Opioid Response Network, there has also been a creation of the Indigenous Communities Response Team. The Indigenous Communities Response Team is both nationwide and is tailored to providing culturally responsive training and resources to communities. We have also, our team that is available will show you their photos here. We've developed this team that is also in support, which each TTS follows the brilliance, expertise, and strengths of each requester, enhances tribal sovereignty, and also tailors their response to ensure that it's culturally appropriate. Each TTS is in one of these five regions. So, there are two team members across the country, and they are serving each of the four regions here. And these are their photos here. Next slide, please. Myself and Francesca are representing the webinar today from the Charitable Southwest region, and you will see, in addition, our colleagues across the country. In addition, the Opioid Response Network has created the Indigenous Communities Work Group. The work group and the purpose is to enhance ORN staff and consultant knowledge around tribal best practices and also build capacity, both internally at the ORN and externally. So, we rely on this work group to share tribal expertise. And moving forward, in order to request technical assistance, our goal is to also respond within one business day. So, we aim within that 24-hour window, and tribal requests can both be submitted virtually online. There will be a QR code and also by access via our website. So, we'll share that information following the slide. And we want to acknowledge that some of you may be joining us for the first time, or you may have contacted us before. So, we'll run a poll here just to see who is all in the room and joining us today. Thank you again if you've been in contact with us before. Okay, so I'm going to launch a poll. So, when we see a pretty picture like this one, that means I get to launch a poll. So, here's the first poll. And if you can't see the whole thing, you can scroll down. So, choose the correct answer regarding the Opioid Response Network. Today is the first time I'm learning about the ORN, or I am familiar with the ORN, but I've not reached out for assistance, or I have, or my organization has submitted a request to the ORN. So, answer the appropriate one. And then there's the second question that says, I am planning to submit a request to the ORN to help us achieve our TOR grant goals and enhance care for my people. True, false, or not sure? I'll give you just a few more seconds to answer these important questions, and then I'll share the results of the poll. Okay, I'm going to end the poll, all answers in, and I'm going to share the results. And Twyla, let me know if you can see those results. I see the poll moving, the results are coming in. It looks like we have 50% of participants today are familiar with the ORN, but not have reached out to us. Our, let's see, we have 30% who this is their first time hearing of the ORN, and we have about 20% that have submitted a TA request before. Going to number two, we have about 70% that are unsure about submitting an ORN request, and about 20% true, they would be planning to submit an ORN request. So, thank you for that. We want to acknowledge that some of you may be, are familiar with us, but not have submitted a TOR request. And we hope at the end of this presentation, you find some information helpful, or it sparks interest in areas that you may need support in, or have questions about. So, we look forward to sharing further information, and we're happy that you are here today. And so, without no further ado, I will introduce our presenter. We, oh, I apologize, this is the camera, I'm sorry. This is the QR code that I meant to share a little bit earlier, that will be also shared at the end in the chat box for a TA request. It is my pleasure and with deep gratitude to introduce today, Dr. Joan Kendall. She will be presenting today. She has worked and lived in tribal communities most of her career. She is board certified in family medicine and addiction medicine. She's also worked with IHS, the Indian Health Service, as a primary care provider on the Navajo Nation and the Hickory Apache Nation for 23 years. In addition, she has also provided direct telehealth to patients with opioid use disorder. Dr. Kendall also serves as addiction medicine consultant with Kauffman Associates, and she is also a treatment consultant with the Opioid Response Network, and also serves as a part of the Indigenous Communities Workgroup. So, with that, I will turn it over to Dr. Kendall. Welcome. Thank you, Twyla. Thank you so much for that introduction, and thank you all for having me. I'm really excited to be here at the inaugural WEBS webinar for this series, for the tour grantees, and working in collaboration with OTAP. I think it's really exciting, and I am honored to be kicking this off. So, I know you guys are going to have a great series of webinars. And so, I'm going to go ahead and start. So, let's talk about today's objectives. And I want to actually go back to the title of this presentation. It's Opioids Overview, Hope for Our Future. And I really want to stress that hopeful part of what we're going to talk about today, because there is hope. Even though we're going to be talking about doom and gloom, and numbers that are not favorable in a situation that is not pretty, there is hope, and we are seeing changes that are happening. So, I just really want to stress that. Things we're going to talk about today include, we're going to talk about the opioid crisis, and how it continues to impact the United States, and certainly Indian country. We'll talk about the relationship of brain chemistry to opioid addiction and overdose risk. We will also talk about identifying opioid use disorder, or OUD, as a chronic disease with effective treatments. There's some hope right there. And the most hopeful part of all is, we're going to elevate cultural connectedness as an important tool for OUD prevention, treatment, and recovery. And there is a lot of hope in that realm. So, oh, here's a pretty picture. I'm going to launch a poll. That's my cue. So, we're going to actually start with a poll. So, I will launch this one, and we'll see what you think about this. So, this question is a single answer. Which of these causes the highest number of deaths per year in the United States? Is it motor vehicle crashes, gun violence, or drug overdose? Gee, what would it be? Okay, I'm going to end the poll in a minute, in a second. Let's see. Do you think it's motor vehicle crashes, gun violence, or drug overdose? And I will tell you, this is not a trick question. I'm going to end the poll. I'm going to share the results. And yes, indeed, it is drug overdose. Most of you got that right. And sad as it is, that is the correct answer. And I'll show you, if you look at this graph, you can see that over time, it has shifted for sure. Look at that shift. Used to be car accidents, and now it's drug overdoses. In 2021, over 107,000 overdoses, overdose deaths from drugs. And that exceeds gun deaths and car accidents combined. So, there's that. So, I'm going to show another brief video that kind of gives an overview of the things that we're going to talk about over the course of the next hour. Millions of people in the United States are struggling with a dependence on opioids. And