Welcome to Naloxone Saturation and Mapping, a resource for tribal communities. My name is Kiara Mattresino with Kauffman and Associates, and I will be managing the logistical support for this Zoom session. At the bottom of your screen, you will find a series of icons. If you have questions throughout today's session, please use the chat function and we will address your questions either by chat or during the Q&A section at the end of the presentation. If you would like to speak aloud to ask your questions during the Q&A, please use the raise hand function under reactions. Finally, please be aware that today's session is being recorded. Closed captioning is available by clicking the CC icon at the bottom of your screen. If you need technical assistance during the session, please type the issue into the chat box and one of our techs will address it as soon as possible. Without further ado, I would like to introduce today's webinar facilitator and tribal monitor for their introductions and warm welcome. Krista, take it away. Zuri in Dada. So hello, and good morning or good afternoon. My name is Krista Catron. I just shared with you my spirit name, which means something to go around, you know, it's to describe something that goes around in a circular or secular motion. So my grandma always called me whirlwind girl. I belong to the fish clan, and I am an enrolled member of the Prairie Band Potawatomi Nation of Mayetta, Kansas, and I'm also a Kickapoo descendant. So I'm actually calling in today from the ancestral lands of the Osage, Osheti, Sakowin, Kickapoo, as well as the Quapaw and Kaskia Nations here in St. Louis, Missouri. And I serve as a member of the Indigenous Communities Response Team with the Opioid Response Network. I'm happy to serve as your facilitator today. And I'd actually like to turn it over to our tribal moderator, Josh Severns, for his introduction as he welcomes our cultural opener. Thank you, Josh. Miigwech, Krista, Boozhoo, Indignawamaaginado, Kiakiz Niakichida Ndishnigach, Miskaa Makwee Ndodum, Minoogizhigat, Stichi'oomshmi Ndushlapap. So what I said there was hello, all my relatives, good morning. I shared my Indian name, which is Kiakiz Niakichida, means the warrior who heals. I am an enrolled member of the Little Shell, Kalishnabe. I'm also Yankton Dakota, and Ani from Fort Belknap, Montana. Currently residing on the lands of the Stichi'oomsh, the Coeur d'Alene people in northern Idaho. I serve as a behavioral health and substance use disorder subject matter expert for Kauffman and Associates. We have a crew of Anishinaabe people, Krista Potawatomi is Anishinaabe people, and Weihan Moon, our cultural opener, also made the connection. So it's important to really ground and start all these talks and presentations in a good way. So I would like to introduce our cultural opener, Weihan Moon Smith. Mr. Smith is from the Shinnecock Nation of Long Island. Go ahead and go to the next slide. He now resides in Albuquerque, New Mexico. Moon is a person in long term recovery from substance use. He began his career in substance use intervention and prevention in 2019, working for First Nations Community Health Source in Albuquerque. He's worked as a certified peer support worker and a licensed substance abuse associate. Currently serves as a senior certified peer support worker for the Albuquerque Area Indian Health Board. He helps provide TA, technical assistance, to nine tribes in New Mexico, Southern Colorado, who are subordinates of the and 988 Crisis Grants. So important to be connecting on that. So thank you for providing your words. I'm going to turn it over to you. Thank you. My brother, Josh. Hello, relatives. Good day. My name is Weihan, aka Moon. And I come from the Shinnecock Nation way out in Long Island, New York, right? With all the beautiful water and the ocean. And then I ended up here in Albuquerque in Dustville, right? But there's a reason for that, right? That's what my recovery has brought me to come back here to Albuquerque to be a father, be a full time father, right? And so I just want to say to Bootenish, to the ORN for providing me with this opportunity to share my medicine, right? And I want to elaborate on that, right? You know, we're in this work for a reason. Well, I'm in this work definitely for a reason. And that reason is because of my own story, right? My own story of, of dealing with substance use, right? And, and how I overcame that. And one of the things that I, that I, that grounded me so much in this work is this term that comes from my relatives from up north, the Haudenosaunee people, specifically in Akwesasne. One of my relatives up there, he comes to my talking circle that I conduct every Tuesday night on Zoom. And he comes and he shares the opening, the Thanksgiving address in his traditional tongue, traditional language. And one day he was sharing and he said this term, and this term says, Gunalunkwa. What that means is that I share my medicine with you. I care for you. I love you. And I was like that term sums up the reason why I do this work, right? As I share my medicine, I share my, my story, right? In hopes that it will help someone else because somebody did that for me. Right? So before we, we could, we, before we continue on, I'm going to light this, this stage here. I'm going to send this smokey away to each and every one of you with good intention, good thoughts, positive energy, love, and light. As we all are here for, for a reason, right? Some of us have lost relatives to this disease. I personally have lost brothers and uncles and relatives and friends and all kinds of people in my life. And it weighs heavy on me. And one thing I have to remember is that they have crossed over to that spirit world, but I truly believe that they are having ceremony for me right now. When I pray, they're having ceremony because they understand, they see the work that I'm trying to do to heal others. Right? And that's it. That's all I'm here to do is provide an option for others to heal. And so I'm going to go ahead and I apologize, relatives. I do apologize because I am a bit under the weather. You can probably hear it in my voice, but I wanted to keep my commitment. And I definitely just want to give a huge shout out to the ORN. I have worked with them closely. We have collaborated on some projects together, and I need to tell you guys, it has been extremely effective within the tribal communities that I work with. I just want to point that out. Right? So now I'm going to share this song. And I was conflicted on what song I was going to sing, right? But I'm just going to sing it. I'm going to sing it. Whatever song comes out, I don't know which one it is. And that was a song that was meant to come out. So again, please forgive me. I might be a little scratchy, but I'm gonna do my best, y'all. Thank you very much for joining us and we'll see you next time. button to get your money due. What that song is saying, it's just a very simple song, but it sums up how I'm feeling today. And I'm feeling thankful. And all it's saying is, thank you, creator. Thank you, great spirit, great mystery, the great unknown. And so I share that with you. And so if you've got to give thanks this morning, that was your opportunity to give thanks. I gave thanks for you, right? So I say to Bhutanesh, to each and every one of you for being here today, for the work that you do. To Bhutanesh, to the ORN, and I say, Wanish, be well. And I'm turning it back to you, Josh. Thank you, brother. Chi-miigwech, chi-miigwech, chi. Thank you. Thank you for your medicine. Go ahead and go to the next slide. We're going to, I feel good. I'm feeling that medicine now. Thank you, Moon. So as we take that medicine on, we're going to, today, we're going to look at the Opioid Response Network, the ORN, and learn from the Indigenous Communities Response Team, which are present today, and all here. And we're going to hear wonderful information from Dr. Jemaine Jones at Columbia, doing phenomenal work in the fields. We're also going to hear from our sister, Kaylee Joseph, over in Tolela, for caring for our relatives, Cheryl. And then we'll review the ORN TA requests, the Q&A, and then go through the survey link, and open it up for any thoughts and ideas, future webinar topics that are planned. And then we'll close out. So with that, I will turn it over to Krista. Thank you. Yeah, you can go to