Thank you so much for joining us today. On behalf of the American Pharmacists Association, we would like to welcome you to today's webinar entitled Reducing the Stigma of Substance Use Disorder, Words Matter. Before we get started, I would like to ask everyone to please take a moment to download a copy of the slides that we have and follow along and prepare your responses for the upcoming assessment questions. My name is Haley Mook, and I will be your moderator today. I am a 2021 graduate of the University of Pittsburgh School of Pharmacy and currently an executive resident with the Education Department at APHA, and I'm so happy that I have the chance to serve as a moderator for today's event. I'd like to introduce you to our amazing speaker, Dr. Tom Franco, Associate Professor of Pharmacy Practice at Wilkes University. As you will see from his brief bio, Dr. Franco is a 2011 graduate of Philadelphia College of Pharmacy and completed his PGY-1 residency at the Wilkes-Barre Veterans Affairs Medical Center. After residency, he developed a pharmacist-run medication therapy management clinic focused on chronic non-cancer pain at Geisinger Medical Center in Danville, PA. He is a current coordinator for pain palliative care and addiction special interest group, and for the American Pharmacists Association, Region 2 Counselor for RHO-CHI, and is the current president of the Pennsylvania Pharmacists Association. Here are the financial disclosures from Dr. Franco, take a moment to go through it. And the ACPE information, so this is a knowledge-based activity and has been approved for pharmacists for one hour of continuing pharmacy education. That deadline to acclaim credit is December 15th. This activity was developed by the American Pharmacists Association and is supported by a grant from the Provider Clinical Support System. Funding for this activity was made possible in part by a grant from the Substance Abuse and Mental Health Services Administration. It is important to note that the views expressed in written conference materials or publications and by speakers and or moderators do not necessarily reflect the official policies of the HHS, nor does mentioning of the trade names, commercial practices, or organizations imply endorsement by the U.S. government. At this time, I'd like to take a moment to highlight two resources that PCSS offers that might be of interest. First, PCSS Mentor Program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from a mentor directory, or we are happy to pair you. To find out more, please visit our website using the link noted on this slide. And the second resource is PCSS offers a discussion forum, which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases, questions, and we also have a mentor on call each month. The person is available to address any submitted questions throughout the discussion forum, and you're able to create a new login account by clicking on the image on the slide to access the registration page. This slide notes the consortium of lead partner organizations that are part of PCSS. Again, just as a final reminder, please take time to download slides to review during this presentation and refer for later on. Give you a moment to go over the learning objectives. And now let's move on to our three pre-assessment questions. We'll allow about 10 seconds to collect your responses before advancing to the next question. These questions will be repeated at the end of the session to measure outcomes and your participation is really appreciated. First question, the mental impact of stigma included being seen as weak or lazy can instill what unhealthy notion in patients of a substance use disorder? Which of the following best represents a person-first method of addressing substance use disorder? And finally, which of the following statements regarding the evidence of buprenorphine use is true? Thank you so much for participating in our polling questions, and now let's begin the presentation. Abega, welcome to our speaker, Dr. Tom Franco. Welcome to the presentation, Tom. Thank you for having me, and good afternoon, everyone, or good morning, if you're out on the West. I'm happy to be with all of you today. So we're going to talk about stigma and what stigma is and how stigma impacts our patients with substance use disorder. So we have to first understand what stigma is, and it's often based on myth or prejudice or superstition. It's associated with a specific group of people that, unfortunately, society determines to be undesirable. And stigma, unfortunately, impacts multiple people across the country, and it can be from health care where we're at now to even still in other aspects of life. I can say that as an avid sports fan and as an Eagles fan, I can say that, well, I have a stigma against people that like the Cowboys because they just don't think right. And obviously, that's not the case. My best friend is a Cowboys fan. While physical manifestations are possible, the mental impact of stigma is what we really focus in on. Unfortunately, the physical violence that can come from stigma is real, but what we don't see is the internal issue that happens. A lot of times, stigma forces people to feel a certain way and can exacerbate notions like depression or anxiety. And if the last 18 months haven't taught us anything, it's that mental health is real, and the effect of stigma on that health can be really traumatic. Now, we know that stigma has a greater impact on negative quality of life than other social determinants of health, such as race or socioeconomic status. So when we look at all of the different things that negatively or put people behind the 8 ball, be it where they live, where they're from, what they look like, all of these things that shouldn't play an issue but unfortunately do, we know that the stigma that goes into certain disease states really does play the biggest impact in whether or not people seek appropriate care. Now, when we talk about stigma as it relates to substance use disorder, we see that it is a major barrier to people getting access to treatment. When we look holistically at the data, we see that one of the biggest reasons, in fact, probably the biggest reason people do not go to get help is that they don't know where to go. But the stigma that can come from the fear of the negative responses from public, loved ones, employers, act as a major barrier to care. People don't want to be known as needing to get help for a substance use disorder. The stigma in society, while it has improved over the last decade, is certainly still reasonably high. These two words you see there, people that's weak or lazy, that notion of, oh, come on, just stop and get over it. That's really difficult. Like, let's play a game right now. Let's have everybody who's out there think about an animal, a real one, not like a Harry Potter