So, thank you all for being with us today. My name is Dr. Bo, and we are going to be talking about Engaging Those with Substance Use Disorders, a Trauma-Informed Care Approach. So, just funding and disclaimer, funding for this initiative was made possible by the SAMHSA grant, and pretty much you should know that the views expressed here do not necessarily reflect the policies of the Department of Health and Human Services, nor does mentioning any trade needs, commercial practices, or organizations imply endorsement by the U.S. government. You can get credit. Yes, so you have approximately one CME credit available, and you can just look in the chat in terms of how to go about getting those credits. Important information about closed captioning and captioning, how to turn it on. You can kind of look at the screen, and just when it shows Show Caption, just select it, click on the arrow, and you can see and view the full transcript, okay? We love questions. We will answer questions at the end of the session, and we have a short 10- to 15-minute Q&A session. How do you submit questions? Well, look at the bottom of your screen. Select the Q&A session, and then go ahead, and we will answer those at the end. A little bit about me, I'm Medina Bo, originally from the Bahamas, and right now I live in Charleston, West Virginia, where I have the best job in the whole world, because I get to work in an atmosphere that's pretty collaborative. I'm board-certified in internal medicine, psychiatry, addiction psychiatry, and addiction medicine, so we have fun over here in taking care of our patients. We have three objectives today. Number one, to describe addiction and the large treatment gap that exists for individuals with substance use disorders. Secondly, to explain trauma-informed care and apply it in caring for individuals with substance use disorders. And finally, to be more familiar with quick, easy, and effective tools used to engage those with substance use disorders. The brief outline, we're going to give a case scenario. We're going to talk a little bit about healthcare disparity with addiction. We're going to talk about stigma and impact on patient care. We're going to talk about substance use disorders and how we actually collaborate with our patients. Okay, case scenario. So Carrie, she's a 20-year-old cisgendered black female, and she is admitted to the hospital for a painful right hand, which is a complication of IV drug use. Her right hand is swollen twice the size of her left. It is red, it is tender, and the digits are sausage-shaped in appearance. Now you know when you hear sausage-shaped appearance, that means it's pretty painful. Carrie asked her nurse for pain medications, and her nurse reports, there's no other medication ordered other than ibuprofen, and she has already received that. Carrie then asked the nurse to ask the doctor for more pain medications, and that ibuprofen is not helping. The nurse rolls her eyes, walks over to the nurse practitioner, who says, I'm not comfortable giving the patient that. After all, she uses heroin, and I don't want to make the problem worse. He was concerned that by giving opioids, he would be contributing towards a substance use disorder. The nurse just said, she better not give me any trouble this shift. I'm tired of taking care of these junkies. They never listen, they always come back, they never get better. It's our own fault anyway. A few questions from my audience. Does this scenario sound familiar? Just kind of think about that, yes or no. How often do we encounter these attitudes? How is this impacting this patient's care? How do you think this patient feels? And finally, is it our own fault? I know certainly in many of the different hospital situations I've worked in, this is pretty familiar, and often time we encounter these attitudes, and actually, a lot of nursing staff, clinicians, and physicians who feel this way, they're not trying to actually hurt the patient or harm the patient. It's just that their view and their attitude towards the patient is not helpful. How do you think a patient feels when they hear themselves talked about in that way? It's devastating, and many of our patients often leave the hospital or leave against medical advice simply because they're perceiving the treatment they get is not caring. And of course we know, is it our fault? Absolutely not. When we talk about substance use disorders, we know maybe the first few times you try a substance, that's your choice, but when it becomes a disease, when it becomes an illness, it is no longer your choice. Another disparity, substance use has been identified as the number one health problem in America. Despite this, in 2018, only 18% of people who were identified as needing treatment actually received it, and that left 17.5 million people who did not receive care for a treatable health condition. In terms of Black Americans, 89% who are diagnosed with a substance use disorder did not seek out or receive addiction treatment. When we look at healthcare disparity, we know that only one in 10 people with addiction receive care, and there are some contributing factors. As clinicians, we can think about stigma, and we can also think about the lack of provider education. And when we talk about stigma, it is so important to think about the importance of language. The words we use, the words you use to describe people with substance use disorders have a huge impact. They can contribute towards stigma. They can create barriers to accessing effective treatment. They can also influence outcomes, including overdose, and that's actually evidence-based medicine. Can you believe that? The way you talk about your patient, the way you write about your patient in a medical record can actually influence outcomes such as overdose. So, people always ask, Bo, do words really matter, or are you all just being politically correct? All right? So, there was a Harvard study, 516 mental health professionals read one of two vignettes and were asked then to complete a questionnaire. The vignettes were identical, except in one, the individual is referred to as a substance abuser, and in the other one, they are referred to as an individual with a substance use disorder. Guess what? The mental health professionals who read the vignette of the patient identified as a substance abuser were more likely to agree that the person was culpable and that punitive measures should be taken. Okay, that's us, right? But what about the public? Do words matter to the public? 