the next slide. Chi-miigwech, again, for that opening, Moon. I can feel on that medicine, as well. Yeah, so thank you, Josh, as well. So just before we get started today, we want to acknowledge that today's webinar is funded by SAMHSA. We do have Opioid Response Network and SAMHSA staff on the call today, as well as leadership and project officers. And we just want to thank you all for making time and being here for this month's webinar. Next slide. So with that support from SAMHSA, the ORN is able to provide no-cost training and consultation to communities across the country. That's how this webinar is in existence, too, today. We can assist with requests through the ORN in relation to anything with opioids, stimulants, prevention, treatment, recovery, and harm reduction. If you're unsure, if we can help you, If you're unsure, if we can fulfill a request, we still encourage you to reach out. And we'll definitely help you navigate how to make that request. And in fact, there will be a few slides in the next couple of slides that we can go through. And I actually encourage you to jot some notes down or get your phone out so you can take a picture of some of those folks who work with the ORN so that you can kind of make that connection a little bit more closely. Next slide. Something we think is very important in the work we do and that we hope that you're translating in the work that you're doing in your communities is to assume Native brilliance always. This means that Native individuals, communities, programs, organizations are brilliant in their own way and in their own right. Assume Native community strengths and expertise. Those in the community are experts of their community. It's also very important to support tribal sovereignty and what that means for the communities that you serve. And then follow those local community leads, those tribal champions who are doing the work. The overall goal of the ORN is to help support you with meaningful education and training that's defined by you, our requesters. So like I said, if you're unsure, I encourage you to still put in a technical assistance request or connect with any one of us directly. So actually, if you go ahead and go to the next slide, the ORN has created the Indigenous Communities Response Team. And this is the one I said, so maybe you jot down some notes or pull out your phone, take a picture of this slide. This is the team that comprises of the ICRT or the Indigenous Communities Response Team. We each have a background and experience in working with tribal communities. And like I said, if you're unsure, maybe even just message one of us. If you see which region that some of us fall in, message us, ask some questions. We'd like to even follow up through email. And if you're unsure of which region you fall in, you can actually go to the next slide. And this is our map that shows the different regions. So just identify which state you fall in. And maybe even take a picture of this slide and make some of those connections with the technology transfer specialists who serve those regions. There are two of us who serve each region. And if you make a request, those requests come right to us. And we have a pretty prompt response time for getting in touch with you to really see how we can support your needs. So we are here to help. We're here to respond and really help design those locally meaningful approaches that make sense for your community. All right, you can go to the next slide. And this is also, we always just want to share the Opioid Response Network's website. There is a myriad of information there. If you create an account and you have access to some information through the ORN's repository. And you can learn more about how to make a request through the website. And that link should be dropped in the chat box here soon. If not, pull up that Google and type in ORN, and you'll go right to the website. Next slide. And finally, before I turn this back over to Josh to bring in our lead presenter, we stress highly, I know we get evaluation and survey fatigue. But in order for us to improve the delivery of these webinars, we really appreciate if you took some time to take this survey before you log off today. So if you want, keep your phone out, pull your phone out, grab that QR code, or grab that link that Chelsea just shared in the box. Just click it, save it there in your browser. And then before you log off today, just go through that survey very quickly. We really do appreciate your responses. We'll also drop this at the end of our time today as well. Go ahead and go to the next slide. And I'll turn it actually back over to you, Josh, if you want to welcome our lead presenter today. Thank you so much. Chi-miigwech. I have the pleasure of introducing our first presenter today. And you're in for a treat. This has got some incredible knowledge to share. As an Indigenous person, we take the approach of the two-eyed seeing. So we honor our Indigenous wisdom. And we also recognize that there are experts with wisdom in the field of modern Western medicine. So Dr. Jermaine Jones is an associate professor with the Division on Substance Use Disorders at Columbia University Medical Center. He received his PhD in behavioral neuroscience from American University, where the research was focused on understanding the abuse potential of cocaine. Dr. Jones' area of focus has been to try and better understand how genetic factors influence the risk of developing substance use disorders and the effectiveness of novel medications. More recently, Dr. Jones' research has begun to focus on community-based efforts to reduce harms associated with opioid and psychostimulant use. So with that, I will hand it over to you, Dr. Jones. Thank you for being here today. Hi, everyone. Can we go to the next slide? Thanks for showing up. So here are my disclosures. I currently just have one grant from the National Institutes on Drug Abuse, which is looking into black churches as potential sites for naloxone distribution and potential cultural adaptation that may need to occur in order for that to happen. And I'll tell you a little bit about that later in my talk. And I have a small grant from the Peter McManus Charitable Trusts. Next slide. So here are my learning objectives for this talk. I know there's been a lot of changes in the substance use disorder market, particularly the illicit opioid market. And so I just wanted to provide a little bit of understanding of why there's still such a focus of naloxone. So I'll tell you about some of these changes that have occurred, fentanyl, xylosine, heroin, like what's all happening, why I think they may be happening. And then why naloxone is still our, still the primary harm reduction strategy for overdose tests that we have, why naloxone's still relevant. And I'll briefly introduce the concepts of naloxone mapping and saturation. Next slide. So this is a poll. So I just wanted to ask, what percentage overdoses do people here think happen outside of a hospital setting? So not necessarily at home, but outside of a hospital. Just give people a minute or two to answer. And do we have the results? So it seems as though people think most happen at home or outside of hospital setting, and that's true. Depending on the year, anywhere between 75 and 80% of overdoses occur outside of a hospital setting. And so that means the first person who's going to be able to respond is typically someone without a medical education, which was sort of the impetus for naloxone distribution, take home naloxone, getting naloxone into the hands of individuals who are going to be at the scene first and foremost. Next slide. So the first question is just to help you all get an understanding of what's happened in the illicit opioid market first and foremost, right? Because we do know that probably for almost the last 20 years, the majority of overdose deaths in the US and in North America as a whole had been the result of primarily attributed to an opioid, but a lot's happened in that time, right? We had the prescription opioid influx. Those people transitioned to using heroin. More recently, the illicit heroin market turned into fentanyl. And then there's the newer phenomena of xylosine being adulterated into the illicit opioid market. So the first thing we'll talk about with respect to naloxone is fentanyl. And so what do you hear most about fentanyl? It's