Afternoon, everybody. I'm glad you're able to be here and glad to be with you today. I'm gonna put my slides up real quick. All right, are these presenting correctly, Sarah? Yep. Perfect, okay. So I'm Jesse Hinkley. I'm a child and adolescent psychiatrist, adult psychiatrist. I've also boarded in addiction medicine. I'm on faculty at the School of Medicine in Colorado, and then I'm also, I currently live full-time in Idaho Falls and also work at Eastern Idaho Regional Medical Center as the department chair and associate program director of the psychiatry residency over here in Idaho Falls. Just a little more background on some of these introductory slides in terms of the Opioid Response Network, or ORN, which is funded by SAMHSA to be able to offer technical assistance related to substance use, which is how we got connected with you all. And so anyone in the community is able to put in a request for a consult with ORN, which will then be evaluated, and essentially there's a wonderful coordinator like Sarah who makes all the magic happen, and then they connect you with us to be the ones that actually will help implement and complete the request. This is the contact information for the Opioid Response Network if you ever find yourself in need of it. Okay, so with that, we're gonna jump in to today's topic. So we're gonna start by talking about trends in adult substance use, and I'm gonna show you some data specific to Idaho. We'll also talk about trends in adolescent substance use because your population of clients will certainly span both of those. We'll talk about the opioid epidemic and then end with a discussion about what a substance use disorder is and how we define that. Please feel free to interrupt as we go along if you have any questions, but we also have a lot of time at the end to be able to discuss anything that you wanna talk about further. All right, so when we start off, we're gonna talk about trends in adult substance use first. Traditionally, adults are defined as 18 and older in most epidemiologic studies. And so the data that I'll show you is mostly 18 and older data for this part. This comes from the National Survey on Drug Use and Health, which is a survey that's done by SAMHSA. The Substance Abuse and Mental Health Services Administration it's part of the CDC. And they help estimate substance use and mental health problems in people that are housed that are 12 years or older. So this will not include individuals that are unhoused in terms of estimates. Substance use estimates are generally lower for adolescents than other studies like monitoring the future. But this is kind of considered the standard study when talking about the prevalence of adult substance use. Idaho also tends to be underrepresented in national studies for various reasons. And as you'll see, as we go throughout, their substance use rates tend to be lower than the region. And it's unclear if that's because it's underreported here or if the prevalence rates are really actually lower. But it kind of give you an idea of what the numbers show and where we stack up against the United States. So kind of the first big substance that we often think about when we think about substance use problems is alcohol. And that's generally true in Idaho as well. As you can see here, just under half of adults in 2021 reported using alcohol at all. And you can see that that puts us on the lower portion of the United States in terms of prevalence with generally speaking about half of Americans or a little bit more 55% reporting alcohol use. Similarly, when we talk about binge drinking. So binge drinking is very specifically defined. It's the amount of alcohol that it takes to raise your blood alcohol level to 0.08 within two hours. And so that's generally speaking five drinks in males, four drinks in females for various reasons. And so about the percentage of people that binge drink in Idaho is about a quarter of the population. So this is very common. And when we talk about adolescents, binge drinking is actually the most common pattern of drinking that they exhibit. They don't usually have one to two glasses or one to two beers at dinnertime. They usually binge drink on the weekends. And so it's about a quarter of adults overall in the state of Idaho that report binge drinking. Similarly with tobacco use, it's about 20% of adults in the state of Idaho that report tobacco use. And you can see how that compares to the national averages. Tobacco is often hit the South much harder than it has the rest of the United States. And so you can see down in the deep South and spreading on up into Ohio, the prevalence of tobacco rates tends to be a lot higher in that part of the United States. Next is cannabis. The West is adequately represented in its love of cannabis. Thank you mostly to Washington, Colorado, and California. You know, I lived in Colorado for a number of years. So this is an area where I've had a lot of experience. I will tell you that I think 12% is probably low, particularly for this substance. But this is what the estimated average is from NISDA in terms of cannabis use. And we're gonna talk more specifically about some of these products here a little bit later on. And then those kind of big bins of things, alcohol, tobacco, and cannabis, they're by far the most prevalent things that people use. Other substances are much less frequent. And so when we talk about illicit substances other than cannabis, that prevalence rate is only around 3.7% in Idaho. And if you look at the legend on the right, generally speaking, it's below 5% no matter what state you're in. And so illicit substances compared to others are still relatively rare. Okay, so now we're gonna jump in and I'll give you kind of the layout of adolescent substance use, what they most commonly use. And then we can get into how we apply that a little bit more. So I mentioned NISDA to you, which is great for looking at state level data. The prevalence rates are lower than they are when you look at adolescent studies than monitoring the future. And the reason is monitoring the future was actually designed to measure substance use rates in teenagers. And so this is done in kids that are in school. So they have to be in school. It's schools that get enrolled in this study, not individuals. And they survey kids in eighth, 10th and 12th grade every two years. You can see that there are three study sites in Idaho that are part of this study. So, you know, fairly reasonable representation. Certainly some of our neighboring states don't have any representation at all within this study. When we talk about adolescent substance use, in most regards, it's not all that different from adult substance use in terms of what's most common. The most common things that adolescents are gonna use are alcohol, cannabis, and nicotine. So very similar to adults. And alcohol, roughly, with alcohol, roughly 60% of kids by 12th grade have reported ever using. So this is lifetime use. I'm looking at eighth and 12th graders. For vaping, nicotine, it's 38%, 38.8%. Cannabis is very similar, about 38%. And then vaping, obviously, since 2017 has become much more prevalent among youth. And so now over a quarter of youth report vaping, about a third of youth overall report vaping. And it used to be that THC was the most common thing that was vaped, but now nicotine has surpassed THC in terms of what's most commonly vaped. The one biggest difference between adults and youth is that youth are much more likely to use inhalants than adults are. And so these are things that they can inhale, often through huffing or something like that. Gasoline, other chemicals, dust off. And they're more common in youth because they're more readily available. And they're thought by youth to be generally safe because they're household products that generally don't have a lot of regulations around acquiring them. But they actually can do quite a bit of damage, quite a bit of brain damage. And so that's the one thing where you'll see that eighth graders are more likely to use than 12th graders. 