Thank you so much for coming. We are fully aware of the challenges of having a session on the last day of a very intense conference like APA. I'm Vineet John, professor and vice of education at University of Texas Houston Health Science Center. We're delighted all of you are joining us today. We have a great session for you. So it's almost like a master class. You can ask any questions to these great experts. The theme is about SBIRT, which stands for Screening Brief Intervention and Referral to Treatment. It's a primary care intervention. It's effective. Yet, we are still looking at 100,000 plus deaths due to drug overdose. So today, we are looking at harm reduction strategies, such as needle syringe exchange programs, naloxone opioid overdose rescue kits, bridge clinics, low barrier medications for opioid use disorder. We will also look at various strategies that would include harm reduction while using the SBIRT model in clinical practice. And finally, we hope to address some of the ethical dilemmas around harm reduction. And our hope is that you would be able to acquire a certain competence, confidence, and skill set from this particular session to address some of your own unique challenges in your various practice settings. It is with deep delight, I would like to introduce our speaker, who will be talking on the introduction to harm reduction. Dr. Daryl Schroeder is a medical director of the addiction services at Menninger Clinic in Houston. He's also the associate professor at the Menninger Department of Psychiatry and Behavioral Sciences at Baylor College of Medicine. Also the program director of Addiction Psychiatry Fellowship at Baylor. Dr. Schroeder is well-published in the area of addiction psychiatry. He acquired his medical education at the Baylor College of Medicine, then did his residency training at Ohio State, then went on to do his addiction psychiatry fellowship at New York University. Dr. Schroeder, welcome. Thank you. Thank you so much for the kind introduction. And so happy that you all came and joined us this morning. You all clearly graduated at the tops of your medical school classes, because you all come early and on time and every day. And so we really appreciate you all for being here. And thank you to the rest of the panel for allowing me to participate with you. It's been really a wonderful experience. So today, I will be talking a little bit about the history of harm reduction, as well as some of the early principles and some more contemporary ways of thinking about harm reduction as we really wrestle with how to implement harm reduction strategies and practices throughout our country. So when we think about harm reduction, one of the funny things that happens when I talk to medical students or residents about harm reduction is that they seem to think that this is a relatively new or recent concept. But the reality is that harm reduction and its principles have been with us for well over 100 years, which I found to be quite interesting. It turns out that in the 1920s, there was the Rolston Committee, which was a really dedicated group of physicians in Great Britain who came together and suggested that narcotic medications be prescribed to patients with opioid use disorder, persons who use drugs at that time. So the idea that people might actually go on to treat substance use disorders with medications, again, not a new concept. But back then, they weren't talking just about the treatment in terms of trying to get people to abstain entirely, but rather just to reduce the harms that people were experiencing as a result of opioid use. This was a strategy that actually gained quite a bit of traction over several years. But then, sort of the social forces being what they were, you found that fewer and fewer people were actually going on to prescribe narcotic medications to folks with opioid use disorder. As a result, there was really only one geographic area in the UK that continued the practice of the Rolston Committee, and that was in Merseyside. So if you hear the UK model or you hear people talk about the Merseyside model, the reason is because of the Rolston Committee and how they continued that practice over a number of years. By the time we get to the 1980s, you have the concept of cautioning. Whereas the Rolston Committee focused on a medical intervention for harm reduction, cautioning was really a much more law enforcement focused intervention, where rather than basically arresting people and taking them to jail, instead people's drugs were confiscated. They might get a ticket, but really they were referred to treatment services, with the understanding that rather than incarcerating people as a result of substance use, referral to treatment would be the most appropriate course of action. At the same time that cautioning is taking place in the UK, we have the development of the Dutch model, which started off with the Narcotics Working Party, which Cree put out a document, a white paper, that really talked about and laid the groundwork for the 1976 Dutch Opium Act, which spelled out that not all substances carry the same level of risk. And this was really quite novel, if you think about it back in the 1970s, to say from a governmental standpoint, from an official policy standpoint, that not all substances are created equal. And so they talked about low risk substances, hashish, marijuana, or cannabis, in comparison to those that had a higher level of risk, heroin, opioids, LSD, and psychostimulants. By the time you get to the 1980s, you have the development of junkie bond, which is a term that a group of users had come up with together to describe themselves. I think of them a little bit like a union, a union of drug users who come together and really try to affect change related to policy. This is a strategy that we have seen take place even more recently here in the States, where it's a grassroots approach, where people who use drugs really advocate for themselves, come together, and really help to determine the strategies that might work best in reducing harms from substances, as well as promoting abstinence or recovery. And junkie bond actually led directly to the first needle exchange program in the Dutch model. So it wasn't until the 1990s that the US really started talking more broadly about the implementation of harm reduction principles and strategies within our society. And that ultimately culminated with the 1995 policy statement and recommendations to our current Office of National Drug Control Policy. So a pretty interesting history, but one that has been with us for, again, well over 100 years. In some of these early principles of harm reduction, it's important to think about the way that you understand an addictive disorder. If you put 100 addiction professionals, counselors, peer support specialists, recovery specialists, community health workers, social workers, therapists, psychiatrists, you put 100 of us in the same room, you might find 100 different definitions of what constitutes addiction. You might find 100 different definitions of what constitutes recovery. And that's because people carry with them certain models of addiction. We talk a lot about the moral model and sometimes can kind of thumb our nose at people who operate from within the moral model. But I think it's important to recognize that that's probably the model that we have all been exposed to the most, because it's the one that we're born into. We hear about it from the time that we're kids. And that's because it's just been in existence for really millennia, dating back to some of our most sacred religious texts. So I try to encourage people to say, well, just can you recognize your moral model thinking and then try to act sort of maybe in spite of it sometimes. There's also the disease model of addiction, sometimes called the biological model, the medical model, the