Minnesota Medical Association. I am 1 of the staff leads here at the MMA who works on opioid issues, and I'm honored to have been part of the development of today's program. Next slide. Our 2 speakers today, Dr. Charlie Resnickoff and Jennifer Byrne have no disclosures to report. Next slide. On this slide, you'll see our target audience, which are health care providers who prevent and treat opioid use disorders as well as substance use disorders. Next slide. On this slide, you'll see our educational objectives. I won't read them all one by one, but you can have them here. Overall, describing trends in overdose epidemics, presenting state and national trends and tools, identifying ways to help maintain or help make pain treatment safer and more effective, and resources for physicians as they're treating those with opioid use disorder and substance use disorder. Next slide. Before we get started, we have a few housekeeping items to cover. All participants are on mute. If you have a question for our presenters, please share them via the Q&A box on your screens. Our panelists will leave time for questions at the end of their presentations. As a reminder, this webinar is being recorded. As quick background for our program today, the Minnesota Medical Association, in collaboration with the American Medical Association and the Providers Clinical Support System, also known as PCSS, is pleased to bring you this physician toolkit to help combat the continuing drug overdose epidemic in Minnesota. Fatal and nonfatal drug overdoses are an ongoing and worsening national epidemic. CDC data shows 107,000 drug overdose deaths nationally for 2021. In Minnesota, drug overdose deaths and nonfatal overdoses have spiked significantly since 2019. The physician toolkit before you today, we are presenting all the data that will help you better understand what is going on here in Minnesota and nationally. It includes physician resources, information, and tools to help treat patients dealing with substance use disorder, and provides opportunities to learn more about better care for pain. I've listed here the different parts of the toolkit, overdose prevention, treatment and recovery for opioid use disorder, harm reduction, state regs and guidance for Minnesota physician prescribers, safer opioid prescribing and tapering, and resources for pain education. Now, before we get started, I'd like to introduce quickly our speakers for today. First off, we have Jennifer Byrne, who is a behavioral health program manager with the American Medical Association and a licensed clinical social worker in Illinois. Jennifer received her MSW from the Jane Addams School of Social Work and University. She has specifically training, specialty training in addiction and trauma. She has over 20 years of experience as a clinician working with people touched by addiction and mental health disorders. Second, we have Dr. Charles Resnikoff, an addiction medicine physician internist practicing at Hennepin Healthcare here in Minnesota. Dr. Resnikoff treats medically complex hospitalized patients and has an outpatient opioid addiction clinic and consultation practice. He's also a member of the AMA Substance Use and Pain Care Task Force and is here today representing the Minnesota Medical Association. Now, let's begin our presentation. I'd like to turn it over to Dr. Charles Resnikoff. Next slide. OK, that's my cue. Thank you to the AMA, the MMA and partners, Stuart, Jennifer, Juliana. You guys have been awesome to work with. I'm really excited to be here. I'm particularly excited and proud for the toolkit. And also this is going to be enduring CME is what I understand, at least for a short period. And so I'm really excited to give Minnesota clinicians these tools today. So this is relevant. I think we've seen headlines about the opioid epidemic for more than 10 years and it still remains on the front page of the newspaper. It affects all areas of our state. It affects all walks of life, ages, all types of people. There really it doesn't really fit into a stigma or stereotype. It's really affecting everyone and it keeps growing. So next slide. There are 654 Minnesotans who died of an opioid related overdose in 2020. And we'll talk more about that in a minute. Next slide. So you can see here the rates of opioid involved overdose deaths. Actually, excuse me, this is all overdose deaths and this is over a thousand overdose deaths in 2020. And like I just said, 650 of those are opioid involved. We'll break it more down in a minute, but you can see that the rates are rising and, you know, COVID may have played somewhat of a role in this, but it can't be the full explanation. And that would be an interesting Q&A for the end of the role that COVID may have played with the rising opioid and other drug overdose epidemic. I will also say, looking at this slide, that I am aware that in one county in our state, Rice County, the death rate from drugs was stable. I mean, it didn't get better, but it also didn't get worse in 2020. And that could be an interesting conversation. What did Rice County do well to have stable overdose deaths that the rest of the state could think about? So, yeah, unfortunately, the news is still bad news for Minnesota and for the country. Largely, the trends are worsening. Next slide. And why, and specifically which drugs? Well, fentanyl and fentanyl analogs are driving the death rate. And then if there's a second reason, it's methamphetamines. So on the slide, the top line is all drugs. The next line down, the orange line, is mostly fentanyl. It's called synthetic opioids there, but it's mostly fentanyl and the analogs. And we're going to talk more about that in a few minutes. The third from the top line, the blue line, is psychostimulants. There is a rise in cocaine use we're seeing, but it's predominantly methamphetamines. So that third line would be methamphetamines predominantly, but also a rise in cocaine use. And people are getting into a lot of troubles with methamphetamines and cocaine lately, more so. And to make matters more complex, often in truth, these deaths are mixed drug deaths with methamphetamines and fentanyl mixed together. So how they get attributed is a little bit confusing. Some of them are attributed to methamphetamines. Some are attributed to fentanyl. But really what we're seeing is a combined epidemic of methamphetamines and fentanyl. That is the primary