animal, a real animal, but it cannot be a zebra. How many people are thinking about zebras? When we are told, just don't do something, we're naturally wanting to do it. Like, now, how many times I'm told to clean my room? It just happens. That's who we are as people. But we know that this labeling of people being seen as weak or lazy and this notion of rejection can lead to a worsening of what's known as unhealthy shame. Now, addiction or substance use disorder, otherwise known as addiction, is hallmarked by unhealthy shame. And that can lead people down a negative shame cycle of anxiety, stress, craving, and use. And let's, you know, think back to Star Wars Episode I, you know, with Jar Jar Binks and all that in it. I know it might be a little painful for some. But there's a scene in that movie where Yoda is talking to little Anakin Skywalker, and he says, we're not going to train you to be a Jedi, because I sense great fear in you. And fear leads to anger. Anger leads to hate. Hate leads to suffering. Well, it's the same thing here. Using causes people to feel shameful, because nobody wakes up in the morning and says, man, you know what I really want to do today? I totally want to use heroin. Nobody wants to do that. So they feel shameful. And it's different from guilt. Guilt is, I feel bad because I had a transgression against another. Shame is a notion of letting yourself down. I often talk to students and say, maybe you studied really hard for a test and you didn't do that well on it. You feel that sense of letdown. That's shame that can be building. And this unhealthy shame can lead to a notion of, am I worth it? Am I worth it as an individual? And it leads to ultimately people feeling a lack of love. And it's if I can't love me, do other people love me? Am I worthy of love from others? And that can lead to a notion of anxiety, crippling anxiety at times as well. And as that anxiety builds and builds and builds, it leads to stress, because we know that anxiety is connected to stress. And when we're under stress, the brain of someone who has an addiction perceives that stress at the level of life and death. And the only way to cure that stress is the drug. And they're going to feel that through craving, which is the true suffering of addiction. And that crave is going to build up to eventually they use, and the whole cycle is going to repeat itself. So what we need to try to do is break that chain cycle. And by correcting how we address addiction, and the stigma that goes with it, will help break it. Because the more we can help people realize that love is something they of course are deserving of, they're deserving of that because they're human, that's going to help them on the path towards recovery. Now in terms of a barrier to care, it's patients with substance use disorder, they don't also see things that the general public can see as well. So we see here a lack of qualified providers and treatment facilities. There's not a lot of physicians out there, or nurse practitioners or physician assistants that have a data waiver, so the X in front of their DEA license to prescribe buprenorphine. Not a lot of physicians want that. There's a fear amongst physicians of DEA oversight, excessive regulation, and excessive cost. Some states, Pennsylvania included, has proposed legislation to add added financial concerns to prescribers to get their data waiver. Treatment facilities is another one. A lot of communities don't want treatment facilities in it because they're afraid that well it could bring in a certain clientele of people, there's that stigma. It could lower home prices, there's that stigma. So there's not a lot of places for people to go or a lot of people to see. We see that there's limited insurance coverage for treatment. Not a lot of insurances want to have it, not a lot of people want to add it to their insurance because when they go to apply for life insurance, even simple things like getting a naloxone at your pharmacy, a life insurance company may see that and say, whoa, we think that there might be a problem here and you might get denied or have a higher premium to pay. Strong social pressures just to quit it or get over it, I relate you back to the zebra example. Just saying quit it, it's like telling someone with diabetes, well just tell your pancreas to make more insulin, like what's up with that, you should be able to do that. It's not like that. Even still, we're seeing growth with things like depression, where even up until a few years ago it was, why are you sad? You might have money, you have a home, just suck it up. We know that that's not the case. If there ever was an unfortunate poster child for how mental health can really impact people, Robin Williams, without question Robin Williams. We never would have thought, child of the 90s, grew up with the genie and Mrs. Doubtfire, we never would have thought that Robin Williams had major depression. If someone of his comedic prowess could lead to suicide because of his mental health and in turn his alcohol use, it really started to shed light on the need to accept mental health just as we do physical. Lastly, the notion that addiction is a choice rather than a disease. We're going to talk about that today, about how that's just not true. We're getting better at recognizing that addiction is a disease and it 100% is. I think one thing that we can do as pharmacists is being the most accessible healthcare provider. Most community pharmacists see their patients about 35 times a year. That's 35 opportunities to provide education to a patient, not just about their medication, but about healthcare things in general. How much are we educating people about COVID vaccine right now? We can be doing a lot to advocate and educate on behalf of patients who have substance use disorder. It's a great way that pharmacists can get involved. As far as social issues go, there are things that stigma can further impact patients with substance use disorder. Many in our society still view addiction as a criminal justice issue rather than a healthcare issue and that we will just arrest our way out of it. That's patently not true. That was what the notion of the war on drugs was and still is. The war on drugs, we can tell, just didn't work. How many people are in jail for having a drug-related problem? Arresting our way out of this is not the answer. This is a healthcare concern. We also see that in terms of the legal system, patients with a substance use disorder are, again, put at a disadvantage. They're put behind the eight ball right from the get-go. That's either as the plaintiff or the defendant. They're more likely to be the victim of violent crime. They're also less likely to be believed when it comes to reporting a crime. It puts them at a disadvantage there. There's difficulty for patients with substance use disorder to