Good evening, thank you for joining today's program. Before we get started, we have a few housekeeping items to cover. All of our participants are on mute, but we would like for this presentation to be as informative as possible. If you have questions for our panelists, please share them via the Q&A box on your screens. Our panelists will leave time for questions at the end of their presentation. As a reminder, this webinar is being recorded and will be posted on the PCSS website. Now I'll pass it over to Jennifer to start our presentation. Good evening, everyone, and welcome. I'm Jennifer Byrne from the American Medical Association. Thank you very much for attending this evening's webinar, Taking Responsibility in Missouri, Reversing the Overdose Epidemic. This webinar and the accompanying toolkit are the result of a collaboration between the American Medical Association and the Missouri State Medical Association, the MSMA. Funding is through the PCSS, which stands for Providers Clinical Support System, a resource for physicians and other providers for educational and mentoring supports on topics related to drug overdose, treatment for substance use disorder, and care for pain. Our presenters tonight are Dr. Drew Shoemaker and myself. And Dr. Shoemaker is from Iowa, but has been in Missouri since 1982. He obtained a BS from Southwest Baptist University in biology and chemistry, and an MS in biology from Missouri State University. He's completed medical school at the University of Missouri, Columbia, and residency at Cox Medical Centers in Springfield, Missouri. He is board certified in family and community medicine, and currently practices family and addiction medicine at Burrell Behavioral Health in Springfield, Missouri. I'm again, Jennifer Byrne, and I'm a program manager in behavioral health at the American Medical Association. I'm a licensed clinical social worker with specialty training in addictions and trauma. I have over 20 years experience working in the addictions field around Chicago. Next slide, please. We have no disclosures tonight for the presenters of this module. Next slide. And the overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications and for the prevention and treatment of substance use disorders. Next slide, please. Here are educational objectives. At the conclusion of the activity, participants should be able to describe current and historic trends in the overdose epidemic, both nationally and in the state of Missouri, demonstrate state and national tools and resources to reduce harm for people taking opioids, identify ways to help make pain treatment safer, more effective, emphasizing safe opioid, non-opioid, and non-pharmaceutical treatments, and discover resources for treatment and recovery for people with opioid use disorder, which we may refer to as OUD. And upon completion of the presentation, you'll receive instructions on how to obtain your CME, first by completing a brief survey, and then a short quiz. And slides from the presentation will be made available. Next slide, please. This Physician Toolkit, which is now one of five state toolkits that AMA has done in the past, is presented by the Missouri State Medical Association, as I said, and the American Medical Association. And this is to provide state and national data and resources and tools for Missouri physicians to better understand and address the drug overdose epidemic in Missouri. We'll have now a brief announcement from MSMA, and I'd like to thank the staff and leadership from the Missouri State Medical Association for their collaboration and support. I'll turn it over now to Chantelle Dooling from MSMA for a brief announcement. Good evening, everyone, and thank you for being on this webinar. Again, my name is Chantelle Dooling. I'm the Director of Legislative Affairs for the Missouri State Medical Association. I just wanted to inform everybody briefly that after eight years, or 18 years, nearly two decades of fighting to pass a PDMP, this year we were able to become the final state to pass a statewide PDMP. We did have some local PDMPs that were in place, but once the statewide is implemented, those will no longer be used within the state. I also wanna thank those that are on the call that are already members of the MSMA for their membership. We appreciate that so much. Without our members, we would not be able to do what we do. If you are not a member, I ask that you maybe consider being a member. If you have any questions, please feel free to reach out to me. Through your membership, you get advocacy and representation on every level of the Missouri State government. We also have member-only subscriptions to Missouri Medicine, which is our bimonthly award-winning, internationally acclaimed peer-reviewed journal. You'll also get subscriptions to our progress notes, which is our newsletters, digital legislative reports, things you need to know that are going on. We like to make sure that our members are kept up to date. You also have access to our statewide network of colleagues and member-only access to the association's physician directory. And then you have an opportunity to shape policy by serving on our MSMA, as an MSMA delegate, or you can testify your patience and profession in the state capitol. So we are happy to help you with all that. And again, thank you for your membership. If you have any questions about membership, please feel free to reach out to me and I will hand it back to Jennifer. Thanks very much, Chantel. So we'll go to the next slide and we're gonna start off looking at kind of an overview of the overdose epidemic from a national and historic perspective. In 2020, 93,331 people were documented to have died from drug overdoses, according to CDC data. That is a very serious and