314 laypersons were asked to complete a questionnaire comparing recommendations for two individuals. One person in the narrative is identified as a substance abuser, and the other is identified as having a substance use disorder. Guess what? Yes, words matter to the public. The person who was referred to as a substance abuser, the public said they need punishment, they would benefit from jail for a wake-up call, they were perceived as a greater social threat, they were thought to having a personality problem, and that they should overcome the problem without professional help. However, the person with substance use disorder, they were more likely to recommend treatment or psychiatric care, and they were said to have a problem that was related to genetics or a chemical imbalance. Isn't that something? I want you all to compare these handover statements. For those of you who are in a safe environment, kind of close your eyes. I'm going to read something to you. 20-year-old female, she's a homeless frequent flyer who lives in the ED. This IV heroin abuser has failed rehab many times. The social workers are tired of placing her. She probably has endocarditis again. We are waiting for blood cultures. She wants detox again, but probably will leave like she always does when she gets into withdrawal. She has a bad attitude. Good luck with this admission. As opposed to, Ms. Jones is a 20-year-old female who suffers from housing insecurity. She has a severe opioid use disorder and resultant probably recurrent infective endocarditis. We are waiting on blood cultures. She has multiple treatment attempts and unfortunately severe withdrawal symptoms. Boy, we should offer her buprenorphine to make her stay more comfortable and avoid her leaving against medical advice. What do you think? If your family member or your friend or your partner was Ms. Jones, how do you want her treatment providers to talk about her? The first statement or the second statement? And you as clinicians, when you hear those statements, how do you feel, right? We all have subconscious biases. And unfortunately, when we hear things like the first statement, we automatically have automatic negative reactions towards that patient as opposed to the second statement. So when we write, when we talk to our colleagues, when we document, avoid these terms, addict, user, drug abuser, junkie, alcoholic, instead use the medically correct term, person with opioid use or patient with alcohol use disorder. And the term addicted baby. Use baby born with neonatal abstinence syndrome. Come on, can a baby be born addicted? No. Addiction is behavioral. A baby can be born dependent on a chemical, but no, a baby is not addicted. Think about that mother who hears you saying her baby is addicted. Instead of saying substance abuse or dependence, substance use disorders. Instead of habit, drug misuse. Instead of opioid substitution therapy, which is very commonly heard in the medical field. Opioid agonist treatment. Instead of treatment failure, treatment attempt. Instead of being clean, being in remission or recovery, because come on, the opposite of clean is dirty. So if a patient is clean, they're dirty. Who wants to be called that? So the first tool, use and principles for language and opioid use disorder, use first person language, avoid stigmatizing terminology, use medically accurate terms for the patient, the condition, and the treatment. That's your first tool. When we talk about addiction, it's important to know what we're talking about. Addiction is a chronic disease. Very similar to diabetes and hypertension. And when I say that, a lot of times a lot of my learners go, what, really? I say, yeah. You know, the success rate in treating those with substance use disorder is very similar comparable to those who are in treatment for hypertension and diabetes. It's all important to know that this chronic disease is lifelong, right? And a chronic disease, for many of them, there's no cure. There's just the idea of managing this disease, keeping the patient retained in the treatment. When you have a substance use disorder, we're talking about dysfunction and neurobiological circuits. Imaging scans, such as PET, have shown that the brain changes if you have someone with substance use disorder who has been using for a while. The brain you had before you used a substance is very different from the brain you have after the substance. With substance use disorders, you have this pathological pursuit of reward. So even though you know what you're doing is hurting you, you can't stop yourself. You have impairment of behavioral control. You have cycles of return to use and remission. It is progressive disease, and at least a disability or premature death. Those are sobering thoughts. So who gets substance use disorders? Well, the development of this disease involves multiple factors. And I have to say, when I think about a lot of my patients, I can see how a lot of this comes into play. For example, many people who I see in my clinic have biology, genes, they have parents who have substance use disorders, they were raised in an environment where they were given their first snort of heroin or cocaine when they were seven, eight, nine years old. The attitudes of what drug and alcohol use is permissive in their home environment or in their society. And then you have different brain mechanisms and susceptibility, and you have things like depression come into play. Things such as your social environment in terms of insecurity and your needs being met. You have things like relational that's setting you up for different issues. If you have a partner who uses, you're a little bit more likely to use. And all these things interplay to have a substance use disorder. It is very important for us clinicians to know the difference between substance use disorder and misuse. If someone goes and use cocaine maybe once a year at a party, it doesn't affect their function, doesn't affect their family, doesn't affect their finances, not getting in trouble, no DUIs, that's substance misuse because it's illegal. That's different from substance use disorder. When you have a substance use disorder, there's huge behavioral changes. You start to use more and more over time, you crave the substance, you think about it all the time, you have parts of your life affected. You're not going to work or school or your spiritual events. You're not interacting with your family as much, or you are and using finances for different things. You're having arguments with your partner, with your children. They're telling you you have a problem, but you don't think you have a problem. Because you know, most people with substance use disorders don't know they have a problem. Because in our society, people think you have to be stone cold