this problem continues to grow. Opioid use disorder is often viewed as a moral failing. In reality, it's actually a chronic disease like diabetes or asthma. And like other chronic diseases, opioid use disorders can be treated. The most effective therapy is medication-assisted treatment, or MAT, which combines drugs with behavioral therapy. So, how does MAT work? Opioids alter the chemistry of the brain by attaching to opioid receptors. When these drugs attach to their receptors, they reduce the perception of pain. That's Dr. Peggy Compton, who's done research on opioid use for NIH. And a person with opioid use disorder is physically dependent on these drugs and needs higher and higher doses over time, which can lead to overdose or even death. Fortunately, there are FDA-approved drugs that can help. They curb cravings and block the effects of opioids. People are then better able to manage their disease, which can help prevent relapse. According to the U.S. Surgeon General, medication-assisted treatments have been shown to facilitate recovery from substance use disorders and prevent relapse. MAT is crucial to long-term recovery and helps people live healthier, more productive lives. Okay, so that is, that's a helpful video. It's slightly outdated in some of the terminology, and we're going to talk about MAT in a little bit later in the presentation and kind of clarify some things about that. But that, I think, is a helpful overview. We're going to talk now about the opioid epidemic. What do we mean when we say the opioid epidemic? How long has this been going on? It's been going on for a little over 20 years. It started around the turn of the millennium, around 2000 or so, 1999-ish. So it's been a while that this has been going on. And this slide sort of talks about the numbers. Overdose deaths in the year 2020 were about eight and a half times the number that they were at the very beginning of the opioid epidemic in 1999, just in that one year. Eight and a half times. An updated slide, 2021, 10 times the number of overdose deaths from opioids, just in that one year alone, compared to the beginning of the epidemic. So in 2019, all across the United States, nearly 71,000 Americans died from drug overdose in that one year alone in 2019. Again, updated, just the next year, 92,000 people died from drug overdose in 2019. 10,000 Americans died from a drug overdose. And yet again, updated, just a year later, over 107,000 people have died from drug overdose in just the year 2021. And 2022 is looking like about 109,000. So these numbers are astronomical. We are losing so many people to drug overdose. And these numbers represent deaths from drug overdoses, from any drug. If we're talking specifically about opioids, it's about 75% of that number. And there are about 187 people that die every day in America from an opioid overdose. This was a slide. This was a graphic from just a couple of years ago. Again, updated, it's about 220 people who have died every day. In the year 2021. So these are big numbers. If we follow the opioid epidemic over time, we can see that it started around 1999, and this is an updated slide going up to 2021. And you can follow these curves. There's been a few distinct waves that we've noticed in the epidemic. If you follow the green line, this is wave one. This was the beginning of the opioid epidemic, and it started with prescription opioids. We were over-prescribing opioids for chronic pain, inappropriately, and we learned that too late. But if you do follow the green line, you notice that over time, we have gotten better. Oopsie, I didn't mean to advance that. We have gotten better, and over time, it's come down. So we're doing, today, we're doing a much better job than we used to do back in the beginning of the epidemic. So there is hope there. We are getting better. So the second wave is this purple line. If you follow that out, this is heroin. So not coincidentally, the heroin wave started at about the time that we realized that we shouldn't be prescribing opioids for chronic pain as much as we are. And so we didn't think that people would get addicted, but they did, and many of those folks were turning to heroin. So we see this big rise in heroin use in the 2010s or so. And if we follow that curve, we see that it's fallen off as well, and this is actually not such a great sign. You would think that it is, but the problem with this is that heroin has essentially been replaced with synthetic opioids like fentanyl, which are far more potent, far more dangerous, and far more deadly. So heroin, it's really hard to come by anymore, which is why we see the drop-off. So then that brings us to the third wave, the blue one, really just skyrocketing fentanyl, and this started in the mid-20-teens, so 2013, 2015, and still on the rise. We're now currently in the fourth wave, which is fentanyl and stimulants, again, just a steep incline. So that's kind of following the opioid epidemic over time. This slide focuses on race and ethnicity, and this shows us over that same period of time, what's the breakdown according to race and ethnicity? And unfortunately, what we see on here is that the one at the very, very top of everything, the highest rates is American Indian, Alaska Native, and this is the death rate per 100,000 people over time. And we see that this community is at the top of the list. And this dotted line is COVID, so that's when COVID happened and it's increasing for all races and ethnicities, but especially for our Native communities. And we need to talk about stigma because we all come across stigma everywhere we look, and our patients and our relatives are faced with stigma for this. And this is not a presentation on stigma. Hopefully later in the webinar series, there will be something because it's of such importance, but I need to mention it here because it's so real and such an issue for us. So stigma is negative attitudes, beliefs, and behaviors aimed at a group of individuals based on stereotypes. And what we see in the addiction field is we see stigma that has evolved from this continued resistance to the whole notion that addiction is a brain disease. People still cling to the notion that addiction is a moral failing, that people have somehow decided, made this decision to do this and that they just need to decide not to do it, and that because they don't, that they are a bad person, and so they are treated horribly. And that still exists today, which is a horrible thing. And as healthcare providers, we should be leading the charge here. We should be role models. We should be welcoming people and not have negative attitudes about people who are struggling. So a lot of that has to do with the words that we use. The words that we use, and this is Don Coyus. He is the founder of Wellbriety, the whole Wellbriety movement, and he's a brilliant man. And I love what he says. He says, words are important. If you want to care for something, you call it a flower. If you want to kill something, you call it a weed. So words really do have power. And so we need to watch what we say. We need to be careful about the words that we use and be really intentional because people notice the words that we use. Especially native people, they're very sharp and they're gonna notice when you use terminology and words that are very insulting. So on the left side in the red is words that we probably should