Hi, my name is Tina Nadeau, and I am the Chief Justice of the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry and other judges, and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. And in this session, you will hear from Dr. Fong, who's an expert on evidence-based treatments for opioid use disorder, and he will talk specifically about medication to assist with opioid use disorder. And there are studies that show for people who are addicted to, for example, heroin, 90% of them cannot stop using even if they have excellent treatment unless they also have medication to go along with that treatment. And I'll give you a brief example of a study out of Sweden, where 40 people were involved in the study, all of them using heroin, they were all highly motivated to engage in the study and it was a year long study. 20 of them received a placebo plus all of the cognitive behavioral therapy that we give for people suffering from substance use disorder. The other 20 received all of that treatment as well and buprenorphine, and at the end of the year where they had to show up at a hospital almost every day, those that had received buprenorphine, 90% were still engaged in treatment and none of them had used illicit drugs. Of the group the 20 that received a placebo, at the end of three months, all of them had dropped out of treatment and four were dead of an overdose. So you will see from this module that it is a moral imperative that we understand and apply evidence-based practices and not some mythological belief that we have that one drug is a substitute for another for addiction. So enjoy this module. Thank you for joining us in today's Opioid Response Network webinar. My name is Dr. Timothy Fong. I'm a Professor of Addiction Psychiatry here at UCLA. I run a number of activities related to addiction psychiatry, including research on gambling addiction, cannabis use disorder. I'm also the Director of the UCLA Addiction Psychiatry Fellowship. Today's webinar is entitled "Evidence-Based Treatment: "Medication for Opioid Use Disorder" and funding for this initiative was made possible by SAMHSA. Let me move forward. Before I move forward, this is a current disclosure of financial relationships that I have maintained through the years that are active to support either the research that I do in addiction or some of the advocacy work I do related to treatment of addiction. Today's webinar really is focused on three main objectives. The first is to describe clinical experiences with currently available FDA-approved medications for opioid use disorder. And within that objective, I really wanted to map out exactly how we use these treatments in the office, dispel some of the myths, talk about some real-world cases, and particularly for the judges listening and the lawyers and the other members of the legal profession, how to integrate medications into properly forensic settings. The second one is tied in right in there, and that objective is discussing real-world cases where medications for opioid use disorder impacted forensic situations in a positive way. And lastly, again, I really wanna spend this time to take some lessons outside of the textbooks and take 'em from the files and my experiences to talk about the myths and realities about medications, and really create a practical roadmap that uses science and will deliver medications in effective ways for men and women involved with the legal system. With that, I wanna get started with a case study. This is from my actual files, a case I actually saw of a woman a couple of years ago. And it really highlights the cross transition and bridge between say forensics and medical world. We'll call her The Assistant. She's 31 and she was referred to my office by her individual psychotherapist for an evaluation of opioid use disorder. During the intake process, she tells me that she uses about eight to 10 Vicodin pills per day that are obtained illicitly. She gets them through a variety of dealers on the street, a little bit over the internet, but at the end of the day, she talks about spending $500 per week. Her clear signs of addiction, the signs of opioid use disorder that she has, are tolerance, meaning she's using more and more pills to get the same effect. She's unable to stop. She says, this is it. Every week, I'm not gonna buy anymore, and yet she yields to the urges and cravings to buy more. She has a preoccupation throughout her day. When am I gonna run out? What happens if I go into withdrawal? What happens if the dealer doesn't show up? And the preoccupation with getting opioids and using opioids, that really is unpleasant. That limits her ability to get things done. She has withdrawal when she doesn't have her Vicodin pills. She wakes up in a state of withdrawal characterized by sweating and increasing anxiety. She has fights with, arguments about, with her fiance over all sorts of things. Not just drugs, but her behavior, her relationship, her inability to maintain responsibilities. And her work production is very, very low. She's skipping out early to get the pills. She's absent at work. She's taking a lot of extended breaks. These are the signs of addiction that we traditionally see. She then talks about that she has an upcoming DUI case. She was arrested about two months ago for carrying some of these pills in her car and also for driving in a unsafe and inebriated manner. So she's worried also about this not only potential arrest, but being arrested again for drug possession and potentially distribution