neurobiological model. And really, harm reduction is intended to be an alternative approach to both of those models, where you might understand that, yes, that our society has approached this with a moral, through a moral lens and with thinking about it from a criminal standpoint. And yes, there is a biological and medical component of it. Certainly why we do the work that we do. But this is a public health alternative to those different types of models. And really, we recognize that while abstinence may be an ideal outcome, we accept that really, we got to keep people alive in order for them to get better. And getting better can be defined by the individual rather than by us as health care workers. Like I mentioned with the junkie bond, there's a bottom-up approach, where people who use drugs actually advocate for themselves rather than just creating policy from the top down and giving that to people and sort of assuming that you know what's best for other folks. And then finally, and I think one of the things that we'll be talking about during the course of this panel is that we really want to make sure that the services, that the resources, that they're readily available to people, that you don't have to jump through lots of hoops in order to access those services. So these contemporary approaches now come directly from our Center for Harm Reduction. But we have to accept that drug use is a part of our world. It's interesting, that can sometimes be a controversial statement for a lot of people, the idea that we have to accept that drug use is a part of our world. And some of you all are participating in the use of one of my favorite drugs right now, caffeine. So is our work really to try to make sure that everyone abstain from substances, or are we really just trying to help people live a fuller quality of life and also to minimize the harmful effects that come from them? We also want to recognize that drug use is a complex, multifaceted phenomenon and that there is a continuum. There's been some really interesting writing in the field from Nora Volkow, who's the director of NIDA, National Institute of Drug Abuse. And she's been talking about and introduced this concept of pre-addiction, which would really sort of help us think about mild to moderate substance use disorders as part of a continuum of substance use disorder. But what that means is that not all substance use is the same. Not all substances are the same. And perhaps not all harms from substances are the same as well. When you're trying to determine whether or not an intervention or a policy is particularly effective, really focusing on the quality of the individual's life and the quality of the community's life rather than cessation of substance use, that has got to be sort of the ultimate goal. And of course, we want to approach with a non-judgmental and non-coercive from that type of stance. And it's interesting because I think we know this cognitively. We know, oh, I don't want to judge people. We recognize that that can be harmful and can really have negative implications for the therapeutic alliance and the establishment of rapport. And yet, in some of our meetings with colleagues when we're talking at conferences, we can hear people use language that obviously suggests that there is judgment present. One of my least favorite things to hear someone say about a patient is, oh, he's just not motivated or, oh, she's just not ready. This idea or this notion that motivation isn't co-created by both the patient or the client as well as the therapist for using a motivational enhancement therapy lens. So it is important for us to be reminded that we want to try as hard as we can to reduce our judgment of folks that use substances. We also want to make sure that persons who use drugs are centered in this conversation, that their attitudes, that their beliefs, that their experience is taken into consideration when creating policies and programs that ultimately will serve them. And we also want to make sure that we understand that they are the primary agents of reducing the harms and empower them to share information. When we get into some of the other more contemporary approaches, we'll talk about that a little bit more. We have been using a social determinants of health, social determinants of mental health lens in our field now for probably the last 5 to 10 years. And I think it's important to also recognize the impact of poverty, class, racism, social isolation, trauma, as well as other types of discrimination and inequality. And how that actually predisposes people to the risk of developing substance use disorders and might also predict why certain communities are more likely to experience negative consequences from substance use. I can think about patients that I've taken care of who have been insulated by wealth. They've been insulated by family. Even to imagine that everyone is going to experience the same kinds of negative consequences from their substance use without taking into consideration that social lens, I think misses the broader points related to privilege and access. And then finally, we don't necessarily want to minimize that there are harms that come from substance use. Dr. John just mentioned that we have, once again, topped 100,000 overdose deaths in our country, which I think is probably an underestimate, frankly, because we're not doing such a great job of tracking that data. That's another talk for another time. So we don't want to ignore the very real and tragic harm that can come from substances that are associated with drug use. So, well, I've got a little bit of data to present about Housing First. But Housing First was a really great model that centers the idea that in order to help someone to reduce the harms from their substance use, you also want to make sure that they have a place to live. Now, this seems sort of basic. But I can tell you that this was extraordinarily controversial and continues to be. The idea that you would give housing to someone who uses substances. Again, moral model thinking, criminal model thinking. Why would you reward them with housing? Well, if you actually make sure that people are housed, you make it more likely that they are able to reduce the harms from substances and maybe even perhaps participate in treatment. This is my first time in San Francisco in a number of years. Certainly since the pandemic. And I don't know if you all have had the experience of walking down the street here, but people are talking about how San Francisco is sort of crime infested or crime ridden, that sort of thing. And what I've been saying is that they are really in the midst of a mental health crisis. This is a mental health crisis that we are witnessing right now. Just so anyway, sorry, soapbox done. Housing, Housing First, critically important. So when we think about harm reduction movements now, there are these AHMs, Autonomous Health Movements. And I will go ahead and read this slide. People have reclaimed autonomy over their own and their community's health by looking past stigma and institutionalized ideals of health in order to meet people's actual needs. And the pillars of these AHMs, there are three. One, you want to use the medical knowledge of the community. It's important to keep in mind that members of marginalized or vulnerable communities oftentimes do not access our care. They oftentimes do not access our services. So what they do is they take care of each other because there's trust and there's communication. As a result, they built their own medical knowledge. Now, is that medical knowledge always sort of rooted in the best science? Probably not, but there is some medical knowledge that is there and that is present. And we have to take that into consideration if we really want to try to create movements that will support a particular community. There's also the sense of