find reliable housing. Like I said, many communities don't want treatment facilities there, clientele, housing prices. It's not what they want. There was a big pushback in Philadelphia when there was thought about putting in a safe injection facility. This was a couple of years ago. Huge pushback. People did not want it. It's near a school. We don't want our kids exposed to this. We don't want it here. Where are these folks going to go and try to get help? Then available housing often has strict rules and limit family visits. It might be so-called sober housing or abstinence housing, or family can only come at certain times. Remember, this addiction is a disease of the recluse. It's not you're out in public doing any of this stuff. It's oftentimes very private, very intimate. Not having that love, that support structure of loved ones, family, can really impact the depression that goes into substance use disorder. Lastly, there could be difficulty finding employment, difficulty from quality care from the healthcare industry, and retaining friends and family. A lot of employers will say, hey, you were arrested, you have a felony charge, or you have this drug problem. No, you're not allowed to work here. A lot of times, we even see that pejorative language in the charts that physicians or any healthcare person writes can negatively impact the quality of care down the line. Lastly, retaining friends and family, a lot of people still feel that this is a choice. If you can't get over it, you're weak, you're less than human, and we want nothing to do with you. That goes back to that, if my loved ones don't love me, am I worthy of love from anywhere? There's that shame cycle that can start to come about. We can see how stigma impacts not just how one feels personally, but we see how stigma can impact how people are treated by society and some of the extra hurdles and barriers that they have to overcome just to try to treat a condition. I always tell my students, imagine if this was someone with diabetes or COPD, if they had to go through all of this to try to get help. That would be insane. We need to try to do better as a society, and we are, but we still have a room to grow to try to improve the stigma so that these people can get better access to care. How can we start doing this? The first thing we need to do is we need to start thinking about how we address substance use disorder and patients with it. This is a highlight taken out of a document that was created by APHA, and it's available online. If you just Google, the link is included at the bottom. It's called Let's Talk About Naloxone. It's a one-page front and back document that can be hung up in any pharmacy or any healthcare setting that has evidence about naloxone as well as how to effectively communicate about it to a variety of different patients. But this is a section of it that focuses in on preferred language to use when addressing substance use disorder. You can see some of them there. We see that it's no longer referred to as an abuser or an addict. You're a person with a substance use disorder. We never want to label people by the disease that they have. Same with someone has clean needles or dirty needles or clean urine or dirty urine. I always found that one funny. Someone says, oh, they popped dirty urine. I'm like, what is it? Are they like urinating mud or like are they urinating soda or what? It's either positive or negative. It's a sterile needle or a not sterile or used needle. The big one, though, to focus in on here is the term overdose. We want to try to get away from it because let's put it in context. We can all think back to the three prime questions we learned in school. What was it for? What did you tell you to expect? How you're told to use it? One common thing when it comes to talking about naloxone with people is here's let's put it into some perspective. Here's this medication, naloxone. In case you overdose on this, on your opioid medication, this medication known as naloxone is there to help you. Sounds pretty innocuous, right? But think about it. In case you overdose, that gives that notion of the overdose is your fault. And if I have a substance use disorder and it's a disease hallmarked by shame, that overdose was my fault. It's on me. It's all on me. I'm the problem. I'm the one who doesn't deserve to have anything. Now let's rephrase that to what we now recommend, which is bad reaction or breathing emergency. Let's rephrase that whole conversation. Hi, in case this medication causes a bad reaction, wherein you have a breathing emergency, there's a medication known as naloxone, which is there to help reverse that. See how it sounds now? See how it's now this medication may cause this. The onus is now on the drug. The onus is not on the individual and that helps break that shame cycle and that's what we want to try to get at. Now, yeah, it's going to take time to incorporate that into our normal vernacular, but it's something that we should do to try to improve the care of patients across the board. This is just kind of going back at some of the things I just said. We don't want to use terms like junkie or addict, even in more colloquial things. We might not be referring to someone who has an addiction, but you'll say like, I really like chocolate, probably eat too much chocolate. So I could go to someone and say, oh, I'm just like a chocolate junkie. It's natural sometimes for us to say that. We want to try to get away from it because it perpetuates that stigma. We always want to try to put the patient first. It's a person with a substance use disorder. It's a person who has an alcohol use disorder. That's what we want to try to focus in on. Remember that respiratory depression is a side effect of opioids. It's not a failing of the individual. The individual didn't choose to stop breathing. It's not their fault. The drug tells their brain, breathing, breathing, eh, you don't got to worry about that. So let's call it like it is. Just like with ACE inhibitors, we say that they cause a cough. The person doesn't choose to start coughing. Same thing here. Let's call a side effect what it is. And pharmacists should act as a provider of care, not a barrier to treatment. Oftentimes we might hear ourselves or our colleagues, if we have a prescription come in, they may say, oh, well, we can't fill this today. Sorry, we can't fill it. They may, you know, no malintent involved, just so you know it's not in stock. You can't fill it today. But we can't. That's just telling a patient no. And a lot of times when patients get told no, they'll shut down. They'll go into their shell and they won't know what to do. Also remember that a lot of pharmacies don't stock buprenorphine products. Several don't. So they might be limited in where they can go. And maybe they don't have reliable transportation to get to the