charges if she actually has pills that are in her possession. She wants to stop using these Vicodin pills, but she doesn't know how. She's thought about going cold turkey, she's thought about going to rehab, she's thought about checking into a hotel and going through withdrawal, but she is not, and this is very important, tried any professional treatment. When I asked her, well, what is the reason you didn't go to rehab, what's the reason you didn't seek professional help? She said, well, I just didn't know it was going to work, or I'd heard a lot of things about rehab, or I don't want it on my permanent record. And she's very worried about overdose. And she's very worried about the pills that she obtains being laced with fentanyl. So during that first visit, as I look at her, I see a woman who's working, I see a woman who wants to get better, I see a woman who is already entangled with the legal system of having one DUI that's being processed and constantly worried about getting arrested for more. What I did in that first visit, I didn't send her to rehab. I did not send her to a hospital. I started her on medication, buprenorphine, to treat opiate withdrawal, and ultimately then to treat opioid use disorder. Essentially what happens after that first visit, and let's say I saw her on a Tuesday at one o'clock. I would then see her for the second visit the following Tuesday a week later. And I would basically talk with her every day in between visits to make sure that she seamlessly gets treated for withdrawal. So in other words, she begins formal treatment with me. We engage in managing medications properly, and we begin the work of recovery of increasing her productivity of work, decreasing and improving her relationship with her fiance, of cutting off access to the illicit pills. I wanna fast forward a year later 'cause then we'll get into some of the details, is that she then describes after, again, after just 12 office visits has not used opiates illegally since that very first visit I met her. She has a new job where she's earning several thousand dollars more and she really likes what she does. She's restored her physical and mental health. She's lost weight. She started to exercise more consistently. Depression, anxiety, insomnia, all of that which she had at the beginning of treatment are all gone. The DUI case was handled quickly and swiftly. There was no mention of opiates. There was no mention of rehabs. And she remained on medications for opioid use disorder 12 months later. Now, that's not made up, this is a real case. I can even have her call the audience right now on our phone and tell you the story, but a highlight that as an example of how medications are used properly without a rehab, without a hospital stay, to get people to meaningfully reduce the addiction behaviors. Let's take a step back. We hear so much constant talk about evidence-based treatment for opioid use disorder. When we break down those term, evidence-based in my mind mean scientifically proven treatments that we know work, not mythology, not hearsay, not even based on well, I used to do it this way, I think it will work with these clients. Evidence-based means the power of science, peer review, professional organizations tell me that this strategy will work. And when it comes to medications for opioid use disorder, it starts with that very first principle. And oftentimes, patients say to me, doc, aren't I just substituting one drug for another? Aren't I just making you my drug dealer now? Aren't I just paying just if not more for prescriptions as I would be for stuff I get on the street? So how does that help me? Well, I'd like to start with this saying that I say to patients and families, that drugs are substances that change the body's functioning, alcohol, tobacco, cocaine, opioids, cannabis, but medications are drugs that restore normal functioning. Again, medications are drugs that restore normal functioning. So the medications that I prescribe to you for the treatment of opioid use disorder, they will restore the brain in terms of normal functioning. They will get rid of the urges, the cravings, the tolerance, the withdrawal, the preoccupation, the loss control. The signs of a brain that's not functioning normally that lead to addiction, that's what medications for opioid use disorder, they restore normal functioning. Secondly, the concept of medications that will assist patients to get into recovery. The goal here isn't just simply to stop using substances. The goal is to maintain a voluntary maintain lifestyle characterized by sobriety, personal health, and citizenship. This is a definition taken about 10 years ago from this journal. It's also a working definition that we work with through SAMHSA and a variety of other professional organizations really highlighting that recovery is what we want here. All right, so in this slide I've described here, what are the evidence-based treatments for opioid use disorder? What is in our toolbox that we use when patients come into the office? We start with three pronged areas. Number one, we have biological treatments. That would mean medications, that also means various physical devices, and things like that. As an example, there's an FDA device that's looked at to treat opiate withdrawal where it's a device that you put behind your ear. That's an example of a device that we're talking about. TMS or ECT, people may have heard about it. Those are not devices that are cleared for or FDA approved for opioid use disorder. Number two, by a psychological therapies. So there are a variety of different psychotherapies that have been proven to be very effective for opioid use disorder. Example of some of these names are cognitive behavioral therapy, motivational interviewing, contingency management, relapse prevention. So for a lot of lawyers and judges, they say, well, I have no idea what I should recommend. The language I like judges to use is that I'm encouraging you to sign up for evidence-based psychotherapy. I want you to go to a treatment program that has not just counseling, but therapy provided by licensed mental health provider or licensed addiction providers. That's very important language. And lastly, the idea of social treatments, these of course, would be this social connections and networks that we use to help facilitate recovery. 