being able to relocate power and return resources to the community in order to balance the power dynamic. This idea, this notion that people have to continually come to medical centers, I'm gonna toss us under the bus real quick. We work in a big old medical center at the Texas Medicals in Texas, in Houston, Texas. And asking our patients to always come to us creates barriers. And so, and the buildings are massive and imposing and you gotta pay for parking and all this other stuff. So, the reality is that there is already a power imbalance that has been created or introduced for many of our folks who are feeling particularly vulnerable. So, how can we relocate power and resources within communities? And then there's this notion about rejecting legality. Now, this gets very controversial. One of the things that I often think about is fentanyl test strips, for example. Fentanyl test strips currently illegal in the state of Texas, is that right? Still illegal in the state of Texas, fentanyl test strips? So, now, I'm not advocating that anybody on the panel go out and get fentanyl test strips and take home contraband. But should we? I think it's important for us to maybe think about that and sort of wrestle with like, well, ethically versus legally, what is the appropriate thing to do? And autonomous health movements help us to begin to question some of those decisions that we're making about how it is that we best take care of patients. So, SAMHSA has a number of supported, federally supported services and supplies that are available to folks. And this, I think, speaks to how much progress we have made in our country since the 1990s, that you have a federal government agency that is actually supporting, through grant dollars, as well as through direct financial support, the implementation of various harm reduction services, as well as supplies. So, when we think about the effectiveness of harm reduction, this has not been, perhaps, as well studied in our society, in our country, as we might have liked. So, there are some significant evidence to support that interventions to reduce road trauma have been effective. So, and thank goodness for the Ubers and the Lyfts of the world, right? Like, I mean, which can and should be game changers when it comes to people operating motor vehicles while under the influence of alcohol. I do think that this will get a little bit more complicated as we have more people that are driving under the influence of sort of multiple substances if they're using both alcohol and cannabis in a city or state where it is legal to do so. Unfortunately, there's limited research to support alcohol harm reduction interventions. And there was a recent Cochran analysis that found that in these managed alcohol programs where they're really trying to promote drinking goals that are compatible with the patient's needs and really not taking a zero tolerance policy, that there were no studies that they could actually even include in the analysis. When it comes to tobacco, medicinal nicotine products, is it harm reduction or is it treatment, right? We have historically kind of approached it as like, well, what we're trying to do is reduce harms, but actually, I really think of it as the treatment of nicotine use disorder. Now, smoking substitution with electronic cigarettes, snus, or heated tobacco, I think is a little bit more complicated and whether or not people are able to reduce harms using those substances, well, kind of remains to be seen. Again, limited research to support tobacco harm reduction interventions related to tobacco exposure, morbidity, and mortality in particular. However, physical activity does, bless you, does show some positive benefits in terms of its ability to delay occurrence of disease and premature death. When it comes to substances in particular, we've got supervised injection facilities in Canada which have been found to reduce opioid overdose, morbidity, and mortality, as well as improving injection behaviors. So the reduction in skin infection and wound infection that can occur as a result of that. Also improving access to treatment, although no impact on crime. Housing First, which I already mentioned, suggests the reduction in the severest forms of alcohol-related medical complications like delirium tremens as well as mortality. There is more research that is needed for this and one of the things that we can do as an organization is to try to promote not only the development of these sorts of programs, but also ongoing research into them. There's syringe service programs, which we've been talking about for years and years, and what they found is that clients may be more likely to seek treatment if they are actually participating in a program like that. And also because you're able to develop a relationship with a healthcare institution, perhaps with a particular healthcare worker, and because of that trust, you begin to reduce some of the barriers, the psychological barriers that are present for folks. And finally, harm reduction agencies, as would be the preferred potential sites for things like buprenorphine maintenance treatment, as opposed to always, again, expecting people to come to our healthcare institutions. So when we think about barriers to implementation, there are certainly several at multiple levels. We've got them at the individual level in terms of fear, mistrust. There's also stigma and this idea that I kind of have to do it on my own, right? Like that's, again, this sort of moral model way of thinking, like, well, you've done this to yourself. It's your responsibility to fix it for yourself rather than seeking out services or support. There are also familial and or relational barriers to accessing care, as well as a history of gender-based violence, and also maybe based on sexuality or gender orientation. There are a ton of institutional barriers that exist, including, I think, the third bullet, that limited regulatory knowledge among health care workers sometimes people don't know what am I what am I allowed to tell patients what am I not allowed to tell patients what are we allowed to do as an institution what are we not allowed to do as an institution. And then of course there are many of the other factors that I've mentioned related to social determinants of health and mental health. So what can actually facilitate implementation. Well hopefully sessions like these just talking having conversation education and developing a sense of openness related to the implementation of harm reduction strategies. How are you interacting with the community. What are your conversations with community partners looking like because this is not something that we can do on our own. It really does require the support and the buy in of the communities that we are trying to serve. We also need to have conversations within our particular organizations and help of help our colleagues and certainly ourselves to better understand the policies and the and the laws and the laws are changing constantly right. Like they're changing all the time. So so partnering with our with our risk management folks and our legal colleagues is going to be a really important part of this work as well. Having flexibility to the types of services that we provide and making sure that people don't just have to show up between the hours of 8 a.m. and 4 30 p.m. Sometimes we have to provide services after hours sometimes we have to provide services on weekends in order to to best meet the teams that best meet the needs of our patients specialized teams making sure that we have continuity of care for folks so that if they are interested in stepping up or down to another level of care that that's available for them and then also making sure that people have adequate access to specific strategies and certain supplies. So again we'll talk a little bit about Esper as it relates to harm