primarily that it's so potent, right? But there's two features of it that I'll discuss with you today. Partly it's potency, which impacts its potential for causing an overdose, and also its duration of effect, which I will try and loop in of how that has led to changes in the illicit opioid market and the adulteration of fentanyl with xylosine. Next slide. So one of the things that people always talk about the potency of fentanyl, like fentanyl is 50 to 100 times more potent than heroin, but one of the other really important things from the perspective of someone like myself who trained in behavioral pharmacology before I got into community-based research is the duration of drug effect. So even though fentanyl is very potent, it's very short in its duration of narcotic effect. So much shorter duration of effect than heroin, than morphine, most other opioids like oxycodone. And so what does that mean for the person who uses these substances? Well, we know that with individuals who use opioids regularly, if you don't maintain a certain level of opioids in your system, you start to go into withdrawal. So one of the problems with that is that then people then have to use more frequently. We also know that people typically don't like an opioid with a very short duration of action. So even though fentanyl is very potent, it's a very short-acting opioid, and so this affects opioid use behavior, and it affects how people experience the substance. Next slide. And so I forgot to follow up on this with that last slide, but one of the other consequences is using more frequently, like I'm certain you all can imagine, is you have to use more frequently throughout the day. It costs more. It makes it more difficult to always use sterile substance use equipment. So you have increased rates of, you know, it affects potentially the rates of hepatitis C, HIV. So there's a lot in addition to just overdose that changes when you change, like, the pharmacology of the substance. And so I won't go into it too much, but another thing is that we do have some clinical evidence from the lab which shows that people who use illicit opioids don't like fentanyl as much as they like other opioids, despite the fact that it's more potent. Potency doesn't necessarily translate to more liking of the substance. So this is a study that was done actually by my mentor at Columbia just before I got there, and one of the things that they were trying to understand was what's the difference among opioids in abuse potential. And so she looked at a few different opioids, had given these opioids intravenously to individuals who use opioids, and found that fentanyl wasn't liked as much as pharmaceutical-grade heroin or oxycodone. But the take-home from the study was that really slight differences in, like, the pharmacology, like, duration of effect and what a drug hits can lead to big differences in the abuse potential of those substances. And so we know that fentanyl isn't as liked as heroin, which a lot of those people who were previously using heroin, their illicit market transferred to fentanyl. Next slide. So one of the things that we know is that when users don't like a substance, then the dealers play around with it. They adulterate it for a number of reasons, right? So they try and minimize adverse effects. So you all may remember, like, a few years back, there was that whole, you know, the whole interest in bath salts. And one of the things that people really didn't like about bath salts was it caused, like, a racing heart, like a tachycardic effect. And so that you actually found that in the illicit bath salts that you would obtain, there would be, like, you would mix in, like, this medication that sort of slowed the heart. So people play around with polysubstance use in order to achieve a certain drug effect. So adulteration improves drug quality, increase the potency. You may want to prolong the drug effect. A good example if you are, that you'll probably be more familiar with was the adulteration of benzodiazepines into the heroin supply in places where you typically got poor quality heroin. People would always say, oh, we add a benzo to boost the drug effect, right? And again, there's just some clinical research that backs that up that shows that, well, when you do add an opioid and a benzo, people do like it better. Next slide. So that's what we think is happening with xylosine. So you may have heard of xylosine. It's often called Trank. Currently, there's a lot of regional variation in its presence here in the U.S. Like, even in New York, where I am, we're seeing it in about 30% of the illicit opioid that we're picking up on the street. In places like Philadelphia, just an hour and a half south of New York, it's probably in about 96%. So as what happened, we don't know that it will sort of sweep across the country as we saw with fentanyl, but it's possible. So xylosine actually isn't an opioid. It's a different type of drug. It's an alpha-2 adrenergic agonist. So it's actually more like clonidine or one of those that people often use to treat opioid withdrawal, if you're, you know, a lot of you are familiar with treating opioid withdrawal. And we do know that there's been a pretty, an increase in xylosine in the U.S. Like I said, the Philadelphia market's almost entirely adulterated with it, particularly anywhere that we're saying fentanyl, we're sort of starting to see xylosine creep in as an adulterant in combination with xylosine. And of course, people are saying that fentanyl is very short acting. People don't like it as much. And so the xylosine added into the fentanyl sort of prolongs the drug effect. Next slide. So this is just showing a little bit of increasing in xylosine over the past few years, the idea being that like it might be the new, might be the new benzo. The first accounts we saw of xylosine were actually in Puerto Rico where people were mixing xylosine with heroin. They had a particularly low quality heroin around in Puerto Rico and they found that people were mixing xylosine in and they were reporting that it was doing the same effect. Like it boosts the effect of the poor quality heroin. Next slide. So what are some potential implications? So now we have this illicit opioid market that's primarily fentanyl, which is a very potent opioid, short acting with xylosine, which is this non-opioid. One of the things that is probably the most concerning has been reports of xylosine related wounds, particularly wounds that are extra local, meaning that they don't necessarily appear at the site of use. Next slide. Xylosine is also, oh, sorry. Yeah, we can stay at this slide. So xylosine is also has a sedative effect. So there are also concerns about the, about the potential implications for overdose. While you have an opioid that is a central nervous system depressant, you combine that with xylosine, which is another central nervous system depressant. And what are the potential for overdose with this new substance combination? So that leads to the question of, is naloxone still relevant? Over the last 20 years, we've been working tirelessly to get naloxone into the hands of more people. So more naloxone in, and they've gotten a lot of naloxone out there, as you can see in this figure to the right, the increasing prevalence of naloxone, particularly starting at around 20, 2015. Next slide. So does naloxone, and this is a big question, particularly for places where, who give naloxone to people, to people who use substances or where naloxone is administered in out-of-hospital settings. So is naloxone capable of reversing a fentanyl-related overdose? And from a strict sort of pharmacology perspective, yes, we do know that naloxone has a higher affinity for the mu opioid receptor in comparison to fentanyl. So it should be able to go in there, displace fentanyl from those receptors, and bring someone back. And we know this from the anesthesiology literature, actually, because fentanyl is an anesthetic, so they use it to put people under, and they bring people back with naloxone. However, we do know that something's going wrong here. Like there's something that we, there's something more to be considered, because, of course, like the word on the street, and the anecdotal reports say that you may need, that something, like naloxone isn't working, or what we're doing isn't working, or we need to revise our strategy in some