new peak number of deaths after seeing some declines during the years of 2016 to 2019, as you can see on the trend line. These declines were due to the efforts of the medical community and many others to address the prescription opioid overuse, addiction and misuse. This new peak is very, very, very concerning. And as we see, it has exceeded some of the peak years of other public health problems, such as gun violence deaths, AIDS deaths, and car crashes. We also see this at a national level. It's not just in Missouri. Overdose deaths increase in all but two states, South Dakota and New Hampshire being the only exceptions. And the highest number of overdose deaths include now from synthetic opioids, such as fentanyl and fentanyl analogs, stimulants such as methamphetamines and cocaine, and sometimes combinations of the two. Next slide, please. So looking at the situation here in Missouri, we have this graph showing rates of overdose deaths had peaked around 2017 and then started to decline both nationally and in Missouri. The orange line shows the U.S. average, starting again in 2015 as illicit fentanyl started appearing. Missouri is represented by the blue line on this chart. It shows that although overdose rates in Missouri have been higher than the national average, progress was definitely made from 2016 to 2017 in reducing overdose deaths. And then again, from 2018 to 2019. For example, in 2016, there were 1,364 deaths statewide. In 2017, there were 1,366. So an increase of only two deaths. In 2018, though, we saw an increase to 1,608 deaths, but then a decrease in 2019 to 1,581. So we made some progress, but that progress has been eclipsed by the rise in fentanyl use. In 2020, Missouri saw 1,878 people die from overdose deaths. Next slide, please. So when we look at the substances involved, they have changed. This chart shows the drugs identified in Missouri overdose deaths with a significant upper trend in the orange line, fentanyl and fentanyl analogs, and illustrating clearly the evolving nature of the drug overdose epidemic. Of concern also are the other upper trends in overdose deaths from stimulants, fentanyl, and heroin. I'm sorry, stimulants and fentanyl. But many deaths involve polysubstances, fentanyl, heroin, and stimulants together. Illicit substances can be a mix of just about anything. Next slide, please. When we look at overdoses by county across Missouri, we see that although there is a concentration in terms of numbers in and around the St. Louis area due to the population density, we see that there are overdose deaths across the state. And we also see that the top 10 counties here in 2020, St. Louis County, leading with 400 deaths, St. Louis City, Jackson County, Jefferson County, St. Charles County, Green County, Franklin County, and Clay County, Boone County, Pulaski County, were the top 10 counties affected by drug overdose deaths. Next slide, please. The COVID-19 pandemic has had a dramatic effect on the overdose epidemic. 81,000 drug overdose deaths occurred in the United States from May 2020 to May 2021, the highest number of overdoses deaths ever recorded in a 12-month period, according to data from the CDC. And in addition, during the period of March 2020 to October 2020, we have a number of other indicators. Increases were seen in the number of ED visits nationally for fatal and non-fatal drug overdoses. ED visits were occurring and increasing despite the constraints of stay-at-home orders, recommendations to avoid public spaces, and also increasing despite the capacity issues that were caused by the influx of COVID patients to hospitals. Now, this finding may reflect some disruptions to the illicit drug supply sometimes coming from overseas and or people using illicit opioids alone or in more risky ways. And also this may reflect a decreased access to naloxone and the other harm reduction services that would be available, but weren't due to COVID-19 related shutdowns. Next slide, please. It's crucial to look at non-fatal overdoses. And as we see from this graph from Think Health St. Louis, which covers the St. Louis area, both city and county, we had seen a small decrease and then now we're seeing an increase. And the highest risk factor for drug overdose deaths is a previous non-fatal overdose. This data is crucial, but not available for the entire state. Oop, let's, yeah, stay on that slide. The data chart above is available at Think Health First St. Louis on their Opioid Action Plan Community Dashboard and is available in your toolkit. And other important data that's available on there are opioid related deaths. Also other indicators such as naloxone doses that have been distributed, who are the reporting agencies, response teams in the community, medication assisted treatment providers, and also PDMP searches and prescriptions dispensed. And the links to Think Health St. Louis are on the toolkit. And again, the greatest predictor of an overdose death is a previous non-fatal overdose. And the AMA encourages conversations with your patients about whether they've experienced drug overdose, are struggling with drug use, or if a loved one has had a non-fatal overdose. Next slide, please. So in terms of non-fatal overdoses, this chart shows some of the costs that result. It's from 2017 to 2018 and shows some of the costs of non-fatal overdose in terms of emergency department utilization and hospitalizations in Missouri. The average cost of a non-fatal overdose ED visit is almost $3,000. And many non-fatal overdoses utilize multiple points of healthcare, namely EMS responders, ambulance, as well as ED care. These types of services, as we know, are very costly. And on the bright side, so to speak, the ED does provide an opportunity to screen and assess patients for OUD and