next town over where the next pharmacy may be, especially if they're in maybe a more rural part of the country. So try instead, how can we phrase this differently? Well, it says here we understand this medication is important. Now, while we cannot fill it today, we can get it for you tomorrow. Do you have enough until then? That way it shows the patient that we're not just outright turning you away. We recognize why this is important to you, and we're gonna do what we can to try to help you. Doing that's gonna further build that trust relationship that the patient has with you and let them know that you're on their side. And maybe you're the only person that day that has been on their side. And that can make a huge difference in that patient's life. So just again, that new vocabulary that we want to try to incorporate. The more we do it, the more other folks are going to start to do it as well. Now, this is a big one. I've seen this a lot with my patients, that there's a notion among some patients that withdrawal means addiction. I remember I had a patient a few years ago who said he was taking opioids for chronic pain and he said, if I stop taking these, I get really sick and I get shaky and I throw up. I'm addicted to it. That's what that means. And a lot of times patients confuse the two. So something that we can do as pharmacists right from the outset on that first fill and even just as good education along the way for people who are on chronic opioid therapy is to make patients aware of the difference between withdrawal and addiction. And withdrawal as a sign of physical dependence is normal. It's natural. You could get withdrawal after a few days of being on an opioid. You can get withdrawals from cold shirkings, depression medicines. Withdrawal from beta blockers causes rebound tachycardia. So we know that withdrawal is normal. It's natural. It's not a sign of addiction. It could be considered part of it if other things are present, but in and of itself isn't. Addiction is defined as a maladaptive pattern of use that leads to significant impairment or distress. Basically it's saying doing the same thing despite the negative consequences associated with it. Wow, I know that having that drink results in me not being able to care for my kids, not being able to maintain a job, getting arrested, getting DUIs, but I'm gonna keep drinking anyways. That's more in line with addiction than I take a couple of days of an opioid and I got shakes and diarrhea after I stopped taking the cold turkey. That's why I said the key point, that negative consequences. And that's important for patients to realize because if they misconstrued what addiction is, when someone who actually has one comes in, it could lead to that, well, they could just stop. So why can't I? Am I not strong enough to do it? And that's where we get that notion of I just stopped doing it and I was fine. Well, I'm proud of you, but you never really had an addiction because addiction can't just flip the light switch and make it stop. So as we educate more patients, let's have this be a great piece of education that we can give to help diminish some of those concerns long-term. Now one thing that we also can do to educate patients is provide them with the insight that substance use disorder is in fact a disease. It's a mental health condition, not undifferent than depression, anxiety, bipolar disorder. It's not curable, but we can treat it. But we have to understand how it happens in order to understand how to treat it. So like I said, we do have evidence to demonstrate that this is in fact a disease. It is not a choice. It is not a moral failure. There are genetic risk factors that go into play. Certainly a family history of it can. And there has to be environmental issues that usually turn those genes on. So a significant family history is genetic, but a history of trauma. It can even be trauma to mom, and that could impact, you know, baby as well. So there's a lot of issues that go on behind it. We see that chronic opioid use always carries the risk of developing an opioid use disorder, but it is not a guarantee. It's not a slam dunk. We do see that the minority of patients who are taking chronic opioids develop an opioid use disorder, roughly only about 8 to 12%. Now I say only 8 to 12%, but when we look at the amount of people who are prescribed chronic opioids, 8 to 12% is a lot of people. It's a lot more than what, you know, was touted back in the 90s, where it was basically, oh, less than 1%. It doesn't happen. No, it happens, and it did happen. And it's unfortunately going to continue to. But when we flip that number around and we look at the number of people who are misusing heroin, we see that about 80% of them got their start with a prescription opioid. So while not everybody who's on an opioid for chronic pain is going to develop an opioid use disorder, almost everyone who has a heroin use disorder got their start from a prescription opioid. Now when we look at the actual pathophysiology in the brain, we see that there are three main areas that are impacted. There's the basal ganglia, the extended amygdala, and the prefrontal cortex. And all three of these are going to be impacted in one way or another, and ultimately work together to demonstrate why someone with a substance use disorder does the things that they do. We're going to talk about them moving on to the next slide. So the first one up is the basal ganglia. This is where sort of the bread and butter start to happen. The basal ganglia contains the ventral tegmental area, which makes dopamine. And dopamine is what substance use disorder is all built around. Dopamine is the happy hormone, makes you feel great, makes you feel good. You can guarantee that I'm going to have a lot of dopamine when the Spider-Man trailer drops tonight, clearly as the Marvel fan that I am. Dopamine then activates the nucleus accumbens and the dorsal striatum. Those are two areas that are in the part of our brain that we really can't control. Part of our brain that's been around when we were like fighting the mastodons and living in caves that helped us survive as a species. The nucleus accumbens is responsible for motivation and rewards. So when we think about, wow, when I eat chocolate cake, I feel really good. I should have chocolate cake or I'm having a bad day. Chocolate cake makes me feel good. I'm going to have a piece of chocolate cake. That's your nucleus accumbens going, hey, chocolate cake equals feeling good. That's great. Then you have the dorsal striatum, which is responsible for habits and behavior. Wow. When I go for a run, I feel really good. Running equals feeling good. So I should continue, the more I run, the more, the better I'm going to feel. So we know that these two areas were responsible for the earliest etiology of humans to be able to survive. It taught