12th graders are more likely to use than adults. Okay, so as I mentioned, adolescents are the most likely to use inhalants. So this is looking at about 45, 50 years worth of data of monitoring the future in one slide. And you have in blue, 12th graders, in green, 10th graders, and in red, eighth graders. And this is the only graph that you'll see from monitoring the future when it comes to substance use where eighth graders use more frequently than everybody else. But overall, as you can see, since about the mid 90s, the prevalence rates of inhalant use among adolescents have declined. And that's pretty consistently true of substance use in adolescents in general. Across the board, substance use has declined over the last 20 years, with the exception of two substances, nicotine and cannabis. They've either remained the same or gone up, but all other substance use has gone down. And so that's also true when we look at alcohol. So as you can see here, now it's inverted back to what we would normally see with 12th graders having the highest prevalence, followed by 10th graders and then eighth graders. And on the left, you see the data showing annual alcohol use. So you can see that that's trended down from nearly all youth using about 90% of youth using to where we're now down around 60% of 12th graders reporting having used. And then numbers closer to about 15% for eighth graders having reported use in the last year. Similarly, and the colors are a bit different on this one. When we look at illicit substances other than marijuana or cannabis, you can see that those rates have also trended down pretty steadily from a peak, really high peak in the early 80s. And then again, a little bit of a resurgence into the early to mid 90s. And then over the last two decades, the prevalence of other illicit substance use has steadily trended down. So to get more state-specific, excuse me, I've got a bit of a cold. So I apologize if I cough every now and then, but the virtual world allows us to do this without me exposing you. So here we are. Okay, so to get state-specific data, we have to look back to this NSDUH study. And again, what you'll see here are the percentages for Idaho and then the map of the United States to kind of get an idea of where we pan out. And pretty consistently we're below the national average on most substance use reported in NSDUH. So for alcohol, it's roughly 6% of people under 18. And this is 12 to 18, 12 to 17 year olds primarily. And for illicit drug use, it's closer to 2%. And now I told you there are two exceptions to the downward trend in substance use. And the first one is cannabis. And what we see here is cannabis use has remained relatively steady over time, particularly over the last two decades when everything else in the United States was declining. There's an initial increase in cannabis use. That's right around the time that a lot of states started considering medical cannabis and California kind of led the charge there. And then in 2012, you had Colorado and Washington who were the first two states to legalize recreational cannabis sales. And then Colorado was the first to implement that in 2014. When we look at daily use, those prevalence rates have remained also pretty steady among youth. And so we don't see the same downward trends here that we see for other substances. So the messaging that we have around cannabis does not have the same impact as some of the messaging that we've had around other substance use. In Idaho, it's estimated that about 5% of youth have used cannabis within the last year. And I would say that's probably a low estimate, especially with the prevalence of vaping now. The other thing that has really come onto the scene pretty strong and reversed a lot of trends would be vaping. So vaping devices are designed to be easily concealed. I don't have pictures of them here for you, but some of them look like pretty routine tobacco-like products like a pipe or a cigar or a cigarette. Others of them look like a highlighter or a USB jump drive. There's a unicorn vape pen. So they look like all sorts of different things. And really what happened when vaping came onto the scene is we'd had years of decline in nicotine use among adolescents. And you can see that here in the lower portion where we have cigars, cigarettes, smokeless, hookah, pipes, all of those trending down coming into 2011 when this data starts through 2019. And then you have this sharp rise in e-cigarette use that reversed years of downward trends in nicotine use at youth. The reason that that becomes important is because sometimes we talk about nicotine or vaping as potentially being an alternative to cigarettes in the adult population, and that's often why they get pushed. But in adolescence, what we know is if someone vapes, they're much more likely to go on to smoke cigarettes and use other substances than if they never vaped at all. And so in adolescence, it's more of a gateway type substance. It's less of a, has a potential as a harm reduction type substance. In Idaho, about 6% of youth use cigarettes, so estimated prevalence is higher than it is for other substances. And I would say that vaping, which we don't have data for, is even higher than that. So that's a little bit of an exposure to what people are using that hopefully will kind of help you get the layout of the substance use among adults and adolescents and kind of have an idea as you're meeting with people where they are. Now know that anyone who comes in for mental health, anyone who gets connected to services, they're more likely to have substance use problems than the general population is. And so the prevalence rates at which you should expect to see substance use is even higher than what those state and national averages are. That's the, we work with a subset of individuals who are just more likely to struggle with substances and it's more likely to have a negative impact on their mental health and their overall wellbeing. Okay, so as we start the opioid epidemic, I wanna tell you a little bit of a story about how we got to where we are. And so this individual may be a little bit older than most of the individuals you work with, although there definitely are some kinship caregivers that would fall into this category. So this is a lady that I actually took care of. Obviously this isn't her, I get in a lot of trouble, but the overall synopsis. So she was about 63 years old. She came into the methadone clinic in Colorado for an evaluation. And this was one of the first methadone patients I ever worked with. As I sat down and worked with her, I learned that she'd been pretty, had a pretty good life up until about 51. She had worked, held down a job, raised her family, was a pretty typical middle-class Americano lady. And then she had a surgery. She got injured and she had a surgery at 51. And that's when she first started taking opioids. And when she first started taking them, she didn't understand the misuse potential. She was told to use them as much as she needed to so she could be comfortable rather than what I would counsel patients now, which is limit use as much as you can and try and get off them as quickly as you can because of their misuse potential. She ended up becoming addicted to them, became dependent on them. And then she kind of developed this pattern of malingering, meaning she would go into the doctor and she would make something up about how she was injured to try and get more opioids. When they got suspicious of that and they caught onto that, she started hurting herself. So she would put her fingers in the door and break a finger or something like that. And then actually go in with a real injury and say, hey, I need opioids, I've hurt myself. Well, eventually the emergency departments caught on to what she was doing. And there was a list of patients that was circulated that were seeking substances. And the ERs were trying to crack down on that and prevent that from happening. So she stopped being able to get substances from the emergency department. They stopped dispensing to her even when she came in with an injury. So she started buying street pills, but at the time an oxycodone off the street cost about $10 a pill. And she couldn't afford that and still support her family. So about three years into this adventure, she starts using heroin. It's much cheaper than the street pills are and she's no longer able to get the prescription pills. So she starts using heroin. Most of the heroin in the West is this tar heroin. And so it often gets injected a lot. She happened to smoke it. And it's got to the point where she started smoking it every day. When she showed up to the methadone clinic for her intake, I asked her, I said, so tell me what's your number one goal of wanting to get on methadone? And she started to cry. And she said her goal was that she just wanted to be a grandma. She just wanted her life back. And I realized like for this lady, she and I had a lot more in common than we had differently. Yeah, I was sitting across from someone with a severe opioid use disorder who used a lot of heroin, but she and I had a lot more in common than we had different and we basically were on very similar paths until hers diverged at the age of 51 down a path that she never expected to take. And so the opioid epidemic really started kind of with what we would call iatrogenic cases where patients were prescribed by physicians opioids and then they got addicted to them and that led to this huge spike in opioid use disorder in the United States. And it really helped open my eyes that, you know, sometimes