to connect them with treatment services and to provide medication for opioid use disorders such as buprenorphine. Many EDs across the country are working on innovative interventions such as warm handoffs and assertive linkages to treatment and connecting patients to peer recovery specialists, sometimes co-located in hospitals, as well as addiction-trained therapists or social workers who can facilitate patients getting into treatment. Next slide. The AMA has been working on the issue of overdose surveillance and looking at the problems with gaps in data. And better data is essential to combating the overdose epidemic. We have to know what's going on in the ground. Current data is incomplete, it's not standardized for comparison, it's not timely enough, and it's widely variable from location to location. And difficulties still remain in accessing the high-quality, timely, and comprehensive and standardized data that we need. Metrics are normally available for drug-related overdose deaths, however retrospective, but data for non-fatal overdoses and other key indicators are not widely collected or standardized across state and communities. And remember, non-fatal overdose is the greatest risk factor and predictor for a fatal overdose. We wanna eliminate some of these data gaps to inform a public health approach that is effective and comprehensive and interventions to reduce overdoses. Next slide, please. As we see from the data presented, prescription opioids are not the primary drivers of the upsurge in overdose deaths. A recent report from the AMA showed that opioid prescriptions have decreased 44% nationwide since 2011, but drug overdoses have tripled. And the opioid prescribing in Missouri has decreased and stabilized. Although it's still somewhat above the national average, there have been significant declines. For example, in 2017, 4.4 million opioid prescriptions were dispensed. In 2020, 3.3 million opioid prescriptions were dispensed. Next slide, please. So we have to talk about the primary driver of the current upsurge in overdose deaths, and that is fentanyl. And that is mostly illicit fentanyl. Fentanyl, as we know, is a powerful opioid. It interacts with the opioid receptors in the brain and elicits a range of responses within the body from feelings of intense pain relief, relaxation, pleasure, and euphoria. Normally is prescribed in the event of chronic severe pain as a result of cancer, nerve damage, back injury, major trauma, and surgery. Prescription fentanyl is 80 to 100 times stronger than morphine. And illicit fentanyl and the analogs, which some of them I've listed there, known analogs on our slide, can be manufactured or imported into the U.S. for use in the illegal drug market. Next slide, please. So it's important to learn a little bit more about illicit fentanyl. It is cheaper to produce and more potent than heroin, and drug sellers may prefer it to heroin due to a higher profit margin. Fentanyl has also been imported from overseas. In 2018, federal investigators uncovered hundreds of online transactions that resulted in packages of fentanyl being shipped from China to the U.S., mostly via the U.S. Postal Service. And some of the packages are what you see in that picture there on the right. Since fentanyl is so powerful, multiple doses of naloxone may be necessary to counteract an overdose. And users of illicit drugs may be unknowingly and unwittingly ingesting a mixture of heroin, cocaine, or other, or methamphetamine adulterated with fentanyl. And since fentanyl overall is so much more strong than, is so much stronger than heroin, this may be a factor in unintentional overdoses amongst people who use drugs. Next slide, please. So I wanna talk a little bit about stimulants and benzodiazepines as they do contribute to overdose deaths. And for benzodiazepines in particular, there were some concerning trends that came out from CDC data analysis in 2019 and 2020, that they saw increases in both non-fatal and fatal overdoses involving benzodiazepines mixed with opioids, and also in some combination of illicit or prescription opioids, and also benzodiazepines without any opioids involved at all. So it's important to use caution. And one of the AMA Task Force recommendations is to try to avoid whenever possible concomitant prescribing of benzodiazepines and opioids. Next slide. So we need to talk about harm reduction when we talk about trying to prevent overdose deaths. Harm reduction is a set of ideas and interventions that seek to reduce the multiple harms associated with drug use. Examples of harm reduction programs for opioid users are syringe exchange programs so people can get clean needles, safe injection sites, including overdose monitoring so that people can be watched as they use and possibly revived, safe injection kits, and most importantly, naloxone rescue. And I've listed the name of one of the resources that I found that's in your toolkit. Most Days Safe has a lot of resources and more information is available at their website. Next slide, please. Naloxone. Naloxone is an FDA-approved opioid antagonist that rapidly reverses overdoses involving opioids. It can be administered through a nasal spray or an intramuscular or IV injection. And know when your patient is at higher risk of overdose or if one of their loved ones may be at risk for overdose. Some of the factors you can consider are whether your patient is currently on a high dose of opioids. Do they have a concomitant benzodiazepine prescription? Do they have a history of substance use disorder? Do they have an underlying psychiatric or medical condition that could make them at higher risk for overdose? Have they recently been in an addiction facility, treatment facility, or gone through opioid detox or been in some