people, our early species, how to get by. As it told us, these things are good. You should continue to do them. That's how we were able to survive up until now. Now what happens is that the brain is hijacked. These pathways are hijacked by the drug or the acts, right? Because this could be gambling. This could be binge eating. It is, those pathways are hijacked and oceans of dopamine are produced. Tremendous amounts of dopamine are produced. The more and more that that's produced, the more and more the brain goes, oh, this feels really good. We need that. We need that. We need that to a point that the drug becomes essential to life itself. It overtakes everything, eating, sleeping, self-defense, drinking water. Nothing is more important in your brain's eyes than that drug. That drug equals life. It equals survival. And remember, this is a part of our brain that we can control. It's so powerful that the brain can associate external stimuli, like seeing a needle or seeing that phone that you, or that phone booth, if we have phone booths anymore, or that gas station or that corner where you used to buy your drugs. Seeing that, even 20 years into recovery, can trigger that dopamine surge and there's that crave that starts to come back. Now chronic use of that drug results in downregulating D2 receptors resulting in what's known as anhedonia, or not feeling pleasure at once pleasurable things. That's, my wife and I are giant Disney people, so that would be like us going to Disney World and just going, meh. That would be known as anhedonia. So we can see that that inability to feel pleasure is ultimately at the crux of what happens with substance use disorder. Now the basal ganglia is only part of it. The external amygdala, which is on the next slide, is going to talk about how our brain perceives stress. Now remember, this is all back to that shame cycle. That stress can lead to craving. Now the extent of the amygdala manages our fight-or-flight system. This is that fight it or get out of here. Again, primal. We don't have control over it. We don't have control over how we respond to instant fear. Are we gonna punch something? Are we gonna run away? It also regulates our emotions, like irritability and anxiety. Now when abstaining from the drug, when the person's not using, there's high levels of corticotropin releasing factor and dynorphin gets released in response to stress. Now when we couple that high level of neurotransmitter stress with the physical symptoms of withdrawal, we see that that produces an insane level of stress to a point where the brain goes, without the drug you're gonna die. The drug, the drug, the drug, the drug, the drug. Go, go, go, go, go. And eventually you'll end up wanting to use. The brain's gonna say, without that drug, without that needle, without that drink, without going to the casino, game's over. You're not gonna make it. And we know how hard it is. Now some of us have noticed this before. If you've ever experienced the notion of being hangry, you know what this is like. You know how when you're hangry, you will, you will like push someone down a flight of stairs to get some nachos. We've all been there and we all probably have or should have a shirt that says, I'm sorry for what I said, I was hangry. That's very tangentially what we can say that this feeling is like. We don't want to do these things, but we almost don't feel like we have control over our abilities to do it. Now the last part of the cycle is on the prefrontal cortex, which is on the next slide. And the prefrontal cortex is the part of our brain that has the highest level of evolution behind it. It's responsible for decision-making and organizing thoughts and regulating our actions and our impulses. It's the last part of our brain to develop. It doesn't develop until we're kind of in our early to mid-20s, which is partially why the drinking age is 21. When it's exposed to external stimuli, it can release glutamate, which excites areas of the midbrain, resulting in an urge to use. And when that urge to use starts cranking, the prefrontal cortex loses the ability to self-regulate and it results in compromised decision-making. In fact, we have functional MRI scans where you scan the brain and it's all different colors. When someone is in the notion of extreme craving, the prefrontal cortex is completely turned off, which makes you realize that when people do the bad things that are associated with addiction, they neglect their kids, they quit their job, they get arrested, they rob a KFC, like all of that, I'm not condoning it by any stretch, but I'm trying to make us understand where it comes from and why it comes from. Now in terms of pharmacotherapy, we have options, which is great, and there are three main agents utilized. Naltrexone, methadone, and buprenorphine. While not a form of treatment also, we do realize that the life-saving medication naloxone is critical in the approach to substance use disorder. We're going to talk about that in just a bit. Unfortunately, much like the condition, the treatment is also incredibly stigmatized. So we have both battles we got to try to fight, the condition itself as well as how can we get above the treatment. We're going to talk about some of the myths associated with treatment in just a bit. Now methadone has been our oldie but goodie, been around for a long time. Full mu agonist, but unfortunately has complex kinetics, half-life of 5 to 120 hours. So that's a bit much. It can cause QT prolongation, so there's a recommendation that we get EKGs at baseline one month after initiation and then annually. And as pharmacists, we should be conducting prospective drug reviews at every opportunity to see if there's other medications on the profile that can prolong the QTC. Now when used for maintenance for a recovery for opioid use disorder, it has to be dispensed from a federally licensed facilities, which means it might not be tracked in your state prescription drug monitoring program or PDMP, which is why we have to do a med rec at every visit. Now the intricate nature of methadone is a bit beyond the purview of our presentation here, but there are several presentations available on APHA's website that you could check out to learn a little bit more about how to manage methadone. Now naloxone though, naloxone gets a bad rap. You can see so many myths that are out there about it. I wanted to share some of them with you and talk about the evidence. This way we can get out there and try to combat some of that misinformation that's going on. First here, naloxone enables drug use. No, there's actually no evidence to suggest that. In fact, there's evidence to show that in areas of high naloxone accessibility, there's a 63% decrease in ER visits associated with opiates. I often tell people naloxone enables one and only one thing, and that's your ability