reduction with this idea this notion that not every time we encounter someone who's using substances do we always have to refer to treatment. The idea is that maybe we refer people to a specific harm reduction strategy or service. So we've got expert for harm reduction begin by approaching your conversation with your patient with openness like we've talked about keeping in mind that non-judgmental and non-coercive approach also thinking about our conversation with members of the community getting that buy in understanding the medical knowledge of the community so that you can ultimately create programs that best serve their needs as well as familiarizing yourself with local laws and programs. With that I am going to pass it along and we'll talk a little bit about the evolution of Esper and the concept of Esper age. Thank you. Thank you Dr. Schroeder for giving us a detailed account of the theoretical basis of harm reduction and also for enlightening us about the factors that facilitate harm reduction and also barriers to implementation. Our next speaker is Dr. Namrata Valia who is actually a PG where one research strike resident that our residency program she's the mastermind behind this session so we are very grateful to her. Dr. Valley is currently the middle of a neurology rotation so we truly appreciate your commitment to organizing the session Dr. Valia Dr. Valley obtained a medical training at Y S M U Medical University in Armenia. She went on to do a T 32 post doctorate fellowship at Baylor College of Medicine and then MPH at UT School of Public Health. Dr. Valley is published and presented on themes such as homelessness mental health impact of e-cigarettes mortality associated with opiate abuse and viability of doing a cell phone survey in patients who are homeless and also suffer from mental health. Dr. Valley. Thank you Dr. John for that introduction. Thank you all for your time and attention. Last year was my first APA. I came here for a poster session representing Baylor College of Medicine as a postdoc fellow. Super excited to come back this year for a workshop and representing my residency program UT Health as a PGY 1. This topic is very close to my heart it recently became very close to my heart and I'll share the reasons why. Thank you Dr. Schroeder for starting with introducing the principles of harm reduction. I'll take a little step back. Talk about S bird and how you know the evolution and the history behind it. Oh it went back. Here we go. OK. So as bird is a screening to I think most commonly used in primary care settings but I think all specialties screen patients for substance use either formally or informally. So this is a tool probably not unknown to all. It stands for screening brief intervention and referral to treatment. It's a very comprehensive tool where we screen patients for substance use and then based on risk stratification we either give them early intervention early treatment or refer for higher treatments. It's been it's been here for more than two decades now. It started in like 1980s where it was mainly used for screening patients with alcohol and drug use. Then as we started accumulating evidence for its validity and reliability of the scope elaborated and it was used for screening patients with tobacco use as well and then prescription drugs as well. By 1990s there were many more programs in the US and other countries that started using this expert model as a formal screening program. Now to date we have several studies that are showing short term improvements as well as long term improvements in individual health who are being screened by the expert model. So as I mentioned it's it's a relatively quick and a very simple way to assess a patient on its substance use and then dividing on their risks of stratification as I said before we see if they need any intervention right now or we keep monitoring them. So as we see on this little graph which doesn't look very clear but if a patient we found is at low risk we don't need to do any innovation intervention right away we keep monitoring visits if they're found to have moderate to high risk of substance use then we either do brief intervention or we do be brief treatment per SAMHSA how these two are different or both are either a single session or multiple sessions. I think brief intervention ranges from one to five sessions of motivating them. The goal is to provide insight provide awareness regarding their substance use behavior. It can range from five minutes to an hour depending on the need. Brief treatment on the other hand includes the same concept as brief intervention but it could be from five sessions to 12 sessions and then we also target long term resources like providing them with rehab resources and then if we find the patient with severe risk or dependency then they are referred to specialty care. If the patient has severe risk or dependency then they are referred to specialty treatment like methadone and suboxone treatment centers. So this tool is pretty easy. It can be implemented within like two to four minutes. And as I said before it's validated by research by several studies. The good thing about it is it doesn't need a physician which means it's very easy to learn by a diverse set of providers. Our nursing colleagues can do it. Social workers and other health care professionals and it really comes in handy in busy clinical settings like ER settings when they're you know there's so much going on. It can be implemented. A quick screening survey can be implemented by any health care professional. And then as I said before it definitely includes referral to specialty treatments also although there are barriers to it especially in rural settings with lack of resources. But overall the SBIRT model has shown to be effective. I found some research studies I shortlisted to three of them because of the lack of space and time but it's been shown to be effective. So the first one that I picked was when they conducted brief interventions in a primary care setting and they showed small to moderate reductions in alcohol consumptions that were sustained over 6 to 12 months and even longer which is quite remarkable. The other study showed brief interventions conducted in an ER setting a very busy setting and it led to reduction in hospitalization reduction in traumas and injuries up to three years post intervention. These brief interventions are very small it could be five minutes to an hour long maybe one session or five sessions but it's been shown to have quite remarkable outcomes. And the third study that I put here was conducted across various different medical settings over a six month period and they showed a reduction 68 percent reduction in that was in the illicit drug use and 39 percent reduction in heavy drinking over a six month follow up period. And then this study was also show was able to show some impact on social and economic parameters like a more stable housing more improved employment status fewer emotional problems and improved overall health of people who were screened by the expert model talking about what the expert is how effective it is. Unfortunately we go back to talking about what Dr. John mentioned in the beginning that despite this very successful model able to reduce the substance use burden by early identification by referrals the annual death toll in the United States still continues to rise every single year. This is the unfortunate situation we are in. It's the it's the overall drug epidemic that we are facing in 2021 alone more than hundred and six thousand people in the U.S. died from drug overdose deaths that included illicit drug use and prescription opiates as well. And I think the projected number for 2022 is even higher. It's 110 thousand. It's been more than two decades and there's been a constant rise in this number of deaths. I think why male are