other controlled environment? Many people come out of controlled environments, even such as jail or prison or treatment facilities, if they return to use, they sometimes return to the level of use that they were at when they went in and accidentally overdosed. And also, might my patient be able to aid someone who is at risk of an opioid-related overdose? And since 2017, any person can obtain naloxone in a nasal spray form at Missouri pharmacies without a prescription. Of course, they must check with the pharmacy to make sure it's in stock. And as an example of that, here is my naloxone nasal spray that I actually carry around with me and have for a couple of years. And it was as easy as walking into my local pharmacy here in Chicago and asking for it. And I got it within a few minutes. And we'll go to our next slide, please. All right. So overdose rescue with naloxone, what does it look like? Who can do it? Who can intervene? Really anybody. First responders, many of them are trained and are armed with naloxone nasal spray, police, fire, EMS, and paramedics. Also bystanders, friends and family can use the nasal spray, not the injections, obviously. And non-physician healthcare workers. And really anybody who has the nasal spray with them may witness an overdose and has read the very simple instructions on its use. And it's important to recognize the signs of a drug overdose. Common signs of an opioid-related overdose can be unresponsiveness, shallow or no breathing, small pinpoint pupils, clammy skin, gurgling noises, and blue-gray lips and nails. Go ahead and advance the slide. Also, there are many wonderful harm reduction and overdose prevention resources in Missouri. I've outlined two here. The first is No Mo' Deaths. It's a collaborative project involving healthcare agencies, academic institutions, and content experts throughout Missouri. And their goals are to expand access to integrated prevention, treatment, recovery support, and harm reduction services for individuals with OUD and stimulant use disorder. Their goals are prevention and various activities among their providing help and accessing naloxone for people that may be already using drugs, primary prevention for youth, pain management, education, and public awareness. And in terms of treatment, providing help and accessing treatment for people with OUD, training and educating providers around delivering treatment, and promoting a medication-first approach to OUD treatment. And to link of individuals with available care resources, be they outpatient or residential. And recovery supports are crucial, especially for people in early recovery. Safe and sober housing can be crucial to helping people maintain sobriety. Training and certifying peer specialists and peer support groups can be crucial in that period. Promoting wellness and recovery and also harm reduction. Many people who have OUD are not ready to stop using, but we can help save their lives with harm reduction strategies and naloxone. Next slide, please. Another program is the Missouri Opioid, Hair, and Overdose Prevention Education, MOHO project. It's a partnership between healthcare agencies, academic institutions, and community groups that is focused on reducing opioid overdose deaths in Missouri. Through expanded access to overdose education and naloxone, public awareness, and assessment and referral to treatment. And this MOHO project actually will provide educational resources for physicians and other providers in treating OUD and in harm reduction. So there are lots of helpful resources I've just outlined too. And those are in your toolkit as well as others. And they're very, we think these are important resources for physicians to know about. So at this point, I'd like to turn it over to Dr. Shoemaker to present the rest of our slides. Dr. Shoemaker. Thank you, Jennifer. You know, one of the tools that is about to become more available to us is a statewide PDMP prescription drug monitoring program. Proponents have been working on getting a statewide PDMP for quite a while now. It's been really pushed by MSM, the Missouri State Medical Association, and we're really appreciative of their efforts. It was a little slow getting passed. It hit some snags in getting passed in the legislature. And the St. Louis area began their own PDMP. Basically what a PDMP is, it gives you the ability to see where your patients are getting their prescriptions and to avoid the fact that some of them may be getting prescriptions from multiple providers. If patients are aware of the fact that this is being tracked, it may slow them from trying to doctor shop, as they call it. It has shown in other states that have these, it's a decrease in deaths from opioids and also a decrease in substance abuse admissions. The number of people who get into treatment then are significantly improved outpatient treatment, and it is really one of the most promising state-level interventions and to protect patients, really. Next slide, please. This is a little bit more about the St. Louis County PDMP. Even though it's called the St. Louis County PDMP, it's used all across the state. Soon we'll have our own PDMP, which has not been implemented yet, but has been passed into law. It's hard if you're a prescriber of opiates to know exactly where people are getting all their prescriptions, and this will just simply give us the opportunity to do that. The other thing that it does is that it really does allow you to identify people who are abusing opiates that you may have a low clinical suspicion that they actually are doing so. We have practice in a federally qualified rural health center, and one of our requirements is that we do look in the database to make sure that there is, you know, to see what people's opioid and