intoxicated, or you have to be at the end of your rope, or you have to be home and without a home in order to have a substance use disorder, but that's actually not the case. As long as you have loss of control, you have consequences, and you're craving, you have a substance use disorder. And in fact, you may only use a substance once or twice a month, and you can still have a significant substance use disorder. So let's talk about it. Let's go back to our case. When we think about Carrie, what do you think is considered a patient-centered approach to her? Because when we talk about a medicine, we want to be relational with our patients. We want to have our patients feel loved and cared about in their environment, in the treatment environment, in particular those with substance use disorders, because there's so often shunts, because there's so much stigma, because there's so much social devastation in their lives. Trauma-informed care is a very effective way to create a healing environment for patients who've experienced trauma. Healthcare providers are trained to recognize how the social determinants of health can impact a patient's well-being. And trauma-informed care examines a patient's health picture even closer. For instance, did they experience a past trauma that led to a substance use disorder? Let's go back to our case scenario. Carrie's butt cultures return, and she is now diagnosed with infective endocarditis. She also is diagnosed with heroin fentanyl use disorder. The nurse reports that Carrie is often rude to her and would deliberately throw urine and food on the ground. She is constantly pushing that call button and making demands for coffee, blankets, ginger ale, and pain medications. The nurse feels exhausted and harassed. Can any of you relate to our nurse? Have you been in that situation before? Have you seen your staff in situations like that before? How have you seen your colleagues respond to challenging patients? And these things are important to consider because they really influence the way we interact with our patients with substance use disorder. It is true, as a nurse, if you have a patient throwing poop and pee on the ground, yelling out, screaming, being disrupted, you are going to be frustrated. You are going to feel harassed. And if you're the physician who has called multiple times or the NP or the PA to come and see this patient, you're going to feel frustrated, right? But we have to know how to manage our emotions and our expectations and adjust to our clients. Trauma-informed care redirects the focus from what's wrong with you to more what happened to you, right? What happened to Carrie? Why is she responding this way? This approach leads to a more trusting, collaborative relationship between patients and providers. And when we engage in compassionate care, it allows us to connect with our patients in their humanity, offering them solace, comfort, hope, and many times, reinstating their sense of dignity. Isn't that wonderful to know that your interaction, the way you respond to your patient, can be can totally shift their focus, provide comfort and hope, make them feel important, make them feel seen, make them feel heard. So when we approach a patient like Carrie using the trauma-informed care model, we think about several things. On this slide, you can see the ACE pyramid. And those are things that can affect and contribute towards adverse child experiences, because we know patients who have substance abuse disorders oftentimes experience more ACEs than those who don't. So when we talk about adverse child experiences, we're talking about, did you lose a parent in the home growing up? Was a parent incarcerated? Was there housing or food insecurity? Was your family ever homeless? Did you ever have to file bankruptcy? What about violence in your neighborhood? Were you or any family member the victims of domestic violence? And remember, violence doesn't have to be just physical. It can be neglect. It can be emotional. It can be verbal. All these things contribute, all right? What was it like trying to sleep at night in your environment? Did you hear a lot of gunshots? Did you hear a lot of police sirens and ambulance? Or was it calm? So when you approach a patient like Carrie, you have to ask yourself, did Carrie experience a past trauma that led to a substance use disorder? Did Carrie experience a past trauma that led to this disruptive behavior? When patients are hospitalized, we have to understand as clinicians that it can be very stressful. It can be an anxiety-inducing moment for many of our clients. And if a patient has experienced trauma in the past, being in the hospital can cause a reaction called re-trauma citation, right, where they subjectively are reliving the experience of that trauma. And that's also important for another population, our veterans. How do you know if someone has past trauma? What do you look for in your patients? Well, you can look at the way they speak, the way they're communicating with you. Are they speaking quickly? Are they having nervous rambling? Are they speaking very loudly or very quietly? These are all different signs, right? You can also see abnormal speech patterns and delirium. So just be aware throughout the way they speak. Does your patient have an excessive or sudden moaning, screaming, or crying, right? Are they tensing their muscles when you go to touch them? Are their eyes tightly clenched? Are they flinching when you touch them? Or are they disassociating, just kind of laying there, not focusing on you, and having a distant stare? So principles of trauma in informed care, we have to bear witness to the patient's experience of trauma. We have to think about safety. What can we do? What can we say? What can we provide to make our patients feel more safe? How can we build trustworthiness and transparency? How do we collaborate with our patients? How do we empower our patients? How do we respond in a humble way? And how do we support our patients? You ask Carrie what it was like for her to be in the hospital. And Carrie tells you she is terrified of being alone in a hospital room. When you ask why, she says when she was a child, her mother's boyfriend would often come into her bedroom when her mother was not around. She didn't want to go into any further detail, but you can guess what happened. You tell her it makes sense why she might be afraid, as being in a hospital may make Carrie feel vulnerable and exposed again. And she agrees with you and says, yeah, this is the reason why I constantly push that call button. I know my behavior is extreme, but I'll do anything to keep someone inside this room