never use. We should avoid using those words. And the green ones are some ideas of ways to respectfully convey the same thing. So we shouldn't be saying addict. We shouldn't be calling people users or junkies. We should say person who uses drugs. If we say alcoholic or meth head or tweaker, those words are, they're assuming that the person is their behavior and that they're no longer a person. So we like to use person first language. We start with person. So instead of those things, we could say a person struggling with substance use or a person with substance use disorder or a person with opioid use disorder. It's a mouthful, but it also is respectful. So using those terms, changing our terminology is helpful. Instead of saying ex-addict, it's a person in recovery that conveys with it so much of a sense of respect for what they've done. And clean and dirty. I hear that all the time in reference to someone. They can say, oh, I've been clean for this long. Well, that implies that they used to be dirty and that is insulting. And if it's for a drug screen, it's a test. It's either positive or it's negative. There's nothing dirty about it or clean about it. So we should be really careful about the words that we use. Ooh, there's a pretty picture. Okay, so I'm gonna do a poll. I'm gonna launch the next poll. Keep you guys awake. Let's see. This one is, I will launch it. Okay, so we're gonna talk about opioids. It's not launching. You're not seeing it, right? Nobody's seeing it. Okay, so did it launch? It did launch, okay. It eventually launched. Okay, so which of these is not an opioid? Is it fentanyl, hydrocodone, methadone, methamphetamine, oxycodone, or heroin? Four of those are opioids. Which one of the four is not an opioid? Give you a little bit of time, just a few more seconds. Okay, I'm gonna end the poll and we'll see what the answer is. Okay, so the answer is methamphetamine. Methamphetamine is a stimulant. It is not an opioid. All the other four are opioids. So let's talk about opioids. Opioids, what are opioids? So opioids is a group of, it's a class of drugs, whether they're illegal drugs or medications, but they all have a similar property. They all are chemically related and they all act on the opioid receptors. Ooh, the poll showed up again. They all act on opioid receptors. Opioid receptors are also known as mu, MU receptors. They are mostly in the brain and spinal cord, but they're also all over the body in the gastrointestinal tract and other places in the body, but mostly in the brain and spinal cord. And names of opioids are familiar to us. We just learned about some of them. There's heroin, fentanyl, hydrocodone, oxycodone, morphine, and paradine, which is Demerol. Those are all opioids. There are two opioids on this list that I wanna pay special attention to, and those are buprenorphine and methadone. And we recognize those as the most common opioids medications that we use to treat opioid use disorder. And I wanna point out that they are on this list of opioids. They are opioids and that's exactly what makes them so effective as treatment. They're incredibly effective for treatment of opioid use disorder because they're opioids and they work at the exact same receptors as the rest of these opioids do. And that's how they are so effective, but they're formulated in such a way that they're safer than these other ones. So I wanted to point that out. And let's talk about the effects of opioids. What do opioids do to the body? So first and foremost, opioids are awesome for pain control. They're really, really helpful. There is nothing as good as an opioid to control pain. They're especially good for acute pain. So pain that is short-term, you're not expecting it to last a long time. It's not chronic pain. But if I have a surgery or if I break a bone, I am gonna want opioids for a few days to help me through the most intense pain. And they work really, really well. The problem with opioids is that they don't work very well for chronic pain, for most forms of chronic pain. I hope we don't live in a world where we say, because opioids are causing such a problem, we've got to get rid of opioids. We have to banish them forever because there is a role for opioids. We have to know what that role is. We need to be smart about it. So they're not great for chronic pain, but they are great for short-term pain. What do opioids do to the body? So if someone takes opioids to the point where they're really feeling intoxicated by it, by the effects of it, what happens to the body is that their breathing will slow down, their heart rate slows down, their blood pressure goes low, they're sleepy, they're kind of, they could slur their speech. Everything is kind of slowed down. Their pupils get really small and they start to kind of nod off. So that's what happens if somebody takes opioids. Now, if they take this a step further in a situation where someone is overdosing on opioids, then these things just are more extreme. So instead of just head nodding, they are out and they will not be roused. You can't wake them up. They are just unresponsive. Their breathing gets so slow that in fact it stops and their heart rate gets so slow that it's barely beating. And that's an overdose situation and that is life-threatening and that's where naloxone comes in to save them. Brand name is Narcan. If you haven't heard of it, it's amazing. It can really help if you are suspecting that somebody is in this situation where they're overdosing, you cannot rouse them, get the Narcan. And the opposite of this, so this is the intoxicated or overdose state, but what's the state that if somebody has been taking opioids for a long time that their body is used to it and they, for whatever reason, because they can't get it or they wanna stop or whatever, they just stop taking those opioids, then their system will go into withdrawal. So withdrawal is the opposite. So their breathing will be really fast, their heart rate ramps up really high, blood pressure goes really high, they feel anxious, they're irritable, they're cranky, they can't sleep. Instead of being small, their pupils get really big. They feel achy all over, everything hurts. Their nose starts running, they're tearing, they're sneezing, they're yawning. And remember I said that the receptors are also in the GI tract. So usually opioids cause constipation. In this situation with withdrawal, everything just comes out. So they have diarrhea, they're nauseous, they have horrible bellyaches. It's a horrible state of being. People don't like being in withdrawal. Anyone who is taking opioids on a long-term basis knows that this will happen. And so they will go to any lengths to avoid this happening. So they can feel very desperate if they know that this withdrawal state is coming. It's very unpleasant. I'm gonna show another video now that talks about how does it happen? How does somebody become addicted to opioids? What's happening in their brain? This is Susan. Susan loves to bike. While out for a ride, she falls and breaks her arm. Special cells called neurons send a signal through the spinal cord to the brain, which interprets the signal as pain. Susan understands the pain. She's able to feel the pain. Susan understands the pain means she needs to go to the hospital. And her body is equipped for survival, helping her not to panic so she can seek help. Many of her neurons are covered