controlled medication histories are when we see them. There have been several times when we really didn't have much clinical suspicion that the patient was getting prescriptions from multiple sources, but only to find out that, in fact, they have been. Then that can be an impetus for a conversation about that. If you don't know, then you can't address the issue, really. Also, it has itself been able to decrease somewhat overdoses from opiates. Next slide, please. On June 7, 2021, Governor Parson signed Senate Bill 63 into law. Basically, this will give us our own statewide PDMP. Until this was passed, Missouri was the only state out of 50 that did not have its own PDMP. So, you know, I think that despite a lot of difficulties in getting legislation through, places like or proponents like the Missouri State Medical Association just didn't give up, and they finally got this. I think it's going to be a huge benefit to patients in Missouri. Until it's implemented, just like anything, you can't just pass a law and then have it immediately be available. It will be the St. Louis area PDMP will continue to be up and operating. After the statewide one is up and going, then that will be what people use for tracking prescriptions. Next slide, please. There are some great tools that have been made available on PCSS. When you get these slides, those hyperlinks are all active, and you can click on those, click on tools for safer prescribing and prescribed to prevent. There's just a great amount of good information there. Some of it's available for CME. Most of it has no charge. I think maybe all of it does not have a charge associated with it, and it's great information that people spend a lot of time putting together some really good information for us. Next slide, please. Here's an issue that has come up quite a bit. We do have a significant, obviously, opioid use disorder crisis with overdoses and abuse here in the state of Missouri. What has really been a big push is to make sure that we don't swing the pendulum so far that we leave chronic pain patients high and dry. There are people who do need to have chronic ongoing opioid therapy, and one of the tragedies that can happen is when people, because of concerns about oversight from regulative bodies, simply just pull the rug out from people. Sometimes it is appropriate to taper some people off of long-standing opioid therapy, but it's not always the best thing, especially those people who have pain due to chronic health conditions or malignancy. The recommendation really is that we not just pull the rug out from other people as far as their opioid therapy, but in a rational way, if people do choose to taper down their opiates, that that be done collaboratively between you and the patient. I think that the regulative bodies really are not wanting to just have people just in a blanket way withdraw these therapies from patients. I think you have to be careful. You have to be responsible when you're doing these things, when you're prescribing opiates, and we'll talk a little bit about that in just a second, but I do think that it has to be individualized. It has to be based on that patient's needs, what's best for that patient, and it should be a collaboration between you and the patient, but it really should be physician-driven. There are a number of regulations from the BNDD and DEA. Some of those are available on those links below, and those are really worth a read. They're some of them are longer than others, but they're all very good information, so next slide, please. PCSS has a chronic pain core curriculum. This is another one of those CME opportunities where you can get some very high quality education about chronic pain management, responsible ways to manage chronic pain. I think that opiates are one tool in your armamentarium, but there are a lot of other options out there. There are a lot of options where you can collaborate with other groups. There's physical therapy, non-opioid therapies. There are collaborations with interventions with pain specialists that can do radio nerve ablations and a lot of other things. A lot of those are covered in those chronic pain core curriculum, and they're all extremely helpful. That comes in about 11 modules. I think it's worth 24 and a half CME credits, so if you're looking for some good high-quality CME credit. I think most of us, especially those of us in primary care, encounter a lot of chronic pain patients on a daily basis, and we'll give you some opportunities to really rationally care for them and really give them the best care. This is more on some opioids and pain management in CME. This talks a little bit about just managing acute and chronic pain. In addition, it also talks a little bit about some of the recommendations from both the BNDD and DEA as far as things that you can do. E-learning series, the AMA offers practical guidance for pain management, and I think that this kind of gives you a framework to work in. I think the days are gone when people were just writing opiates for people without much restraint. I think that now that people are beginning to understand that you need to do so, make sure you're doing urine drug screens. Make sure that you're doing pill counts. Make sure that you're not just utilizing the opiates as the mainstay of their pain management, but there's a lot of other options, psychotherapy, physical therapy, a lot of other options that are available. Next slide, please. Here's some more resources for physicians on pain management. There's a glossary of terms there. There's an article. The middle one's not a very long article. It talks a little bit about what are some of the barriers that we face. There are a lot of barriers to our being able to provide the best pain care for our patients. Then also, the bottom one, it's a little bit longer, but it just covers really some of the basic pain options for managing chronic and acute pain. Next slide, please. I think that this is something that I've seen over and over. I've worked in addiction, both in inpatient and outpatient settings, and that there are about two million people nationally that have an opioid use disorder. 