with me. I don't want to be alone. If you were the clinician hearing that story, hearing her response, how might that shift your attitude? How might that shift the nurse's attitude towards this patient? When we talk about safety and trying to create an atmosphere of safety for our patients with trauma, we are trying to help them feel safe in a space and to recognize their need for physical and emotional safety. So you think about what can you do or say to Carrie to make her feel safe? A safe and predictable relationship with a healthcare provider can be critical. And a survivor of ACEs, Adverse Childhood Events, may be very sensitive to non-verbal communication. For the better, for the worse. What do I mean? I mean, if you're a provider and you're coming in the room and you're rolling your eyes, you're clicking your tongue, and you kind of tap in trying to get them through their story, that sends a different message than if you come in, you sit down, you look at them, keep eye contact, not answer a page in front of them, and just make them feel heard, okay? Things that you might do or say to Carrie to make her feel safe, ask her what she needs. Ask her if she needs the door open or closed. Ask her how she feels being examined. Ask her if she wants someone in the room with you all, okay? Tell her what you're going to do ahead of time. Kind of explain the treatment plan and treatment progress. Some people, when they come into the hospital, they don't know someone's going to come in their room. They don't know what's going to They don't know someone's going to come in their room every hour and do a nurse check. They don't know someone's going to come in every six to eight hours to do vitals. Those things are important to tell a person. Helping patients feel that they're in a safe space and recognize their need for physical and emotional safety is paramount. Clinicians must not re-traumatize a patient through an interrogation. That's important to know. If a patient discloses something to you, this happened to me when I was younger. This happened to me in my past. It is not necessary to go in and get great detail, okay? You can just say, that sounds pretty painful. I'm so sorry for what you've gone through. If you ever want to talk more, just let me know. If you want help, I can refer you to people who can talk to you. If you need a therapist, you need an advisor, you need a peer, just reassuring them and offering support will be very effective, even if they say no. Also, understand in areas of domestic violence, you ask them to disclose domestic violence, and especially if that person is there, the person who's hurting them is there, can make them victims of more trauma in the future, okay? They can trigger physical danger for them. You find a lot of people don't necessarily say things if certain people are in the room because they're trying to keep themselves out of trouble when they get out of the hospital. When we collaborate with our patients, we include them in the healing process. We use informed choice. This will encourage your patient to move towards a more active engagement in healthcare, rather than passivity or dependence. You know what I mean? Like sometimes you would ask a patient, so you have pneumonia, I'm carrying. We have a choice of antibiotics we can use. We can either use piperacillin, tazobactam, or we can use doxycycline. What would you like to do? Some patients say, go ahead, you're the doctor, you pick, right? But giving that opportunity to pick gives them a sense of control. Even offer them, how would you prefer your medications? Do you want them IV? You want them oral? Just give them a chance to choose what they would want. Also, give them the choice to say no. If they don't want you to touch them, they don't want a physical exam, it's okay. Just documentation is important. When we talk about empowerment, we're talking about believing in the patient's strength and resilience. We see them as someone with tremendous strength and resilience, and not someone who's the victim. For example, Carrie, man, that's a big deal you came to the hospital. You're allowing us to take care of you, knowing that you might go through withdrawal. You're coming in here, even though you know we know you have a substance use disorder. That's awesome because so many patients like you are so scared to come to the hospital. Carrie, I am so happy you're allowing us to take care of you. How can I make your stay better? All right. You can tell them, oh my gosh, that story you shared with me about your mom's boyfriend, that's so heartbreaking. I am sorry you go through that. But boy, look at you. Despite that, you're still here. You're fighting for your physical health. You want to get help. You want to get treatment. Man, that's amazing. How courageous is that? Communicate that to them. Empower them because victims of abuse often feel disempowered, and you can help break their passivity. So when you empower someone, an example will be, for example, instead of saying, I'm going to give you this shot, you might say, may I do this? Right? And just validate a patient's decision to come in for care. When we talk about humility and responsiveness, it is so important to understand as providers, boy, we don't know everything, right? We don't know what patient's background is. We might not know their culture. And even though people may belong to a certain race, different people in the same race have different cultural backgrounds, different values. It is so important to be curious about your patient. Just ask them where they're from. What's it like being you? What neighborhood are you from? What's it like having substance use disorder in your neighborhood? What's it like coming to get help for your illness in this neighborhood, from your neighborhood? What do your family think? What do you think? How can me as a provider be helpful to you? And say, you're from, I don't know, Jamaica. I don't know anything about Jamaicans. Tell me more about that. Just be curious. And don't be afraid of saying, I don't know much about your culture. I don't know much about who you are. Can you teach me? Can you show me? What can I read? Just incorporate that in your process, just in general, right? Because when you're sensitive to a patient's culture, ethnicity, personal and social identity, you really bond with them and you empower them and you teach them that their views and their cultural aspects are important too. And you are definitely trying to include them. When you think about someone who has trauma and has come to you for help, so important in our system is peer support. How do you think peer support can be helpful