or what we have been doing at the UAB hospital. And I believe we have a Q&A time at the end of my slides. But I'm OK to be asked questions during my presentation. Either way, it works for me. Whichever works for you all. OK, so this activity is sponsored by the ORN, which is the Opioid Response Network. And I appreciate this specific organization. I have done many work within this organization. I really appreciate that. And I think it's a lot of rewarding for me. So today, I'm going to focus on the substance use disorders in unhoused population. So these are kind of housekeeping slides before I run my own slides. So ORN is sponsored by SAMHSA grants. And the grant number is at the bottom. And it's to assist states, organizations, and individuals by providing the resources and technical assistance they need locally to address the opioid crisis and stimulant use. And technical assistance is available to support the evidence-based prevention, treatment, recovery, and harm reduction of opioid use disorders and stimulant use disorders. So we can always sign this grant number when we do ORN activities. And ORN provides local experience consultants in prevention, harm reduction, treatment, and recovery to communities and organizations to help address the opioid crisis and stimulant use. And also accept requests for education and training, like what we are doing today. And each state and territory has a designated team led by a regional technology transfer specialist, like Karen, who is an expert in implementing evidence-based practices. And this is their website and email address. I have worked with Karen and another person, and they are super helpful when we work together. So I really appreciate their efforts on that. This is my disclosure. Even though I'm funded by different organizations, including NIDA, and SAMHSA, and a private foundation, but I have no financial conflicts to this presentation. So there's a couple of learning objectives. Introduce opioid use disorder-related sub-studies and projections in my own place, which is a UAB hospital. And then discuss the treatment options for the opioids and alcohol withdrawal and use disorders. Then the last is the Q&A session. So I want to start the talk with the projects I have been running or involved or in charge since 2018. This has been going on for seven, eight years now. And so the first project I'm leading was an emergency department-based project, which is identify patients with opioid use disorders and buprenorphine initiation in the emergency room setting. And then later on, we received grants from Alabama Department of Mental Health, which allowed us to do the bridge clinic, focus on the patients who are discharged from the hospital and ED or community patients. Then this foundation grant is the Foundation for Opioid Response Efforts. It really just helped me to refer the patients to FQHC. I'm not sure how much you know. FQHC is a federally qualified health clinic. It has a lot of different funding mechanisms and the mechanisms for patient care, visit, medications, and it's very nice to work with them. And then a couple of NIH grants focus on the post-discharge patient care. So this is kind of really like a summary of the project I mentioned. So the kind of patients with opioid addiction or detox or overdose or acute pain, chronic pain in a setting of opioid addiction, when they presented or they brought it to the UAB hospital, we will assess this. Also, assessment started in the ED setting and the patients meet the criteria for OUD and they will be initiated with buprenorphine or they will continue with buprenorphine if they were taken already before they come to the ED. So most of the time, like maybe 70%, 80% of the time, buprenorphine is the primary treatment option. We do provide methadone treatment in the ED setting as well. So from ED, patients either be discharged to community, to home, or to shelters, or they might be admitted to inpatient setting. But no matter where they go, the buprenorphine will be the main treatment we are going to offer. And then after patients are presented to the emergency room, we have like a peer support specialist, which is relatively new. We started in 2023 and they will be notified then they will start to work with the patients parallelly with other providers. And then when the patients are ready for discharge from either ED or inpatient, there are different routes to continue the care. The first is if patients do not have insurance or they are underinsured, we will refer them to the bridge clinic and they can stay with the bridge clinic for up to three times in two months period after discharge. So the bridge clinic has psychiatrists, addiction providers, MPs, peer support specialist, counselors. They will offer the patients assessment and treatment options, continue buprenorphine. And then if patients need a higher level of care, they will be admitted to the inpatients and from inpatient, they will be referred to the residential programs, kind of like a door-to-door treatment. And the patient usually stay there for like up to one month, then either go to the partial hospitalization or go back to the clinical outpatient, per se, like FQHC, which is Federal Qualified Health Care. That's why we need an FQHC to absorb the patients after the patient has finished the residential program or finishing the bridge clinic. Another kind of financing that we have here is like a bundled intervention program to the patients who are discharged from hospital. So this is more designed for the patient who need a little bit more higher level of care, but patients do not want to go to residential program. They just want to continue outpatient treatment program. So then if they are enrolled into this program, they will have like a PS and buprenorphine treatment, and everything will be done over telehealth, by video call or by phone service. At the end of the three months of treatment, we have counselors in the team. They will refer the patients to the programs for definite care, either like a certified addiction program or either like a privately run addiction programs for medication management and for like psychosocial management. So in my opinion, like a bundled intervention or bridge clinic or outpatient program, these are all outpatient treatment, but it depends on patient severity and social support. So they can go to different places for continual care. And I talked to Dr. Martin, I do have a collaborative pharmacy started in 2018 in the first project, and I continue to collaborate with this particular pharmacy. And there's many reasons. The first reason is that they're charging me very reasonable price, like a buprenorphine, snatch naloxone, eight milligram sublingual tab, but they're only charging me $5. And a second reason is very close to the UAB hospital, only like a, if we walk in distance, I write a patient prescription, patient bring the prescription to the pharmacy, only take like a seven minutes of walking from hospital to pharmacy. And the third reason is in these pharmacies, six days they're open, from Monday to Friday, open early morning and close later night. And on a Saturday, they're also open from 7.30 to 2 p.m., even though they close on Sunday. And it's not easy to find a pharmacy who can open six days, and also close to UAB hospital, and also offer very affordable medication. That's the main, three main reasons I have been stay with them for a few years, continue to renew the contract every year. And