thing we're seeing today in Minnesota. However, the also prescribed opioids are still down in the mix, but they're still in the mix. Prescribed opioids, that's the green line. And even lower than that is heroin and other drugs. I see they've split cocaine out separately at the bottom. So the psychostimulants would be just methamphetamines. So that's kind of how the death rates have broken down in our state. Next slide. Our state is similar to the national trends in this way. I think it's also important to know that there are significant racial disparities in addiction and overdose in our state. African-Americans are twice as likely to die from an opioid overdose than Caucasian Americans in Minnesota. And American-Indians are seven times more likely to die of an opioid overdose. And then many other ways of looking at harms from addiction are disproportionately affecting Native Americans or American-Indians and African-Americans as well. And we don't even know the full data on the Somali-Americans. These are largely the children of the immigrant refugee population that came to Minnesota, the first generation born. There's a major problem with opioids in that group. And there's not a fully understood effect on the Hispanic or Latinx Minnesotans. But we know that that's out there causing a problem as well. So there's major racial disparities. What can you do about systemic racism or racial disparities? It can feel really daunting. I think the main thing is to understand and recognize that it exists. And to not offer any additional treatments above and beyond the evidence-based proven treatments, but to really go above and beyond to offer those treatments. In other words, we just really need to make sure that all people with these conditions have equal access to good treatments. And to bridge that communication barrier, to bridge those social determinants of health, and really make sure everybody has access to the good treatments that are currently available. OK, it's a big ask, though, and this is a big thing we should all be thinking about. Next slide. It is very interesting that 10 years ago, this was all about the oxys. And today it's not. And that's a change. And to understand how prescription opioids have an evolving role in the opioid epidemic. And this is a whole talk unto itself. But to understand that people are largely not dying from, and many people addicted to opioids are largely not even using prescription opioids. They're using fentanyl, street fentanyl, illicit fentanyl. So what is the role of our opioid prescriptions for pain? And that is a super complex thing, but it's just important to know that it's evolving and that the people who are currently using street drugs and dying from street drugs are, it's largely illicits and not prescribed opioids. So keep your eye on that. It's a very exciting and challenging topic to understand. So ask questions if you want to discuss more. Next slide. The next slide is a representation of how our prescriptions have decreased. And what is the right amount? Is there a right amount we should be prescribing opioids? We don't know. And so I think people would say generally that this decrease is a good thing. Are we happy where we're at? Should we try to prescribe less even? Are we prescribing too low of opioids? Those are open questions we're really wrestling with right now. And we'll touch base on that more later in the talk. Next slide. So I just gave you a lot of bad news. So what's the good news? The good news is that there is a tool that's available to clinicians, which would be physicians, physician's assistant and nurse practitioners. I think nurse midwives, among some other clinicians, can become wavered to prescribe buprenorphine. And buprenorphine, as a buprenorphine provider, is one of the highlights of my job. And it is really an effective way to help people live better lives, avoid overdoses, avoid overdose deaths and be successful. It doesn't help 100 percent of everyone, but it does help a lot of people. And many people are patients that I care for on buprenorphine go back to really meaningful, healthy, long lives. I've been doing this for 15 years. And like I said, it's one of the highlights of my job. Currently, anyone with a prescribing license in our state can become buprenorphine wavered. There is no required training. There's free training available and support available, but there's no required training anymore. So I really encourage you to think about it. We can we can all do this together as a community, as a treatment community, and offer the best treatments to patients with opioid use disorder, prevent opioid overdose and help people live more meaningful lives. And to do that is to get a buprenorphine waiver and start thinking about, could my patient benefit from a buprenorphine for opioid addiction prescription? Next slide. There are actually three medications that are FDA approved and evidence based for opioid use disorder, buprenorphine, which I just mentioned, and you could get a waiver and you could do that in your own office. Naltrexone, the tablets are actually not FDA indicated for opioid use disorder, but they can be started in someone who are then switched to the intramuscular injection. The once a month intramuscular naltrexone injection doesn't have as robust of data as the buprenorphine, but it's an option and it's an option worth learning about if you really want to understand. If you had to pick only one med, it would be buprenorphine. But if you want to really understand this deeply, the naltrexone injection is a great option to learn about. And then methadone and methadone clinics are very highly regulated. You cannot prescribe methadone for addiction out of your clinic, but you can refer people to methadone clinics to get that treatment. And methadone is increasingly popular for complicated reasons these days. So you may have patients who specifically request methadone. So keep that in mind. That's a referral to an outside clinic that's licensed to give methadone for addiction. Next slide. So there are a lot of benefits. The most science is on either buprenorphine or methadone. There's not as much science on the intramuscular naltrexone. The buprenorphine and the methadone improve people's physical and mental well-being, decrease their drug use. That's an important thing. They decrease their drug use, decrease the chance that they will die of an