to breathe. Naloxone is only for those with a substance use disorder. Not the case. Evidence shows that 97% of patients on chronic opioid therapy believe they should have naloxone. In Pennsylvania, when we look at the last few years, the number one age group that has death associated with opioid induced respiratory depression from prescription drugs are people over the age of 75, which leads me to think that there's either an overprescribing problem or the more likely seniors get confused. My grandmother's right off the boat from Italy, cannot speak English very well, and it's 95. If she if you she had a prescription that said take one or two tablets every 4 to 6 hours as needed, I guarantee you she would get confused. So it's for everyone. It's a safety precaution at the end of the day. It's not just for people who have an addiction. It's a waste of taxpayer money. This was a big one. I noticed out in, I believe it was Ohio, people were saying, oh, we can't have naloxone. I'm not gonna give it was a sheriff. I'm not gonna give it to people. It's a waste of money. Not the case. We see that it's actually a cost saving measure in terms of money generated for quality of life you're safe. And lastly, that they result in Narcan parties. If you haven't heard of these, it's a theoretical concept where people are gonna get together, purposefully go into respiratory depression, but it's okay. Someone's there with naloxone to wake them up, and the party continues. And there's no empiric evidence that this actually happens. It would it would also cost way too much money, and you'd be putting people into opiate withdrawal, so it's not like they're gonna want to continue partying after that happens. So this is more of a scare tactic more than anything. In terms of access to buprenorphine, this is something that we can try to do to improve overall patient care. Increasing rates of non-prescription use of buprenorphine though is kind of a concern to some people. Now we do see that 56% of high-risk counties, this is CDC data, 56% of high-risk counties lack the ability to provide adequate buprenorphine services to patients. So the majority of the counties that need help don't have the ability to do it. One in five treatment gap nationally, meaning 30 million people do not have access to care who need it. That's crazy. Most people who use non-prescription buprenorphine don't do it to try to get high or to try to get euphoria. They're doing it to minimize the symptoms of withdrawal. It clearly demonstrates the functionality of the prefrontal cortex. If they're going, wow, I can either use heroin or fentanyl or I can use this. I'm not from from buprenorphine. I'm not going to go into respiratory depression. I'm not gonna get HIV or hep C from using a needle. I'm going to mitigate the symptoms and continue to live. That shows that they're making a step towards recovery. Now recent changes in HHS regulations around guidelines for prescribing buprenorphine for up to 30 patients may help. But like I said, a lot of prescribers are hesitant of getting data waived because of regulatory issues or scrutiny from law enforcement. And even physicians who do have their data waiver aren't prescribing to the max amount that's permitted just because there's a great deal of fear behind it. There's also a great deal of fear behind stocking this stuff in pharmacies, from DEA oversight to issues with wholesalers. So we see that access is a tremendous problem, but what we can try to do is educate people about the benefits of this to hopefully improve that long-term. Now, there are plenty of urban legends, we'll call it, about buprenorphine, and I wanted to share much like with naloxone, some of them here. So buprenorphine is trading one addiction for another. No, it's not. Remember, addiction is doing the same thing despite the negative consequences. But when we look at people who are taking buprenorphine, we see that they're much more likely to stay out of jail, maintain a job, be there for their kids. And we also know that treatment programs that utilize buprenorphine have a greater success outcome and less people dying compared to abstinence-based. So by definition, being on buprenorphine is not trading one addiction for another because the social symptoms aren't present like they are with people who are not taking. Buprenorphine should be weaned in time. Again, no real evidence exists to say that after X period of time, you must wean off of this stuff. It's like telling someone with diabetes, well, you gotta stop that insulin after two years. You've just had enough. Like, we wouldn't say that. So there's no reason to do that to people who are on buprenorphine. It's more difficult to manage than other forms of pharmacotherapy. And not true. It's a mu-agonist with a ceiling effect. The dose will plateau in time. So it minimizes the risk of euphoria and respiratory depression. Furthermore, medications like insulin or warfarin, where pharmacists have made their bread and butter in co-ed clinics and diabetes clinics, are way more likely to cause harm to someone, whether it be hypoglycemia or bleeding with those drugs, than it is to cause harm with buprenorphine. Buprenorphine without counseling or behavioral modification is not effective. It's something you have to go to counseling. And yes, counseling is incredibly important. And the behavioral therapy associated with recovery is incredibly important. But we shouldn't use that as a barrier to getting people on to help. Remember, people on buprenorphine have better outcomes than people who are on abstinence-based treatment. So if somebody doesn't want to go to counseling, we shouldn't say, well, then you get nothing. We should say, okay, well, here's your buprenorphine and engage in some motivational interviewing at every opportunity, be it at their pharmacy and at their prescriber's office, to try to help them find the benefit of going into some type of counseling. Same goes with benzodiazepines. Shouldn't give it with benzodiazepines at all. And evidence shows that the combination of buprenorphine plus any benzodiazepine has less incidence of respiratory depression than withholding buprenorphine because of the risk of a relapse. So if it's benzodiazepine plus buprenorphine or nothing, that person may get their benzodiazepine. And for all we know, they're gonna go out and buy heroin laced with fentanyl on the street, game's over. So we know that the benefit is still there. So at the end of the day, all these myths are just that. They're based on conjecture. They're based on negative perceptions or urban legend. We have to follow the evidence and what the evidence tells us. And clearly this medication is safe. It is effective. And when used to help people, it helps them maintain their recovery. Now, what can we do as pharmacists? Well, we can advocate for the ability to prescribe and manage buprenorphine, much like we do with a lot of our co-ed clinics or diabetes clinics. 