we use them a lot, significantly, they are very helpful, and they're very easy to work with. Another thing like for the urine drug and test. So at a UAB hospital, we do like a point of care, the urine drug screening, and these are all the substances we screen at a hospital, from amphetamine, barbiturator, benzos, buprenorphine, cannabis, cocaine, fentanyl, heroin, hydrocodone, methadone, opiates, and oxycodone. So this is a urine drug screening. So we always kind of have these kind of issues, if they are positive or negative, are they true or are they false? So that's why we all, sometimes we consider confirming the test. I want to say, if the patient's UDS is positive for amphetamine, I usually don't go to confirming test, because there's so many different medications, over-the-counter medications, even some, like meals can cause, like weight loss medication or meals can cause false positive, and amphetamine, so I don't do confirming test for amphetamine. And also some substance, you do not need a confirming test either, let's say for cocaine. If cocaine is positive, it's 99% chance it's positive. So there's no reason to do the confirming test. But sometimes I do confirming test, let's say for benzodiazepines, because the cross-reaction is very common with SSRI and SNRI and even trazodone. And another confirming test I like to do, which is opiates, because, but opiates at UAB is more tested, codeine, morphine, and like donuts or poppy. So I wanted to see if it's a positive, is true positive or false positive. Many times the patient will tell me they eat a large amount of donuts. So I want to make sure how likely is true or I don't want to miss anything. So that's the kind of confirming test I would like to send. Also for buprenorphine, there's no reason for you to do confirming test. If it's positive, it is positive. So I tell the patients, so then we can work together better and don't miss too many things. At a UAB hospital, we don't have a confirming test on site. So all the tests are sent out, which take up to two or three business days to be back. Sometimes if patients are in the ED, they are not very meaningful, but they are more meaningful if patients are admitted to the hospital. So that really depends on the setting and what's positive, what's negative, and when I decided for the confirming test or not. So for all the patients who started with buprenorphine treatment at a UAB hospital, this is a treatment agreement we will review with the patients, either physicians or either social workers or nurses or peer support specialists. They will review with the patients what we anticipate you to do, what we are going to do. It's a more kind of a mutual agreement. And since we provide a bridge prescription at the end of their discharge, so we will make sure the patient agree not to take other alternating medication like Xanax or other amines initiated during the buprenorphine treatment. And if they have a prescription from another provider, we do want to see that. Even though we highly depend on the PDMP to tell us how many providers each patient have, but some pharmacies do not upload the data in a timely manner. So PDMP can be very helpful, but sometimes missing the data. And also want to make sure patients agree not to work with another provider who will provide the same medications like buprenorphine, Suboxone, methadone. The trick is for the methadone. PDMP does not allow methadone to be up-noted if it is prescribed for opioid addiction. So that's the really thing that I miss many times because PDMP does not show it and the patients does not share. I have to reach out to methadone clinic to confirm it when the UDS is positive for methadone. Patient could deny as well. So that's a kind of a little bit challenging on that. And also want a patient not to refill the medication too early. Like we gave them two weeks bridge prescription medication and send the patient to the bridge clinic. And the patient sometimes just show up at a clinic earlier than two weeks and request early refill. So want to make sure patients know that. Know early refill and that's some very special reasons. And also make sure patients can follow up with the appointment. And if they don't show up for two times at a bridge or in my own clinic, we may let them discharge them. And we order urine drug test from time to time, not all the time, but we want to make sure patients will be compliant with treatment. And for the urine drug test, if they are consistent with the prescription pattern, that will be great. But sometimes they are not. I want to tell the patients that it's okay at the very beginning, the first one month or two months, the urine drug test positive for non-opioids, maybe for the marijuana. I'm in Alabama, so recreational marijuana is not legal here. So I want to make sure if it's positive for marijuana, I might be, I could tolerate it. But I may not tolerate it if a patient urine drug test positive for buprenorphine, opioids, opiates, fentanyl. That is not tolerable, because that's a significant increase of overdose risk. So I want to make it very clear on the front, patients understand my expectation. And also I deal, I work with unhoused patient population. So it's very likely patient's medication could be stolen, lost, or destroyed. And let them know they could request another refill or early refill, but let me know why. They cannot take unprescribed medications. That's not expected. And even if they need to change the dosage, I want them to let us change the dosage instead of they change the dosage themselves. Either run out of medication earlier, or they take, when they are out, they don't talk to you, they take other people's medication. So I want to make sure they do that. I highly, highly encourage them to do some recovery meetings, AA meetings, NA meetings, CA meetings, whichever they feel is fit them. I want them to do some meetings. And also let them know, medication management are very helpful, but not like you have to take forever if you don't have to. And if you want a table offer, or if I think a table offer can help you, I will bring this up with the patients. And all the medication have side effects, which is true for buprenorphine as well. So we'll review with them the side effects from mild, moderate to severe side effects. The most severe side effect, of course, is overdose, and even overdose death. So I want to review with them, make sure they understand the side effects. They can be more careful when they take medications and get them educated on that. So this is the treatment agreement that we have been in place since 2018, when we started buprenorphine initiation project at the UAB hospital. Has been ongoing for years. Most of the time, it goes very well. We do have some times they don't go very well because the patient don't agree, or some providers get irritated by what the patient's acting like, so. This is in the first SAMHSA project back to 2018, and these are the measures we have. So in the older time, probably you remember that buprenorphine need an ex-waiver to prescribe. And so we have an education and get people to ex-waiver. And then we also have a three-year project, how many patients we wanted to take care of, from 150 first year, second year, 200, then 30 or 200. And also, what's the retention rate we would like to have at a six-month post-enrollment? So 75%, we prefer them to be abstinent from initial opioids. And also, I'm in Jefferson County. We have probably the