overdose. Actually, all-cause mortality, not just overdose, decreases all-cause mortality by 50%. That includes suicides, heart disease, infectious disease, and of course, importantly, overdose. And the commonest cause of mortality is overdose, but they also have infectious diseases, suicides, and other causes of death that are increased in this population. And methadone and buprenorphine improves all-cause mortality. So that's great. They report that they have better social functioning. They're back at work. They've improved family relationships. They use needles less, which kind of stands to reason if they're using drugs less. But using needles less is a really important thing because they're less likely to get and give infections in the community. They have less cravings. They have less withdrawal, less infectious disease, and improved pregnancy outcomes. And we didn't even list improved criminal justice outcomes. So these are really wonderful medications that can be offered to patients with opioid use disorder to improve their outcomes, meaningful outcomes. Next slide. Okay, so that's great, but you may feel like you really need to learn more. You need more support. You need more information on how to treat opioid use disorder appropriately. And the good news is there are great resources out there. So the PCSS is a great resource to both teach, to learn about addiction and its treatment, and also to get support from other clinicians. So I would just really, if this is something you want to continue to learn about and treat, PCSS can be a great resource for you. Next slide. So I'm just going to comment briefly. There'll be a couple different slides about fentanyl, and I'll just comment briefly on fentanyl. Why is this happening with fentanyl? And it is a whole story. It's amazing and intriguing, and there's a lot to it. Basically, fentanyl can be cooked in any laboratory anywhere in the world. It's very potent, which means very small bits go a very long way. It doesn't take much to get intoxicated or to overdose, and therefore, it can be smuggled very effectively. So it can be cooked secretively. It can be smuggled easily, and tiny, tiny bits get people very intoxicated. And so therefore, it's just much more practical or pragmatic if you are a drug trafficker to traffic fentanyl than heroin. It's cheaper to make than heroin. So everything is pointing towards we're only going to see more and more of these synthetic opioids that are cheap to make, easy to smuggle, very potent. So it's kind of heartbreaking, but it is the future of addictions is these synthetic drugs, and it's going to be challenging. So we have to face that. And methamphetamines is similar. It's cheap to cook. It's easy to smuggle. It can be cooked anywhere. So these are challenges we're facing. I think it is worth knowing. I mean, I guess here's what I would say. More on this in a minute. It's worth telling our patients that if you use any illicit drug that you get from a friend or you get on a street that you borrow or buy, and you are not 100% sure what it is, you can assume it has fentanyl in it. Fentanyl is adulterated into almost everything these days. Methamphetamines is adulterated into quite a lot these days as well. So if you're using anything and you don't know its provenance, you can assume it has either fentanyl or methamphetamines or both in it. And I tell that to patients all the time, and they're sometimes surprised by it. They often, honestly, have heard this already or experienced it already. So fentanyl is adulterated into everything, even if it convincingly looks like a pharmaceutical. It's often a fake pill. Next slide. So some more things you can do or tools you can use. One is many clinicians are like, I have my buprenorphine waiver, but I haven't found any patients to use it with. Well, first of all, it takes time to build up a practice. So I would say that. But second of all, how do you screen your patients for opioid use disorder? Because they come in all walks of life and they look like everything. You can't stereotype someone with opioid use disorder. So you really need a good screening tool. And in this link shows you access to a screening tool. And then once you have the screening tool and a patient screens positive, then you need to have a very sort of appropriate and delicately worded conversation with them. And it's funny, you know, you say one thing wrong, and people assume you may have stigma or that you're judging them and they walk away. So it is a learned skill, talking to patients about opioid use disorder. And many clinicians have done this with, for example, talking to patients about suicide. That's something that's really awkward at first, but we just do it and we practice and practice and most, most clinicians get comfortable with it. It's kind of like that with opioid use disorder, it takes practice, it's kind of a soft skill. Anyways, there's a link here to help you better understand how to effectively communicate with these touchy conversations about opioid use disorder and addiction, and to navigate that well for you and for the patient. And then again, the PCSS is a is a great resource for you if you want to start caring for patients with addiction. Remembering that PCSS has a lot of resources to support you doing so. So those are some good resources for you. Next slide. So, um, what are the risk factors for overdose? And there's a lot of outcomes that we want to improve. If you have an opioid addiction, we want to improve your life, we want to improve your work life and your financial and your legal outcomes, we want to prevent you from getting HIV, we want etc. We got a lot of outcomes for you. But the first and foremost, we want to keep you alive. And so it prevent an overdose. So what helps us predict whether you might overdose if you have opioid addiction? Or if you're on a prescription opioid? Well, opioids plus benzodiazepines, that's a really bad mix, that's a high risk for an overdose. So benzos would include diazepam, lorazepam, clonazepam, alprazolam, mixing those with opioids is very high risk. Second, if a person has opioid addiction, if you know that they have opioid addiction, that's very high risk, right? So those are two really high risk categories. Mixing opioids with stimulants can be high risk for interesting reasons. And we can talk about that later, if you want to hear more people with psychiatric