way. So the question is, the next slide, what's potentially going wrong? Next slide, please. Oh, sorry. No, go back. I'm sorry. Can we just go back one slide? Okay. Sorry, forward one. I think there's a slide in between those two. Yeah, so what could be, what could be the problem? We do know that in out-of-hospital settings, the amount of time it takes to admit, to get naloxone into someone varies significantly. You know, someone, you may have just come up on somebody who you see is in trouble. You don't know how long they've been in trouble. So you administer your naloxone, and the person still might not make it. So one of the things that we think is that because fentanyl is so potent, that there's less time to intervene with naloxone. So that decline from I'm feeling okay, to I'm in trouble, and I'm not breathing properly, it might be much shorter. So with traditional opioids, like heroin and oxycodone, we think that there's a longer window of time in which you have to intervene. And so I know, at least in New York, when we started doing a lot of naloxone, a lot of take-home naloxone, the guidance that we got from the Department of Health was that you, if you see someone's in trouble, you know, you do the sternal rub, you put them in the recovery position, you call 911, you, you know, you do all this stuff. And then if none of that works, then you give them naloxone. They actually changed guidance to where if you think someone's in trouble, you get naloxone in right away. And then you do all of this other stuff. And so a part of that is in response to trying to make naloxone more, more effective in the area of fentanyl. Next slide. Another problem is that we do know that fentanyl causes what's called a chest wall rigidity. So it's a tightening of the diaphragm that actually prevents or makes breathing more difficult. And this is actually an effect that's unique to fentanyl. And it's not actually related to, it's not an opioid effect. So naloxone being an opioid antagonist isn't going to work as effectively on this particular aspect of fentanyl's adverse effects. However, what we do know is that this is a smaller contributor. It's a contributor, but it's a smaller contributor to fentanyl related mortality. So we do know that with naloxone, you get naloxone, you can reverse a significant amount of the opioid effect in order to save lives. Next slide. And this is just what I went through before. It's chest wall rigidity isn't an opioid effect. So naloxone has less effectiveness against fentanyl because it has this additional effect. Next slide. So what are some potential solutions? So one could be to, and their drawbacks. So nothing's ever simple, right? There's pros and cons to everything and things to consider. So one of the things is that you could encourage intramuscular use of naloxone. We do know that a lot of take-home naloxone is intranasal. The intranasal does work very well, but we do know that intramuscular naloxone, there has been some clinical studies showing that intramuscular naloxone gets it into the body a little faster. And so it may have more efficacy. However, there are drawbacks to that, right? Because I don't know if you've ever seen an intramuscular syringe. It's a beast, like it's a 26-gauge syringe. And for a number of reasons, people don't want to carry it. At least a few years ago in New York, you couldn't bring syringes into shelters. People who use substances often said the syringes were triggering. And so they didn't want to carry them. So it's this balance of like, what can we do? And so are you going to, if you switch to intramuscular, are people going to use it less? Because it's, you know, it's a higher bar to possibly inject someone with something than it is to squirt a little something up the nose. Potential, another option is to give more standard doses of naloxone. People say, you know, the two doses aren't enough. And maybe you need to give more naloxones. Altered recommendations for naloxone administration. So like I said before, in New York, it used to be do all this other stuff before naloxone. Now it's naloxone is the first option. So are there other ways that we could recommend, other recommendations to the practices that we could come up with that may be effective? And also we do know that there are newer opioid antagonists coming out. One that's been approved is nalmethine, which is a little bit more potent than naloxone. But potency isn't necessarily all it's cracked up to be because we do know that with more potency, you also get more precipitated withdrawal. So, you know, it's, like I said, I wish I had a good solution for you. But it's a, you know, it's a complicated problem. Next slide. There was a very, a study that came out, however, because one of the things that we're finding is that, you know, there's a newer formulation of naloxone that's almost double what you get with with Narcan. So Narcan is about four milligrams as Cloadox is about eight milligrams, it's shown on the on the right hand side in the in the orange. However, the concern with the higher doses and higher potency is that yes, you could potentially like you could potentially be more effective, but no one wants to be in withdrawal, right? It's so uncomfortable. And no one wants to produce withdrawal in someone who is opioid dependent for a number of reasons, right? In or out of a hospital setting. But there's a really interesting study that just came out from the New York State Department of Health, and they actually found that in out of hospital naloxone administrations, the there was no difference in the survivability when law enforcement gave four milligrams or eight milligrams of naloxone. Basically, the only difference that they found is that the eight milligram dose was more likely to cause precipitated withdrawal. But it looks like we like we saw naloxone still a great tool, despite the xylosine. You know, xylosine may contribute to opioid overdose. But if you if you handle the fentanyl with naloxone, naloxone still should be very effective. Next slide. So, um, I just wanted to introduce two concepts with you. And they're really two newer concepts within the field. One's called naloxone mapping, and the other is called naloxone saturation. And the idea, one of the things that happened with naloxone is that we, the field and the country was so desperate, like we and we still are to an extent for for interventions for opioid overdose that we rolled out naloxone, you know, full force. And I think now what we can start to do is sort of try and understand what are the best ways to go about it doing some of like what we call the implementation science to maximize the the intervention. So we've done a number of things to improve access to naloxone. It's now over the counter, lots of new funding sources for naloxone, the standing orders, the immunity laws, the Goodsman laws, all of that. However, there's a concern that measuring naloxone distribution, it's challenging, but we don't want to waste this resource because naloxone isn't an isn't an, like it's not free. It's also not like a, you don't want to want to waste a resource. So what naloxone mapping seeks to do is to better understand who should get access to naloxone relative their risk of experience or witnessing an overdose, because we don't want naloxone sitting around and expiring, right? We want naloxone in the hands of people who are actually going to use it and be able to save some lives. Next slide. So what we, what naloxone mapping seeks to do is to try to identify where that naloxone needs to get to, how much needs and how much needs to be there and what are some of the best ways to get it into the hands of those who need it, whether that be distribution at syringe exchange sites, vending machines, all of that. So, next slide. So the second concept is just naloxone saturation. And the idea behind naloxone saturation is that you want, as a goal, we want there to be a certain amount of, we basically want naloxone to be present at every overdose event. And so how do we sort of meet this very lawfully goal? And there have been some people saying that a program should aim to distribute 20 kits, 20 times as many kits as there are overdose-related deaths per year. But that's just, that's just sort of like the science that we're still pondering. And we don't really have best practices for, for this. We do know that the