second highest overdose death at that period. So we want to reduce the overdose rate in this particular county. So that's the measures we have in the first SAMHSA grant. And then this is the current bundle intervention, NIH grant outcomes. We have primary outcomes. We also have secondary outcomes. So we kind of look at the outcomes, most of the times, every three to six months, because the primary outcome for the current project is that we want to see how many patients we enrolled every month, and how many patients were retained at a one-month and a three-month follow-up assessment. So in this particular NIH grant, more targeted at patients who are homeless, who do not have insurance, who do not have a job, and have limited social support. In this particular grant, we even offer patients at a low cost burner phones and the millions, so they can be reached out by us, and also they can reach out to us if they need our social support, or peer support, or physician support. So, and also we look at the adherence rate to buprenorphine treatment, and how often patients refill medication, take medication, and look at overdose every six months. So we work with the county to get their overdose rate every month, and also look at our own. So UAB EMR is able to pull out the data about opiates overdose rate every month, then we get to compare the overdose over the time during the project period. And also look at the emergency department and revisit the rates and re-admission rates. And the secondary outcome, we just look at a patient's quality of life and the mental health status. We use some measures, like PHQ-9, and the GATA-7, and according to NIFA, they have specific skills as well, we also measure them every three months. And so that's the measures, it needs a particular measure to target the unhoused patient population. So I mentioned like a peer support project back to 2023, and our peers reached out to over, I think over 1,200 patients in this particular period, one year long. And as you can see, most of the participants, like 500 participants, do not have any insurance. And also we have a good amount of unhoused population, which is 300. These are the patients who probably benefit the most from our project after we implement it. And then this, since I work on this particular manuscript, so I have very detailed data on this project with the peer, and like I said, in the 30 days after ED and the 90 days after ED and how many of them return, Canadian patients who are unhoused, they have much higher return rate at one month and three months follow up compared with the patients who do have a house. So housing is really determining factors for patients to stay well or not to stay well. And so these are primary projects I have been involved in the last few years. I would say what I have learned from project is really we collaborated with Alabama State Department of Mental Health and also Jefferson County Public Health very closely. We have a standing meeting every month, every quarter, and we have a report to them because we are sponsored by them. And the regular meeting and get their needs, get their expectations, share with them our progress, our problems, our issues. And overall, I feel like Alabama and Jefferson County are very supportive to all the initiatives. And also I'm very grateful I have very good team, a big team, like over 10 people who work together and we have very similar values, interests, and passions for this particular patient population. And I'm very goal-driven person, so each grant, each project, I have very clear goals on what I want to achieve, how to achieve, and also review the goals with the whole team maybe every month or every other month to see where we are and what's the problem we have and how do we need to change the goals due to what we have. I think it's very nice, very goal-driven. And also we promote our studies across Jefferson County, across Alabama, and also of course across the hospital and they help us to promote our studies so patients come to UAB Hospital and receive our service. We also identify champions in the hospital, in the ED setting, in the hospital setting, like physician champions and staff champions who can help us to enrollment, engage the patients. And we have two coordinators, full-time coordinators who help to run the study coordinator. So many different pieces, they are very good. We have three full-time peer support specialists as well in the ED and in the hospital to run the project. Just so many meetings, I have to admit it, so many meetings every month, every week, but overall meetings run very well and we get what we should have done. Again, the pharmacies, I cannot say more about the pharmacy. It's really the best pharmacy I ever have in my practice. And I have two collaborators, collaborative shelters, one for men, one for women, and so when the patients, even the patients are discharged from ED directly to the street, I will talk to the shelters or my coordinator will call the shelters, make sure the patients are discharged tonight or this afternoon have a place to go instead of on the street. They may lose a prescription or medication or something like that. So make sure they do have a shelter, they do have a bed in the shelter so they can stay tonight or tomorrow night. And we provide them social support, like meals and stamps, and also the burner phones and the meetings so they can always reach out to us when they need us. We provide them Narcan, spray kits, and fentanyl test strips just in case they continue to use these drugs to make sure they minimize the overdose risk or they can prevent overdose events. I think the lesson I learned from this, even myself, before I was deeply involved in addiction care, I used to use a clean UDS or dirty UDS until I realized, got more education myself, especially I took a certified body exam and realized we should use a very totally different language to minimize the stigma in this population. So I educated myself and also educated my research team and asked my research team to have a brochure. So I created some brochure using NIDA website, a kind of side-by-side comparison, this is the current language, this is the language that should be used, so side-by-side comparison and let them distribute to other providers in the hospital, in the county. I think language is very important, that's what I learned. And also the loss of follow-up. So it's very easy for us to lose the follow-up with the patients, especially in the three months assessment and a six-month assessment. So we work with community partners to really, sometimes my coordinator always says that I'm a detective because I need them to reach out to all the community partners to see where my patients are. I want to make sure I get a hold of them, I can do a three-month assessment, a six-month assessment. That's one reason. Another reason, I'm really, really curious or nervous when I cannot get a hold of my patients because I just wonder, are they overdosing or are they what? So just patients always keep you worried, that's what I kind of see from myself. The second is another thing, the counter-transference. It's very calm among the healthcare providers. Many patients come back to the ED numerous times, maybe 20, 30 times per year in a 12-month period. So we have sort of like a healthcare provider fatigue, and we also feel like we are very helpless because patients never get better. They always come back to the ED, they always overdose, and