comorbidities, PTSD, anxiety, depression, OCD, these put people in potentially eating disorders, these put people at risk for overdoses more so than the general population. So be aware of people with mental health disorders. Someone with COPD or respiratory failure, renal failure, liver failure, organ failure of some sort have a more fragile system, and maybe more likely to overdose if they use opioids illicitly, or even as prescribed. You can give someone an opioid as prescribed, and then if they develop renal failure, it could become very dangerous for them. Anyone who just got out of a controlled setting, like if they were just released from jail, or if they were just released from a treatment program in which they were not treated with buprenorphine, they were just had a prolonged period of enforced abstinence, either in jail or a strict treatment program, and they have no opioid tolerance, and then they go back to opioid use. That's a very high risk. The first couple weeks after you get out of a abstinence based treatment program or out of a jail, the first couple weeks is very high risk for an overdose. And then just people taking a lot of opioids, either prescribed or illicit, those could all be risk factors for overdoses. Next slide. I will also say, solitary users, isolated individuals, and COVID created more social isolation. So isolation is another risk factor for overdose. Solitary use is a risk factor for overdose. Just wanted to throw that out there. So fentanyl, more on fentanyl. Fentanyl is, I mean, imagine 50 times as potent as heroin, or 100 times as potent as morphine. That's fentanyl. And carfentanil is an analog to fentanyl, is even more potent than fentanyl. And so carfentanil is shockingly potent. Tiny granules can kill a person. So these are incredibly potent chemicals. And ingesting even small amounts can kill you. Next slide. It said in that slide also, this fentanyl is not prescribed diverted fentanyl. This is illicitly cooked fentanyl. This is illicitly smuggled fentanyl that's trafficked into our community. These are not from doctors or advanced practice provider prescriptions. So who's at risk with fentanyl? Well, I mean, anybody using any kind of illicit substance, borrowed, bought, traded for, drug, you can assume that it might be fentanyl, and you can assume that they're at risk. Interestingly, a lot of people dying from fentanyl overdoses are younger than age 35. So this is a younger population, whereas older people with more medical illnesses are more likely to die from something like a prescription overdose. But the fentanyl overdoses are more younger people. So again, they were released from jail, they relapsed to street drug use, and it's fentanyl, and they died. They didn't even know they were ingesting fentanyl. They were intending to ingest something else. They borrowed a pill from someone, they thought it was something else, it turned out to be fentanyl, and they died. Those are counterfeit pills, they're out there. People who have opioid use disorder, they're using recreationally or experimentally with street drugs. That's a high risk thing in a young population. Yeah, and like I said before, people recently, if we could just improve the transition from incarceration to in the community, we would save a lot of lives. But it's not just incarcerated individuals, and I don't want you to stereotype opioid use disorder as people who are criminal justice involved, because there are a lot of people that have no criminal record that are still using illicit drugs and at risk. Next slide. So yeah, I mean, this is to show you that there are counterfeit pills out there. People are taking these, the illicit, illicitly cooked fentanyl, and they have a pill press, a machine that can, that they can create counterfeit pills. And then they'll tell you, hey, do you want to buy a 30 milligram oxycodone? And it looks like a 30 milligram oxycodone as shown in these slides. But it's not that, it's fentanyl. And if you take it, it may be many times more potent than the 30 milligrams of oxycodone you think you're buying, and then you die. And the famous Minnesotan who suffered this fate, of course, was Prince, who thought he was obtaining Vicodin illicitly. I mean, this is reportedly, and it was not Vicodin, it was fentanyl. So he, so but he was only one of many, many people who've suffered this fate, thinking they were getting a pill, but it was a counterfeit pill, and it was actually a more potent, and it was fentanyl. Next slide. Interestingly, and this stands to reason, but not only are fatal overdoses rising, but non-fatal overdoses are rising, the near misses. And for every person who dies of an opioid overdose, many people, five to 10, don't die. And they seek help. They go to the emergency room, they, maybe someone gives them a Narcan, they call 911, they didn't die. That's good. But what are we doing to help those folks? Because if you had a non-fatal overdose, that's the number one risk that you will then go to go on to have a repeat overdose, and, and actually die. So, so catching people who have a non-fatal overdose, and getting them access to good care is critical. And more on that a minute. Next slide. So, when someone has a non-fatal overdose, lots of things can happen. There are these sort of pulmonary issues that can happen from non-fatal overdoses that look like ARDS or wooden chest syndrome. There's a couple different phenomenons there. I'm not going to go into those details. But that would require an emergency medical visit for sure. Most likely thing that will happen after a non-fatal overdose, if nobody does anything, is they're going to go back to drug use, usually within a day, they'll be back using opioids again, because that's the nature of opioid use disorder. And then they're going to be at risk of repeat overdose. And often repeat overdose happens pretty quickly. So, they overdose once, they could overdose again within a week. And also, each overdose can, it can create a little bit of a hypoxic episode for the brain. And those can build up over time, and it can almost look like traumatic brain injury, or concussions, how having repeated hypoxic events in the brain can affect your cognition. So, it is really important that we intervene early for non-fatal overdoses. Next slide. So, there's a lot on this slide. But basically, it's a really call to action for emergency medical providers, that when