in proteins called opioid receptors. These receptors act like a brake to slow down the neuron's ability to send pain signals. When injured, her body releases natural painkillers called endorphins. Like a key in a lock, endorphins activate opioid receptors, slowing down the pain signal and preventing a panic. Susan gets treated for the broken bone. But three months later, her arm still hurts. And now that pain is making her feel depressed and anxious. So her doctor prescribes an opioid painkiller. There are many different opioids, but they all share a chemical similarity to our own endorphins. This allows them to bind to the same opioid receptors and stop pain signals. But that's not all they do. Deep inside Susan's brain is a region called the ventral tegmental area, or VTA for short. The VTA is full of neurons that produce a chemical called dopamine. When something good happens, dopamine is released, giving Susan a feeling of pleasure. This helps teach her brain to keep seeking out good things. To keep dopamine neurons in check, inhibitory neurons keep the brakes on until something good comes along. Just like the pain neuron, these neurons are covered in opioid receptors. When Susan takes the painkiller prescribed by her doctor, the opioid receptors turn off the inhibitory neurons and release the brake on the dopamine neurons. The rush of dopamine temporarily eliminates Susan's depression and anxiety, and she feels relief, calmness, and even euphoria. As Susan continues to take the painkillers, her brain responds by trying to regain its balance. Her inhibitory neurons work extra hard, even when the opioid receptors are activated, and it becomes harder and harder for her dopamine neurons to release dopamine. Susan finds that she needs to increase her dose of painkillers in order to feel comfortable. This is called tolerance. Eventually, Susan's pills run out. Inhibitory neurons that had been working overtime are let loose, clamping down on those dopamine neurons and shutting them off almost completely. Now, not only is Susan in pain, but the depression and anxiety come back. On top of that, Susan feels ravaged by an inescapable physical sickness far worse than any flu. Susan's body is going through withdrawal. Most people who take opioids for a long time tend to experience some withdrawal, but they can still stop taking the pills and return to normal. But for people like Susan, it's not so easy. Her genetics and the environment she grew up in put her at a higher risk for addiction. Her withdrawal symptoms aren't just unpleasant, they're unbearable. Susan thinks the only way to feel normal is to find more opioids, and this is how the cycle of opioid addiction emerges, driven by a brain trying to regain its balance. But there is hope for Susan. Though the road to recovery can be challenging and there may be setbacks, treatment can retrain Susan's brain. With the help of medication and therapy, Susan finds pleasure in her life once again. Okay, I forgot to mention one really important thing, and that is that you guys are gonna get a PDF of all of my slides. So, and I wrote on there the links, but I see that Twyla put the link to that in there as well. So, you're gonna be able to go to Twyla's website and get a PDF of all of my slides. And I'll put the link to that in there as well. So, you're gonna be able to go to Twyla's website and get a PDF of all of my slides. In there as well. So, you're gonna have access to these slides. Everyone always wants to know that, and absolutely you will. So, we can learn a lot from Susan's story. And, you know, Susan is not unique in that, that happens. Everyone has their own story. This is not the way it happens for everyone, but it's really, it's really a complex process. How I mean, obviously, how does someone become addicted, there's a lot that that goes into that who is who's at risk for becoming addicted. So there's the there's the nature versus nurture versus neighborhood concept. It's not just one or the other. It's all of them. It's the as we learned about with Susan story, it's the biology, it's the genetics. It's the environment. Are they coming from a from just chaos in their homes? Are people using all around them their their parents use their siblings use their their friends use? What is the attitude in the community? How engaged are they in in healthy activities as opposed to unhealthy activities? So all of that goes into who will become addicted and who who won't. One of the this is a really obvious statement, but one cannot become addicted to a drug if one never takes the drug, right? So that's what drug is in the middle of this graphic here. But it's actually a really important point that our brains are are in development mode all the way through our early 20s. So, you know, 20, a 24 or 25 year olds brain is still developing. And that active active development happens younger in life. And so if we can just delay the onset of drug use, even by a little bit, it lowers the risk of becoming addicted. Most of my patients that I that I see in my practice, when I asked them when they started using, it's usually, you know, 12, 13, 14, very young, and the brain is developing. And so, so that really is a much higher likelihood of becoming addicted. So what is addiction? We kind of think we know what addiction is, but how is it actually defined? What is the definition of addiction? What is it? So I actually want to read you the definition. It's a three part definition from the American Society of Addiction Medicine. So the first part says, addiction is a treatable, chronic medical disease involving a comp involving complex interactions among brain circuits, genetics, the environment, and an individual's life experience, just like we saw with Susan, and that we know. The second part is people with addiction use substances or engage in behaviors that can become that become compulsive and often continue despite harmful consequences. And then the third part is that prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. There again, the hope it treatment works treatment is successful. So let's talk about other chronic diseases. So if we think about chronic diseases, we often think about diabetes, high blood pressure or hypertension, asthma, those are all chronic diseases that for many people, maybe even most people with those chronic diseases, they take medications to control those so that those diseases aren't uncontrolled, aren't in a bad way. This graph in the red, you'll see it says drug dependence. This is an old slide. That's an old term for what we now know as substance use disorder. In the DSM-5, it is called substance use disorder, because that drug dependence is a very confusing term. But this basically compares those, the relapse rates. So we don't usually think of a relapse rate for asthma, but that's exactly what it is. So this is for somebody who has chronic asthma, they're usually taking an inhaler every day, once or twice a day. And if they don't take it, this graph shows us the likelihood that it's going to come back and it's going to be a bigger problem than it was without being medicated. So it's around 40-50% for all of these, including addiction. So it can be compared to other chronic diseases. Yet our beliefs and our attitudes about treatment specifically is very different for those other chronic diseases compared to addiction. And that's the stigma that