20 million are thought to have some kind of substance use disorder, but only about 21.2 million Americans need substance abuse treatment. Only about 3.7 million get any kind of treatment. That's about 17 percent of the people who need to have some treatment. In Missouri, we're ranked 30th in buprenorphine, which is the active drug in medications used for medication-assisted treatment, one of them included in like Subsol, Suboxone, Subutex. We've got a little room to go in regard to opioid use treatment. Next slide, please. Next slide, please. So, the harm reduction that Jennifer talked about earlier is very important. You know, in a perfect world, everyone would just stop using any opiates, and then we wouldn't have any problems with overdoses, but that's not the real world that we live in. The real world is that if we can get people into treatment for opioid use disorder, and they are not overdosing, and they are becoming involved with their families again, if they are getting involved in work again, then, you know, I think that those medications really make a huge contribution to our ability to to assist people who have opioid use disorder. In addition to just medications, also, you know, therapy is very important, making sure that people get involved in groups, and there's just a lot of legs to substance use disorder treatment, rather than just the medications. So, a recent change that has come about is that you, for physicians, you don't have to get the training now to get an X waiver, and an X waiver is needed so that you can write medications that have buprenorphine in them for the treatment of opioid use disorder. There are some other nuances about prescribing buprenorphine, but I think they're kind of outside the scope of what we want to talk about today, but even though the training is voluntary, you still have to apply for a waiver, and that being said, I would still recommend that people who choose to write buprenorphine would get that training, because it's, for one thing, it's free, and second of all, these medications have some unusual pharmacologic characteristics that you can cause some misadventures for patients if they're used incorrectly, and specifically, one of the things that we worry about is the phenomenon of precipitated withdrawal, which we tried to avoid. And so I think that the training is really important. It is voluntary for physicians now, but you do still have to have a waiver to be able to write buprenorphine, which is like Suboxone, Subutex, that's also. Next slide, please. So what are some of the medications that we use for treating opioid use disorder? The first one is buprenorphine and buprenorphine with naloxone. So you're mixing a partial agonist at the mu receptor, which is an opioid receptor, as well as a partial antagonist. And so the way that these drugs work is that they stimulate the same receptors that opioids do, but they don't do it fully the way that a full-on agonist would like, like, excuse me, oxycodone, morphine, or any of the other full agonist opiates. These medications are available as a sublingual film. They don't absorb very well if taken as a pill, so they really have to be used, they're put in the mouth underneath the tongue, they're allowed to dissolve fully, and then we recommend that people don't eat or drink for anything for at least 10, 15 minutes afterwards, the reason being is any residual drug in the mouth will be washed down into the GI tract and won't be absorbed. That is true of both the tablets as well as the films. They've come out with injectable, long-acting, buprenorphine, goes by the name Sublocated, there may be some other names in addition to this. It has some difficulties in delivering it, it has to be delivered to a pharmacy, and it has to, you can't, the patient can't go by and just pick up a prescription for it, but it works largely the same way, but it has some cost barriers. Obviously, diversion is not an issue with the long-term injectable buprenorphine. Then also, they have intrathecal pumps, which are not really used for opioid use disorder as much, mostly used for local anesthesia. Another medication that we use very frequently is something called naltrexone. Naltrexone, just like naloxone, is an opioid receptor antagonist. In other words, it blocks the opioid receptor. It's available as 50 milligram tablets that can be taken, usually dosed once a day. It can be oral granules that are dissolved in water, and also it's available as a 380 milligram injection that can be injected once a month. And so then by using the injection, once again, the medication is there, it's in the system for at least another month. Certainly helps with cravings, also helps to protect from overdose risk. And then another one is methadone. Methadone is different than buprenorphine in that it is a full opioid antagonist. And the certification for this is a little bit more stringent in regard to the DEA. There are a lot of places that do medication-assisted treatment with buprenorphine products. Often methadone clinics are freestanding, and they kind of specialize in that. But once again, it's prescribed under pretty supervised conditions. It works on the same receptors that buprenorphine and opiates do to help with craving. Usually, once again, they also will offer counseling with this. So next slide, please. When I was doing primary care, and a large portion