90% of the US population lives within five miles of a pharmacy. That's tremendous. And remember, community pharmacists see patients on average 35 times a year. Wonderful opportunity for us to get involved. And we can act to supplement the role of the physician, not supplant the role of the physician in high-risk areas and connect patients to other community resources like 12-step, AA, NA, Al-Anon. There are plenty of opportunities for us to act as coordinators of care. And I think it's important to realize pharmacists do not want to play physician. We do not want to be the physician. We want to be a teammate, a vital player on the team. And the more we can get brought onto the field, the better it's going to be for everyone. We also want to consider investing in telehealth. If nothing else, COVID has taught us telehealth is here to stay. Most common reason people don't go to get help, don't know where to go to get it. In 2018, 17 million people who needed help did not go get it. Now, evidence shows that pharmacists' involvement in telehealth improves outcomes. So if we can get involved in telehealth to not only manage meds, but also coordinate care and direct people to community resources, that's a great way to help take care to where people are, especially in rural areas or where people lack adequate transportation. There's a really great way to help pharmacists get involved. We want to provide education on proper medication disposal or put a take-back box in your pharmacy if you can do that. We want to utilize the Prescription Drug Monitoring Program in your state as a method to engage in conversation rather than a tool to remove someone from your practice. So if something's amiss on your PDMP, sit down, not indifferent than if somebody spiked a 500 on a random glucose test. It's an opportunity to engage in a conversation to try to help the person find help. And lastly, seek educational opportunities on substance use disorder. I included a link here for you to check out the APHA Institute on Substance Use Disorder. It's held annually at the University of Utah in Salt Lake City. I've gone several times. I intend to go every time it's offered. It's a beautiful program. It's eye-opening. It's one of the most powerful conferences I've been to. I'd encourage you, if you have not gone to Utah, to check it out. I believe it's going to be held in June of this year. Really encourage it. So in summary, stigma leads to exacerbating unhealthy shame, which can lead to further use or relapse in our patients. Substance use disorder is a disease. It is a mental health condition. It is not a choice. It is not a moral failure. It has a clear disease model and clear opportunities for treatment that are evidence-based at that. Evidence exists to demonstrate the importance of pharmacotherapy for substance use disorder. We talked about it, the benefit of buprenorphine to get people to have a job, stay out of jail, be with their kids. It's not trading one addiction for another. And they can use it to help maintain a normal life or at least as normal as they can. And utilizing person-first communication techniques can improve stigma, help get rid of it, and ongoing work to adjust social culture to consistently use that language as necessary. I'm not going to sit here and tell you that I'm perfect at it. I'm not, you know, I'm human. I'm going to make mistakes, but I'm trying my best to improve the way that I communicate about this with my students, with my physician colleagues, and with folks in my state. And I'd encourage you to do the same. Remember, we all can just learn and become a little bit better each one day at a time. Now I guess we'll turn it over to you guys for questions. Are controlled substance use laws based on stigma associated with substance use disorder? As far as I could tell, no. The federal government has strict guidelines into what constitutes C1 through five. So that would be more of the definition of the law and, you know, their physical and psychological potentials for addiction, rather than, oh, this drug is highly stigmatized, so we're going to purposefully, or even, you know, an unconscious bias, schedule it in a certain way. There's strict criteria for them to follow, so I would go with, I hope not. The next question has two parts. What is non-prescription buprenorphine? And is buprenorphine with benzodiazepines considered a red flag? So what is non-prescription buprenorphine? It's buprenorphine that somebody would buy on the street. We're not wanting to go to, say, things like illicit or illegal, because, again, that has that notion of you're doing something wrong, when in reality, the person's just trying to help themselves because they don't know where to go to get prescription buprenorphine. Or maybe they can't find a pharmacy that's toxic or their insurance doesn't cover it. So that's why when we say non-prescription, it's meant to try to help take stigma out of it. And is a red flag, or is buprenorphine plus benzo a red flag? It could be. There are a lot of things that could be considered red flags. I would look at it as an opportunity to engage in a conversation. If I saw someone with a benzodiazepine and buprenorphine, I'd sit down and be like, hey, so tell me, I'm just curious, how often do you take this? Why do you feel you need it? What other options have you explored? Now, there's a way to provide our so-called clinical intervention in the community setting. But is it something that I'm gonna look at and go completely no way, hardcore contraindication, no? Again, that's like seeing someone on insulin walking in with a Dairy Queen blizzard has a red flag to engage in conversation. What is your view for using naloxone for alcohol use disorder? So view on naloxone for alcohol use disorder. Unfortunately, naloxone won't work for alcohol use disorder. Naloxone is a full antagonist of mu kappa delta. So it would work for any and all opioid, but alcohol, unfortunately not. Best thing we could do for alcohol intoxication is get the person into supportive care. And if it's an ongoing issue, get them into a detox program. Is buprenorphine something that you would advocate for a patient to be on long-term to manage opioid dependence? Yes, I would. I would say as long as the patient feels that they are receiving benefit from it and they're living a good life and they're happy and they're doing all the things that they were unable to do as part of their addiction, then yes, they stay on it as long as they feel it's beneficial for them. Can you speak on Generation Rx as prevention curriculum and how it's implemented? A huge question. Generation Rx is a prevention curriculum. I can touch base about what we did at our school. We're working to follow the guidelines set out