more naloxone that a community has, particularly a high mortality area, the lower, the more likely that naloxone is to get used and the more effective it's going to be against overdose rates or more effective in reducing overdose rates. We do know that the face of the overdose epidemic has changed. So there used to be a reliance on just harm reduction service providers, but, you know, like syringe exchange places. However, we do know that people are overdosing more who are younger, people who are just experimenting with substances. So people who might not necessarily have opioid use disorder, but they're experimenting with substances, particularly in places like the West Coast, where the fentanyl is now adulterated into, into pills that are often sold as other substances. So, and that demographic isn't going to go to a syringe exchange facility. They're, they're going to, and they may even not see themselves at that certain, at a level of risk of overdose. So how do we get naloxone to, to those people? And so some of the things have worked, things like pharmacies, emergency department, walk-in clinics. And, but to be honest, I think we still need to, you know, grind out to, to think about novel ways to get naloxone out there because we're seeing the demographic change of, of who, who needs it. Next slide. And the last thing that I'll discuss with you is the potential for adapting overdose education and naloxone distribution to, to new settings, because I think that's another thing that may improve effectiveness. Next slide. And I'm by far not an expert in this, but like I was telling you at the beginning of my talk, I do have a grant with a co-investigator that is, that are looking at black churches, starting off with black churches, specifically in New York, but black churches as potential places for naloxone distribution. So we're in the ground setting phase of this study now, just trying to understand what might be some of the adaptations to this intervention that needs to occur in order for it to be successfully rolled out into black churches. And while we're still compiling and trying to understand that, I just wanted to give you some examples of things like sociocultural adaptation. So one might be, if you, are you going to get people more motivated to be involved if you frame overdose as a health equity issue or as a social justice issue? Because we do know that the demographic of opioid overdose has changed and to where it's more of a black and brown problem than it was initially. And why is that? Well, because certain people got access to medication better based on how buprenorphine was basically promoted and rolled out. And so framing it in that way may make it more effective. Ecological adaptation. So finding ways to get church leaders to talk about overdose. I found in my qualitative interviews with church leaders, everyone knows someone who's at risk in some way. And they will admit that so-and-so came to them with this problem and so-and-so came to them with this problem. So these various church members are coming to the leadership with these issues, but no one's really talking openly about it. And so how do you get people to talk openly about a problem that we're all sharing, but no one wants to disclose for whatever reason, we know the primary reason, which is stigma, which is another potential adaptation. So stigma and just sort of mental health literacy in general and how those might need to be approached upfront in order for it to be effective in this setting. Next slide. And so one of the things to think about with respect to this group is what might be some of the social adaptations that need to occur or that may make this more effective or more likely to be utilized in indigenous communities. One potential is using culturally grounded stories and teachings or just incorporating representation and traditional beliefs into what we do know about Naloxone into the medical jargon, right? That we use to describe Naloxone. Next slide. Community adaptations as well, which are listed here, emphasizing community-based approaches that involve natural or social environment of the tribal community. And this is just sort of based on the literature that has done this before, right? Because this isn't the first time that, or this wouldn't be the first time that an intervention has attempted to be adapted into this setting. Next slide. And I guess the last thing I'll leave you with is I think substance disorders are incredibly isolating conditions or incredibly isolating a mental health issue. And I think in our research, we found that the majority of people with opioid use disorder primarily use alone. And I think that's still probably the biggest barrier to Naloxone is that if you're using by yourself, you can have twin Naloxone kits and it's not going to help you. So I do think we still have to think about ways to target this being one of the most at-risk groups, right? And people who use alone. And I think as substance use disorders progress, that isolation progresses as well. So the risk to the individual increases. And I think that's my last slide. Next slide. I think that's the last one, but. So I just want to acknowledge like the group that I work with at Columbia who do this research with me. I think that is, I think that's all from me. So I'll turn it back over to Josh. Chi-miigwech, Dr. Jones. That was incredible. And really, I really appreciated how you talked about at an individual, at a scientific level, how those things work when you're helping relatives. And then looking at it from a community aspect, because really we can't bring every single patient into our office. We have to get connected to the community. And so I think about it, a story that I think about is Wayne Abaju, he's a hero in our culture. And there's a story about him in the maple trees and how everything has a medicine that we must respect. And when the community's involved, it really highlights the importance of things like health equity and responsibility, shared responsibility. So as a medicine person, I appreciate you coming today and sharing your knowledge. So thank you. If you'll go to the next slide, I will pass it over to our friend with the Tulalip tribes, Kaylee. Go ahead and take it away. All right. Thank you for having me present today. It's such an honor to be with you all. And I always feel so empowered when I'm in a space, whether it's virtual or in person, and I get to share some of the work that we're doing and see what other folks across native country are doing to do some of the hardest, truly some of the hardest healing work that we have to do to help heal our communities and save lives. So I just wanted to share that and I'm ready for my next slide. I'm gonna introduce myself in Lushootseed and that's Tulalip's traditional language and a lot of the other Coast Salish tribes in the Puget Sound area. Kaylee Seeds Dot, Othisayustiichid, Kugugwagwachid, Atikwetaayootseed. And I said, I'm Kaylee. Hello, you honorable people and my relatives. I will only speak a few words to you today. So I wanna introduce myself a little more so that y'all could get to know me and know my community more before I dive into the presentation. So like I said, my name's Kaylee. I'm a member of the Tulalip tribes and I recently earned my master's degree from the University of Washington with a concentration in health and mental health integrative practice. And I come to you all today from my community on the Tulalip Reservation here in Washington State. And these are some images of my ancestors here and it highlights some of the ways that we used to survive. And a lot of the ways that we used to survive was by fishing, hunting, crabbing, using our land's natural resources like cedar. We would strip cedar from the cedar bark or from the cedar tree and separate the inner bark from the outer bark to make all different kinds of things. We would have to take the cedar and hang it up for a year so that the cedar could cure so that we could turn that cedar into cedar baskets and mats. And the Puget Sound waterways was our traditional way of travel where we traveled for trading and fishing in cedar canoes and we lived in long houses and we hunted for deer and elk and we harvested berries, salal berries or salmon berries and that was our way to get nutrients. And I'm currently, I get to do a lot of healing work with my team