disproportionately affected more than the females. That's probably another topic of discussion but our point here is we have such a successful model but this is what we are constantly facing. There are many other reasons why this is happening like more increased use probably lack of resources but despite a comprehensive and easy to use very successful model we are still facing this epidemic. Before I talk about what changes are we proposing today through this workshop I want to take a step back again talk about trans theoretical model of change. Has ever any of you ever heard about this model or used it. You've heard it. OK. So this has been around for more than two decades again. It was defined in 1990s. It's based on a very simple theory that any behavioral change goes through a common set of changes like Dr. Schroeder mentioned caffeine addiction. Probably I have that too. So if I have to make changes to my caffeine addiction I decide to quit my caffeine or cut down on my caffeine addiction and maybe somebody else is cutting down on their gaming addiction. Both of us will go through a similar set of processes while we start while we decide to change our behavior. These processes include five stages of change which start from a pre contemplation phase to a contemplation phase to a preparation phase and then the action phase and the maintenance phase. The pre contemplation phase is where people do not intend to take any action in the six month period. They are not aware that their behavior is problematic and they do not see the negative consequences behind it. A little scary but there is a chunk of those people then contemplation phase on the other hand are people who intend to make changes in the next six months. They understand that their behavior is problematic. They are giving a very thoughtful consideration of the pros and cons of changing their behavior preparation phase. It means what the word means. They are preparing to take an action then they take action in the action phase and then the maintenance phase is where they work towards sustaining the behavior that they have already changed. So consider this model like a big loop. There are different phases you can enter at any stage you can exit at any stage and then re enter at any stage. I mean we can always fail. Well you know probably weight loss is a big example. We keep trying to do exercise like I'm going to start January 1st then we fail then we make plan again and we enter again. So it's it's a loop. This is the most exciting slide for me. This is like where my thoughts come into life for the first time today. So what we are proposing today is introducing harm reduction which is the edge we added into the expert model making it as birth. So we introduce harm reduction model into the screening of expert model and we target the people in the pre contemplation phase the ones who are not ready to make changes yet and will probably not benefit from the other resources that we have like referral treatments because they're not ready to make changes yet. So we provide them with the harm reduction strategies because our goal is to prevent fatal outcomes. Our goal is to bring that drug overdose number down as much as we can. So this principle is a pragmatic approach. I mean this is what we haven't tried it yet. I probably by next year I come here I'll have some data but it sounds like a pragmatic approach to reduce health reduce social and economic effects of substance use without requiring a change in behavior. We don't have to insist on abstinence. We give them the resources of harm reduction because our goal is to prevent fatal outcomes. So question big question is how do we do this. So when we screen patients formally or informally I'll tell you a story of how this all came into my mind but when we talk to our patients screening them for substance use we explore what their goals are. We explore what their motivation is instead of using a traditionally a traditional approach where we would negotiate a plan to abstinence and then they could be successful or they could feel as well. But again when we do this our goal is to prevent fatal outcomes and bring those drug overdose toll as low as possible. I was talking about how this came to my mind. This was my first few years as an intern as a PG by one I was doing an interview a discharge interview with one of our patients and talking about substance use and how to address it. And he clearly told me on my face that he wasn't ready to quit and I paused for a few minutes because this wasn't how my other interviews spent. We always it was the same set of rules that I followed what gave them resources and discharged them safely. This patient told me on my face he wasn't ready so I didn't know what to do next. Like there's no point giving him resources to you know rehabs or resources to methadone clinics because he wasn't ready to go there yet. We talked about I think the next thing I said was OK whenever you're ready there are resources available. We discharged him safely home but I don't think I could sleep that night because I was thinking maybe I missed something. I knew the principles of harm reduction but I don't know why did I not talk about it. Did it was there like some ethical dilemmas behind it or were there. I didn't know what was the right way to put it across but I did not give him that information. And then one of the days when I was driving back home from work this idea came to my mind why do we not make this a norm like include harm reduction into when we are screening our patients for substance use. I went home I Googled it. I thought it was a very fresh idea. It wasn't. Somebody else is already working on it which is great. Oregon expert program is very famous is very well established and they are working on the same thing and I'm glad that somebody else is thinking on the same terms that I was thinking and somebody else also wants to do the same. Have we have the same goals. This is a graphic that I found on one of the harm reduction websites which I think some of the principles really echoed with the principle of expert that we are proposing. Of course there's no recovery from fatal overdose and that's our goal to prevent fatal overdose and not everybody is ready to stop using drugs which is the pre contemplation phase population. So we are targeting that population until they're ready to make a change in their behavior. We provide them harm reduction resources and you know keep them safe and then meeting people where they're at not insisting them on abstinence but meeting their way meeting them where they're at meaning wherever their goals are we work with their goals and meanwhile if they're not ready to make that change which is again the pre contemplation phase people we provide them with harm reductions resources and keep them safe so we see them again. I talked about the dilemma that I had in my mind when I was talking to that patient or maybe the right words that I didn't know how to use that. This is where Dr. Weaver will help us on addressing the issues that I had in my mind that that time and probably not the next time when I see a patient that I have to talk about harm reduction strategies with them. Thank you. Thank you number that I was actually getting all excited that I was witnessing all of us witnessing the birth of this book but now you tell us that it's already been birthed in Oregon but but maybe more data from from you will give us more excitement to talk about ethics of harm reduction. It's my honor to invite my colleague Dr. Michael Weaver who is a professor of psychiatry at McGovern Medical School is also the medical director of Center for Neurobehavioral Research and Addiction. Dr. Weaver is a distinguished fellow of the American Society of Addiction Medicine and member of the Academy Master Educators at McGovern Medical School is well published in the