we stigmatize a lot of times we stigmatize substance use, but there are people, there are humans down in there that have a lot more in common with us that is different. So when we talk about opioid use, remember that illicit substance use overall is pretty rare in the United States. And so it's not, it's not something that's super common. When you include marijuana, it's about a quarter of the country that use it, but the majority of that use is marijuana. So you can see that marijuana is by far and away more prevalent than any other category of illicit substances. By the time you get down to things that cause opioid use disorder. So prescription pain relievers, about 8.5 million past year users, and then down to heroin, about a million past year users. So you can see that these prescription pain relievers, these were much more commonly misused than heroin was, but heroin was cheaper. And so that's how most people got onto it. Similarly, when we look at a past year prescription pain reliever subtype misuse, and this is looking, this is looking at people 12 and older. So this is also from that, from that NISDA study, you can see here what, what is most prevalent in terms of what people are using. So methadone, generally speaking, is a prescription, and then buprenorphine, generally speaking, is a prescription. So you can see that the two medications that we use for opioid use disorder are among the most commonly used within the past year, and then prescription fentanyl. So we'll talk about fentanyl in a minute, but the reality is fentanyl has been around for a long time. It's been a medication that has been used in patches for long-term pain relief. And it's also a medication that's been used as an anesthetic for procedures in the United States for quite a while. So we have a lot of experience with fentanyl. And so looking at those then that have opioid use disorder, and opioid use disorder is not common enough in these big studies in adolescents to really give us a prevalence rate. So we're kind of limited to what we have in the adult population, but the estimated prevalence of opioid use disorder in Idaho is about 2%. And so that actually places us more on par with the rest of the country, right about the middle, in terms of the prevalence of opioid use disorder within our state. Overall, over the last couple of decades, we started to see an increase in the number of admissions related to opioid use. And this is really what we call the kind of the beginning of the opioid epidemic, when we start talking about how opioids started to break away in terms of their prevalence of the problems that they were creating, and people having trouble getting sober from opioids. And so they typically would get admitted to help them detox, get sober, and then they might be referred to a methadone program. That was kind of the first major breakthrough in managing opioid use was methadone. To give you an idea, if you've never been involved with methadone, and you have a client and you're telling them that methadone is part of their treatment plan, or it already is part of their treatment plan, just to be aware of what they're asked to do. Generally speaking, they have to go to a clinic six days a week, between the hours of five in the morning and noon, to get their dose of methadone. Once they've done that long enough and established care, then they can start getting take home doses. Obviously, in rural communities, that has to happen differently, because that's not readily available to them. And so in different parts of Idaho, this is going to look different. But overall, getting someone on methadone is actually quite a burden to them. It's a very challenging thing to do. And that's where buprenorphine was breakthrough, because then we were able to prescribe a medication that they could take it home, and it didn't interrupt their daily life or their work nearly as much. At the same time, we started seeing these rise in admissions. We started seeing this upward trend in opioid-related overdose deaths. And that actually really started spiking up around 2013 to 2015. We started seeing a much sharper rise in opioid-related deaths. And that's really when, in the adult population, this started to hit the news as, hey, we have a problem. Something's going on here. And so we kind of break the opioid epidemic down into waves. That first part I talked about when we were talking about the rise in iatrogenic or prescription opioid-related overdoses, that really started in the late 90s. And then, as people had trouble getting that, progressed into wave two in the mid-2000s, early 2000s, into primarily being driven by heroin by 2010. And then a rise in synthetic overdose deaths around 2013. And so the most common synthetic one that we talk about is fentanyl. Similarly, when we look at adolescent substance use, so this is looking at adolescents in 2011, 2016, and 2021, what you see is similar to the graph that I showed you, which is substance use rates in adolescents for illicit drugs, other than cannabis, have steadily declined in the United States over the past couple of decades. And that's also true for the types of substances that would cause an opioid use disorder, like heroin or narcotics. At the same time, there's been a sharp rise in opioid-related overdose deaths in youth. And so what you see here on this graph, kind of in that bottom cluster, are most substances that are associated with death. Benzodiazepines like Xanax, methamphetamines, cocaines, prescription opioids, and heroin. The prevalence rates of all of those substances in overdose-related deaths in youth have remained steady over really the last 15 years or so. Starting about 2017, shortly after we saw that upswing in adults, we saw a big upswing in overdose deaths in youth. And that's almost entirely attributable to fentanyl. So between 2019 and 2021 alone, overdose-related deaths in youth doubled. And overdose-related deaths due to fentanyl increased more than 23-fold. And so by 2021, 77% of overdose deaths involved fentanyl. And so that's pretty remarkable for one substance to have that kind of an impact. And when we talk about who's at risk, it's really all ethnic groups. And so within the opioid epidemic, within most things related to substance use, and this is definitely applicable here in Idaho as well, where we have some very large tribal populations, American Indian and Alaskan Native populations are at the highest risk, typically, of having the worst outcomes related to substance use. And that's also true when we talk about opioid-related overdose deaths. They also tend to be under-resourced. And so that can be a real struggle for them to have adequate resources. And if they don't have relationships or trust with the systems of care around them that are available through others, it's hard for them to be willing to sometimes engage in those services and get the help that they need. So what is fentanyl? Why is fentanyl so much more dangerous than some of these other substances? Fentanyl is a synthetic opioid, meaning it's entirely made in a lab. So it's not grown or harvested or refined. This is just something that's made in a lab. It's 50 times more potent than heroin is, about 100 times more potent than morphine, and it's highly lipophilic. What that means is each cell has what's called a lipid membrane around it. That's what keeps the inside of the cell in and the outside of the cell out, and it creates that buffer zone like a wall. Anything that's lipophilic means that it loves lipids. It can readily cross that. There's no protection that your body has against it going into whatever cell it wants. So that's what fentanyl can do. Fentanyl can go into any cell it wants. It can cross into the brain. There's really no barriers to it. It can go into any cell in the brain. There's really no protection against it. And so this has an easy time getting in and out of cells wherever it wants to go. When we talk about why it's so dangerous, because of that high lipophilicity and because of its relative potency, it doesn't take very much fentanyl to be lethal. So what you see there on the edge of that number two pencil on that exposed lead, that's a lethal dose of fentanyl. So it's about one to two milligrams is all it is. By comparison in that image, you can see how much heroin it would take to generally be considered a lethal dose. The way that most people get fentanyl now is in pill form. And so this is an example looking at oxycodone M30 tablets. And on the left, you have ones that are from a pharmaceutical company. Those are actually oxycodone. On the right, you have the fake ones, but they're designed just to look like the real thing. This is where the term blues comes from. If you ever hear about people talking about taking blues or smoking blues, that term has become less popular