for caring? I want you all to think about that. When I talk about peer support, what is Dr. Bow talking about? I also want you to think about the resources you have in your system. Here at CAMC, we have peer recovery coaches that come to our patients who have substance use disorders and we offer treatment. They may come, they sit, they talk, they teach them about the system, tell them how to access treatment. And even though someone might not want to engage at that time, because you know when you're sick, a lot of times you don't want to hear other people talking about recovery, right? You just want to get help for your illness at that time. They come back, right? And as outpatients, they also connect them to care. We've had some peer support go to people's homes, okay, and just connect them, help them set up telecommunications, help them set up tele-visits with us. Peer support is very important. That peer support is so important that sometimes when the relationship between the patient and the physician is fractured, they can help repair that. If you do not have peer support in your organizations, that might be a good place to start for advocacy because there are certain grants you can use to get that peer support. So the second tool is use trauma-informed care with your patients. When we talk about what's actually effective treatment in our patients with substance use disorders, we recognize that addiction is complex but it's very treatable and it affects brain function and behavior. We also know that no single treatment is appropriate for everyone. So when you're in the inpatient or outpatient unit, wherever you might be, what might work for one patient does not work for the other patient. And we have to be very curious. We have to ask patients, what's worked for you in the past? How can I help you? How can I link you to care? And you have to be so flexible because when you realize one approach is not working, just shift. It goes to another approach. Some people need family involvement. For some people, family involvement is the worst thing ever. Some people benefit well from 12 steps and recovery groups. Some people, it's not their thing. They need other kinds of support. Treatment in your organizations need to be readily available. All providers should need to know where to go for substance use disorder treatment because most people with a disease, this disorder, don't come to psychiatrists, right? They go to their family doctors, their OBGYN, their surgeons. So us as mental health clinicians and physicians, we need to be able to connect with other providers and tell them where our resources are. Effective treatment attends to multiple needs of the individual, not just drug misuse. So are they on a job? Do they need jobs in recovery? Do they need transportation? What is their housing situation like? Do they need food vouchers? Do they need housing support? What else is there that's needed to keep this individual safe, to help this individual along in their treatment process? Remaining in treatment is so important because research has shown us that the longer someone engages in treatment, the longer they're likely to be in recovery, okay? That is very important. So I always say when you meet your clients with substance use disorders, they may come the first or two visits and they go away, call them, go after them, all right? Talk to them, reach out because remaining in treatment is critical. Back to our case. The addiction service team is consulted and carry a screen and the diagnosis of opioid use disorder is made in addition to major depressive disorder moderate. The addiction service team recommends oxycodone every four hours in addition to hydromorphine, two milligrams IV every two hours PRN. And that's so important for this patient because people who use opioids, they don't respond to regular doses of pain medications or narcotics. And many times treatment providers just need your expert advice telling them that it's okay to increase those medications. Here where I work, being an addiction as well as an internist and a psychiatrist, on our CL team, my partner and I, my work partner and I, we run this service where we help our physicians with pain management. So for example, if we have someone who was on buprenorphine or methadone and getting open heart surgery, they don't know what to do with the medications. They consult us and we might give them recommendations in terms of how to continue the methadone, how to dose the buprenorphine, when to add a pain pump, how much pain pump medications needed. For example, hydromorphone, do you need a basal? Do you need a continuous? How much should the lock-off period be? So we really try to help our providers because when other physicians have clients on buprenorphine or on naltrexone or on methadone or other medications, for example, alcohol use disorder, they feel so overwhelmed, right? And many times they kind of turn an eye because they really think four milligrams of IV Dilaudid is going to get a patient intoxicated, which we know is not true. Not someone who uses one to two grams of fentanyl a day. Fortunately for Carrie, the nursing manager assigns her to a different nurse who is much more responsive to the patient. Carrie recovers. She does really well. She has transitioned to buprenorphine during a hospital stay via micro-dosing. She's established with our clinic as an outpatient. And as an outpatient, we start her on sertraline for depression and she does very well. And a thing that's also important for our patients with substance use disorder, I always say, man, go look for the comorbid psychiatric underlying diagnosis. Where's the depression? Where's the anxiety? Where's the PTSD? Where are the panic attacks? Because we know evidence-based medicine says 40 to 60% of our patients do have comorbid psychiatric illnesses, right? I would say it's even more. I mean, because in my clinics, I actually don't have anyone with only a substance use disorder. There's always something comorbid with it. You just got to look for it and see what it is. It is very important to treat underlying mood disorders because if you don't, the patient is not treated and they're more likely to return to use. So just a note on micro-dosing of buprenorphine. I think some of you are familiar with it. Some of you might not be, but boy, it's awesome, all right? I recommend this to our patients, both on inpatient and in the outpatient setting. So it's officially recognized as the Bernice method and what it does, it involves prescribing tiny, tiny doses of buprenorphine naloxone over certain times and frequency in addition to full dose agonist opiate at