field of addiction medicine. He's an author of a textbook in addiction treatment which has been described as most concise clinically grounded and practical guide in addiction medicine is an exceptional teacher as lectures are very popular with our residents and medical students is also frequently sought out speaker for professional conferences. Welcome Dr. Weaver. All righty. Thank you for the kind introduction. And once again I want to extend my thanks to everyone who showed up this morning. Thanks for taking time on the last day of the conference even though the exhibit hall is now closed. So thank you for spending your time with us. I really appreciate it and we're honored to be able to talk to you about these topics that are near and dear to our hearts in terms of what we do for our patients on an ongoing basis. So I'm going to talk a little bit about ethics and also about how some of the laws interact. Unfortunately not all of the harm reduction strategies that we employ are truly legal. As Dr. Shorter pointed out a little bit I'll go into a little bit more of that as well. But I wanted to kind of give you the overview and dive into the ethics piece of it but also want to finish up with some practical applications some examples of even conversations or ways to talk to our patients on a one to one level. If there is Dr. Wally his patient was not ready at that point. OK how do we appropriately frame that and what can we say. How can we encourage them to incorporate some of the well studied harm reduction interventions that Dr. Shorter had mentioned. So starting from the highest view we have morality. That's an absolute. That's what tells us right from wrong. And this is what is the purview of religion basically. Then below that we have legal aspects laws and regulations. That's what provides structure. Tells us how to implement those kinds of moral requirements basically. But of course they change all the time. It depends on where you are what time is it what political party is in power or in fashion. And you can ignore laws you can break laws but there are consequences for doing so. And then we have ethics ethics is at the bottom because ethics is always on a case by case basis. It's not the right or wrong so much as it is what do we do with the patient that's in front of us. As the saying goes, all ethics is situational, just like all politics is local. So when we're making ethical decisions, and I don't want to belabor this too much because I don't want people's eyes to start glazing over with all the terminology, but what we want to try to do is identify is there a particular ethical issue, does it have to do with things like autonomy, beneficence, justice, non-maleficence, and other kinds of jawbreaker terms. So we review, okay, does it have to do with these principles, consider solutions, and then take an action. But the important piece of this is at the bottom. Figure out did that action work? Was it ethical? Was it appropriate? Did it have the desired response? And that is really the key when we're talking about making ethical decisions, is going back and thinking on it. Did that work? Did that feel right? And was the outcome a positive one, at least as much as we could get? So when we start talking about ethical principles, I promise I will only cover a couple of these. Again, don't want the eyes to glaze over. So let's talk about autonomy. We've heard a little bit about it already with Dr. Shorter. Just as a quick review, we're talking about self-determination or respect for persons. And so in the clinician's standpoint, what we're trying to do is respect the rights of our patient to determine what they consider to be an appropriate action for themselves. So we're not trying to impose our views and values or our own morality on them. And we allow them to act in accordance with their own authentic sense of what is good or right or best for them, because they're the ones who know their own situation, their own background, their own skills and talents, as well as their own deficits the best. And we want to give them the opportunity to make a choice that is free from coercion. Now beneficence is the last principle that I'll talk about here. And this is one thing that us as healthcare providers are very in tune with. It's our duty to do good for all our patients, and in this context, patients who have a substance use disorder. As providers, we have a responsibility to act in ways that provide for the best good for our patients, not only by helping them, but by helping them to avoid harm. And so that's where harm reduction starts to come in. It's both sides of the coin. It's not just telling them the right thing to do, but depending on what they want to do, we can help them to accomplish their own goals and be safer in doing it. Of course, we don't want to be overly paternalistic. We want to respect the first principle, which is autonomy. And this involves shared decision making, which I'll come back to a little bit. So that's going to be an important aspect of that. It's a brief negotiation with our patients so that we can help them to be as safe as possible based on what it is that they're willing to do. So the question comes, is harm reduction ethical? It may not be legal, but we can make a determination based on ethical principles that in many cases, harm reduction is ethical. It respects the patient's autonomy, their decision to choose to continue using substances if that is what they desire. And so we respect that. We may not agree with it, but we can certainly value their autonomy by understanding what it is that they're going through and they're not ready yet. They are in pre-contemplation or maybe contemplation, but not ready for action yet. In terms of beneficence, what we want to do is help the patient to avoid the harm from continuing to use by engaging in shared decision making. So we come together, a meeting of the minds to figure out, all right, if you're not going to do the absolute, where can we meet in the middle? And so that you can be as safe as possible. And this fulfills our duty to inform them of what are the potential consequences. That's where we can provide our knowledge and our experience by letting them know, hey, there may be risks that you hadn't considered. Let me help you figure out how to deal with those effectively. Let them also know that the ideal goal is abstinence. So if we're talking about even the morality level, and in many cases the legal issues that are at stake, abstinence really is the highest ideal, and that's what we would want them to aspire to. But we want them to know that there are alternatives that will reduce their risks to their health, both short term and long term. And so that's where we can find common ground. Of course, what this can do is establish our concern for the patient and for their safety and be an area where we can continue to make progress. So we have this understanding. It's not an adversarial position. It's not the clinician against the patient because the clinician wants them to quit and the patient isn't ready to quit. It's the clinician and the patient working together against the problem, which is the addiction. And so what we're trying to do is get that common ground in the middle so that we can build on that, build the relationship and progress forward so that they understand, you know, I may not be ready to quit, but my doctor still cares about me and still wants me to be safe. So maybe there is something to what he, she is saying after all. And so they can recognize that compassion and we can grow the relationship that way. And that can enhance the patient's own motivation for continuing to make positive changes. And so they may not be ready to stop, but they might start thinking about cutting down once they're aware of the risks and they're aware of some of the issues around how they've been using or what