over time. But that's where this originally came from, is from these tablets. These were also called perks, which I never fully understood because they were fake oxycodone, not fake Percocets. But I guess that's only a nuance that a doctor is interested in. But these were also also became called perks. Now, no kid walks around with a bag of blue M&Ms, that just looks kind of funny. Adults probably don't walk around with a bag of blue M&Ms either. And so we started getting into what are called rainbow pills. And these are where they're produced in different colors, they're much more attractive. You can see that they almost look like candy. The most common way that I've seen these used is people smoke them, and they tend to get high faster. So they'll crush them and smoke them and have a rapid, rapid onset that way. So as these pills started flooding the market, and they started becoming much more prevalent in the substance use market, we really started to see things change a little bit. And before it used to be that maybe a lot of people they were at first exposed to something because they would seek it out. Like, I want to try marijuana, I want to try alcohol. I got these opioids from my doctor. But when fentanyl became really prevalent on the substance use market, things started to turn a little bit. And so we started to see cases where that first exposure might actually be unintentional. So this is another patient that I treated, we're going to call her Lucy. She was a 16 year old young lady that had generalized anxiety disorder and PTSD. As a result of that, she had developed a pretty robust benzodiazepine use disorder. She really liked her Xanax. Xanax was what got her through the day, it's what got her through school. It's what allowed her to be home and around her family. Without that, she was super overwhelmed and anxious. And this was not a prescription she was getting. She was just getting Xanax off the street and misusing it. It's often called Xanies or Z bars, if you've ever heard that term. But that's what she was primarily using. She was at a party with some friends and they knew that she likes Xanax and she'd misused Xanax a lot. And so they offered her something she'd never had before. They called it a blue. They gave it to her at the party and she used it and really, really got high. She said it was unlike anything she'd ever experienced in her life. So after that, when she got back home from the party and she went back to using her Xanax, she couldn't get high anymore. And so she talked to her friends about what they'd given her. They told her it was a Percocet or a Perc. So she found some Percocet in her grandmother's medicine cabinet and she started misusing grandma's Percocets. Well, there's a big difference between an actual Percocet and a street pill that contains fentanyl. So she was not able to get high off of the Percocets like she could off of the illicit pills that she'd taken. So she ended up going back to her friend, figuring out who the dealer was. And then she started getting the pills directly from them. And within two weeks of her first exposure to this illicit manufactured fentanyls, she started using it as her preferred drug when she started smoking about four to five blues a day. And so that's the point at which I start treating her kind of in the early part of this. She came in primarily with benzodiazepine use disorder and then actually in my course of treating her transitioned to using blues. And I still remember when she came into clinic one day, she looked really good and she didn't have a lot of anxiety. And I said, you seem to be doing a little bit better today. And she said, yeah. And I haven't even used Xanax all week. And I said, oh, tell me what helped you be so successful. And she said, well, I smoke like five blues a day now. I'm like, oh, that's not a, that's not really a win, but I'm glad you're not using Xanax. Now let's work on the other one. And so we were able to get her sober, but it took several months of work to get to the point where she could be sober. And then she actually had a surgery about two years ago. And I worked very closely with her surgical team to come up with a pain management plan for her that would, you know, lower her risk of relapse. And so we were able to collaborate together and help get her through the surgery without having a relapse into her opioid use disorder. And it was a major open chest surgery. So it was something that was definitely going to need quite a bit of pain management. But really kind of two different stories, right, of a lady who didn't mean to get addicted, thought she was taking a prescription medication as prescribed, down to a young teenager who didn't even know that they were getting exposed to opioids and hadn't intended to use them in the first place. Okay, so when we talk about opioid use disorder, this is something that has a lot of stigma, even within the professional community around opioid use disorder and how to treat it. And some of that stigma comes in when we start talking about the fact that we have medications for opioid use disorder. So I mentioned two of them, methadone and buprenorphine. I'll often hear from people, well, I don't know why you would ever put someone on buprenorphine. You're just trading one drug for another. And so that's the point that will get brought up. Now, where you might say that's a fair argument is these are medications that act on the opioid system. So they're called agonists. In the case of methadone, it's a full agonist, which means it's gas pedal. In the case of buprenorphine, it's a partial agonist, meaning it's gas pedal and brake pedal at the same time. What makes that nice about buprenorphine is you can't actually get high off of it. And you can't overdose on buprenorphine alone. And so there's some natural protections in people on buprenorphine. All of that aside, though, I think this is the single most compelling piece of data as to why we should use medications for opioid use disorder. In green, you see death and the general population. So this is overall mortality and the general population standardized to one. In individuals who have opioid use disorder who don't receive any medication, their mortality rates are six times higher. And when you see individuals with opioid use disorder who get medication, that intervention alone lowers their overdose or lowers their all cause mortality significantly. Not quite back to general population, but generally overall, a lot lower than it is without treatment. It also really increases their chances of staying in treatment longer, which we call retention, and overall ability to get help. And so we won't go too much into medication management, but I did want to throw this pearl out there that when you are working with individuals with opioid use disorder, you will run into stigma around medication. But the single most compelling reason to use it is this piece of data, the number of lives that these medications can save. The other thing that's really important because of fentanyl, fentanyl, I mentioned that it has a high amount of lipophilicity, which means it crosses into the brain very quickly, also comes out of the brain very quickly. That's why it has a big misuse potential, because it's quick on, quick off. That crossing the brain quickly also means that its potential overdose effects take place within minutes. So when someone overdoses on fentanyl, they can stop breathing within minutes because it's able to get right into the brain, sits on the receptor, on the cells that help drive our breathing behavior. And when it does that, it stops our drive to breathe. So people that overdose literally just stop breathing at some point. Naloxone is a rescue medication that most of you have probably heard of. What's typically available to the public is an intranasal spray, so one spray at each nostril. It's very easy to use. And what it does is it blocks the receptor, that opioid receptor that fentanyl sits on. And so it goes in, sits on the same receptor, pushes the fentanyl off, and that restores the person's drive to breathe, and they'll start spontaneously breathing again. And so this is a life-saving medication. This video resource here that I've given you from Denver Health, this is designed for the general public to teach them what naloxone is and how to use it. So it's a great video if you're ever working with someone who has naloxone, either they have opioid use disorder or someone else in their home does, and you wanna give them an additional resource to use to understand the naloxone that they've been given, this is a great resource to be able to do that. The other two things that I'll say about naloxone is it's generally safe. It blocks the opioid receptors. It doesn't really have side effects to it to speak of. And so if you