12 step groups, online support groups, non-12 step groups like Smart Recovery. Anything that can facilitate a social setting. Now what's interesting, 12 step groups are really not treatment because they don't have a licensed facilitator running them, but we still consider them as part of the social treatment plan and effectively getting help for opioid use disorder. Okay. Next is, what is a medication-assisted treatment? Now this is a term otherwise known as MAT, which came to be over the last 10 years or so to really describe the use of FDA-approved medications in combination with counseling and therapy and behavioral therapies to really provide integrated whole person approach. We've had years of research now, time and time again, showing that when you use both medications and behavioral therapy, that's when you have the best outcomes. This is very much what we take from the world of say cancer treatments, where a combination of say surgery and chemotherapy and radiation therapy and physical therapy and immunotherapies. The idea behind addiction is that no longer is it appropriate to just say 12 step only, no longer is it standard of care to say, well, you should go to a 30-day rehab and you should then be fine after you leave. Medication is really more about assisting men and women to get into the recovery, laying the groundwork for them to do the work necessary for a successful recovery. So the medications that we use are really looking to do five main things in treatment. And the first is to treat withdrawal. As we see time and time again, and I'm sure many judges and lawyers have seen this as well, that opiate withdrawal is characterized by an immense state of physical and emotional suffering. There's physical withdrawal symptoms that are very difficult to bear. There's emotional withdrawal symptoms that are very, very difficult. So when you have a medication that blunts that, that reduces that intensity, that takes away the, the profound withdrawal symptoms from happening, that's really, really important. That's going to help people stay off and break the cycle of continuing to use opiates. Number two, when you have medication to block and reduce the intensity again and those craving, the urges that people have, in between the times that they use, that's also going to be very effective in helping to extend the likelihood of abstinence. Third, medications that block the euphoria or the pleasurable response or the rewarding experience that people can get from opioids, again, will be very helpful in reducing the likelihood of people turning to opioids. And lastly, there are opiod use disorder treatment medication that just improve the quality of life, improve sleep, improve general states of being, improve the likelihood that people can follow through and sustain attention in a class or in a full work day. Those are all medications that help basically improve quality of life and allow people to do things that they weren't previously able to do under a full addiction. And lastly, engage in treatment. By this we mean, some patients, when they show up into the office for a 30 minute visit, if they're profoundly struggling with urges or craving or withdrawal or their preoccupation, or they're thinking about something else, they're not really engaged in present, they're not really able to listen and take away from the lessons of that visit. So medications help kind of calm the brain down and enhance focus and attention to the moment so that patients can stay more focused on what they're doing. All right. So our medication approaches are pretty clear and they start with these different ideas. So action lists as we call the mechanism of action, or basically, how does that medication work in the brain? What does it do? And I've listed here three strategies for medications to work in the brain. The first is what we call an antagonist strategy or colloquially you can think of it as a blocker, if you will, strong on defense. This are the medications Naltrexone and Naloxone, where they're medications that bind to the opioid receptors and they essentially block the opioid receptors from firing or they block other opioid receptors from binding to those receptors to make it work. So they're really defending the brain from opiates from working. The second is what we call partial agonist or antagonist. These are medications, specifically buprenorphine, that bind to opioid receptors, and they can do both. They can activate the receptors in what we call an agonist sort of way, where they can then act like a full opiate, where they can then be helpful for pain, for removing withdrawal symptoms, for handling the urges and cravings that come, and yet they