of my practice was not opioid use or substance use disorder, when a patient would come in with an opioid use disorder or substance use disorder, I was almost at a loss to really find out who do I reach out to to help with this? Do you just get in the phone book and look for addiction treatment services? And they put together a pretty good list here of options for us as far as places to reach out. SAMHSA, the Substance Abuse and Mental Health Services Administration, has a link that's the bottom link there where you can click on that, put in your area where you are, and you can look and find someone who is wavered to do MAT therapy, see if they're taking new patients, see if they take Medicaid patients. You can see a lot of good referral sources there. So next slide, please. This is another good core curriculum. This gives you, this is on the PC, if you Google PCCS now, it'll take you to the page where this is easy to find, and you can click on it and just begin that course. Once again, just kind of takes you through. I think it's important to have a well-rounded knowledge of opioid use disorder, and I think this will make you a much more effective clinician as you approach your patients with opioid use disorder, and just another really good resource. So next slide. Once again, another option for some really good learning about opioid use disorder is the ECHO Project, and I'm actually what they call a hub member for the Opioid Use ECHO, and ECHO is every other week, most of them, and there's a lot of different topics, but the one that we do for opioid use disorder is every other Friday, second and fourth Fridays, and they have a number of people, myself and some other people who do addiction medicine, and people from all over the state can call in, and it's a Zoom call. There's usually a didactic that's about 30 minutes long, and then we'll do a case presentation, and everybody takes turns bringing a patient to the meeting. We'll have people make suggestions about how they would have treated the patient, and then we'll get some input from everybody. It's available to everybody across the state. It doesn't cost anything, and so it's a really good resource, and then there's another list of the educational resources for treatment of substance abuse and opioid use disorder. Also, it's from PCCS. Also, once again, just Google PCCS now, or even PCCS, and it should take you to a page that'll have all of these links on it, so. Next slide, please. You know, I think that one of the things that is a significant barrier, and this is mentioned in some of those articles that I referenced earlier, is that people often don't come for treatment because of the stigma. You know, they're afraid that they're going to be treated like they're just an addict, that they're just seeking drugs, and I think that welcoming people when they come in in a nonjudgmental, nonpunitive manner when treating opioid use disorder is really key. If people come in and they feel like they're judged and marginalized, they probably won't be back for another visit. The clinic I work in, in Springfield here, I think everyone there is really tuned in to that. They know that relapse is part of what happens with opioid use disorder, and just letting the patient know that you're there when they're ready to pick up and take the next step towards sobriety. So then, once again, there are some good links on here. We don't really have time to talk about all of them individually today, but when you get these slides, which will be made available after this, you can click on those links, and those links will take you to those. So next slide, please. This is just a slide that just shows you that non-Hispanic African-Americans have been significantly more impacted by overdose deaths. These are 2018 model numbers, and I believe that these numbers have continued in this trend. So next slide, please. PCCS has a mentor program. You can go on there and sign up. It's somewhat similar to what the ECHO is. Once again, it doesn't cost anything, and there's a link to that on the bottom where you can sign up for that, too. So next slide. All right. Anybody have some questions? No. Thanks, Dr. Shoemaker. And now is the time where we can do some question and answers. Okay. And I think if I can address the first question, is it possible that the decreased rate of pharmaceutical opioid prescriptions is shifting those who would have overused prescription opioids without dying to using illicit opioids with a high risk of a fentanyl overdose? You know, we congratulate ourselves on fewer prescriptions, which seems a good thing for those who are not yet opioid-dependent, but we seem puzzled at the effect of the opioid-dependent may be increased risk. And certainly, fewer opioid prescriptions are being written at this time. And certainly, I hear that story very frequently, that people say that they've gotten hooked on opiates, and then when their prescription source runs out, then they're forced to buy them on the street, whether it's pharmaceutical opiates or not. And of course, once they get it on the street, they may be buying things that look like pharmaceutical-grade opiates, and in fact, they've been made into pill press. It's a complex and very good question. I think there are a lot of people who have been driven to illicit opioids because they've gotten hooked on them, and they realize that they can no longer afford them, and they do seek them in an illicit manner. And so I think that it kind of behooves all of us to become a little bit more adept at dealing with and helping those patients. So... I'd like to just add to Dr. Shoemaker's answer on that. And yes, there has been a subset of people who were unfortunately possibly cut off from long-term opioids, inappropriately