they always relapse. So we have a lot of negative feelings, which in psychiatry enabled us counter-transference. So I educate myself, educate the team, educate other providers about counter-transference. So bring this to our awareness, hopefully we can minimize counter-transference, we can minimize our fatigue at work, and always offer the patients help wherever they are and whatever they do. Just always keep the hope there, I feel it's very, very important. Sometimes I do realize that I have fatigue as well, counter-transference, so it's kind of reminding me, keeping me awake on that. Another thing we learn is flexibility with the patients. At the very beginning, and I shared our treatment agreement, we have so many things we want a patient to do, and we are very kind of follow up with the textbook, very rigid. If patients don't do these things, we may discharge the patients or terminate the patients. Then I realize what we are doing here, the whole project we designed for patients, but right now we ask the patient to change so much, change from one person to another person in a shorter period. How likely does it happen, right? So then we realize we should be very flexible with our patients. The more flexible with our patients, actually then I realize the better outcome with patients. So lack of flexibility is a kind of issue at the very beginning of our projects. And also this flexibility is also affected by the COVID due to disruption of the project and the patients and other access. So flexibility is what I learned in all these projects. So after I talk about, introduce our projects, I want to talk about more withdrawal protocols we have here in the outpatient setting, in the ED, and the inpatient setting. The funny thing is that we use the same protocols in the different settings, including ambulatory settings. And so probably you all are very familiar with the alcohol withdrawal protocol, which is the CEVA protocol. And this is kind of based on, since the last use of alcohol and the timeframe of symptoms and how, when you anticipate to see symptoms, what are symptoms you anticipate to see during the, after the last drink, from a few hours, what are you going to see? So I think it is probably easier to see the timeline for the alcohol withdrawal. So from the first day, from the first, in the first two days, you are likely to see like a physical symptoms because like a non-epinephrine symptomatic system are very active. So you see lots of like nauseation, vomiting, anxiety, agitation, hallucination, even seizures. And from later on, like 48 hours later, if patients are not treated, the DT risk is much higher. And after one week later, all these symptoms either subside themselves or either are treated medically. And I think that stage one, stage two symptoms are much easier to manage than the stage three symptoms. Because stage three is more like a mental health, psychiatric craving, insomnia symptoms are more challenging to manage them than the physiological symptoms. And the clinical institute of withdrawal assessment we have here. So you didn't like, I always tell the people just go to this website, MD Calculator. Probably some of you are using as well. You put the patient's symptoms there, patient's blood pressure there, then we automatically come up with a score. And these are the ASAM recommended assessment interval. If the patient's score is like a relative low, and it's every one to four hours, if you did patients' symptoms will subside after two to three days, you can do every four to eight hours. So it really depends on what symptoms patients present and what score patients have. So these are 10 items for you to score patients from agitation, anxiety, hallucinations. So in the patients with alcohol withdrawal, auditory hallucination actually is not prominent. The prominent is more is the tactile hallucinations and the visual hallucinations. So just keep in your mind, it's different from a patient with psychotic symptoms. And so anxiety level and the patient confused orientation and the headache and the GI symptoms and the sweating and the tremor, right? So these are the 10 symptoms up to your observation and the patient report. And you will put them together, then you come with minor, moderate, and severe symptoms. And the total score is a six, seven, and a minor is zero to eight, and the moderate is less than 16, and the severe is more than 15. And higher score and predicting the higher risk for seizures and the DTs. And so, like I said, always the same scale in a different settings. And when you have the patients, for example, in the ED or in the office, the patient presented with the withdrawal. And so this kind of guideline we use here to consider is should we admit a patient to the inpatients or should we discharge a patient with some medication management? So if a patient's severe score is less than eight, and we assume they have very low risk for severe withdrawal, so you can prescribe some gabapentin, carbamazepine, or benzos, like pus and lorazepam, and or diazepam for patient to take home for self or detox. And if a patient's score is 80 to 18, that means a moderate withdrawal. And if a patient has never had a history of withdrawal seizures, DTs, or hallucinations, you can still discharge the patient, send the patient home with the above management. But you just need to make sure if the patient's score moderate, and you send the patient home for home detox, you do want the patient to have some social support, like a patient stay with someone, and you can call the patient the next day to check on the patient to see how the patients are doing. And these are concerning in the middle is patients are sent home with lorazepam, for example, but the patient, the lorazepam dosage is not enough to manage their withdrawal symptoms. The patient will do what? They'll just go ahead and open the bottles, drink again. So that can make things worse because of respiratory suppression. So that's why you need another person to keep an eye on the patients, supervise the patient at home, making sure they don't do these dangerous things. If a patient's score 19 or patients that had a history of a seizure, DT, hallucination in the past, even though they may score lower than 19 or 18, you want to consider inpatient treatment because they need a little bit of, they need more medical supervision. And all the patients, alcohol level is more than like a 200. All patients are pregnant. So for the patients who are pregnant at UAB hospital, we admit all the pregnant patients for inpatient treatment. We don't do the outpatient treatment just in case some other worse incident. And then this is my protocol we used here, and this is for the inpatient protocol or the ED protocol. And we use the same protocol, just based on the same protocol. We use how much medication the patient should receive. So I usually print out this for my patients if I decide to send them home. I will tell them, you score yourself. How to score yourself. I just show them how to score themselves. And this is the score I'm going to use for your prescription. You score yourself every four hours, and then when you have which score and you take how much norepinephrine. So I usually only give patients one day or two days of norepinephrine dosage based on a score in the office, then send them home with social support, then call them back next day to see how they are doing. That's the kind of things I have been doing for the outpatient ambulatory