also have antagonistic properties. So they are in the idea of if you use an analogy to football they play both offense and defense, they block opiates from binding, they block opiates from creating a withdrawal of state, but they also can mimic opiates in taking away pain, anxiety, and treat opiate withdrawal. And the last mechanism of action is what we call full agonists. Or again, in a football terms, this would be offense only. These would be opiate medications like methadone that bind to the opioid receptors, and they activate the opiod receptor in full strength, full capacity. Why methadone is useful is that when it activates the opioid receptors, it stays on for a long, long time and it diminishes the withdrawal, it diminishes pain, it diminishes cravings. There is of course, risks with methadone in terms of overdose, but its effectiveness has been proven now for well over 45 years in clinical experience. Here is slide called FDA-Approved Medications for Opioid Use Disorder. And as of 2020, these are FDA-approved options. What's interesting, when I was in medical school back in the 90s, these options were very, very much limited, basically to just methadone and that was it. Now, by 20 years later, we now have a variety of different options. And the partial agonists are the buprenorphine in a variety of different formats. SL means sublingual, implant means we can actually implant buprenorphine into a person. SC means subcutaneous means we can give injections of buprenorphine into the skin once a month. So a lot of different options there. Secondly, full agonist methadone available only as a liquid and only available as dispensed through an opioid treatment program that's federally regulated and monitored. Sometimes judges and lawyers and doctors think, oh, if someone can just take methadone and go to the pharmacy and get them dispense like pills, that actually is absolutely incorrect. It is not standard of care and it actually is against the federal laws to prescribe methadone by tablets in an office-based setting for the treatment of opioid use disorder. And lastly, we have our antagonists Naltrexone oral as a medication pill tablet, or Naltrexone injection monthly, otherwise under the brand name of Vivitrol. That has gotten a lot of attention by being very popular in the criminal justice system for men and women coming out of jails to reduce the likelihood of relapse when they leave jails. So that's our menu, agonists, antagonists, and partial agonists. So let me just now tell some of the stories related to buprenorphine back starting now 2002, when it was first FDA approved. So we have almost 18 years of experience with this medication. And in brief, I'm just gonna say that this medication has really revolutionized our treatment for opioid use disorder. It allowed in 2002 for the first time, the ability for any physician in America to prescribe a medication from their office to treat opioid use disorder. Now to do so, physicians have to go through an eight hour training in order to have a certification and a waiver from the DEA to prescribe prescription opiates for the purposes of opioid use disorder. Very simply, buprenorphine treats the withdrawal, it takes away the urges and cravings. It minimizes relapse potential. It's safe in terms of there's very little threat of it causing an overdose from itself. And I think the 18 years of clinical experience have really shown that in terms of how successful it's been in terms of treating opioid use disorder. This next side is a visual of what it would look like inside the brain of full versus partial agonists. On the Y-axis is percentage of receptor activity that's actually happening, on the X-axis is the dose of the medication. We can see that if you have a full agonist like methadone, morphine, fentanyl, or any of those opiates, Vicodin, as the dose goes up higher, the percentage of receptor activity also goes up higher, but ultimately reaching a potential of overdose when you have too much receptor activity. And when you have too much receptor activity, that then triggers a cascade of events that ultimately leads to overdose and the subsequent shutdown of the brain and body functions. When someone is in a partial opioid agonist, even as the dose increases, there's a maximum ceiling effect of receptor activity that is going to be achieved. So if someone takes an entire bottle of a partial agonist, like a buprenorphine, they can only max out on the total amount of receptor activity that they can actually get. So that's why with buprenorphine, it can treat the withdrawal 'cause they can get more receptor activity to suppress withdrawal, but not enough receptor activity to treat, to achieve a state of intoxication or overdose. Very, very important slide there. This is a visual of what sublingual buprenorphine looks like. Buprenorphine comes in a variety of formats sublingually under the tongue. Here is an example of a film strip on the branded product that looks like one of these breath mint strips, slide to open. You put it under your tongue and it dissolves in about five to seven minutes. So buprenorphine is also available as a tablet, traditional tablet that also dissolves in the tongue. But I wanted to put this visual to give people an idea that this is what it looks like. You take it once a day. It's under your tongue. Your medication gets absorbed into your mouth, and then it starts to provide the medication dose to the body and to the brain. This slide of treatment outcome describes what happens