give it to someone and they didn't overdose on opioids, you're not gonna cause them harm by giving it to them. So it's not something where you have to be sure this is an opioid overdose. I have to know that that's what happened. If you find someone down who's having trouble reading, they can safely be given this medication. The other thing is that this medication only lasts for a certain amount of time. And if you took too much fentanyl, you gotta remember it's like a race between these particles or the molecules trying to knock off the fentanyl molecules. So if the fentanyl molecules outnumber them, they'll eventually get back onto the receptors. And so people often require multiple doses of naloxone to overcome a serious overdose. And that means they have to go to the hospital. And so if you ever give naloxone, even if someone wakes up, you call 911 right away and allow them to take over. We've even had paramedics have to give naloxone again in the field or in the ambulance before they ever made it to the hospital. So sometimes they get it two or three times in the field before they ever get to us in a hospital. Okay, so with that, I wanna transition to another case that kind of highlights some of the opioid epidemic and the severity that we were running into. This is another individual that I treated. This was a 16 year old who came into clinic for management of opioid use disorder following a psychiatric admission. And so interestingly, this young man had had three overdoses on fentanyl. The first overdose he had, they said that he had attempted suicide. And he said, no, I didn't, I was just trying to get high. But they admitted him to a psychiatric hospital that did not address his substance use problems. So they kept him, said, oh, he's not suicidal. And then three, five days later, they discharged him home. And then he had a second overdose, got readmitted to the psych hospital. And again, discharged without any substance use care. And then the third time he overdosed, someone said, well, what if this isn't, what if this isn't just suicidal behavior? What if he actually does have a substance use problem? And why it took three overdoses for someone to get to the conclusion that he might have a substance use problem, I don't actually know. But that's what it took. It took three overdoses. And then someone's like, I think he's actually telling us the truth. He has a substance use problem. And so he had started using six months ago. He had previously misused prescription Percocets. Then he was at a party and someone gave him a Perc. And so he used it. Turns out to be a blue, like same thing that happened with our other friend. But he thought it was a Percocet, like similar to the ones that he'd taken before. He got to the point where he was smoking 20 pills a day. So quite a few. So his risk of overdose is obviously pretty high because of how much he's using. And the variability within a pill is quite a bit. And so some pills have no measurable fentanyl at all. Other pills have about a thousand times a lethal dose of that. And so the variability really varies. And part of the reason we see outbreaks and opioid overdose deaths among adults is because individuals will often say, oh, this one that killed Jack, Jack just didn't know how to use it, but that's the good stuff because it gets you really high. And I know how to use it better than Jack does. And so in the adult community, where we would think run away from something, like if we find out there's an outbreak of E. coli at Chipotle, people stop going to Chipotle for a couple of weeks. It's not that way with substance use. When people find out that there's a lethal batch, they actually seek it out because they think it's better stuff and get some higher, faster and longer if they know how to use it smarter. So I took this kid into treatment, obviously extremely high risk of overdose with his level of use and his history. Okay, so I wanna jump in now and start talking about, well, what are substance use disorders? So the first thing I wanna highlight, and we'll talk a little bit about this as we go throughout, substance use disorders are by definition, problems related to substance use. So it's not the fact that they use a substance. So using a substance does not automatically give someone a substance use disorder. They have to have problems related to their use and they continue to use despite those problems. As you can see from this list, substance use disorders are generally classified by major category of substance, alcohol being one of the most common, tobacco is actually the most common, but alcohol is the most common for which people seek a higher level of care of treatment. This was written by mental health professionals, substance use professionals. These definitions come from the DSM, which is the Diagnostic Statistical Manual. It's the guideline for diagnosing mental health disorders. Substance use disorders are technically a mental health disorder, even though you're not able to often get treatment for them from mental health facilities. And if you ever wanna have a really boring, interesting conversation, we can talk all about the policies that led to that problem, but I'm sure you encounter it as well in your line of work where it can be really hard to connect people with the resources that they need. Because this was written by professionals who really like one of these substances in particular in their personal lives, there is a substance on this list that has an intoxication state, a withdrawal state and no use disorder. And that would be caffeine. And I always found that fascinating that in all measures, it would meet the definition of a substance use disorder, but the committee ultimately chose not to give it one. But they still include it in there because you can get intoxicated on it and you can withdraw from it. And so that really points to the reason I include that is because every now and then you'll have someone argue with you. I don't have a problem, you have a problem that I use, but I don't have a problem with it. And I've even had patients tell me substance use disorders are social constructs. And that sounds very like dystopian, but it's true. I mean, they are a social construct. We define them based on problems. There's not a lab that tells me that you have a substance use disorder. Like there's one that tells me you have high blood pressure or diabetes. And so to some extent they have a fair point, but they're still having problems related to their substance use. So what is a substance use disorder then? It specifically is the problems that they have and they continue to use despite that. And so we kind of break those down into categories. So impaired control would be the first one, using more than you intend to, using for longer periods of time, wanting to limit or stop your use, but not being able to, spending a lot of time either acquiring, using or recovering, and then craving, often thinking about the use when you're not using and wanting to use. So you really have this impaired control. You're using more, it takes longer, all of those types of things. And then there's social impairment, failure to fulfill major duties, social roles. So failure to take care of your kids, failure to go to work or people who are in school, failure to go to school. Those types of things are failure to fulfill duties and social roles. Continued use despite problems. And so oftentimes people may not realize or recognize that they have a problem related to their substance use. And so that becomes important for us to kind of help them connect those dots and see the losses that they have in their life related to substance use. Now, if I just tell you, Sarah, you have a problem, look at all these things you've lost. Sarah's naturally gonna become defensive and not listen to anything I have to say. But if I can sit down with her and work with her and help Sarah identify losses in her own life and then help connect the dots, I wonder how your drinking might've affected the fact that you lost your driver's license. Rather than telling her, you got a DUI, you lost your license, it's your fault. And so we'll talk more about that when we get into motivational interviewing, but there's a way to help people identify these problems within their life. But this is the biggest reason that people don't go into treatment is they don't see that they have a problem. And so we often have to help them with that. Overall, the nice thing about those criteria, all the substance use disorders have the same criteria. So if you have a general idea of what a substance use disorder is, what the types of symptoms are, the types of problems, pretty much all the disorders have the exact same problems. They're just caused by different substances. And so that's generally pretty straightforward