that time. So for example, you might have someone who is getting hydromorphone or oxycodone or hydrocodone consistently in a hospital. You don't stop that medication. What you do, you give him a little smidgen of the buprenorphine naloxone and you just go up and up over the next few days. And at the end of a certain day, whenever you choose, three, five, or seven, you just stop the full agonist and wham, the buprenorphine is in the system. The patient does not go through severe withdrawal. It is awesome and it's a wonderful way to engage your patient. I've also tried that as an outpatient with my clients. Those who probably have opiate use disorder relapse back to fentanyl and they need to go back on. They're so scared, right? They're like, oh, that's the box zone or the buprenorphine naloxone is going to throw me into withdrawal. Dr. Bo, I don't want to do it. And I go, hey, we can start you in tiny pieces and take it from there. Sometimes you might have to involve a compound pharmacy. So the final tool is you have to consult with the addiction service teams. That's your tool number three. It is very important you consult with your addiction service team if it's available. If they're not available inpatient, perhaps get this person, get your patient connected with them as an outpatient. So we're going to have lots of room for questions today. So we're going to have lots of room for questions today. These are my references. In terms of the opiate response network, just want you to know that the ORN is your resource. It's no cost education. There's training available. There's consultation. There's mentorship. Okay. We're located everywhere in every state and we can help people. We can help establish and help organizations develop their own treatment programs. So share your needs via the submitter request form at this website. And within one business day, you will be contacted. So I'm just going to pause here and go into our question and answer session. And please, I'm just going to give everyone a minute to ask any questions they might have. And I'm going to ask Hannah, if you see anything in the chat you want to bring up, please do so. Okay, I'm being asked, what are my views on educating the teenage and adult population on the consequences of substance use disorder so they can make informed decisions? Okay, I absolutely think so. I think it is very important that pediatricians, that parents, that teachers, we just need to educate our young people in terms of the truth about substances, because giving the wrong information, such as, if you try this, you're going to die, is not very helpful, right? Because when young people try something, because a lot of young people do experiment, and they don't die, they just don't take you very seriously. It is important to have an evidence-based medicine approach towards substances, in particular what's in vogue now is cannabinoids, right, THC, right? We should know as clinicians, the AMA, the APA stands, and promote this, and, I mean, for example, I'm asked many, many times, Dr. Bowe, what do you think about marijuana and prescribing it? And I say, as far as I know, there are no randomized, double-blind, placebo-controlled cells staying one way or the other. These trials are happening right now, and when the evidence comes out, then I'll be able to weigh in on the evidence. I hope that makes sense. Okay, thank you for your comments and seeing here. You enjoyed the presentation and. Thank you. Hi, Dr. I actually have 1, a couple questions for you just to continue the conversation unless we get any more. So, my 1st question to continue hearing more about your work is, can you expand just a little bit on? I know you mentioned this in the presentation, but. Stand on how trauma informed care changes or shifts kind of or can be adjusted based on the age of the patient. And I know that you kind of cover that in that 1st answer when we're talking about adolescence. But if you could continue expanding on that, that would be great. Okay. So, when you talk about trauma informed care, it is very important to know your patient and which and what you're dealing with. For example, if I have a patient who is adolescent or a child, the way I approach them is very different from an adult. With a child, I make sure they have a safe person in the room. I make sure that they may even have safe objects like a blanket, make sure there's music in the room, certain things in their atmosphere that we advocate for and make them feel more safe. No sudden movements around children. It's often very important to have parental consent or guardian consent when you talk to a child. I try not to be too probing if they have severe trauma because it actually doesn't make sense to have someone retalk a lot of trauma unless there's supports there for it. So, you can acknowledge, you're in the hospital. I'm so sorry that happened to you. I'm sorry that I heard that maybe your mom or your papa hit you. Okay, that sounds awful. What can I do to help you? Just keep it very safe because what you don't want to do is do excessive probing, unless that's your role as a forensics, and make that child just more emotionally labile. If I have an older person, perhaps someone in their 80s, and they've been a victim of, perhaps there's someone who survived who's a veteran, right? We have this happen all the time. We have veterans in our hospital who might have an alcohol use disorder, an opioid use disorder, and man, in the hospital, they really relive the trauma of Vietnam or they relive the trauma of a war they participated in, they've had to experience. And how you would know is that they were hit at staff, cursed at staff. You could hear them talking about shooting and who's being killed and so forth. So, what you would do, if they're very confused, just implement those delivery precautions, right? Make sure the cycles are set, calendar up on the wall, sunlight in at daytime, nights out at nighttime. We might even minimize how much times their vials are taken because you just don't want to keep bothering them at night when they need to be sleeping. Give them medicines to help them sleep. Also, from their home, what's their favorite TV show? What's their favorite type of music? Have those playing in the background, okay? Have someone who's very responsive to people who have trauma, who won't take insults, cuss words, and hits from patients to heart. Because sometimes our nursing staff, they don't understand, or even our physicians, they don't understand where a patient's coming from and they think it's intentional. I can't tell you how many times you have someone with mixed delirium who's a trauma