when men and women stop buprenorphine too early. Essentially, here you see the difference is that if you maintain buprenorphine, you stay in treatment. If you stop buprenorphine, that's what the control group is, that they tended to leave treatment and they last treatment quickly. The number one goal of addiction treatment is getting people to come back. Think about the case I mentioned in the beginning, she came back every single month, in part because she was on medication and in part because she was getting value out of every single visit. I would argue and I would say that this experience has also mirrored my clinical experience, where patients who are not on medications tend not to come back into treatment. They tend to say, well, I'm gonna do it on my own. I'm gonna try and do it by 12-step. That's what my sponsor did. And unfortunately, that's not giving this disease the full on, full sleight of treatment options. Let me turn to methadone now. So buprenorphine very briefly, office-based, very effective. Only can be dispensed by a provider who's gone through the certification process. I'll to some of the myths about buprenorphine later, but we'll talk about that in a second. Secondly, methadone. Now methadone is a full opioid agonist where once it's ingested bind to the opioid receptors in the brain, and it will last for 24 hours until the next day. A methadone clinic, again, dispenses this on a daily basis. And we know that the withdrawal symptoms though from methadone could still happen. But if I were to stop methadone, say on a Friday, I probably would not go into withdrawal until Tuesday or Wednesday of next week. And then when I do so the withdrawal symptoms would be way less intense than say, going off of heroin or fentanyl. So the advantage of the methadone as a liquid is that you can't inject it. You can control the dispensing through federally regulated opioid treatment programs. And that again, that had a very long duration of action. So that throughout the day one doesn't go into withdrawal. One doesn't go into having urges or craving, and one should then be able to go about their day's business properly. We call Methadone Maintenance Therapy. That's how it's been called for a long, long time, where essentially the patient is physically dependent on the opioid methadone, but does not then go do the behaviors and the signs and symptoms of addiction, the compulsive, disruptive, impulsive, potentially criminal behaviors. And that's why Methadone Maintenance Therapy remains an option. Data from this over the last 30 years has shown that this improves physical and mental health. It decreases criminal activity. It allows people to stay employed. It's still is one of the effective routes for pregnant opioid use disorder patients. So it's available. It works. It still has some stigma, it still has some false beliefs about what it is, but it still is an effective tool. The other valuable thing about methadone maintenance is that you can then get urine drug testing very easily because patients would go in on a daily basis. Once they've established a period of sobriety, recovery, and disability, many methadone clinics will then taper them down of course to what we know as take-home doses, where they can get a three, four, even five days worth of methadone to take home and manage themselves accordingly. So methadone remains a very viable and interesting option for opioid use disorder. And lastly, Naltrexone, again, very different medication option. This is the blocker. This is the one where the medication available by tablet or by injection. Once it's delivered, binds to the brain, to the opioid receptors and then blocks the ability of opiates to bind, or it blocks the ability of the opiate receptor to be activated. The consequence is for patients to say, is this strong anti-craving? I think of the medication, I think of substances less. I don't worry about going into withdrawal. I'm not as triggered when I drive by the store or by the spot where I normally inject or buy drugs. So that's exactly what we're hoping for. Because it's an opiate antagonist, the risk of minimizing overdose is very real 'cause there is no overdose potential, because it by definition, actually reverses overdoses. So this is an example where Naltrexone, which is available again as a tablet, as an oral pill taking daily, or once a month, the value of once a month injection is really highlighted here where you will get sustained steady amount of medication throughout the entire month. Whereas oral medications, you take it one day, it's gone the next, you take it one day, it's gone. And if you go two or three, four days without it, you then go a few days without any medications whatsoever in the brain. This is why injections are actually very interesting because you can ensure compliance and you know wherever that person goes on, that actually means that they are likely to have, that is why will have medication in their system. So when patients are coming out of jail or when they're coming out of prison or they're coming out of drug rehabs or they're coming out of the hospital and then they go off, this is a great way, we believe, and science tells us to get medications for the first 30 days into their system. What this will do, it will reduce the likelihood of relapse. It will reduce the likelihood of an overdose. It gives patients some protection from their opioid use disorder. So that's what this slide showed, injectable version and enhances compliance. A month of medication in