thing to remember, so you don't have to remember them for every given substance. The severity of it is not based on how much they use or how often they use, it's based on how many problems they have. So mild would be two to three symptoms, severe would be six or more. By the time someone's moderate or severe, they typically need to be referred to treatment. People that have a mild use disorder, they can still be pretty functional. They may be resistant to treatment, but they're certainly at risk of going on and developing more substance-related problems. So even though it's not about frequency, frequency is still important. Regular use predicts having problems. And the frequency of use is associated with the severity of their use. So people who use something more frequently are definitely more likely to develop problems related to their use. But again, it's the problems, not the frequency that define the fact that they have a substance use disorder. Going back to our friend NSDUH, when we look at NSDUH for substance use disorders, the estimated prevalence in Idaho on those 18 and older is about 18%. So about one in six adults in Idaho are estimated to have a substance use disorder. Alcohol use disorder is closer to 12% in the state of Idaho, which may be low. Certainly for our region, it appears to be low, but you can see that these are very prevalent. At least one in 10 and one in six have an alcohol use disorder or a substance use disorder within our state. In adolescence, we can estimate alcohol use disorder and the prevalence of alcohol use disorder in Idaho among youth is estimated to be about 6%. So that might be higher than you suspected, that 6% of youth would meet criteria for an alcohol use disorder within our state. So some key points then as we talk about adolescence and adult substance use. Substance use and use disorders, they're common. Alcohol is the most commonly used substance that causes problems. In other words, more people have tried alcohol than have tried anything else. Nicotine and cannabis are the most frequently used substances, meaning that people use them more often than they use anything else. So if someone uses substances every day or every week, that's more likely to be nicotine or cannabis than it is to be alcohol or anything else. Even though we've seen that rates of substance use have remained relatively steady and adult populations have declined in youth, rates of overdoses in both age groups have risen sharply over the last decade. And that's primarily due to the prevalence of fentanyl and fentanyl related overdose deaths. Substance use disorders are defined by their problems related to continued use. And while the use is an important part of that and frequency is an important part of that, not overstigmatizing the use of a substance, but remembering it's really the problem. And how do we help people identify the problems and the losses that they've experienced in their life due to substances? That's what's most likely to help them be willing to engage in services and be willing to receive services. I apologize again for my loss of voice and going through this a little bit more quickly today to hopefully make it to the end. But I hope that this was helpful to you. And there is a QR code for a survey that I'll- Nope, that's my bad. We are not doing the survey yet. We'll do the survey at the end, I promise. Okay, no survey. But with that, I'm happy to have a conversation about these things. I know that when we talked about how we wanted to do these sessions, we wanted to leave a lot of time for discussion and questions. And so I'll just open it up to everybody to jump in with any questions or anything that y'all wanna talk about with the time that we have left. So this information that you've given us today, how does it relate to pregnancy Medicaid as far as what you see or pregnancy? In terms of like the prevalence in pregnancy? Yes, here in Idaho. Yeah, so substance use rates in pregnancy can be pretty similar to the general population. And so that's certainly something that can be affected by socioeconomic status. There's a lot of variability in substance use in pregnancy where some people view it as very harmful. It used to be that I think that we had a pretty robust message against drinking in pregnancy. And now you'll see people be like, well, the reality is a drink or two here or there probably won't be that harmful. And you see people will go back to using substances at some point in their pregnancy. One thing we'll talk more at another session about how to actually manage substance use in pregnancy. But a couple of things that are really important to remember for opioids, for example, you don't wanna encourage someone who's pregnant to stop misusing opioids. You want them to get to a medical provider who will put them on a medication and get them off of the opioids because the risk to the mom and the pregnancy is pretty high if they just quit cold turkey. And so that's one in particular where, yeah, we're gonna try and get them to stop smoking. We're gonna get them to try and stop drinking. But with opioids, they really need to get on a medication so that we can get them off the opioids safely and preserve their pregnancy. The other thing related to pregnancy that's really important when we talk about substance use, earlier exposure has a bigger impact. So when you're in the first trimester, substance use exposure can have a much bigger impact on the baby than later exposure. So think of things like fetal alcohol syndrome. Most women, if you ask them, did you drink during your pregnancy or are you drinking? They'll probably say no because they know that's the right answer. And they don't wanna give you the wrong answer, especially if there's something on the line. And so what I generally do when I'm taking history from people is I'll ask them before you found out that you were pregnant how often would you drink alcohol? And I would get an idea of how commonly they would drink, what they would drink. And then I would say, when you found out that you were pregnant, how far into your pregnancy were you? What happened with the alcohol use at that point? And so they'll be like, oh, I quit right away as soon as I found out I was pregnant, but I found out I was pregnant like 12 weeks in. So that baby still has 12 weeks of exposure. Not intentional, right? The mom did never intend to hurt their baby but that baby still through the entire first trimester has quite a bit of alcohol exposure. And then mom quit and got sober. And you'll see some women who will say I cut back but I didn't quit altogether. And then you'll see some who just will continue whatever substance it is through a normal pattern of use. And so it can be really helpful. There are actually questionnaires that have been designed to get at substance use during pregnancy in a way that feels more supportive and less like in your face, did you do something that was wrong? But yeah, but overall we still see this. And cannabis use in pregnancy is actually quite prevalent as well. And there are actually midwives and OBGYNs who will recommend cannabis to their patients for morning sickness during their pregnancy, even though every major healthcare professional group, including the Society for OBGYNs, which is ACOG, the American Academy of Pediatrics, the American Psychiatric Association, the American Medical Association, all of them have stances that say that marijuana use during pregnancy is not good for the baby because of the developing brain. But you still have health professionals who will actually recommend it. And so we get a lot of mixed messaging around cannabis that someone makes it more prevalent. Unfortunately, the prevalence rates for cannabis in pregnancy are highest among young women who are 18 to 25 and their brains are still developing. So you've got two patients. You've got the unborn child and you have the mom. Both of their brains are still developing and being exposed to cannabis. So that's kind of a group that's really high risk that we pay a lot of attention to when it comes to cannabis use. Thank you. If you wanna take your screen down, we can have everyone come on camera and we can chat. What are you finding the, where your barriers are in Idaho with the treatment that is available out there? What barriers are you facing? Yeah, there's definitely, that's a good question. So there's some real challenges. So part of it is who's able to give treatment and offer services. And so the Boise area, Treasure Valley has more resources in terms of available treatments than other parts of the state do. And so in Idaho Falls, for example, there is a, there's a, an organization that has therapy related to substance use over here. They've had a hard time maintaining clinical staff. And so when you have high turnover, it