we have. So I'll talk you through this. So if we look at this, we see these bars here. So this is the severity of the condition. How bad is the condition? So if we're looking here at this high blood pressure, so someone comes into their doctor's office, and they get their blood pressure taken, it's really high. It's way out of control. And they have a discussion with their provider and they decide, you know what, it's really dangerous to have this blood pressure so high. Let's see if we can get you some treatment. And so you start them on lisinopril, for example, a medication to bring the blood pressure down. They're in treatment, they're doing great, really low, and everything is going great. After a period of time, you guys may have a discussion and say, well, let's see how you do off of your meds. You might be doing okay, because you've made some changes in your diet, you've lost some weight, you seem pretty healthy. So let's see how you do. So you stop the meds. And what happens is that the blood pressure comes up. Without the meds, it's not as high as it was, because you because you have made some changes. But we're really not very surprised by this, it would have been nice if you didn't need to be on the meds. But we're not really surprised that the blood pressure comes back up. And you might need to start it on maybe on a lower dose, but you might need to get back on treatment. Right. So that's kind of how our attitude is about that treatment. With addiction treatment, it's different. We have a different mindset about it. So it's the same, if you notice, it's the same exact bars, it's the same picture. But we think about it differently. So in addiction, somebody's life is a mess. They are deep in addiction. They've lost their family, they've lost their job, they've lost everything. They are in a desperate state. And they say, I need help, please help me. Say this person has opioid addiction. So you start them on treatment, you start them on buprenorphine. They're doing great. They do great during treatment, they're on treatment for a long time. And they maybe they're on a 90 day program, and they've been totally stable. Maybe they went to inpatient or residential treatment, and they're totally stable after 90 days, and they go back home, and there is nobody to prescribe buprenorphine for them anymore. And lo and behold, they start using again, they return to using. And it's not it shouldn't be a surprise. This medication was working, treatment was working. But the thing about this is that somehow we're surprised by this. We sent you off to treatment, you were there for 90 whole days, and you were doing great. What's wrong with you? It failed. Treatment didn't work. You're back to your same old stuff. So that's our attitude about it. That's, that's our problem. That's not the treatments problem. What we should be thinking is that treatment worked. How can we get you back on that treatment because you were doing so great. So again, that's, that's stigma. Oh, and again, we have a pretty picture. So we're going to do a poll. This is the last poll. All right. This one is, I will launch it. And okay, so this is a two parter. It says, the first part is addiction is best described as, is it a chronic disease involving complex interactions among brain circuits, genetics, the environment and an individual's experiences, or a moral failure that is a choice made by each person, or an absence of positive environmental and psychosocial settings, or learned behavior arising for only from negative environmental influences. The second part is, I have a clear understanding of how to diagnose someone with opioid use disorder. Is that true or false for you? Do you know how we actually make the diagnosis of an opioid use disorder? So I will end the poll. Get your answers in. I will share the results and let's see what we got. So 100% of you got the answer right about what addiction is. I'm so proud. Okay, and actually 77% of you say that you have that you know how to diagnose someone with opioid use disorder. So that's cool. I love it. Okay. So that's actually very helpful and very impressive, actually. So I will stop sharing that. And let's talk about how we diagnose opioid use disorder for those of you who know, and those of you who don't. So this is just a cartoon. I'm not going to go into this, but you'll have it in your slides. That sort of gives you an idea of the kinds of things that you might suspect someone has a substance use disorder. But this is not how we actually diagnose it. But these are things that you might notice about friends or family or yourself that you think, oh, maybe there's something going on here. And I want to point out what I did here. See what I did. So this is not my cartoon, but it's a criteria for substance abuse disorders, which always rubs me the wrong way. So I crossed out the AB, substance use disorders. So I always do that. I'm just such a, it's horrible. I'm always correcting things. Okay, so this is how we diagnose opioid use disorder. So this is the DSM-5 criteria. There are 11 things, 11 criteria. And people don't have to have all 11. They can have some, but not all. But the number of them that they have will determine if it's mild, moderate, or severe. The more you have, the more severe it is. But what I want to point out about this, I'm also not going to go through all of this. This is more as a reference for you guys. But the thing I want to point out about this is there are two of these 11 criteria that are physical, physiological. One is tolerance, which is the need to take more of the substance over time to achieve the same effect. So you need to take more of it. And the other is withdrawal, which we already talked about. So those are the only two physical things. All the other nine are behavioral. They're things that people do, not what happens in the body. So one thing about this diagnostic criteria, even if somebody has both of those physical things, both tolerance and withdrawal when they stop taking the medication or the drug, you cannot diagnose a use disorder based on solely those. They have to have some of the behavioral components in order to diagnose it. So 11 things is a lot. Four is easier to think of for me than 11. So I break it down into the four C's of addiction. There's craving for the substance. There's compulsion to use, always thinking about it. Hard to think about anything else, just this compulsion to keep using. There's control or lack of control over their use. And there's consequences. So continued use despite negative consequences. So that's the four C's of addiction. And again, I want to talk about dependence versus addiction and just point out that there is a difference. Just because somebody is physically dependent to a medication, which happens with other medications, not just opioids, doesn't mean that they're addicted to it. The addiction has those behavioral aspects to it. Okay, so now we're getting to talk about the FDA-approved medications that we have to treat opioid use disorder. And I alluded to this before, but we have three of them. And they're all really good. They all are amazingly effective in helping people who struggle with opioid use disorder. So they all act in different ways. But they all act on the mu receptor. So this is a graphic that shows this is what the mu receptor, this depicts the mu receptor. And so this is how the