detox. So this is three medications approved by the FDA to treat a patient with the echo use disorder or compressed by suffering and naltrexone. Naltrexone has two different formula, one's by oral and the one's by IM injection, which is a vibratory. And very effective in my impression, just it's not easy to engage the patients so they can take the medication. Some patients are very resistant to the treatment, to the medication management. These are a few of the neighbor use medication for echo use disorder from gabapentin, tolupiramide and baclofen. And so for American Psychiatric Association, who should take medication, who should not take medication, there's a very clear guideline there. So for anyone who are interested, you can go back to this guideline to take a look. I want to talk about a little bit of gabapentin. The main reason is that we use gabapentin to detox the patients, right? Patients have echo withdrawal symptoms and I prescribe gabapentin for ambulatory detox. The reason is that I can continue this medication after patient finish detox and then continue medication or even go up the medication to manage their cravings. So one medication can heal two stones, detox and maintenance treatment. So it can reduce their relapse. That's why I prefer gabapentin all the time when I do the ambulatory detox. So this is an opioid withdrawal. So let's share a little bit from echo withdrawal to opioid withdrawal. And for the opioid withdrawal, probably we see more like a physical symptoms and patients are super uncomfortable and very bad shape. And we know that when the withdrawal means like opioids receptors are widely open and opioids are not enough to combine, to occupy all the receptors, especially like a mu receptors. That's why patients go to withdraw. And the opioid receptors are distributed in the entire body from the head and GI. So that's why a patient has a lot of GI symptoms when the receptors are not occupied. And then due to like a non-epinephrine neurons in the nocus and runus, so cause the elevated blood pressure, heart rate, respiration rate, patients sweating, diarrhea, and the clonidine and norepinephrine and opioids can help these symptoms. And also there's like a GABA theories as well. That's why patients, GABA is the primary, like a suppressive neurotransmitters right now. There's too much GABA there, less dopamine there. So patients that are depressed and dysphoric and irritable and their cravings come back. These are another kind of timeline for the opioids withdrawal. Sometimes it depends on what opioids we talk about, also depends on the half-life of the opioids. For example, hiring half-life is only four to eight hours. So patients can go to the peak of the withdrawal very quickly in the first day or second day. For a lot of people, norepinephrine half-life is 36 about. So patients will not go to like a withdrawal for one or two days. And then methadone even have a longer half-life, but patients could have delayed withdrawal symptoms, but withdrawal symptoms will last much longer just because no half-life. So different opioids have a different half-life, and then withdrawal symptoms have different time to start. There's one thing we always worry about, like a perceived withdrawal symptoms. And since fentanyl become the dominant drugs back to 2019. So perceived withdrawal means that you start an infarction with buprenorphine, and in the first one or two hours, patient withdrawal symptoms become significantly worse. And that's why we say perceived withdrawal. So there's a few reasons, and the medications have different facility or binding capacity. That's how the perceived withdrawal symptoms comes from. And like I said, fentanyl is the main reason to cause the perceived withdrawal symptoms because fentanyl and buprenorphine, they have very similar binding capacity. They compete with each other, but buprenorphine is a partial agonist. It's not as potent as fentanyl. That's why receptors are occupied, but the potency is not as good as fentanyl. That's why patients go to withdrawal symptoms. And these 11 items for the scale and the clinical opioid withdrawal scale, we also use these to guide us the severity of withdrawal symptoms in the patients. And it depends on, so from the resting pulse to sweating, restlessness, and pupil size, aches, and a runny nose, GI symptoms, tremor, yawning, anxiety, and the skin. And then total score is 48 from mild, moderate, severe to very severe, and different scores. And there's a timeline to see the withdrawal symptoms from the last use. So four to six hours, what do you anticipate to see? And then more than half a day, what do you anticipate to see? This can guide you to estimate when the last use of opioids in patients. And then again, this is a kind of cartoon to show the timeline for the opioid withdrawal. It really depends on the half-life of opioids the patients are using, and they present different symptoms. I want to highlight here again that physical symptoms are really, really easy to manage in patients. Psychological symptoms, unfortunately, are very challenging to manage them. That's the main reason patients relapse. So patients could stay sober for a couple of weeks, then they relapse. Then one of the main reasons is their craving is not managed very well. Their depression, mental health are kind of ignored. So the patient relapse. And this is a comfort medication. I usually call to manage a patient with withdrawal symptoms, depending on what kind of symptoms the patient present, then you can use appropriate medication to treat them. But then the two main medications I use actually in the hospital to manage the withdrawal, one is buprenorphine, one is methadone. And this is our protocol in the hospital, in the UAPED and in patients, and also in the ambulatory setting, we use that. So we can only use a couple of protocol to guide us how to treat a patient with withdrawal, use buprenorphine and with methadone. So I did not include methadone here, and this is the paper from myself. We studied the protocol, we tested it in our own ED and in patients, then we get this protocol published and still using this protocol as of now, very effective, very convenient. We just built this protocol into EMR. So we have a PowerPoint, patients with opioid disorder and overdose or detox, when they present, and the nurse will assess them, use a call protocol, they will record a call in a computer. So whenever the call is above eight, this PowerPoint will automatically activate it, then patient will receive medication management for buprenorphine. And also, like I said, at the end of the discharge, if patient could be discharged from ED or patient could be admitted, discharged from inpatients, this is the kind of protocol we use to prescribe it to all the patients who are willing to continue buprenorphine, like one type of BID with one-week supply, and then patients can go to the bridge clinic or stay with a three-month intervention or go to the FQHC, depends on. So that's kind of what, this is all built up in the PowerPoint. The physicians need to connect the PowerPoint, then everything is set. So these are three medications for the opioid use disorder treatment. One is buprenorphine, we are well-known. One is methadone, has to be prescribed by opioid use treatment program, Clinica, and then niatroxone is antagonist and for the patients with buprenorphine, no, I'm sorry, a patient with opioid use disorder. So the kind of things like alcohol and