makes it really hard to get any sort of good standard implemented within your program. And so generally speaking, there just aren't a lot of places for people to go. And that's true for adolescents as well. There are very few treatment programs in Idaho that are available to them. And so often it becomes what's available, not what's the best fit or the most convenient or the most likely to help them. It's usually, well, here's your one option. So good luck. And I hope it works for you. And so that, that can be, that can be a real challenge. A lot of our state is rural and rural communities are always underserved, especially when it comes to substance use and mental health. And so our biggest barrier right now is we just don't have a lot of treatment options. There aren't a lot of people doing this work. And quite honestly, to be candid for a minute, which you all can appreciate because of the jobs you do, this work is underpaid. And so without getting grants or contracts, it's really hard for substance use programs to take insurance and be profitable. They'll largely lose money. And so they have to get grants or contracts that can insulate them from those losses. And so that's part of the payer reforms and insurance that becomes a real challenge and part of the reason we don't have a lot of these programs. Is the state doing anything to try to make this better or improve it? I think, I think they try. Yeah, they, so they definitely have been some legislation that has passed to try and increase resources. Getting those resources outside of the Treasure Valley area sometimes can be challenging because the infrastructure and the people that can do it are not necessarily there. So that can be hard when you don't have the workforce to do it anyway. So that's one barrier. Going to Magellan, I think they were hoping that by mainstreaming that payer system for Medicaid that that would help. And one area where that actually might prove to be the case, when you have a single payer like Magellan, it's easier to go to them and negotiate a contract and say, hey, I'm willing to provide this service for your patients, but this is what it actually costs to do that. And that's how you can make these programs solvent is by finding partners and someone like Magellan or the state that could then actually provide supplemental resources and help you build a program that would meet the needs of the patients. But then again, in some ways, the state makes things more difficult because we really like criminalizing things. I think that's because people may believe that's the best policy, and I think sometimes it's a political statement more than a policy statement. And I have a youth that I treated the other day that has a felony. She's 14. And I asked her what her felony was, because that's really, I guess, impressive is probably the wrong term, but in my line of work, it's kind of impressive to be 14 and already have a felony. And she said that she was charged with felony drug distribution. I said, what did you do? And she gave her 17-year-old cousin a nicotine pod. And I said, that's what they charged you with? And she said, yeah. And I talked to her parents and her parents said, yeah, that's what she was charged with. I've never met someone in my life charged with a felony related to nicotine possession. That's a real barrier when we criminalize. And I talked to a lot of parents whose kids have substance use problems, and they feel like the system is more designed to punish their kid than actually get them help, and more likely to try and detain them than get them into treatment. And so that does become a challenge when you're in a putative system that is postured towards punishment rather than postured towards treatment, and makes it so people don't trust and don't want to be forthcoming and get the help that they need. I can soapbox on this forever, but the hope is that we start finding solutions. Yeah, absolutely. So what are the current levels of care that are offered in Idaho for youth, adolescents or adults? Yeah, so generally speaking, the front line is unfortunately the emergency department. So anything related to intoxication is generally going to end up in an emergency department. And so they inherently have to know a certain amount of substance use. The way that Idaho law works, a lot of those individuals might get placed on a mental health hold, and so their next stop, if they need to go to a higher level of care, is likely to be an inpatient psychiatric setting. And then once they're sober and they're no longer impaired, that hold is often going to get dropped by an evaluator, and then they're going to be discharged with minimal aftercare. Excuse me. And that's what's going to happen with a lot of these cases. There are going to be a subset that are able to get the substance use treatment programs. Some of those might have a residential program. There's one in southeast Idaho. There's a couple over on the west side of the state as well, where people are able to stay. Typically, residential programs are about a month in length, and people stay inpatient for that time to help them get sober, and then they transition out into a partial hospitalization or IOP-type programs, where they go to therapy multiple times a week. And then below that, you're going to have individual outpatient therapy resources. The most commonly substance use disorders are getting managed either by primary care doctors or mental health professionals who are operating outside of their element and outside of their knowledge base, but that's really all that these individuals have available to them. So I do a lot of consulting in Colorado with primary care doctors. We have a network set up for them to call in. They ask questions about substance use disorders and management, because a lot of times, they actually can't get treatment for their patients, and so they have to manage it themselves. And they'll call in and ask someone like me questions about what to do and how to manage their use disorder. So the front line of all of our healthcare has ended up having to be the primary service here as well. For adolescents, the ones that are most likely to get into substance use disorders are the ones that are adjudicated to it. So they've been arrested, they've been charged with something, and then they end up in court, and the court sends them into treatment. There's a residential program in Pocatello that will take teenagers, Bannock House. So there are some resources. They're kind of spread out. They're not super common, but the standard levels at the highest would be residential. Below that would be intensive outpatients, and then below that would be individual outpatients. But it can be very difficult to find those and get people connected to them. There are treatment finders. SAMHSA maintains one. So if you Google SAMHSA treatment finder and you plug in a zip code, it will list the licensed substance use treatment programs within that area. And what was the name of that again? SAMHSA. S-A-M-S-H-A. I can find it and put it in the chat for you, too. Got it. And then I get a question. What is your opinion on the changes from the third to the fourth edition on the ASAM criteria? So the ASAM criteria. So the adult version, candidly, I've not had a lot of time to look at, and that's in part because I'm on the committee writing the first adolescent draft. And so I have been knee-deep in ASAM working on the adolescent criteria. And ultimately, if you're not familiar with the ASAM criteria, they look at six domains to really help you kind of determine what level of care somebody should go to. Now, on the one hand, I think it's a helpful construct to think about what are the domains that are affected by substance use and that help determine outcomes. And that's what it's really designed to do. On the other hand, and when you live in a state like Idaho or when you deal with kids and this is a conversation we've had several times within the committee around adolescents, it's almost an academic exercise because I can sit down and be like, oh, the ASAM criteria say you should be at a level three facility. The reality is there isn't a level three facility anywhere for you to go to. So that's not what you're going to get. And so they can be impractical to implement in a number of settings. And that, I think, is the barrier. In terms of the idea of understanding the domains of substance use and how those things all integrate into a whole person to affect their care, I think it is useful in thinking through that in treatment planning, but it's an ideal that assumes the entire spectrum of care resources is available to everybody that walks through the door. And that's aspirational, but it's simply not realistic. I don't know if that answers your question or if it's similar to your experience