people are coming into the emergency room, with non-fatal overdoses, we need to give them the best possible care, it's an opportunity to intervene. And we should be intervening in the emergency room, or wherever we're seeing these folks with a non-fatal opioid overdoses. They can be hospitalized, maybe rarely they could just be in an outpatient clinic, but often it's the emergency department. And emergency medical providers can become buprenorphine waivered, they can start buprenorphine, and hopefully they can develop relationships with community clinics, so that you could start a patient after an overdose, you start a patient on buprenorphine in the emergency department, and then refer them to a clinic to follow up. Patients who after an overdose are started on buprenorphine, the risk of death decreases by 50%. You can decrease someone's risk of death in half by starting this medicine. That's a great outcome for a medicine to have. And we're not consistently doing it. So we need to be consistently intervening in these cases, starting buprenorphine, offering follow up, bridging them to a clinic that can continue the buprenorphine, and counseling the patients. So it's really an opportunity for the emergency medicine colleagues to step up and primary care colleagues to partner with the emergency medicine colleagues to take care of these patients. Next slide. And then in addition to starting buprenorphine, we can help people with harm reduction. What is harm reduction? There are so many patients using opioids, not all of them want treatment the way we think about treatment. And not all of them can access treatment. So while they're waiting to access treatment, while they're ambivalent about getting treatment, how can we keep them alive? So that when they're ready for treatment, they're alive, so that they can get treatment? Well, number one would be naloxone. More on that in a minute. Narcan is the trade name, but making naloxone available to them. Number two is needle exchange programs, which can do a lot for these folks, including reduce the risk of hepatitis C and HIV, but not just that. So needle exchange programs, there are many good Samaritan laws, including in our state that protect individuals who call for help, if there was an overdose, that can legally protect them, give some limited immunity. We have a good Samaritan law such as that in our state. So the catchword we use is don't run, call 911, if you witness an overdose. And then in our state, now we're going on a year, we're on the one year anniversary where fentanyl test strips are legal. More on that in the Q&A period, if you want to hear more about our state's ability to give fentanyl test strips, this is just another harm reduction tool. And then there's also community trainings that can train members of the community on how to handle an overdose if they witness it. So there's a lot out there. Next slide. Naloxone, it's FDA approved, there's a number of products out there that are FDA approved to reverse opioid overdose in our state. Basically anyone can walk into any pharmacy and ask for it. It might not be in stock. Some pharmacies require certain protocols, but almost all the commercial pharmacies and I know many of the health systems have protocols in place and have a stock supply of naloxone. And usually it's whatever the it's covered by the insurance, and it's whatever the lowest copay is. So usually people can get it either for free or pretty cheap. So, and usually in Minnesota, it's the naloxone nasal spray. So next slide, you'll see a picture of the nasal spray, that's the one on the right is the one they'll probably be picking up from the pharmacy. So you would you would prescribe the naloxone nasal spray, and it'll be the typical insurance coverage from any other as if it were any other pharmaceutical, or patients usually can just go into the pharmacy and access this without your prescription from a standing order within the pharmacy, totally legal. Once the patient has the naloxone, they can give it to anyone like administer it to anyone or even just give it like give it as a few for future use to a friend, a family member or whatever. If it's done in good faith to protect someone for an opioid overdose, we have a very broad protection for distributing naloxone in our community. So I think there's a low threshold. There's also a lot of online resources to help people understand how and when to use naloxone. And I think we'll show you some of that on the next slide. So next slide. Well, it may be coming up later, but there's, there's a link to some online resources to train people on how to use naloxone. So who should you give naloxone to, in particular? Well, I mean, I think the easy answer is anyone who wants it, you know, anyone who wants it can get it. And you don't need to know why a lot of people want it and they want to just have it in their backpack in case they ever witnessed an overdose. So they have it. And that's great. That's totally legal. But again, this we're repeating slightly some of the other risk factors we already talked about anyone at risk of an overdose, people on high dose opioids, people who are opioid naive, or who had been detoxed from opioids, people who are using benzos, people who are addicted to anything, and using opioids would be at risk of an overdose, people with an underlying mental health issues, we've gone over some of these before people with medical problems that put them at risk of an overdose, I'm going to talk about the bolded one in a second. But also the final bullet point, of course, clearly, anyone coming out of jail, anyone coming out of prison, anyone coming out of a detox center, those are all great candidates for naloxone. The bolded one is, even if the person you're with themselves is low risk, they might know someone who's high risk. So anyone who's got a family, friend, or associate or acquaintance, or a community member, who then this, the person you're prescribing it to may be low risk, but they may be connected to someone who's high risk. So if they if a mother has a child who has opioid use disorder, that's a great person. If a spouse has another spouse, you know, has opioid use disorder, you can prescribe the naloxone to the unaffected spouse. So he or she will have it in case the affected spouse overdoses, etc. If a parent has young children, toddlers in the home, and there may be control substances