patient and everyone thinks they're intentionally behaving their way. So, it's important as a CL team, as psychiatrists, we educate our staff, hey, that person actually doesn't know what they're doing. I know you said they're oriented, but oriented doesn't mean they're not delirious. Okay, I hope that answers that question. Yes, and it looks like we have another question from Robert in the chat that says, where does motivational interviewing fit in with trauma-informed care, or should that be delayed until the patient is in a recovery phase? Oh no, get it in right away. Because motivational interviewing is the way we connect with our patients, right? We experience what is their value, what is their wish, what's important to them? And we collaborate with them even in the hospital. So, for example, when I'm rounding and I have a patient, I definitely start MI right away. I go, hey, you're in here today, you came to get help, that's awesome. Why might help be important to you? What are your goals? You're interested in buprenorphine? Wow, what makes you so interested? What, you have a granddaughter? Your granddaughter sounds so important to you. We want to make sure you get through this hospitalization. Does that make sense? Absolutely. Start MI right away because you're going to make their views and their goals even more pronounced in their mind. And we know when people are motivated by the things that are important to them. I never try to push my views on a patient in terms of recovery or what I think they should be doing. I want to listen from them, what they think is important, and then ride with that because that's much more powerful. So, as we're talking about the trauma-informed care model and going through your fantastic presentation, another question that came up was, how do you, as a practitioner who's implementing this model, take care of yourself as you are moving through some of these situations with your patients where they're sharing a lot of what they've been through? That's a fantastic question. So, I do several things in order to take care of myself, and I do that in an emotional basis, a physical basis, and a spiritual basis. So, when you hear all this trauma from your patients, it hurts, right? You can kind of take it with you at times. So, what I do, I'm very, number one, intentional about deep briefing with my colleagues and similar physicians. And we talk through cases. We make sure we support each other in the choices that were made. If it's a painful story we heard, we just leave out identifiers. We kind of talk about it because many times the stress, the anxiety, and the burden is often lifted when there are others. I also do, I am awesome at setting boundaries. I've gotten better at that. At the beginning of my career, I always said, yes, yes, yes, yes, yes to everything. Now, I don't. I'm very specific with my time in terms of what I do and what I commit to because by setting boundaries, you're able to accomplish more than saying yes to everything. Other thing I do, I'm a big deal person who likes to work out. I work out all the time because, for me, it's a stress reliever. So, I often go to the gym and do tons of cardio. I might lift some weights, do a lot of dance, move my body. The other thing I love to do to balance myself is spend time with my family. I have a one-year-old, a three-year-old, and a partner. We have a blast together. So, I make sure I don't take work home. I do not, and unless I'm on call, or unless it's a resident question, I don't answer calls or pages. I finish all my work at work, right, just to make sure I have that family time. Wonderful. It looks like we have another question in the Q&A from Sean, if you want to review that one. Okay. So, this question says, what is the best strategy to address patients who present with trauma in a CL setting, and you're not able to see them in long-term care? Patient was aggressive with med staff, on a psychic valve, and they uncovered significant history of trauma. Okay, so when you're not able to provide long-term care, I always approach patients in terms of how much they're willing to disclose, because if I'm not going to be the one following up, it may be actually too painful for them to start to divulge. So, I ask my patient, well, we always ask about trauma, whether it's physical, sexual, or emotional, are you willing to talk about it, or would you prefer not to? And a lot of times they would say, I've had it, but at this time, I don't want to talk about it. And I say, I understand, and here are some resources if you're ever willing to do so. Now, the patients who do want to talk about it, and I know in CL, I won't see them in my clinic, we make sure we have follow-up appointments with therapists and a psychiatrist on discharge. Now, it is kind of up to the patient to make that connection, right, because oftentimes we will make an appointment and the patient doesn't show up, but we do make those connections. But I always say, be very sensitive to your patient, because I usually encourage my residents and medical students, you don't have to probe to make a diagnosis, right? Because all you have to do when you talk about trauma, if you're looking for PTSD from that trauma, it's asking about flashbacks, intrusive thoughts, nightmares, reliving, avoidance, and you can do that in a very generalized way. And they can say yes or no without you retraumatizing them. And I love that question, because the other thing is, not everyone, even in the outpatient setting, is ready for CBT or trauma care to address that. Always be sensitive to your patients. Just because a patient has trauma, doesn't mean they're ready to address trauma. Many of my patients are not ready until 10, 15 years down, away from the trauma, or years into therapy before they're willing to even address it, because you need tools to be able to address trauma. Okay, so what are your thoughts on vaping, and how is it being advertised to teens and younger adults? Okay, isn't it just as bad as smoking in terms of harmful mutagens that's packing there? I've heard that it disrupts the quality of egg cells in females, which is highly alarming. Okay, so that's a great question. My thoughts on vaping. So whether it's nicotine or cannabinoids, I see vaping as something that it's not ... Okay, our medications, our vape, things that are in vape are not FDA regulated. You don't know what you're getting. So for me personally, when my patients ask me, is it safe? Is it okay to vape? I go, I don't know. I have no idea what's in there, and you need to find out what it is. What we do know is that there's been significant problems with vitamin D, vitamin