tapered or suddenly tapered, or just for some whatever reason, due to regulatory changes, payer pharmacy changes, unable to get the opioids, the high-dose opioids or long-term opioids that they've been on. There has been a subset of those patients who have turned to illicit opioids. So the answer in that way is yes, but there's also a no in there that we're seeing another subset of people using fentanyl that are not coming from that group where they started with prescription opioids. And these folks tend to be younger. They tend to be maybe in that 15 to 30 range, and they're starting out actually using illicit opioids. So it's really two subsets. Next question is that someone says, here in Indianapolis, we're preparing to kickstart an academic detailing program. Do you have any resources? Question just went off. Do you have any, where'd it go? Any resource for prescribers that cover how to talk to their patients about drug and alcohol use? I think a couple of great tools, one of them is called SBIRT, S-B-I-R-T, Screening Brief Intervention and Referral to Therapy. And there are a lot of opportunities for training in this. It doesn't take very long. You can do it in the middle of a busy clinic day. And then there's something else called motivational interviewing, where you use the tool of the patients. You try to move the patient from ambivalence and just have them evaluate, like you might ask them, okay, if you had to grade from zero to five, why you would wanna continue to use versus why you would wanna get clean. And it kind of makes them process that, what are the benefits of getting clean? What are the benefits of continuing to use? And it makes them kind of evaluate things. So it's called motivational interviewing. And it's really used quite a bit in substance use therapy. Jennifer, you have any thoughts about, you wanna add anything about motivational interviewing? Very effective modality used in most treatment centers. Also, one of the resources that we covered that's on the PCSS website is literally a virtual presentation of how to talk to your patients about opioid use disorder. And that's available on PCSS for free. A simulated discussion. Okay. Does the PDMP include a treatment center locator? I don't think that the PDMP does. And is there a limit on provider delegates that can access the PDMP? I don't know. I haven't seen the legislation, so I really can't answer whether there'll be... I think the question there is, can you have all the people in your office all log on so that you can utilize them to help you? I don't know if there's a limit on that or not. I haven't seen that legislation yet. So another question is, consider using buprenorphine for pain. There is some pain relief that is obtained with buprenorphine because it is an opiate. However, what we're discussing today is buprenorphine for treatment of opioid use disorder. There are some restrictions on how buprenorphine can be prescribed. And specifically, if you're going to use buprenorphine in any way for treating opioid use disorder, you do need to be wavered. How can we get people in their 20s and 30s into treatment they do not fear death? Yeah, it's hard when you're 20 years old, 10 feet tall and bulletproof because nothing bad is ever going to happen to you. And that is a challenge. And that is exactly the kind of patient that motivational interviewing can help with. Kind of move them off their ambivalence, so. I think too, just to kind of piggyback on that question that we have always have the choice of talking about the risks involved with recreational drug use, with misusing prescription drugs with patients in their 20s and 30s. And through those conversations, we may be able to get through to a few of them. Normalizing those conversations can help physicians and other providers make those connections and at least start the conversation. And there's a question about if multiple doses of naloxone are maybe necessary for fentanyl overdose, are there any guidelines or recommendations for deciding to give a second naloxone dose if the provider or bystander is not sure if fentanyl is involved? A good rule of thumb and the recommendation currently is if you give Narcan, if you give naloxone, you activate EMS and you involve people in emergency medical services because there's a very high likelihood that that patient is going to go back out again. So to simply give them Narcan and then not monitor them further is very ill-advised. So the recommendation currently is if you do, because there's no way for you as a bystander or even as a clinician to know if this was an overdose on fentanyl or if it was overdose on another opiate. Even with a non-fentanyl overdose, depending on how much they've taken, if it has a longer half-life than the naloxone or Narcan does, they're going to probably start experiencing more signs of opioid toxicity and sedation and overdose, so. Go ahead. I think we're out of time. I think we are. We're very happy to do follow-up on the questions that are remaining and to get you answers to your questions following the presentation. And I will leave it to Dr. Shoemaker to wrap up. Thank you all. I just want to thank everybody for coming and for your interest and your attention. And I certainly want to thank also Jennifer, who did most of the legwork for this, and I'm very appreciative of her. Thanks for the support from Missouri State Medical Association and also our facilitators. Thank you, Dr. Shoemaker, and thank you all for attending tonight. Thank you.

Taking Responsibility in Missouri: Reversing the Overdose Epidemic

collaboration

drug overdose epidemic

harm reduction

opioid use disorder

prescription drug monitoring program

medication-assisted treatment

physician resources

stigma

overdose prevention