in the home, and they're worried the toddlers will get into control substances. All of these are great examples of appropriate people for opioid, for naloxone prescriptions. Next slide. I'm going to go through a slight change of gears, I'm going to go through some of our state guidelines. And I think this is really beautifully described in more detail in the toolkit. If you're a practicing clinician, and you want to know what's the latest on laws and regulations that affect you and your license, go to that toolkit and check it out. I think I think you'll find it helpful. The first thing is that we've had a state process to create an opioid guideline, it has been updated, the update may not have been published yet, but it's just going through final editing, and it will be published soon. It was originally written in 2018 and revised in 2021. Put very, this is like a 100 page document with a lot of helpful information, but put very simply, this is about prescribing opioids. Let's limit excessive opioid prescribing. And you can see from the trends in opioids that I think there are efforts already underway to limit excessive opioid prescribing. But let's be really thoughtful and deliberate when we're prescribing opioids, because it can cause harm down the road. Two, let's be not only reduce our opioid prescribing, but let's reduce our variation in opioid prescribing. So if 10 people get this identical surgery, if 10 people get the same wisdom tooth extracted, and it's all an uncomplicated wisdom tooth extraction, hopefully they'd all get about the same amount of opioids, if at all, you know, so let's keep things as consistent and non excessive as possible. But then the third point is we really need to work to support people who are currently on chronic opioids. Because I think what happens sometimes is people currently on chronic opioids get stigmatized and discontinued against their will. They're non-voluntary tapers. And that results in a lot of harms to them. So let's stop people from getting onto opioids chronically, unless it's really necessary, and let's take care of those who are already on chronic opioids. And that's kind of what the state's interest is. Next slide. So again, lowest effective dose and duration, and assume a good outcome. We used to say, I'm going to give you extra just in case you have a bad outcome. Don't do that anymore. We say, we're going to give you what's the normal amount, assuming a good outcome. And if you have a bad outcome, come back, we'll talk about it. Once you give the first prescription, 90% of people won't even use all those pills. But 10% of people will use those first prescription, will use all the pills, and might not even inquire about a refill. Maybe you should, maybe you shouldn't give a refill of opioids, but what you definitely should do is carefully talk to that patient about what's going on. Why do they need that first refill of opioids? Let's start talking about this early and not let it get out of control. And then really trying to avoid initiating chronic opioids. The state is really interested in not expanding the population of those on chronic daily opioids, prescription opioids, because we're just not sure, I say we, as if I'm the state, I helped write some of these guidelines in 2018. We're just not sure that opioids are benefiting those people. So we need to be very careful about starting new people on chronic opioids. Next slide. This does not mean cut off the current people on daily opioids. That's a different issue. So those are some guidelines, again, the updates should be published soon. You can find links to that on the toolkit. The second thing, there is now a requirement that everyone with a prescribing license in the state of Minnesota get two hours of opioid CME. And that opioid CME has to be vetted by the board of medicine or the board of nursing. So there's a very specific list. The MMA has some offerings. And we have some guidance on how to access appropriate CME if you have this requirement. You will notice when you go to renew your prescribing license, that it will prompt you to do this, your medical license. When you go to renew your medical license, it will prompt you to get the CME. And again, we have some resources on the toolkit to help you navigate that requirement. Next slide. If you are enrolled, so there's two programs in the state. One program I just told you about, everybody has to do two hours of CME. A parallel program is called OPIP, O-P-I-P, and you are automatically enrolled in OPIP if you take care of Medicare, Medicaid patients, basically, state or federal insurance recipient patients. You're automatically enrolled in OPIP. You will know you're in OPIP if you received a letter from the state with your opioid prescribing practices. This is not the PMP opioid letter, not from the Prescription Monitoring Program. It's a confusing point for people. This is specifically from the Department of Human Services, DHS, from OPIP, O-P-I-P, talking about your opioid prescribing practices, and they'll give you seven measures of your opioid prescribing practices. If you got that letter, you are in OPIP. And if you're in OPIP, you're exempt from the two hours of mandatory CME I just told you about. So it's confusing. It's more carefully laid out for you in the toolkit. But if you're not sure if you're in OPIP or not, and you're not sure if you're exempt or not from the two hours of opioid CME, there is an email. You can check that. You can email them and ask if you're enrolled in OPIP, or you can go to the toolkit and look there for further information. Next slide. A couple more slides on regulations. There's a lot of information about the PMP. If you're initiating opioids, if you're refilling opioids, there are required PMP checks for you. You're supposed to be checking the Prescription Monitoring Program. I just assume that I should check it every time for every patient. There are actually a lot of exceptions, and again, resources on that are in the toolkit. In addition, if you have a delegate who's doing the PMP searches for you, you are required to audit your delegate's searches to make sure that your delegate is using this tool in good faith. You've given your access to this tool over to a third party to do your searches for you, like a nurse assistant or an executive assistant. You got to make sure that they're doing it in good faith. Actually, it's audit time