E, and significant lung injuries in our teens who do vape, and even our older adults. So it does not carry as risk. That being said, there's also some studies that show that vaping nicotine is less harmful than smoking a cigarette. Not safe, but less harmful. The way it's advertised to teens, it's advertised to attract them, right? Teens and young adults. They have the pretty little cartridges. You have the pretty little stickers on it, and you have different scents inside it. They taste a certain way. They smell a certain way. It's a whole thing towards our teenagers, which is alarming, particularly when you talk about cannabinoids, because we know the adolescent brain is still priming. Your brain doesn't stop priming if you're an adolescent until you're about 23, 24. And unfortunately, studies show that adolescents who start vaping marijuana use heavily in their teenage years are more likely to develop a use disorder, which is unfortunate. It also affects the way, for some of them, not all, it affects the way they function as adults. And certainly in those adolescents who have genetic disposition towards psychosis or bipolar schizophrenia have more harmful effects than those who are not. Yeah, I've read studies about the effect on the quality of eggshells in females. Yeah, all that stuff is alarming. And the thing is, we don't know everything yet, right? Because if you go to one head shop to another head shop, content's different. Everything's different. You don't know what you're getting. I also always encourage clinicians, make sure you go to dispensaries and see what's there so you know what your patients are talking about. I'm not telling you all to buy anything. That's your choice. But at least you should know what's there, what's in your community. Another question from me, Dr. Bo, I was thinking a lot about your third tool, which was consulting with addiction service teams and the idea of creating kind of a collaborative nature in your practice. So could you expand a little bit more on how you create that culture of collaboration that really shifts patient outcomes? Okay, so we have an addiction service team that was set up in particular to address the issue we're having with IV users with methamphetamine and opioids. Because what we found over here, we've had so many patients with recurrent admissions with cellulitis, bacteremia, infective endocarditis. And before addiction teams were consulted automatically, a lot of these people returned to use them. And before addiction teams were consulted automatically, a lot of these people returned to use when they left the hospital system, which was horrible for their health because nobody wants to have open heart surgery twice. And it's a huge loss financially to healthcare systems and a huge loss of patients in terms of health. And so the addiction service team was championed by a nurse practitioner here. We got SORB grant funding and we have peer recovery coaches. So when people come and they flag possible for substance use disorder, automatically a recovery coach goes to see them and they're offered an addictions consult. Okay, so that's how we do it. And then we help the clinicians in terms of recommendations for medications, if it's alcohol withdrawal or opioid withdrawal. And we help in terms of medications for tobacco, opioid, and alcohol use disorder inpatient as well as outpatient. We also connect them to either higher level of care inpatient rehab, or we connect them with outpatient help in terms of rehab. So that's how we work. Now, the thing is, we have such a big issue with substance use disorder that people are very happy to see us. They love our team. And so we're sought out a lot. It looks like we have one more question in the chat. Okay. Can you? Oh, what is my opinion on legalizing? Okay, that's easy. So my opinion as a physician who belongs to AMA and APA are, there is no FDA double blind placebo controlled studies that show benefits. There's lots of studies that show harm. So for now, when I speak, I'm always pro-AMA, APA standpoint. And as clinicians, you all supposed to be as well. Okay. I think it's great that marijuana is being decriminalized because there are so many people in the criminal justice system. And if you look at it, it's disproportionate because whites and blacks use at the same rates. However, blacks are three times more likely to be put in the criminal justice system than whites, right? For marijuana use. So I'm very happy it's decriminalized. In terms of legalization, that's a different story because I don't think enough of the risk and benefits and enough studies have been done to show how it's beneficial. I think there may be a lot of harm in the future in terms of psychosis, education level, job attainment. I've seen a lot of that. Now, coming from a Caribbean perspective, I remember when I first started residency, I told everyone how THC causes psychosis and it can cause schizophrenia-like syndromes. They laughed me to scorn. Now everyone realizes it's true. Because in the Caribbean, in Jamaica, I trained in Jamaica. I'm from the Bahamas. We see this thing for years, right? We see problems with relationships, troubles with jobs, troubles with cognition, even in the kids of people who heavily use. But we're from a system, we're third world. We can't really publish and do those studies. We just know. So I'm very worried about marijuana being broadly just available. In particular, because the THC content is much higher now than it was 15 years ago, and the CBD content has gone down. So when it comes to marijuana, THC, as you know, is an active ingredient. It used to be 3, 7%. Now that's 300 times the stuff they're putting out there. It's 300 times the amount. And that's what's causing psychosis and all the different issues. And the mood instabilities. And the CBD content, which is supposed to balance it out, is being diminished. You all go to the dispensaries, look and see what they're doing in terms of genetic engineering. Look at those plants, man. You'd be shocked what they have available. And unfortunately, many people think if it's legalized, it's safe. We know that's not true. So that's my opinion. But as clinicians, we are actually supposed to say what AMA says, American Medical Association. Those are awesome questions. I'm so thankful you all were here today with us. I love spending time with you. Thank you for listening. And I hope you enjoyed it and learned something from this session.

trauma-informed care

substance use disorders

SAMHSA grant

treatment gap

peer support

consultation with addiction service teams

motivational interviewing

vaping impact

self-care strategies