and the location that is very, very close and adjacent to the spot where the Tulalip Boarding School used to be. And I just always like to share that because it's a wild phenomenon to be doing healing work to help reverse some of the trauma that has been done to our people as a result of settler colonialism cycle of harm in a place where our ancestors and our people faced a lot of adversity. Just something I always like to highlight. I'm the manager of the Tulalip Recovery Resource Center and I'll talk a little bit more about the Resource Center but that's my title and that's a little bit about me and my community and I'm ready for the next slide. So like I said, I'm gonna highlight the Tulalip Recovery Resource Center. So we are sort of a drop-in center where we have a lot of recovery enrichment activities including self-help meetings. We host NA meetings here, Gambler's Anonymous, Well and On Talking Circle. We have several, what's the word? Several life skills workshops. So we've done nutrition classes. We've done money, mastering money and money management and early recovery and mastering your debt and early recovery. We do cultural activities. We've done drum making, dream catcher making. We got folks together and spent the whole day making strawberry jam. So things like that. Our program is also an outreach program and it's where we have our three outreach workers who go into the community and meet our folks who are struggling with substance use disorder or living with substance use disorder where they are at and we offer them help. And we know that respecting their self-determination, our clientele's self-determination is important and we ask them, hey, would you like a Narcan kit? Or hey, are you interested in services? And if you're not interested in services, that's okay but may I give you my bracelet that has my number on it so you can call me if you ever need any support or if you're ever interested in getting our help, our guidance and accessing services. And then we also, another big part of our program is harm reduction. Narcan is very important part of our program and I get to talk to you guys about that today too. And that being said, I'm ready for my next slide. This is a snapshot of our activities calendar. It just highlights some of the stuff that we do and I thought it was a good way to illustrate what our center hosts. So I'm ready for the next slide. So our program, the program that we are now started out as a lot smaller program. Originally, we were a small overdose detection mapping and application program, our ODMAP. And it was actually a grant funded program that started at the Tulalip Tribal Courthouse. And this is a snapshot of what overdose mapping is. So we were able to use software and partner with our local first responders, such as the Tulalip Police Department and the Tulalip Bay Fire Department. And then the fire department that's near the town that's connected to the res, that borders our res. And we would use them to give us the information so that we could map overdoses that were happening in our community. And this was a snapshot and you could see some of the hotspots where we're seeing more overdoses. And then with that, there was also a ledger where it highlights what overdoses are fatal, what ones are non-fatal, and what ones were unknown if naloxone was administered, whether naloxone was administered or not and how many doses were administered. So that was sort of the origin of the program that we are now was ODMAP. And I can move on to the next slide. So with ODMAP, we got to collect that data and geographically map the overdoses. And then we were able to use that data to respond. And one of the first things that we wanted to do was NARCAN. So at this time, our tribe had already had our own Good Samaritan Law and it's called the Luella-Jones Law. And we also were aware of Washington State's standing order for NARCAN. So we leaned on those as a way for us to make NARCAN more normalized for our community to use. And NARCAN was already in the community, but it was still very new. So I just wanted to share that piece of context. And we also started our program during COVID. So using the overdose mapping system and knowing that we had a lot of limitations with COVID, we were like, hey, let's work with our TDS department, Tulalip Data Services, and let's make a website so a community member can click on a link and they could watch a video about NARCAN and then they could provide information on this website for drop-off of NARCAN. So we were able to drop NARCAN off doorstep just using this link. That was one of the first ways that we started to get naloxone more saturated in our community, especially during COVID. And I'm ready for my next slide. And then after we started using the website, COVID had kind of subsided a little bit and normal life was coming back slowly. So we started doing outdoor pop-up events and we started distributing NARCAN in the two tribal developments that had the highest rate of overdoses. We have a good handful of tribal developments in the Tulalip area. We looked at the map and we said, hey, this tribal development and this tribal development have the highest rates. Let's just start posting up in the community and getting a table and a canopy and we're gonna distribute NARCAN. And we also did things that made them related to certain events. So this was our one that we did for Valentine's Day and we wanted to incentivize folks for dropping by and getting a NARCAN. So we said, hey, if you come get a NARCAN, you could get a $5 Starbucks gift card. Or if you come get a NARCAN, you could get a coffee tumbler or a tote bag or just a variety of other freebies, things like that. And I'm ready for the next one. And then, so after we started doing the ones in the targeted areas in the certain tribal developments, the NARCAN distributions evolved into a monthly recurring event where our program and our chemical dependency program, our pallet shelter program and other divisions throughout the tribe come together. And we set up in a certain area and we distribute NARCAN for a few hours. And it also turned into res meals on wheels and community NARCAN distribution where we provide a warm meal to our community members who are houseless. And we actually just had a NARCAN distribution yesterday from 11 to two. And that was our one for the month. And we'll do our next one in March or in April. And yeah, so I'm ready for next one. We also make sure to be present in the community in any way that we can. So if we're invited to table at, for example, this weekend, there was a gamblers, a non or gamblers, the problem gambling program here at Tulalip had an event with some really funny comedians who are from Indian country. And we got to pop up there and distribute NARCAN and hand out resources. And then one of the images in this slide was a, it was a winter, it was a youth event and it was winter holiday gift making, or I think it was like a winter break bash. And we make sure to, any opportunity we can table in the community, no matter what division it is, we try to be there. And then we also do events every year for Overdose Awareness Day. And another big emphasis on Overdose Awareness Day is highlighting NARCAN and how it could save a life. So I'm ready for my next slide. So the next way, the next step that we took to get NARCAN in our community was purchasing Nalox boxes or opioid rescue kits. And we started with getting nine of them. And we wanted to make it accessible for someone 24 hours because on our Nalox boxes, there's no keys on them. So anyone can go up to the Nalox box and twist the little knob and take out the NARCAN. And we provided a flyer that shows geographically all of the locations where a community member could find a NARCAN med box. And with a heavy heart, we recently purchased six more NARCAN med boxes and they're in our administration building now because we had lost one of our community members in one of the restrooms at our administration building. And it prompted the staff at our administration building to give us a call and say, hey, we need six more of those opioid rescue kits here in the administration building. So I think we're gonna get some more for sure. We did order those six, but we're definitely gonna get more. And I'm ready for my next slide. So another thing that we have purchased this year was a harm reduction