opioids, they are really linked with each other, and so many times the patient use both substance, alcohol and opioids. This is the kind of data in the American states of how many patients who use both. And alcohol use does reduce the physical pain. So there's research to show it. That may also explain that the patients, when they don't have opioids to treat their pain, they will use some other substance. One substance is alcohol to treat their pain. So in a patient who has a concurrent alcohol use disorder and opioid use disorder, I would say there's so many options you can choose. For example, niatroxone is approved to treat both opioid use disorder and alcohol use disorder, so this can be one option, right? Another option is patients sometimes they don't want to do niatroxone, which is opioid antagonist. They prefer to take opioid antagonist, like buprenorphine or methadone. Then we can always treat the patients with alcohol use disorder with a composite, gabapentin, buprenorphine, disulfide. So there's many other different combinations for pharmacotherapy for concurrent OUD and AUD, depends on what a patient have, what a patient prefer, what your experience is. So when I consider medication, that's when I talk to the patients, sometimes a patient ask me or the other provider ask me why I choose this medication rather than other medications. I think this is kind of my rationale here, that the patient has a preferred preference because we can prescribe any single medication to patients. If a patient do not take a medication, they don't want to take a medication, they prefer not to take a medication, the medication will never work. So if a patient are preferring this sort of medication, I will meet their expectation and give their preferred medication so hopefully they can increase their compliance rate. That's how when I decide, I would ask a patient, what do you want first? Does the patient have any goal? Do they just want to cut down the use or do they just want to completely stop? So that's make a huge difference when I pick up a medication for them. If patients only want to cut down their alcohol use, I may choose the gabapentin, buprenorphine, or naltrexone or composite. If patients have very strong desire to stop alcohol completely, then I would say maybe disulfiramine is a good option. Or then the patients have a concurrent psychiatric disorders or not. So if a patient has to take a medication for psychiatric disorders, I need to consider if there's a drug-drug interaction. What's the vulnerability, potential side effects and the benefit from that? I prefer not to prescribe naltrexone in a patient who have a current depressive symptoms episode. The main reason is naltrexone is a dopamine antagonist. Patients are currently very depressed. Naltrexone might drive their depression worse. So that's the kind of things I would consider that. Or some medications, they have neurohepatic impairment, like acute hepatitis or hepatic failure already. So naltrexone may not be the first option. So disulfiramine sometimes cannot be prescribed in a patient who have a psychotic symptoms and also depend on patient's medical condition, tolerance. And so these are the main factors I consider when I choose which medication to prescribe. Okay, total real nice, this is my last slides. So this is probably, I already finished here, go through all my slides and I will pause here. So each of you can scan this QR code and it's really for the quality improvement. And so please help us, help ORN to improve our service. And this only take at most one or two minutes to finish it. So after that, I will go to Q and A session. Thank you. Okay, Dr. Lee, so we'll get that QR code. Will these slides be available? I know they're recording, will it eventually? Yes, I will go ahead and send you Dr. Martin the slideshow. And also once the recording is posted, the slideshow will be posted as well. And once that's completed, I'll be sending you the information to access that. That sounds great. Do you guys have any questions? I have a couple. I have a few. Great, go, do it. So have you noticed with your patient population, how do you handle like weekends when they're at the beginning stage, when you're really just comfortable with seeing them on a daily basis as far as dispersing the buprenorphine? So you mean I say on the weekends or holidays? Yes. Okay. Sometimes we have some three-day weekends being a government institution. We have several of those. Okay, thank you for these great questions. So in the past, when ex-waiver was required to prescribe buprenorphine, all the ED physicians, including NPS, PAS physicians, are required to get ex-waivered. That's admin requirement for hospital. So all the people can prescribe in the ED. And also all the psychiatry. So in the ED department, in the psychiatric department, we have admin policy. Each of the provider has to be ex-waivered. So that's why the holiday and the weekend are covered in the past. Building on that, these patients will have maybe a few days' supply on them. With our population, literally, they live right on our doorstep. What are some ways and some measures that the patients protect their supply? Because once word gets out to other individuals that are on the street that they actually are in possession of this substance, they put a target on themselves. This is another good question. We all have these issues. So for the patients, like I said, I work with two local shelters. One is a men's, one is a women's shelter. If a patient sometimes, you may have the same experience, the patient prefer to be on the street. They don't want to go to any shelters. You cannot force them to go to shelters. If that's a patient that chooses to be on the street, I will give them at most two days' supply because they can walk to the Harbin Pharmacy, which is closer to my ED, every day. They are on the street. They can go there every day except Sunday. So I don't give them one day's supply. I only give them, they can go to the Harbin Pharmacy every day to receive a medication there. So I can specify under my prescription, patients will walk in daily basis for medication up to 14 days. But please dose the Sunday at the end of Saturday. Give the patients very clear on my prescription. So we have like three primary physicians who do the prescription and we cross-cover each other. That's kind of our contract with the Harbin Pharmacy, make sure clear. They have to read our instruction very well when they dose my patients. So they'll give, so you'll prescribe like a week at a time. And then the pharmacy will dispense two days at a time to the patient. One day on the weekday, except Sunday. So if a patient, tomorrow is a Sunday, patient go there to get a prescription to get a medication today, they also receive for tomorrow's, but only at most one day. Because these pharmacies open every single day except Sunday. So the patients might have to go there every day to pick up their weekday. They have to, yeah. If they are going to go to the shelters, I have a contract. The shelter will manage their medication, so I don't have to worry about that. It's only for the patient who choose to be on the street. So the shelter will actually do the dispensing? Yeah, if they end up at the shelters. But I would say half of the patients choose not to go to the shelters. They are so tired of the shelter. They wanted to be on the street. They want a free air. So then that's fine. We had also been discussing, you