they've been using or what the context of using is. So how do we actually break it down and incorporate this into practice? As has already been mentioned, we're meeting them where they're at, all right? We want to try to find that common ground in the middle, not absolutes. And really harm reduction in its best utility is as a form of outreach, trying to engage the patients that are most challenging, most distant, most resistant, right? It is a way to start to bring them in so that they can see, you know, maybe that's not so bad engaging with these healthcare people. Maybe I should start to think about how life might be different if I weren't using as much or maybe thinking about the idea of not using at all. So we can start building bridges through harm reduction, and I think that's one of the best utilities for which we can use something like this. So we have a range of options. Dr. Schroeder already mentioned this, a continuum from safer use, managed use to less use, even if we don't get all the way to abstinence, and trying to address the circumstances in which people are using and the risks related to that in addition to just the fact that, you're using drugs that alter your mood and your mind, that should be something you should not do, it's bad. And then even if we don't get very far, you know, first visit, just like with Dr. Walia, you know, she was stymied, okay, how do I respond to this patient that doesn't do what I want them to do, right? That's frustrating. But rather than beating our heads against the wall, and I see patients with substance use disorders on a daily basis, it's easy to get frustrated. You want to grab them by the throat and go, can't you see you're destroying your life and the people that you love? Okay, but we shouldn't be doing that. But what we can do, instead of beating our heads against the wall, is recognize, okay, let me build these bridges, they'll be back, I'll get another opportunity to at least further the conversation. Keep raising the issue at subsequent visits, even if they're not ready yet, at least they know, I'm waiting for you when you're ready. Let's start talking about it, just like Dr. Walia mentioned. All right, so let's talk about some examples, all right? So avoiding use of illicit substances in hazardous situations, and certainly includes alcohol, even though it's not illicit unless someone's underage. So talking to them in very practical terms. So I have lots of patients that have blue-collar jobs. If they're operating heavy machinery, this can include long-distance truckers, or folks that are carrying hazardous loads and things like that, and letting them know, you know, this is something that could be dangerous, plus Department of Transportation testing will put them at risk. And so talking to them about how do you find a balance, how do you make sure that you stay safe for yourself and the folks that you're working with. Even something as simple as avoiding hangovers on workdays. So if they have a particularly good weekend, then all right, how is it that they recover from that? What are some practical things that they can do, again, so that they're not in a position where they're likely to have problems with their coworkers or their supervisors, so that they don't have their use encroaching into other areas of their life that is going to lead to more problems that may lead them on a further downward spiral. Even using in circumstances where they would be impaired to the point that they may not be able to appropriately say no to unwanted sexual advances, not just in the context of date rape drugs, but if you're intoxicated, you might be less choosy about who your partner for the night would be, and you may be less choosy or less able to stand up to a request to not use protection. So talking about practical circumstances like that, hey, if you want to be able to avoid an unwanted pregnancy or an STI, think about this. Let's think about some practical ways to accomplish that. Using and driving long distance or otherwise, not just the legal consequences, but of course injury to themselves and others, and of course that brings in other ethical issues, harm to others. And legal issues as well. There are some mandates if we find out that someone is a bus driver. We do have some reporting requirements related to impairment. And so we need to let the individual know, hey, there are some areas where I may have to inform others. And then the usual, not combining prescribed medications with illicit substances because of not only risks of interactions, but if it's not going to work at all, then why would you put yourself at that risk? So are there some parameters around this so that at least you're taking a medication for a beneficial effect? How can we separate that out from use for recreational effects? Getting a little bit further into the weeds, with opioid overdose rescue kits, there's a variety of those that are available. We have excellent evidence showing that these save lives and prevent opioid overdose deaths. Whole bunch of versions of these nowadays. The whole purpose, I'm sure everyone is well aware, is not necessarily to give someone a dose and they wake up and they're better and go about their business and can go about their day. It really is simply a stopgap. You are buying time to call 911. That's the purpose of a rescue kit, an overdose prevention kit. You give them the naloxone and then they wake up enough, start breathing from just a couple of times a minute to 12, 14 times a minute, better oxygenate their brain, while you get on the phone to EMS and then have the paramedics come to bundle them off to the emergency department where ideally they will get brief intervention, maybe even a dose of buprenorphine, so that they can have additional opportunities and interventions above and beyond just the prevention of an immediate death episode. So it's important to make patients aware of this and let them know, hey, having naloxone is a really, really good idea for you and for anyone else in the household or other people that you know that you may use with on a regular or occasional basis. Fortunately, most states have a standing order for naloxone currently, what they call third party prescribing, although the FDA just voted to approve naloxone to be over the counter and so the manufacturer is gearing up and so within a few months we should be seeing naloxone available over the counter. So even currently, though, it's a very low barrier. Anyone can get naloxone from a pharmacist in a pharmacy who has completed a one hour training so that way they can train folks in how to use whichever device it is, the auto injector, the nasal spray, things like that. And then in terms of how people get it, as I said, it's like the medical director for the Pharmacy Association in Texas signed all the prescriptions in advance and so very low barrier. Also, again, referring to Texas, the major chains, CVS and Walgreens for pharmacies have agreed to carry naloxone in their stores and have at least one pharmacist trained in how to educate patients about using it. So I strongly recommend all of you in this room to at least tell your patients, hey, you can walk into a pharmacy and you can get naloxone and you can have it available for yourself or someone else that you know. In terms of the cost, if they have private insurance, it's whatever their policy says it costs them. If they have Medicaid, then the copay is zero. So they can get the naloxone, the basic injectable with a syringe that has a nasal tip on it for nothing. All right? They can go and ask it for it. They can get a couple of those kits at any pharmacy at no cost. Or you can get the fancier versions with the nasal spray or the autoinjector. Unfortunately, they can get a little bit more expensive. A couple of the autoinjectors are around $150, but, again, not as expensive as a stay in the