vending machine. And I also wanna get one of the Bougie NARCAN vending machines that you could click on and the touch screen. But this is the one that we have for right now. And we have it set up at our pallet shelter, which is the other image on this slide. And the Tulalip pallet shelter is a newer program that our Tulalip board of directors and leaders decided to implement about a year ago. And it's 20 units. It's a low barrier style living and it's for tribal members who are houseless and or are currently using substances or struggling with substance use disorder. So our harm reduction vending machine, it has NARCAN, it has hand warmers, gloves, fentanyl testing equipment, among other things like that. Ready for my next slide. Another way that we make sure to have NARCAN normalized is by sharing information. So these are just some of the fact sheets that we've worked on. And in almost every fact sheet that we have or piece of information that we provide, we make sure to let community members know that you're able to get a NARCAN from our program, you're able to get a NARCAN from our chemical dependency program, from some of the locations that we have the NALOX boxes installed, where the NARCAN vending machines located at, and oftentimes we highlight the Good Samaritan Law and Washington State Standing Order for NARCAN. But yeah, these are just some of the fact sheets that we've worked on over the past few years. So I wanted to share those. Ready for my next slide. Oh, I love this one. This is something we created, I wanna say a year into ODMAP. We were formerly ODMAP. So about a year into ODMAP, I think I was meeting with the ORN actually, and they had shared a link to another tribal behavioral health program that did a NARCAN promotion PSA video. And I was like, hey, we should do that in our community too and utilize our elders who value this work and the youth council. So we can go ahead and play this video. You know, the blame can go around to everybody. We look at how we need to accomplish things in life. And each one of us are part of the community. So we need to be able to be more responsible in any way of our bet. And worry about how we're gonna take care of the child so the child lives to be an elder. I carry NARCAN because I love my people. I carry NARCAN because we as native people have lost too many lives to overdose. I carry NARCAN because I know it will help our homeless people that are out there lost and this will save their life. I carry NARCAN because I love my people. And this will save their life. I carry NARCAN to help the community. I carry NARCAN because the opioid overdose rate among native people has been on the rise since the year 2000. I carry NARCAN because every life matters and you never know when you have to use it. Carry one of these NARCANs in your vehicle or have one at your home so you can save all of us, save our people. A little bit more today than you did yesterday and think about how we're doing it because we're the community that's gonna save our people. We're the community. So please, have a NARCAN with you and carry it with you all the time. Thank you. ♪ Oh, Ohio, oh, Ohio. ♪ All right, so that was our first PSA video and I just really valued getting to work with the Tribal Youth Council and in creating that, it provided the preventative measure of us being able to offer some education and awareness around this issue to the Tribal Youth Council and I think it really prompted some of the members of the Youth Council to see that it was a really, it's a really important thing to talk about in our community and a really important way for us to teach the youth that there are other ways to cope with mental health and things like that. And with that, I'm also ready for my next slide. Every year since the year 2000, there has been an increase in the number of deaths due to opioid overdoses among the Native population in the country. With one in every 10 Native persons reporting that they have a substance use disorder of some kind. When someone takes an opioid, the drug works to trick your brain into thinking your body is doing better than it actually is. As a person's tolerance builds up over time, they may take more and more of the substance, eventually resulting in an overdose. An opioid overdose can be recognized by several signs, including unresponsiveness, tiny pupils, clammy skin, and most dangerously, slower breathing. If someone is overdosing from opioids, immediately call 911 and then administer Narcan. Narcan is a nasal spray that works to free brain receptors from opioids long enough that professional care can be provided. Once brain receptors are clear, the drive to breathe should be restored and allow time for medical help to arrive. Because of its effectiveness, Narcan is readily available and free of charge to those who might need its help someday. If you are interested in obtaining a Narcan kit, please contact the Tulalip ODMAP Department at 360-722-2255. And we always inform and offer a disclaimer to everybody that we provide Narcan training to that there's no certification to administer Narcan, that Narcan is designed for a bystander, community member, or someone who might be using substances to administer the Narcan. But these are just some examples of some of the departments that we visited to provide some information and resources regarding Narcan and overdose response and recovery. So we've done presentations to the Tarot vocational class. We've visited Summer Youth Orientation, which I think is really cool because every summer, our Youth and Education Division in the community has a youth employment opportunity where youth age 13 to 18 can have a summertime job for up to 180 hours and they have a two-day orientation. So it was really nice to be able to visit the youth because our leaders, our Board of Directors here are often telling us, what are we doing for primary prevention? So any opportunity to visit with the youth, we take the opportunity. Legacy of Healing, which is the domestic violence program. And FDACHA. FDACHA means Our Children in Lushootseed, and that's our tribe's Child Protective Services. So that's that slide. I'm ready for the next one. This is the most recent overarching Narcan project that we launched. And it was actually my coworker, my employee who led this project. And he said, he came to me one day and said, hey, I really want a big project to work on. And I said, well, there's this thing that you've been talking about for a while. And you said you want to do a door-to-door Narcan project. I was like, hey, you could make that happen. And he said, OK. And a couple months later, after working in collaboration with a social worker from our police department, they launched the first portion of door-to-door Narcan project, where they went to the Mission Highlands and Silver Village. They're the two names of the two tribal developments that they went to. And they literally went door-to-door knocking and offering and providing a Narcan kit with some other resources. And I think the kits included a smudge kit, a brochure, a bracelet with a contact number on it, and then the Narcan and information on how to administer the Narcan in every kit. And if folks didn't answer, it was left at doorsteps. And I remember the numbers for Narcan during that time. That week was like 300, I think, were distributed. So in every house in Mission Highlands and Silver Village since January 8th through the 12th, there's Narcan there. We also put this sticker on all of our Narcan, just reminding everybody that if you use your Narcan kit or if it expires, then you can always give us a call and we'll get you another one. Yeah, that's that slide. So after hearing the different things that we've been working on here in the community over the past few years, we are wondering how likely or motivated are you to implement some of these strategies into your community? All right, I see that the poll, I see we have a lot. 93% of y'all are very motivated and 7% are somewhat motivated, so that's a lot of motivation. That makes me really excited for for all of us in our own areas to bring forward this work. So, and then I'm not sure if Josh had anything to add to this slide or, yeah, just wanted to offer that space. Chi-miigwech, thank you so very much, Kaylee. That was incredible, and I love those PSAs. Seeing your community, you have the elders and you