three medications work at that receptor. So methadone is the oldest of the three. It's been around for about 60 years or so. It is time tested and true. It has been through so many rigorous studies, and every time it proves effective. And clinically, it proves effective. It is a really good medication. The problem with methadone is that it's really highly regulated, and it's hard to get. And people have to go to an opioid treatment program to receive it. And often people have to go every day, or multiple times during the week, multiple days during the week. So it's, it's difficult to get it. And it's a hard program, but it's super effective. And the way that that works methadone is, it's what we call a full agonist, just like most of the other opioids that are out there, it completely binds to the receptor to that mu receptor. So that's its chemistry, it goes in there completely. And it's, because of that, there are, there are some fine points to prescribing it. So we have to be really careful when we prescribe it. And, and, and it cannot be prescribed in a doctor's office, you have to go to an opioid treatment program. And, and the folks who work at opioid treatment programs understand the nuances of it, and know how to prescribe it in a safe way. Buprenorphine, which is this second one, is an extremely effective medication. It's, it's been around since around 2000-2002 in America. And, and it is really effective. This one can be prescribed in a doctor's office, it can be prescribed by anyone who has a DEA registration. So anyone who has the ability to prescribe controlled substances can prescribe buprenorphine. That was not always the case, we used to have to have special training and a special X waiver, but not anymore. So that is fantastic. And we should all be prescribing buprenorphine from our offices for people who have opioid use disorder, if it's available, and if they want that. That works as a partial agonist. So it occupies the same receptor, but just partially, and it doesn't completely occupy it, which actually gives it a tremendous safety profile. So it is, it is easier to prescribe, it's really hard to overdose on buprenorphine, which is good, because of the chemistry of the of the molecule itself. Both buprenorphine and methadone have been shown to be extremely effective at reducing death rates for people who have opioid use disorder, and retaining people in treatment long term. Then we have naltrexone, which doesn't quite have quite the impressive effectiveness profile that methadone and buprenorphine do. But for some people, it's a godsend, and it and it works really well. It works in a totally different way. As you can see here, it's a blocker. So it sits on top of that receptor and blocks it so that nothing can get in, it does not activate the receptor at all, it just blocks it. So. So that's known as an antagonist or a blocker. So those are the three that we have. And I think that's about all I want to say about those. There's a lot to say about those. But I want to move on. So how effective are medications? Are medications, is it better to be on medications, or not on medications? If you have opioid use disorder? The answer is a resounding, it's more effective to be on medications than off of them. This is a simple study that was done in 2003. So it's an old study. But I love it because of its simplicity, it's so easy to understand. And you can see the human beings in this study. This was a study that was done, it was a randomized trial of meds versus no meds, buprenorphine versus placebo. So what happened is, everyone in this study, so there were 40 people in the study, 39 people on this chart here. And everybody had intensive relapse prevention therapy. So everyone was in therapy, everyone had monitoring, everyone was watched closely. And these folks, with the circles up here, received buprenorphine. This was a one year study. So it went out to a full year. And the folks who got buprenorphine, 75% of them were still in treatment at a year, which is fantastic. These green squares, these are the folks who got placebo. So they came into treatment, nobody made it to the whole year. Only one person made it even to two months, the vast majority of folks dropped out by the first week, and were no longer in treatment even after the first week. And the tragedy of this is that 20% of those folks who were on placebo died. And this is serious. This is really a serious finding in this, because what we have now is we have people who are seeking treatment, and not being offered effective treatment, and they're going back out and they're taking these really powerful synthetic opioids like fentanyl, and they're dying at rates higher than this. So this is the standard of care is to offer medications for opioid use disorder. And this is just another graphic showing that medications for opioid use disorder do decrease mortality. So if we, I'll just explain this one briefly, if we, if we assign the death rate of the general population as one, so randomly just say, okay, people Seems that we have a glitch. Oh, we lost Dr. Kendall. In a few seconds, she may be able to join again. Hey, I'm back. Did you miss me? Sorry, you guys. You can hear me, right? Yes, you're back. Okay, so I'm going to reshare, and I'm at a hotel, and they have been having problems with their internet, so I apologize for that. So let me share this again. Is this where we left off? Yes, this is where we left off? I can't see anybody. Okay, so if we say that this is the death rate in the general population of one, people who have opioid use disorder, this bar in red, this is people who have no treatment, and they have over six times the rates of death as the general population. For people who are on buprenorphine or methadone, this cuts, just being on the medication to treat their opioid use disorder, that cuts their risk to less than twice general population. It's still higher than general population, but it's so much lower than no treatment at all. Okay, so right here, I want to clear up some of the terminology, because it's really confusing. I've got this slide that says M-O-U-D. It says M-A-T. It says medication-assisted treatment, and it's super confusing for everybody. So M-A-T or MAT is what people call these programs, and it used to be medication-assisted treatment. There are many programs and many people who still call it medication-assisted treatment. I think that we should stop calling it medication-assisted treatment. We are moving away from that term, and the reason that that is not a great term to use anymore is that it is stigmatizing. Once again, you're setting addiction apart from other chronic diseases, and it is now in a special category. It's a special kind of outcast to say, oh, you're on medication-assisted treatment for your opioid use disorder. Really, it's just treatment for your condition. Nobody says, oh, you're taking insulin. You're on medication-assisted treatment for your diabetes. Oh, is that inhaler for your medication-assisted treatment for asthma? No, it's just my treatment. It's just treatment. So in order to preserve M-A-T, because there are lots of programs that say we have a MAT program, M-A-T, when I hear M-A-T, I think medications for addiction treatment. So it's been rebranded medications for addiction treatment. It's no longer medication-assisted treatment, and more specifically, when we're