now. We're at the quarterly audit time, so if you have a delegate, it's time to do your audit. I need to do that as well. Next slide. Again, this is more resources. This isn't anything new. I've already told you this stuff. You should be checking the PMP often. It's embedded in my EHR, so it's only two clicks, and I can see the PMP for any patient. That's really user-friendly for me. Hopefully, you get it embedded in your EHR, so it's easy for you as well. Next slide. Final topic for me, and I touched on it briefly, but what do we do for patients who are already on chronic opioids for pain? Those are high-risk patients. We have to treat them compassionately with shared decision-making and work with them in a collaborative way to improve their health. We cannot suddenly change their opioid prescription without them wanting it. That will cause a crisis. They'll end up in the emergency room, or worse, they may die. They may have an overdose. They may have suicide. These are very vulnerable patients. They're high-risk. I find it very rewarding to work with these patients, but you need to go slow, and you need to be constantly talking to them and checking in with them. There's some resources here that can be really helpful for you. When you have a patient on chronic opioids for pain, it worries you. The state is telling you you shouldn't be prescribing opioids, and you want to stop it, but you also want to do right by your patient. The answer is to go slow and be collaborative, and there are some tools there for you. That's all I've got to say. Next slide. Thanks for everyone's attention, and I'll pass the mic off. Thank you very much. Thanks, Charlie. Thanks, Charlie. I'm Jennifer Byrne. I'm from the American Medical Association. I'm a program manager on behavioral health. Just a couple of moments left here, I just want to point out all of the resources that we have at the AMA in terms of opioid therapy and pain management, CME. As you can see, it's a large number of hours, up to 45 hours of CME, guidelines, research treatments, pain assessment, all sorts of great resources on our education hub. Also, we have task forces at the AMA, and I wanted to just touch quickly on the work that they've done and continue to do. From 2014 on, our opioid task force has been working very hard to provide recommendations, practical resources and strategies for physicians to help combat the ... At that time, it was perceived as the prescription opioid crisis and epidemic, and rightly so. As we've seen in the wake of that crisis, there became a pain care crisis, probably because there was some over-reliance on opioids and underdevelopment of other therapies for pain that were not opioid analgesics. We've worked on that in 2018, and actually, Charlie is a proud member of our task force. It started out as a pain care task force. We've got some great products on the website and the epidemic from both task forces. These areas that you see here are overdose data nationally and broken down by state, stigma reduction, and all of our recommendations and reports. I would just encourage you to spend some time looking around. Also, physician stories. We hear from physicians on the ground, what are the challenges? We relate those stories, and also spotlight successes in what the physicians on the ground are doing all across the country. And we'll go to ... Oh, and now, task force related. We've recently merged both task forces in this year, realizing that, obviously, this epidemic is evolving, and we have to evolve with it. It's becoming more clear that it isn't, and actually never really was just a prescription opioid epidemic. It's a drug epidemic, and it's a substance use disorder epidemic. That has such intersectionality with pain care, obviously, because of opioids. But it's a bigger problem. We're coming up with more and new recommendations built upon previous work, and again, I'd encourage you to check that out. And we'll go to the next slide. I also want to point out quickly, this is in the toolkit. It's another repository of great resources for harm reduction, naloxone, and other tools for prescribers, prescribed or prevent. We have the link on the toolkit. Next slide. PCSS, our funder for today's webinar and for the toolkit, is an amazing repository of educational modules and support for physicians. And I'm highlighting here the chronic pain core curriculum. They also have the substance use disorder 101 curriculum, substance use for the health team, not just for physicians. And I just want to encourage you to take advantage and check out. There's national experts from all over that it's funded by the government, so there's no cost to you for any of the offerings as far as educational modules. Next slide. They also provide mentoring. They will match physicians up with another physician mentor who has experience in addiction medicine, who has experience in overdose prevention, has more experience in maybe non-opioid pain practicing, and experience in evidence-based medications in buprenorphine prescribing, and who can kind of answer those questions. And then in addition, and I'll ask you to go to the next slide, PCSS also hosts regular clinical roundtables, which are getting more and more popular, where physicians can just get together and talk, talk about specific issues, specific clinical issues that they encounter and get some help, discussion forums. So it's a wonderful, rich resource for physicians, and that's providers clinical support system. So I want to thank Dr. Resnickoff, I want to thank the Minnesota Medical Association, and I want to, and especially Juliana, and for collaborating, coming together with me and making this happen. I will have a short Q&A, which we have about maybe seven minutes, and I kind of volunteered to take the first two questions. There was a question in the chat, have illegal drug purchases increased because of a decrease in clinical opioid prescriptions? I'm going to say the big answer is no. We've seen these two parallel trend lines, but they're not necessarily causal. We have many, many subsets of people who are at risk for opioid overdose, and who are at risk for developing OUD. So there is this small subset of people, maybe at one time more than now, were transitioning out of using prescription opioids in having developed opioid use disorder, and finding that the safer prescribing practices were making those prescription