have the youth, and all my work in Indian country, I always say if you want something done in a tribal community, get get Youth Tribal Council on board and they'll help you. So, I was just thinking as you were sharing, there's an Anishinaabe story about the balloon's necklace, and the story is a hunter was struck blind, and he was providing for his village, for his community, and he struggled losing his eyesight over time, and he struggled to provide for his family and his community until one day he went to the sacred waters of the lake, and the loon came up to him, seeing he was struggling, and the loon told the hunter, he told the man, he said, take that medicine water and put it in your eyes. This medicine will take care of you, and he did. He went home, and as he woke up the next morning, he could see again, and out of gratitude that hunter created a necklace, sacred necklace, using the medicine water and shells, and he gifted that necklace to the loon, and that's why the loon has that beautiful necklace around its neck. It makes me think of today, our people sometimes need that medicine, and that medicine may look like Naloxone, it may look like Narcan, it may look like these other medicines, and the wonderful gifts that we have to give one another. Sometimes it just takes a little bit of help, so that's just sort of my reflections on that, and I know we had a couple questions, and I wanted to defer to Dr. Jones. As a former medic and firefighter, I know that there's certain protocols for administering Naloxone and things, but the question that was asked was about, bring it from one of our TAs can put it in the chat, the importance of using Cloxato versus Naloxone, and if you could speak to that. I'm just reading the question now, would you be able to explain it? To just explain the difference between the formulations, so the one that I showed you, Cloxato is eight milligrams, it's the same drug, and not Naloxone or Narcan that we're all familiar with is about half of that, so Naloxone is the active substance in both of them. I think the premise behind having these higher dose formulations was the idea that as we transitioned from a heroin overdose epidemic into a fentanyl overdose epidemic, that you would need a stronger opioid antagonist, and I think for a while there was that belief, either more Naloxone or higher concentrations of Naloxone. I think there's still a lot of knowledge to be gained in this debate, but the worry with the higher dose formulations is that there's a potential for the medication to get a toxic reputation because it's more likely to induce withdrawal, but not have much benefit in bringing people back. At least that's what that study from the New York State Department of Health was told, but that's really the one head-to-head study that I have to cite, but I do know that in a lot of settings there's a lot of concern about using more Naloxone or higher dose formulations because even though you might save someone's life, you don't want people to come back in withdrawal because they don't want to use. People are often concerned about how that person is going to react to them when they come out, so you get this high dose of Naloxone out there, and then no one uses it because everyone's sort of scared to use it, and so it ends up being not as effective. Thank you for speaking to that. The other question is, does Narcan expire and how does heat affect it? So as far as the heat, I'm actually not certain. I would avoid extremes of heat with Naloxone, but Naloxone, like any medication, does have an expiration date, so that's one thing to keep track of. Like Kelly was saying, if you have an easy source, if you have access to Naloxone, take your Naloxone, your expired Naloxone in. However, I would also say that if you're in an overdose scenario and all you have is expired Naloxone, use expired Naloxone. That expiration date is like a best-by date, right, for food, so it might not taste as good by the best-by date, but it's still food, so that Naloxone, that expiration date isn't the date that it stops working, and it's probably not going to do any harm if that's the only thing that you have access to. And I see there's another question here. Why are the wounds for Xylosine more severe? That's one of those things where I think we're still trying to understand why that is. So I know with, at least with certain drugs, like I know with drugs like cocaine, cocaine's what's called a vasoconstrictor, so it can cause blood vessels to shrink, so if you use at a high concentration of cocaine, if you inject in the same area repeatedly, that constriction of blood vessels causes necrosis, so the skin and the tissue and wherever you inject it, you can get local, like on-site necrosis, and people think that's what might be happening with Xylosine. There's some effect like that, but that still doesn't explain these wounds that are occurring in other places where people aren't directly using, right? So if you inject in the arm, the wounds are appearing in other places. There's been, you know, some substances have what's called immunosuppressive effects, meaning they suppress the immune system, so, you know, it may not necessarily be a Xylosine wound, but Xylosine affects the immune system in a way that makes a wound easier, like a scratch or a cut easier to proliferate or to get worse, so, but the easy answer is we don't know, but we need to understand this better. This is very helpful information, so thank you for sharing, Dr. Jones. Do we have any other questions from the participants, and any questions for Kaylee? seeing anything. So, chi-miigwech to both of you. Thank you very much. I'm going to turn it over to Krista to close us out today. So, thank you all. Awesome. Miigwech for everyone and everything you shared with us today. So, just to close us out today, we just want to remind you that the Opioid Response Network is here to help. Here are some examples of ways the ORN can help you in relation to the topics we discussed today. Again, if you're unsure, we just encourage you to make a request and those will be funneled to the TTS who represents that particular region. Next slide. And the link will actually be dropped in the chat here soon. I've seen it was dropped actually throughout the time here today. So, if you are interested, go ahead and click that link and submit a request or if you just have any questions, that will be shared with your technology transfer specialist. Next slide. And for April's webinar, that registration link is available. That will also be dropped in the chat. We encourage you to register as soon as you can. The topic will be what to do, pregnant people and substance use. I know this is a very important topic, especially those who happen to work alongside and in collaboration with your child welfare, your child protection department or office or those who work there with the state. I think that this is a topic of interest, especially as we, you know, unfortunately our mothers who are pregnant and use substances, there's a lot of factors that play into why, but then also the outcomes that they're also dealing with with some of the other social determinants of health and law enforcement especially. Next slide. And then these are just at a glance some other topics we have in the future. So, May we'll actually be talking nurturing brilliance of Native youth, community and cultural connection as prevention. And June we'll have some presenters discuss some examples of whole Native substance use treatment care. And finally, to round us out on our next slide, we do encourage you to take this survey. That link will also be dropped in the chat or you can pull out your phone and take a picture of the QR code. We will leave this slide up until the webinar ends. We really do value your feedback so that we can cater these to the topics of interest to you all as well as ways that we can improve. So, if there's no other questions, I will close us out today. Thank you so much for being here, especially those with very, very busy schedules. We understand that 90 minutes is a big ask to be here. So, thank you so much for sharing this time and have a good rest of your week.

Dr. Jermaine Jones

Columbia University

opioid overdoses

fentanyl

naloxone mapping

saturation

distribution

at-risk areas

community partnerships

naxolone formulations

harm reduction

youth involvement