talking about opioid use disorder, it's medications for opioid use disorder, or M-O-U-D. So that's where all the terms come in. It is most accurate to say M-O-U-D, but I'm using some of these graphics that are old, and the video was using medication-assisted treatment as well, which I no longer like to use. So just share that with you to kind of help with the confusion. But we know that medication for opioid use disorder works. It reduces drug-related overdose deaths. It reduces disease like HIV and hep C. It reduces violent crimes, and treatment outcomes are much, much better when people are on medications to treat their disease than when they are not. But why don't we see more M-O-U-D out in the world? And we actually are seeing more than we used to. I've been prescribing medications for opioid use disorder for about 16, 17 years, and boy, oh boy, have I seen a huge shift in what we're seeing. So it is more accessible. It's more acceptable. It is out there more. It's easier to prescribe now. So we are seeing progress, and again, there's the hope. But we still need to see more. Why don't we see more? Some people have never heard about it. Some people do not know that there is treatment for their family member who is struggling with addiction to fentanyl. Some people don't know that it's available. Sometimes there's limited access. It's improved now since they got rid of the X waiver, but still there aren't enough people prescribing it. There are too many places that are are putting up barriers and restrictions. There are a lot of misconceptions out there about M-O-U-D. Many think that it doesn't work. There's not enough science. Well, that is not true. There's been decades of really good science that show over and over again that it is more effective to be on medications than to not be on medications if you have opioid use disorder. It's too dangerous. Well, it is not nearly as dangerous as taking using fentanyl, especially in this day and age. It's better to quit the natural way, just stopping. Well, that would be nice in an ideal world to just be able to say, okay, I'm done. But too many people are dying trying that way. Some say it's substituting one drug for another. And you actually could say that this is true. You're substituting an FDA-approved, proven medication for a drug that is quite actually likely to kill you. So, you can choose to substitute one for the other, and I would take that. Substituting one addiction for another, and that is not true because we learned about addiction is not just a physical dependence, and people will be physically dependent on their methadone or their buprenorphine as they were physically dependent on the opioids before, but they lose the behavioral components. They do not show evidence of addiction because they are not having those behavioral components anymore, and we already learned that. People are just trying to get high. That is not the case. When people are on a stable dose of their medication, they are not feeling high. They are feeling normal. They are feeling functional. They are feeling whole, and they're not getting high. They're actually, if they are not taking it, they don't feel normal. So, this kind of normalizes them. It's okay for short-term detox, but they shouldn't stay on it. That has been debunked a long time ago. Short-term detox is not treatment. People do much better when they're on treatment for a long term. They're not really clean if they're taking meds. That is just not the case. If they're not using drugs, they're not using drugs, and they're abstaining. So, the main reason that we don't see more of it is stigma. Once again, we get back to stigma, and Maya Angelou says, do the best you can until you know better. Then, when you know better, do better. So, it is upon us to do better. We need to do better right now, especially for our Native communities, because we all know that our Native communities have challenges, that there are huge challenges in Native communities, and there are high rates of traumatic exposure, high rates of suicide. But what we also know about Native communities is that there are huge strengths in Native communities, and we need to have culturally meaningful treatment and prevention strategies within Native communities that really harness those strengths and offer hope to folks. So, incorporating the traditional aspects of healing and recovery, I'm just looking at the time. I've got to wrap this up. I'm sorry. I've gone over. It's really key to have that in our programs that we're offering to folks, because it can renew a sense of personal and cultural pride. It can help people rejoin cultural practices. A lot of our folks either have lost that or never knew that. They don't have a sense of their role in their community. They don't have a sense of belonging. They don't have a sense of what it means to have cultural practices. And so, your programs can be the bridge to bring them back to themselves, because they have it within them. But they may not have grown up with it. They may have become unattached to it. And if you are offering that in your programs as part of the healing, that can be a real lifesaver for folks. And the culture itself is medicine. And I want to say something about medicine versus medication. I am a huge proponent of medication, as you've just learned in the last hour. I think medication is great. I think it works. I think it's essential to offer folks medications. But as much as they've helped, and I truly believe that Creator had a hand in developing these medications. So, there is some sacredness to these medications. But these medications that I'm talking about, buprenorphine, methadone, naltrexone, these are babies. These are babies. I'm talking about buprenorphine, methadone, naltrexone. These are babies. They're very young. They do not have the ancestral wisdom of sacred medicine. That's medicine. So, you've got medications, and you've got this medicine. So, you have the medicine that is embedded in the drum circle. You have medicine that's embedded in smudging. And you have medicine that's embedded in dancing and bird singing and traditional ceremony. And you have medicine that is in the basket. The prayers that are woven into that basket, that is medicine. And so, when we think about our programs that we're offering to Native people, we need to value that as much as medication. And there is no reason that these two things cannot coexist in our communities. So, this is my last slide, and it kind of sums it up. There is no reason that the conventional approach and the Indigenous approach cannot live side by side. So, you've got medications for opioid use disorder that can live together in these approaches. You've got psychosocial and behavioral health approaches, the conventional ones, and the added bonus of having the Indigenous approach to this. And you've got recovery-oriented activities that are more conventional, like AANA. But you also have wellbriety and ceremony. And you also have, both can have harm reduction programs. And we can indigenize our harm reduction programs to make them more meaningful. The thing that the Indigenous approach has is it has a foundation of culture. So, our programs need to be built on that foundation of culture with all of the things that the conventional approach can offer, but in a way that offers much more to the special and sacred relatives that we