opioids harder to get a hold of, and who may have switched over to illicit opioids as a result. And of course, those are going to be a one subset of people who have suffered overdoses and sometimes fatal overdoses. But there are many subsets of people who are already using illicit drugs, both older subsets, younger subsets, people using recreationally, people using experimentally, people thinking like we talked about earlier, that they're getting a prescription opioid pill from a friend when actually it's a counterfeit fentanyl pill. So I would say big answer to that is no. And then the second question about where is illicit fentanyl coming from? It's coming from everywhere. It's being made domestically, and it also is coming from outside the US. Two of the big, unfortunately, exporters of illicit fentanyl is China and India. And there's probably other sources that we are continuing to learn about. It's getting in here, and it's also being made here. And unfortunately, as we said, it's extremely potent. And our government is doing a lot. I would say check out the DEA efforts on interdiction, and they're doing everything they can. But physicians really are the front line, a front line of defense against fentanyl overdose by talking to your patients, letting them know that you know about it, and also educating them as much as you can to protect themselves. And also naloxone. I have a naloxone in my backpack that's a few feet away from me that I carry around with me all the time. And I recommend that practice for everybody. And then I'll toss it back to Juliana for the rest of the questions. Thank you, Jennifer. Thank you, Charlie. So I got one in a private chat question, actually. Are there any harm reduction approaches that Minnesota doesn't have that maybe other states do that we should look into legislatively, collectively? Well, I can try to answer this, and then, Jennifer, you can chime in. There's a couple different ways of answering not just harm reduction narrowly, but just other approaches. So the answer to the harm reduction question is safe injection centers. And I think there are, if you look at Switzerland, there are other countries that have implemented this and have seen a decrease in opioid overdose deaths. America is not Switzerland. Minnesota is not Switzerland. So there are cities in America that are beginning to do injection centers. I think Philadelphia, there may be some other major metropolitan areas. And I can't fully speak to their success, but I think that is going to get looked at. I don't think the research is as solidly there as for some of our other interventions, but it is very attractive and appealing to some folks on the harm reduction front. And I'm not 100% sure what the AMA's policy stance is on that. A common policy stance you'll hear is, this is something worth researching and thinking about more. It's a common thing you'll hear. So that's one, and Jennifer can respond to that. But then the second one that I would say, which I think is really promising, and there's movement on this, is lowering barriers to accessing medication-assisted therapy. So right now, to get a methadone dose, you have to go to a clinic, wait in line. There's only clinics in metropolitan areas. People in rural areas don't have access to this treatment. In other countries, and in America in the past, there have been mobile methadone units. People can pick up methadone in a commercial pharmacy through special arrangements and regulations. So lowering barriers to accessing medications for opioid use disorder, we've already had, you know, within a year or so ago, waiving the training requirement for buprenorphine. So these are sorts of things that could be successful and that are being considered or have been done to lower barriers to care. I think those would be my answers. Jennifer, do you have any thoughts? Yeah, you're absolutely right. And I think just even expanding what we already know works, expanding access to naloxone, getting more of it out there. And then the other one I would say is, in particular, fentanyl testing strips. That's a really, really good, smart way to keep people from overdosing and to help them know what's in their drug supply if they continue to use drugs, which some people will. And so decriminalizing things that we would normally think is drug paraphernalia, and some states have done that. And the AMA actually is advocating for decriminalizing fentanyl testing strips in particular. Thank you both for that. In the interest of time, I want to ask one more question related to the OPIT program. So Charlie, this might be for you. I'm a doctor. I got the letter, and I don't agree with it. I don't think I overprescribe. What's my response? How do I get a response back to me that says, here are your next steps? Yeah, I mean, so I'm sort of the point person for a major health care institution. We have hundreds and hundreds of physicians and clinicians, and we've had our share of people who got the OPIT letter and didn't agree with it. And I have the advantage of having access to the people and the knowledge and everything. And it can be very daunting at times. You could reach out to me privately if you want to talk it over. On the slide set, there is an email for DHS on the OPIT slide. I know the person who reads those emails, and she's very responsive and thoughtful. She's busy right now, but she's a very reasonable person. So I would try to find a way to express your concerns and contact them. Or if you want, you can first reach out to me and contact me and go over it with me, and then I can kind of coach you on how to reach out to the state. Also, the state will provide you with patient-level data upon request if you don't have that already. And you say, I really want to know who these patients are. They can provide you that data as well. I guess that's my answer. Good luck. Good luck to you. Thanks, Charlie. So any closing thoughts from Jen and Charlie before we close the forum? Just thank you very much for attending today's webinar. We really appreciate it. You will be getting CME. And also, when we send out the How to Claim Your CME, you will be getting a copy of the toolkit, which has today's information and more. So appreciate it, and take care.

opioid use disorders

healthcare providers

prevent

treat

overdose epidemics

safe prescribing practices

buprenorphine waiver

fentanyl

racial disparities