by AACP that came out in 2020. So we do naloxone training to all of our P1 students in the spring semester. They're taught pain management and opioids in the P2 year. And then in the P3 year, they're taught pharmacotherapy for substance use disorder. They're taught SBIRT, so screening, brief intervention, referral treatment. They're given a refresher on naloxone therapy and we talk about stigma. We also have an elective course in pain and addiction where we talk about stigma and we do a lot of active learning in there. And then students on my rotation get exposure to a half day a week substance use disorder program where they are involved with buprenorphine prescribing. Is there a standard for reducing buprenorphine for recovery? Not that I'm aware of. There's some suggestions to say, reevaluate after certain periods of time, but in terms of at X time back down the dose, nothing that's out there. And in terms of weaning, we would just follow half-life of the drug, wait till new steady states and incorporate mental, the mental side of it in there as well. How can a pharmacist learn more about substance use disorder from APHA? Yeah, so within APHA, there's the opioid resource page, which has a lot of great information. There's a lot of CE programs that are available via APHA that you can check out some as long as two hours and some as short as a couple of minutes. So I'd encourage you to check that out. Like I said, there's the APHA Institute that's held at the Salt Lake City every year. It's a phenomenal, I cannot speak more highly about that program. It's amazing. There's of course content at the annual conference that is offered. And then I know that APHA has links to SAMHSA, Substance Abuse and Mental Health Services Administration's website, as well as NIDA, National Institute of Drug Abuse. There's a lot of information about stigma reduction. A lot of the data from this presentation was found at those sites. So I'd encourage you to check out SAMHSA and NIDA's website as well as APHA's to learn a little bit more. How do you manage medication for alcohol use and heroin use disorder? Do you provide the liparium taper and concurrent buprenorphine? That's needs to be shared decision-making right there. That's something that, you know, you would need a physician, preferably someone addiction medicine certified to be there because there's more than just the drug. There's physical conditions that are going on, current conditions that are happening. We have to look at where the patient's located. Is this something that's going to be done at home? Are they gonna in a detox facility? Are they in the hospital? So we need to look at, that needs to be more team decision-making. I would say that, again, this is pure anecdotally from what I have seen in my own time. I have seen patients given flordiazepoxide as well as a buprenorphine product concurrently to help mitigate alcohol withdrawal seizures and mitigate the symptoms of opiate withdrawal. But again, I think there's so much nuance that goes into that. There's so much more than I would feel comfortable answering solely by myself. Should pharmacists treat buprenorphine with the same red flag as other opioid medications? Well, red flags is, again, are we looking at diversion? Are we looking at just general misuse? I think those are big questions. I mean, any controlled substance, we're legally obligated to look at it with a certain sense of scrutiny. We have a corresponding responsibility to the prescribers. So we always should, it's due diligence. But I think what gets lost is that we end up looking at it only as the, call it the drug police, rather than as a healthcare provider where we have the opportunity to, if we do see something that is amiss, that we have that conversation. And I'm not ignorant to the fact that in a high-paced community pharmacy, that's asking a lot, that's hard. But as we continue to advocate for change in our profession, as we continue to look for how we can advance our profession, that's something that we can use to help change policy and to help get the ball moving. So yes, I would look at it under that scrutiny, but I would also engage in the conversation rather than use it as a, I'm not gonna fill it. Let's look at how we can try to identify what's going on and help our patient. What are some of the stigmatizing behaviors that you have seen in student pharmacists and pharmacists that could be avoided? I think that the biggest one I've seen is that addiction is a choice, that people just need to suck it up and get over it, that it's often seen how it's portrayed on shows like Law & Order, where it's usually somebody who's not financially well-off, might be, they're usually dirty, street clothes, stuff like that, and that's not the case. We know that addiction is nondiscriminatory in every sense of the word. It's certainly not a choice, it's a disease, and it can impact anyone. I did some training at one of our local drug and alcohol programs, and folks who were there are physicians, nurses, pharmacists, dentists, lawyers, FBI, NYPD. So this really can affect a lot of people. I mean, go to Utah. Utah, a lot of the folks who go to Utah who've been going for a long time are in recovery to consider it part of their recovery. So I try to help students understand that it's not what SVU or any of the shows out there think it is. We try to, we talk about it, we have hard conversations about it, but those are conversations that need to be had. And same when we go out there in public, we have the hard conversations because we can't shy away from it because the stigma does not shy away either. So we're gonna fight it head on. Thanks so much, everyone, for sharing your questions. We're now gonna go ahead and take a look at our post-assessment questions. Again, the mental impact of stigma, including being seen as weak or lazy, can instill what unhealthy in patients with substance use disorder? Correct answer is B, shame. Looks like just about everyone got that one right. Next question, which of the following best represents the person first method of addressing substance use disorder? So it looks like correct answer again, and most people got that right, opioid-induced respiratory depression. And now on to the final question, which of the following statements regarding the evidence of buprenorphine use is true? Correct answer again is D, can be effective with or without concurrent behavioral therapy. So it looks like most attendees got those correct. Again, on behalf of the American Pharmacists Association, we appreciate your interest and participation in today's webinar, and hope that it's been helpful, and thank you so much. This concludes our webinar. Have a good rest of your day.

Substance Use Disorder

Stigma

Appropriate Language

Pharmacists

Advocacy

Education

Barriers to Treatment

Shame Cycle

Patient Care