a single dose. Many jails are able to do this on the way out now, here in Los Angeles County, we have those programs out there and it really gives the patient, the assurance and for the providers and family members, the assurance that there is medication in the system. Naloxone, now Naloxone is also an opiate antagonist. And essentially, the only difference between taking Naloxone and Naltrexone, they're biochemically very, very similar, is that Naloxone is much, much more shorter acting. It's available only through an injection or through a nasal spray and is not available as an oral medication. Naltrexone oral, Naloxone not. Now, we don't think of this as actually preventing relapse. We think of Naloxone and Narcan as it's known through the brand name is that this is the opioid overdose reversing agent. This reverses respiratory suppression in event of an opioid overdose and allows patients to return. So the overarching view on Naloxone, it is safe, and that some cases of first responders who are doing overdose reversals with Naloxone, the person may actually need one or maybe twice or even three times in order to actually reverse their overdose. From the legal standpoint, I think this is really critical for the language now of courts to be encouraging anyone with an opiod use disorders to also be carrying Narcan with them. This is no different than someone with a peanut allergy who really should have epinephrin pens on their persons at all times. I think it's a little bit of change in shift for judges and lawyers to be discussing this, but it really is an important part of recovery and saving lives and minimizing potential of drug overdose. Naloxone, as we mentioned, as we've seen in this slide, again comes in a variety of different ways. The injection solution is available in hospitals and the emergency rooms. It's not something that people carry around, it's drawn up and then people are injected either through intravenously. So that's not gonna be commonly found. Evzio is injection solution, which is the manufactured version, the brand name Evzio of Naloxone, which is essentially a plastic cartridge that when opened up automatically injects into a person's thigh, that can be done by the person themselves or it can be done by a bystander. The third version is a Narcan nasal spray, which comes in a couple of different formats, but the one that's more common now is a three prong plastic device. It kind of looks like Flonase or Nasonex or some of these other Afrin nasal sprays, where in the event of an overdose, the nasal sprays are opened up and it can be either self-administered or administered by a bystander very quickly to initiate that overdose. Again, those are the three forms of Naloxone. Now, we filed them here under evidence-based treatments, 'cause they're really part of the medication stories to have when patients are at threat of relapse or at threat of overdose. Here's a visual of what the Evzio auto-injector looks like, very easy to use. A child could administer it. Very simple. Turning from medications to psychological treatments. I'm not gonna spend too much time on this again. I just really wanna highlight the elements of psychological treatments should be delivered by a licensed program or a licensed clinician, that there are a lot of different various forms of psychological treatments. And one of the things that we see too often in our field of addiction and recovery are some non-tested treatments, and they sound really phenomenal, but there's no evidence to really back it up. So one question that I would always ask the judge and always ask lawyers to say is, well, what is the evidence I know that this is a scientifically proven treatment center or that this mandated treatment that I'm recommending is actually delivering best practices to clients? So the treatments, as we mentioned before, really are meant to develop the social networks that are required for a strong recovery, reduced access, increased access and knowledge about other recovery opportunities. I usually like to tell my patients this, I'll say to them, going to 12-steps meeting is not what you need, you need to participate in 12-step meetings. So that means having a sponsor, having a commitment to set up the chairs or make the coffees, being part of 12 step recovery opportunities. Maybe they have a job fair or maybe they have a picnic, or maybe they have other activities that run in the community that are for the community. That's how I encourage people. So the language should be, I don't want you to go to 12-step, I want you to go and participate in 12-step and its related activities. That's how I like to say it to patients. All right, so let me get to some common myths that we hear about treatment. And these are common things I hear all the time, whether it's from patients or from families or from the legal system as well. Aren't I just substituting one drug for another? We addressed this earlier. Aren't I just making you my drug dealer now? And the answer to that I say to clients and families, no. I give them the education that medication is not substitution. Medication is restoring normal functioning. What I will say though is that these medications can create physical dependence, but physical dependence is not a sign of addiction in of itself. You're dependent on your insulin for diabetes. You're dependent on your high blood pressure medicine to keep your blood pressure in check. It's the same way where we think of medications for opioid use disorder are really meant