have a very specific protocol when you do transportation of control medications like buprenorphine from the pharmacy to the shelter with like taking a picture and making sure that, you know, patients can't claim that medications might disappear en route or something like that. Could you explain that? Yeah, so at the very beginning, we always assumed that patients pick up medication from a harboring pharmacy and then patient will go to the shelters, right? And then when patient arrive at the shelters, they will give medication to shelter coordinators or staff. But during this process, the patient pick up and then go to the shelter then realize the medication may, I said, 14 for seven days, go to the shelter only five. Why they disappeared? So I just tell the pharmacy. Shoot, why is this not? She's talking. Well, it'll be recorded. So that's good. She see us? We keep shaking our head if we hear. Can you guys hear me? I can't hear you. Yes. Okay, the internet cut me off. So I'm sorry, we missed part of that, but. Okay, I can repeat it. So at the very beginning, the medication will miss a few medication from the pharmacy to the shelters. So later on, I just ask a pharmacy to take the picture, like a person, even 14 tabs, they take a picture and send it to my coordinator. And then when patient bring the medication with them and go to the shelter, because we have a bus pass for patient to go to the shelters. When they arrive at the shelters, they should give the medication to the staff. So staff can hold the medication for patients. Then the staff will take a picture again and send it to my coordinator. It's a 14 instead of a 12. And it was some pieces, if some medication will be missed in the bottles, I will say, patients, you just take a little bit less. These can happen only once. If it happens second time, we are going to let you to go back to the shelter, go back to the pharmacy every single day, even though you stay in a shelter. So just make sure the right person take the right medication. Helpful, thank you. I was going to change the topic, so we're still on security measures. Okay, when you do an induction for naltrexone, how often do you usually provide comfort measures and the comfort medication? So if you have a patient who struggled with alcohol use disorder and opioid use disorder and is kind of in the throes of opioid use withdrawal, how often do you find, like, do you give comfort medications in the interim? Yeah. Okay. I will go back to, so if a patient has a concurrent, okay, so your patient has a concurrent alcohol use disorder and the opioid disorder, right now they are opioid withdrawal, right? So depends on, when you say the comfort medication, depends on, do you want to use a symptomatic treatment or do you want to go to like a buprenorphine or methadone? If I understand the patient's final goal is to be on a naltrexone treatment for both the opioid addiction and alcohol addiction, I will stay with the first top medication for symptomatic treatment. The main reason is buprenorphine has no half-life and wait for buprenorphine to run off the system and start naltrexone, take like a seven to 10 days. And the craving will be significant during this window time. So I prefer not to do that. And then I will say, Hey, I will explain to the patient why among these three options, I choose the first option because as long as you feel better, I can, next days I can do the naltrexone. If you don't feel, if you continue not to feel better, I will continue treating your symptoms and wait until your symptoms subside, then I can initiate naltrexone, do like a one quarter or one half of a 50 milligram per day until they can tolerate. So that depends on the patient preference and what the patient have. Do you ever also provide comfort medications and by comfort medications, I mean, not buprenorphine in the setting of somebody that has struggled with chronic fentanyl use to try to get them to that 36 hour point? I do. If a patient has a buprenorphine, I would say if a patient will not choose to be on their naltrexone treatment, they prefer to be on the buprenorphine treatment for the maintenance treatment. And also they are open to the other options for alcohol use disorder treatment than buprenorphine for sure. I will consider it. I'm sorry. I was going to ask another question, go ahead. Because buprenorphine has, I would say buprenorphine has a much quicker efficacy compared with the top symptomatic treatment for the withdrawal symptoms. And usually after two dosages, patients feel significantly better. But for the symptomatic treatment, and you treat a patient with a cannabinoid, gabapentin or zofran, patients' sickness can last more than one or two days. Patients are suffering there. Do you ever do ambulatory detoxification in a patient that you're also initiating buprenorphine? What do we do all the time? Because buprenorphine is highly recommended to do hormone induction. So the patient presented to the office or to the bridge clinic, usually in a bridge clinic, your patient presented earlier, like a bridge clinic open from eight o'clock until 11 o'clock, but the clinic were not closed until four o'clock. So your patient presented earlier and their cal score was higher than eight, and the UDS positive for fentanyl, we were kind of started to induce them. So they can take a medication when the first dosage in the clinic itself. Sorry, alcohol detoxification. Do you ever do alcohol ambulatory detoxification in a patient that you're initiating on buprenorphine? So if a patient, okay, that's two different questions, I would say, doesn't matter how I understand. If a patient are taking buprenorphine already, they are sober from initial opioids. They are taking buprenorphine, however, and they continue drinking alcohol and they meet a criteria for alcohol use disorder. And then they come to a clinic, they are in alcohol withdrawal symptoms. I would depend on their cal score. So if their cal score is above 16, then I may recommend an inpatient observation. If their cal score is lower than 80 to 10, they have a social support, they have a significant other, or they have friends or family who can keep an eye on them. I will prescribe norezepine or gabapentin to home for two days dosage, and then call them back the next day. They continue buprenorphine as they are. So buprenorphine itself does not prevent me from treating their withdrawal symptoms with gabapentin or norezepine. Do you ever perform ambulatory detoxification for alcohol at the same time as doing a buprenorphine induction? I have not done that yet. Actually, you asked this question in our Zoom meeting last month. That makes me think. I really have not done that. A patient could present with both withdrawal from opioids and alcohol. I feel like that's how I take it. Alcohol withdrawal symptoms are more life-threatening than opioids withdrawal symptoms, except in pregnancy patients, right? Because opioids withdrawal patients are very discomforted, really sick, but not life-threatening. In contrast, alcohol withdrawal symptoms is life-threatening. If they are left not treated, they could have hallucinations, they could have seizures, they could have DTs. So that's different. If a patient presents with both withdrawals, I will prioritize alcohol withdrawal over opioid withdrawal. But in this type of patient, if they present with both withdrawals, sometimes you may want to consider inpatient observation. Do you guys do any observed drug testing