serve. So, that is the end of my portion of the talk. I think that because I kind of popped offline for a little bit, I want to allow time for the OTAP folks to be able to do some updates and to be able to introduce themselves, since this is the beginning of the webinar series. And so, I want to bring them in. And then maybe at the end, if there is any questions, if there are any questions, then we can return to that. Certainly, I'd be happy to, this is my contact information. You can email me and I'd be happy to engage in conversation with any of you. And then I do want to advance it. This is how to ask for help from the Opioid Response Network. We are here for you. And if this presentation has given you any ideas for, gosh, I really want to work on that. I really want to start to offer that. I want to just think about that with someone. Call the Opioid Response Network. Submit a request. There's a link here. It's probably in the chat. I can't see the chat right now, but there are links to submit a request. Reach out to us. We're here to help. And then I do want to put this up here so that you can do an evaluation of the presentation today. And I just want to reiterate that the recording will be available. I think the link is probably in the chat. We will send out a PDF of the presentation today so that you have my links and you have my information. But I do want to make space to invite Will Longinetti to speak on behalf of OTAP and the coordinated efforts that we're doing here today. Thank you so much. Thank you, Dr. Pandell, for that wonderful presentation. And I'm just going to try and jump through the slides that I have. So, if you could go over to the next slide. I just want to share some updates with our grantees that we have from SAMHSA on some things that are happening on the grant at this point. Okay, great. You can go to the next slide. So, some of these updates may or may not apply to your grant, depending on where you are. So, just keep in mind, you know, what grant year you're in. But if you have a SAMHSA TOR grant which ended on September 29th, then you should be preparing for the closeout process. And we had sent emails out about that. But if you didn't receive that email, please be sure to contact your GPO to get the instructions for closing out the grant. And we'll make these slides available as well so you can see some of the details of the closeout process. Next slide, please. And then, if you just reached the end of year one of your grant, or if you requested a no-cost extension and now you're into a third year of your grant, then you will have a progress report due by the end of December. And we had sent an email with some instructions on that as well. So, if you haven't received that, please, again, reach out to one of us at SAMHSA, one of your GPOs, and we'd be happy to help you with that. Next slide, please. And then, if you just went from year one to year two, and you had some unspent grant funds from year one, you have the option to request to carry over those unspent funds into year two. And we had sent instructions about that on September 26th. And if you need more information, and if you need more information about that, reach out to one of us. So, this is for grantees who just finished year one and are going into year two. Next slide, please. And then, if you received a supplemental TOR award from us recently for your TOR grant, we're asking you to submit a few things by the end of October, and those include an updated narrative, an SF-424A budget form, and an updated budget narrative for that supplemental award. And all of that gets uploaded to the ERA system. Next slide. And this is just a regular reminder about the GPRA data that we ask you for on this grant. So, all TOR grantees are required to collect and submit the data for the quarterly SOAR TOR program instrument. So, if that doesn't sound familiar to you, please reach out to us. Please reach out to your GPO, and we would be happy to review that with you. But you might know this as the instrument that collects information about the number of naloxone kits you purchase and distribute, naloxone trainings, fentanyl testing strips, and then a few other questions about education and outreach. Next slide, please. And then, if you're doing treatment through your TOR grant, then you should also be collecting the GPRA client-level data through the GPRA interviews for those clients and submitting that into SPARS. So, I'm pretty sure everyone has heard plenty about that. Next slide, please. And then, when we make these slides available on this slide and the next slide, you'll see this is just a sort of cheat sheet of when things are due on your grant. So, you can go to the next slide. So, we have the dates for both years one and two. Next slide, please. Next slide, please. And then, we just have the SPARS contact information. If you ever have questions about SPARS or you're having trouble logging in, you can reach out to them through this information. Next slide, please. We have a couple things coming up on the TOR grant. One is that our evaluation division at SAMHSA has coordinated a sort of listening session with TOR grantees, and that will take place on November 7th at 3 p.m. Eastern Time. And we're hoping to hear feedback from grantees about our GPRA data collection. So, if you have interest in that, be sure to register for that event. Next slide, please. And then, on November 9th, that's a Thursday at 2 p.m. Eastern Time, SAMHSA will be holding tribal consultation with tribal leaders on the upcoming TOR grant, specifically on how we determine the TOR grant awards. So, we want to hear from you about that. So, you know, that affects everyone who will be applying for the TOR grant in the future. So, be sure to check that out and register for that. And you can find more details about this event on the Federal Register through the link that's in the slides. Next slide, please. And then, we posted some brief information about the next TOR grant on grants.gov. You'll just find, you know, some of that information. The NOFO for the grant will go live, likely sometime in February or March, but you can sign up on grants.gov to be notified when that happens. Next slide, please. If you are not having regular conference calls with your TOR project officer, please reach out to us because, you know, we always want to hear from you and stay in touch. And, you know, that allows us to talk to you about your grant activities and spending and also make sure you're not having any issues with the ERA conference system. Next slide, please. And here's a list of all of our contacts, the five of us, and I think all of us are here today on the call. So, it was great to see you all. And those are the slides that I have. I know we're almost at the end of the time frame, but I'll turn it back over to Dr. Candle. Thank you. We highly encourage you may participate. That is also in the chat box. And the webinar will also be posted on the opioidresponsenetwork.org backslash TOR. We are aiming to have that posted in about two weeks, so stay tuned. Again, thank you all for joining today and spending your time with us this morning and this afternoon. Thank you. Thank you all. Bye-bye.

opioid epidemic

American Indian

Alaska Native

drug overdoses

stigma

addiction

person-first language

respiratory failure

dependence

withdrawal symptoms

buprenorphine

methadone