or if you had more specific questions about ASAM. Nope. Just wanted your opinion on that. Thank you. Yeah. I will say, too, most things that are federally funded and that comes down into state funding require a diagnostic evaluation using the ASAM criteria because it is the standard that gets set. And so that can be frustrating sometimes to do these evaluations that take a very long time, like a gain, and then feel like, but I'm not actually able to actually connect them with what it tells me to anyway. And so there definitely can be some frustrations in that process. But generally speaking, it becomes the standard bar that most federally funded things require us to assess by. Is there a way to get more federal dollars than just kind of more on state for these types of situations? Yeah. So there's definitely a way to compete, right? So most federal organizations within them have part of their charge or part of their interest to fund underserved communities and underfunded areas. And I can tell you that in most things related to healthcare and substance use, when it comes to federal money, Idaho is underfunded. And so if you have people who are willing to write the grants and who know what they're doing and can build an infrastructure, there are funds that would basically pay for that to be built. But it takes stakeholders coming together. Some of those funds are only awarded at the state level, which meaning that the state has to submit a proposal to get funding. Others of them, individual groups can go seek funding for and they can say, hey, as an organization, we're going to apply for this and we're going to try and get this money. But there is federal money out there. When I moved from Colorado to Idaho, I had a lot of people I'm well connected with and resources through Colorado. And a lot of people say, when you get to the point that you can write grants in Idaho, you'll basically be a shoo-in because you're going to be competing in a smaller pool of people because everybody wants to fund underserved areas. And so there's money, but it takes people willing to write and implement the grants. And that's been a barrier is getting the people who are interested in doing that and who want to do that and make that happen. So this first training was focused on giving you guys sort of a general knowledge of substance use before we kind of dive into like more specialized trainings. So in the scope of thinking about just general substance use disorder, are there anything, are there things that you're seeing with your caseload that you have questions about? Are there instances of things coming up where you're like, what do I do with this? Because this would be a really good time to talk about that. Generally, I don't know that many of us are having the substance abuse patients. And when we do, we have, we would hook them into Magellan and try to find help through Magellan. But we do want to build this program for substance use disorder for our pregnant population. And so, you know, again, we're not seeing that as often as you would think we would. But we're hoping with them being able to get this up and going, we will start to see more. Because I think a lot of ones that are out there just have no access to anything or to help or flat out lie about their use. Yeah. And a lot of it, a lot of it has to do with the posture too. Our programs that were successful for pregnant women and new moms, they were postured towards supporting them and helping them. And they were never designed to appear or feel punitive in any way. And so, you know, there was like a community pantry where they could come and get diapers and formula. And those things were used as contingency management. So maybe then like giving them a gift card if they showed up to three appointments in a row, you know, they would get a certain amount that they could spend in the community pantry and be able to get resources for their baby or for themselves. And it was really, you know, they were really designed to be, hey, we're not here to take your child away or punish you. We know that this is a struggle and we're here to help you and we're going to show you. By help you, we mean actually support you in some of these things that you're struggling in and have additional resources and wraparound services available to them. And I think that really helped kind of create what people felt like was generally a safe place for them to go. With the pregnant women, do they usually present just through the physician or as far as substance use disorder? Is that how they usually are found able to help them at that point? So oftentimes it may be someone who is known that ends up then becoming pregnant. And so they may already be in the system. But then some of them, we find out that they're pregnant and we'll try and help connect them. Colorado, and candidly, I haven't actually reviewed Idaho's laws on this, and I probably should before one of our sessions. But in Colorado, using a substance and reporting using a substance as a pregnant woman is not reportable. It's not a crime. It's when it's measurable. And so we have to be careful, right? So like if a woman comes to me in Colorado and tells me, hey, I'm doing X, Y, Z, I can help her without this becoming a punitive event for her. If I take a sample from the pregnancy, so a blood draw from the baby, amniocentesis, and take some fluid out of the sack, essentially, and I measure drugs in that, that then becomes reportable. So it's part of how do you set up your infrastructure, what's reportable and what's not. And so we intentionally created a system, and it took a long time to do, where women could come ask for help without getting punished for doing that. But even though we have that in place, we still routinely have women not be willing to tell us about their substance use or not be willing to enter studies about pregnancy and substance use because they still have this fear that somehow this is going to result in their baby being taken away from them. And that's a huge barrier. That's a huge fear that a lot of women have. And so we had to explicitly encode basically in the law, we're not going to take your kid away for coming and telling us you're using substances. Our job is to help you get better. I've noted that within the NICU, that if someone is on treatment, they don't normally take the child away. But if they have not been on treatment and they present, then they will look at taking the child at that point. That's what I've recognized with the NICU records that I see. Yeah, so definitely if someone's engaged in treatment, the system hopefully is postured towards helping keep them together and working through that. And that really should be the posture. But if we can set that from the beginning, then it makes it more likely that people will ask for help. Yeah, that's the whole premise of the program that we're working on is to identify this in pregnancy. So we're not seeing these babies having to go to foster care. So we're helping these moms navigate sobriety, you know, teach, you know, sending them to classes to become better moms, those types of things. Yeah, there's no punitive opinions or anything, you know, that will come from our staff for sure. And that's where those little things like having diapers and formula available as incentives really send that message that you're talking about. Because if I'm giving you diapers, that means I'm also planning on you having your kid at home. I wouldn't be giving you diapers if I'm going to take your kid away from you. And so kind of these little things of like, hey, we're going to give you extra resources for this kid can really help send that message that, yeah, we're here to help you keep your kid. Like, I wouldn't give you diapers and formula if I'm just going to take your kid away from you. Like, that's a waste of my money. And so there are ways to send that message to people that, yeah, it really is about keeping you together and working with you through this. So lots of things to consider. You know, it's a very important thing to do because, you know, you think of what people are going through now in our current climate who are transgender or who need a medical abortion in certain states and can't get them. That's the kind of fear that women who use substances often have around someone finding out that they're using during their pregnancy. And so that's an example that's more visible in the media now, but can be a similar level of fear. I'm sure I'll have a lot more down the line, but so far, so good. Okay. Thank you, Dr. Hinkley. We really appreciate your time and you doing this with us.

substance use disorders

adolescent substance use

Idaho

opioid-related issues

fentanyl

opioid use disorder

treatment infrastructure

methadone

buprenorphine

pregnant women

mental health