like saliva? Like do you do, I mean observed urine, yes, but do you do saliva testing? We don't do the saliva, we only do the urine drug test. But, um, um, so in a ED, we, ED has our own laboratory, um, place, so when patients go to the, uh, in the ED, they go, they're kind of half observed. The reason I'm saying that the restroom room is left open and the patient leaves the urine sample half open, but in an ambulance setting, we don't observe them to leave the urine sample. Do you have more questions? Do you ever use intranasal naloxone for the naloxone challenge before starting naltrexone? We don't use that because naloxone and nasal spray kit, those are too small. It's only 0.4 milligram per each. So if we do the naloxone challenge, we usually use one to two milligram before. We don't want to wait too many days before the naloxone initiation. So we do a one to two milligram naloxone challenge test. And that's sub-q or that's intranasal? That's sub-q. Okay. We had a question come up the other week. What are your thoughts on beta blockers in ongoing stimulant use disorder? It's off topic, I know, but. No, I like it because I work with a patient with a stimulant use disorder all the time. I think it depends on. So beta blockers, I would assume you talk about propranolol, right? Or metapro. I think you may mean propranolol because propranolol has a very specific role in addiction field now. Yeah. I was thinking about that one. I had read up and it said, well, if you choose for heart type effects, then you could go with lobetalol or carbetalol because there's some alpha blocking. But I was also thinking about propranolol because you have that anxiety component. So yes, definitely. What are your thoughts? I think as a. So even a patient presented, even their brain pressure is super high. And when you talk about stimulants, you talk about two different stimulants, one is cocaine, one is meth, and the other is ice. So for the cocaine, I'm very concerned just because cocaine stimulates a lot of norepinephrine to be released in a synapse. So when too much norepinephrine is released at one time, the significant increases the risk for seizures, stroke, and heart attack. So propranolol is not enough to bring the blood pressure down. So you want to consider something stronger, like beta-binocular, to get a patient's blood pressure down. Lobetalol is kind of a thing to avoid a seizure and a stroke. But if a patient just uses meth, ice, the only stimulant pre-synapse release of dopamine and norepinephrine, their blood pressure, heart rate, will not be that high. So maybe propranolol is a reasonable option. It also depends on what a patient uses in terms of stimulants, because cocaine and meth, they are so different. But propranolol is a good option in the ambulatory setting for the patients who have a concurrent anxiety disorder, and so it's finding that social anxiety is very effective. Like a 10 milligram TID really can help patients. And Dr. Lee, there was a question earlier. Is there a protocol for starting someone back on buprenorphine after a period of abstinence? And what are the risks of a more rapid induction? And how to safely and rapidly get someone back on buprenorphine after a period of abstinence, like incarceration, or in high-risk situations, like after release from jail? Okay, that's another great question. So patients are released from incarceration to community. If a patient has been sober from opioids for even one month or even three months, does a patient have three different options? They could be on naltrexone or Vivitrol, or they could choose to be on methadone or buprenorphine. If a patient chooses to be on buprenorphine, the duration of sobriety is very important now. The reason I'm saying that is, if a patient has been sober for only one month or three months, their immune receptors are still very sensitive. Their tolerance has not been really dropped yet. But even more than three months to six months, their tolerance has started to drop. So when you dose the patient's buprenorphine, you may want to start with a very tiny dosage, maybe two milligrams, two times per day, to see if a patient's craving is reduced or a patient's anxiety is induced, a patient's insomnia improved. I would say you do want to use the patient's two things. One is tolerance. Does he have drowsiness feelings? Does he have constipation? What does he say about his craving? There's an opioid craving scale, which is only three questions. You can ask the patient to answer those three questions to see where his craving is. If his craving is reduced by 50% already by four milligrams per day, you may just only need another two milligrams or four milligrams, then the patient will be settled down. That's for the patients. If a patient is only sober for one month or no less than three months, patient's immune receptors are still very sensitive and it depends on how much the patient was using before, right? So you can also start with a low dosage, penetrate up slower, and based on the patient's insomnia, anxiety, drowsiness, and craving scales. So I do this all the time, but I do ask the patients how long they have been sober. And also before I restart buprenorphine, I will check a patient's urine drug test first to make sure they don't use, first, they don't use other innocent opioids. Second, if they are using something else besides opioids. So I have some kind of baseline data to monitor patient progress. Hopefully these answer your questions. And anything else I missed on these questions, because these are known questions. I don't know what Alabama's regulations are like, but in Tennessee, there's essentially a therapy requirement. Do you guys have anything like that? Do you have a therapy component that is expected? Different clinics tend to deal with this differently, yeah. So actually, psychotherapy or counseling are not required anymore since 2021 or 2022. So this is like a national recommendation, it's not required. I think it's more like your own state requirement. We don't require it anymore after the national update their recommendations. Dr. Li, so it could be highly encouraged, but it's not a mandate. You have to do this. It's not required. Right. It's not required. In the past, it wasn't required, but it's not required since 2021, 2022. Right. So it's a revised treatment recommendations from ASAM. Are there any other questions? It sounded like, but I can ask. My understanding of when you went through your protocols and things was that you didn't do any observed dosing. But is that correct? My understanding that you guys don't do any observed dosing on site, you will prescribe and then the patient will take offsite. Yeah. In the ambulatory setting, we do not, except at a bridge clinic, if patients come earlier, we may observe them. Otherwise, most of the time, we just assess the patients in the ambulatory setting and send a prescription to a herping pharmacy, patient go there to pick up. But we do ask the patients to download like a buprenorphine hormone induction protocol in their cell phone or print out for them. I think that's all of our questions. Thank you so much for your time. No problem. Thank you. Let me know if any of you have any further questions. Thank you. Thank you very much.

substance use disorders

unhoused population

UAB Hospital

Opioid Response Network

SAMHSA grants

buprenorphine treatment

bridge clinic

telehealth options

peer support specialists

patient outcomes

provider burnout