to provide a reduction in the chronic nature of the illness. Is it better for me to be in recovery without medications? I get this a lot. And my first answer to that is based on what, where are you getting your opinion, what are you hearing? Because too often, many men and women who come into treatment say, if I'm getting off of opioids by using medications, I'm "cheating" or I'm just not following the directions or I'm zombie-ing or I'm zoning out. So I say to patients, well, question, isn't it better for me to be in recovery without meds? It really is, what is the best treatment plan for me to have the best possible recovery period? Now, science is telling us that for most patients, it's a combination, but what I also say, medication and therapy, what I also say to patients is that there are many patients who do not need to be on medications for addiction forever. These are not life sentences. I have a lot of patients who I've treated where after about a year or even two years of full sustained recovery, were able to successfully taper off medications for opiates and they continue to do very, very well. We never stopped treatment, we never stopped monitoring, but oftentimes we can achieve a state of recovery that is characterized without medications. That goes into the next question. How long do I need to take medication and could this be lifelong? Again, I like to say to patients, I don't want anything to be lifelong. I want to achieve full sustained recovery first for at least a year before we decide what we wanna do with medication options. And my experience has been that many, many patients, once they get into a zone of really strong recovery and the medications, if it's not causing them significant side effects, if it's not super expensive that interfers with their ability to pay bills, that many are are saying, I would much rather continue with what I'm doing, have my visits with you, Dr. Fong, and ensure that all those symptoms that I went through, all the emotional pain and the suffering I had prior to coming into treatment, never comes back. That tends to be more often what we see in treatment. My sponsor got sober without medications, so why can't I? My response is always, your sponsor and you are two different humans, different set of genetics, different set of biological operating factors, different psychological conflicts and psychological views on the world. Everyone has to have an individualized treatment plan. Oftentimes, this gets into more about how do I deal with peer pressure from my network in recovery? And I say to many patients, your medications are a private matter. Public information is not what this is about. I'll say to them, if your sponsor says, well, I have to know exactly what you're taking in order to be your sponsor. The response I say to patients is that that's not really a mandate. That's not something that the sponsor has to know. It's really your choice. There are now other 12-step groups that are medication friendly, who are accepting to medications. And I think it's important for clients to know about those or explore those in the future. All right, so in summary, here's what the message I have for the legal profession, for the courts, for the judges, for any of the lawyers attached. That we know that treatments for opioid use disorder are very effective when they're actually offered, particularly in combination. Outcome data of recovery rates of men and women with opioid use disorder that received medication plus psychotherapy, plus are actively participating in 12-step groups, reaching in the order of between 40 to 50% successful after one year. Now, those numbers are about on par with statistical treatments, say for obesity, hypertension, certain types of cancer, diabetes. So we know when we do things right, that we really can make people's lives significantly better. We know that also, unfortunately, most people with opioid use disorder don't even seek treatment, only about 10% with the diagnosis ever actually bother to do so, and that's where the legal profession comes into mind because so many of them come in first into the legal profession first, an arrest, an overdose, criminal activity, and that's when the diagnosis becomes revealed and that's when it becomes important, vitally important for them to be referred from the legal system into hand-in-hand and in partnership with the medical system that treats addiction. And lastly, more treatment options than ever before. So as an example, in the state of California, we have over 1700 licensed substance residential treatment programs. That's a lot. We also have about a million physicians in America and of those million physicians in America, I would say approximately about 5,000 of those physicians are board certified in some form of addiction specialty. So it's not a lot, but it's growing more and more every year. We have more medications that are available. We have more treatment clinics that are expanding their addiction treatment skillsets. We have more jails, we have more legal assistants that are interested in that ability. So with that, I'll conclude the webinar. I wanna take the time to thank the audience for their attention to this very critical issue. <v Announcer>For free localized education</v> and training designed to meet your needs, contact the Opioid Response Network.

Chief Justice Tina Nadeau

addiction in courtrooms

medication-assisted treatment

opioid use disorder

study results

buprenorphine

Dr. Timothy Fong

evidence-based treatments