ICU. Also, it's going to be over the counter soon. That doesn't mean it's going to be free, but there are still going to be groups out there that are helping with covering costs for this. So it's well worth talking to our patients about, letting them know, hey, what are the risk factors for an overdose, and in the interest of time, I won't go into that in detail other than using opioids, whether they're prescribed or non-prescribed. How to identify an overdose, I think most of you here went to medical school. So the fact that you were educated on when someone starts turning blue and breathing just a few times a minute, non-responsive, then those are the things to look for. And ideally, we demonstrate for patients how to use this. I have demonstrator kits in my office, a little autoinjector, you take the cap off, it starts talking to you, put this end against the patient's leg, and it's as simple as that. Or how to use the nasal spray, this is the end that goes in their nostril, and this is the button you push. So it's very straightforward, and so they have some familiarity for when there's an adrenaline surge if they recognize that someone might be doing more than nodding off in the same room. And it's important to let them know, this is something that is evidence-based, that anyone could do, everyone should do. It's not a judgment against them because they're using it in a high-risk situation. It can be for anybody. They can be walking down the street and see someone in an alley that needs help and can save a life. So it's something that is well worthwhile for anyone to have available as an option. So carry it in a purse or briefcase just in case. Also if you are wrong, the person wasn't having an overdose, they were just sound asleep, or had their earbuds in and you couldn't see. If you give them a dose, nothing bad happens. Nothing at all. It only works the way it should work in the cases where it should work. If you give it to someone inappropriately, then nothing bad happens. They have a wet nose. Okay, all right, get a tissue. That's the end of it. No harm, no foul. So that's a very good aspect of this. Again, you can use it on anybody, but you can't use it on yourself. So make sure that everybody else in the household knows where it's located. If it's under the sink, if it's in the bathroom medicine cabinet above the sink, whatever it is, let them know this is where it is. It's here. And tell everyone else in the household where it is. I try to have family members come in as well, spouses, parents, children, whoever I can get. And the good news is that most people aren't actually alone during an overdose episode. So I try to bring people in and give them the same information, even if they're not the ones that are using. Anybody can use this to save a life. So it's well worth considering that there may be someone you hadn't even thought about that this might be useful for. I tend to use the analogy of a fire extinguisher. Most of us have a fire extinguisher in our house, certainly in our place of work. We hope we never need to use it, but we'd be really, really glad that it's there if we do. Same thing with Naloxone. You hope you never need it. But if you do, you'll be really, really glad that you've got it on hand. And then once it's been used, that's the important time. Do a lot of listing. Figure out, okay, why did this overdose happen? Ideally after they've come back from the emergency department and gotten some brief intervention. And then say, hey, what did you think about that? Has that moved the needle any? Thought about the risks. Thought maybe about the benefits of changing some of this behavior. Try to move them a little more along these stages of change from pre-contemplation to contemplation and preparation. All right, last thing I'm going to talk about in terms of harm reduction are needle and syringe exchange programs. So unfortunately, federal laws prohibit the use of federal funds for needle exchange programs because in most states syringes, needles, things like that, works are considered paraphernalia and so they come under paraphernalia laws and are prohibited. Just by a show of hands, anyone live in the San Francisco area? Who's local? Okay. In the back. Great. All right. So I'll get to why I said in a second. So even though federal law prohibits syringe exchange programs, there are still more than 500 programs in existence in 45 states in the union. So people have certainly found ways to accomplish this. And in San Francisco alone, there are five programs in this area for syringe exchange. And of course, they do a lot more than just give people clean needles. Again, this is an outreach program to try to bring in the folks that are most resistant to making that behavior change. But they'll exchange other things besides needles. So crack and meth pipes, things like that, getting clean pipes because it's not just needles that can get bloody and can transmit blood-borne pathogens. So you can exchange other paraphernalia. Do testing for those blood-borne pathogens, the ones we hear a lot about. Hepatitis B and C, and of course, HIV and others. A lot of them will also give out naloxone rescue kits and then try to get people engaged. So who works at syringe exchange programs? Former users, people in recovery. In fact, folks that go to a syringe exchange program may see someone that they were using with a few months back or last year. That's a powerful advertisement. That sends a message. That's who you want to have there, working the windows, getting people engaged. Those are the ones that can start to see, hmm, he's doing better now. You know, when he OD'd, I thought he was a goner, but he's here, right? They start thinking about what could be, and that's a powerful message. And so that's one of the beauties of having these kinds of syringe exchange programs. It's outreach to get people to start thinking about how could things be different? And of course the obvious, reducing the spread of blood-borne pathogens, great from a public health standpoint. And then lots of good information's in the slides that have the references and other information. The North America Syringe Exchange Network, where you can actually go on the website and find the different programs that offer needle and syringe exchange programs in your area. Okay. Now of course, I mentioned that some of these programs are not strictly legal, certainly not at the federal level. So how do we ethically and legally make these kinds of decisions to help our patients? So with the paraphernalia laws, lots of variability from state to state, and needle and syringe exchange programs may not be as readily available. They have limits on funding and things like that, but they've certainly found ways to survive through donations, endowments, things like that. But an alternative is that even if someone has a hard time accessing a syringe exchange program because of transportation difficulties, because of paraphernalia laws in their community, because of concern about stigma, in many cases, we can actually take the step of prescribing clean needles for patients. That way they can get them legally. Pharmacies then are able to dispense needles to individuals and they can obey the law and we can obey the law and so can the patients, but they still have the benefit of getting clean needles. So it's something to think about. And nobody else needs to know that that patient's not diabetic or needs an injectable medication, which nowadays all the biologics are by injection. So, okay, that's getting less and less stigmatized. And then, okay, talking to patients very frankly about what are the risks, what are the risks we're trying to reduce, and that helps from a legal standpoint, from a liability standpoint, discharge our end of the bargain to let them know, all right, I couldn't get them to stop, but I talked to them, I warned them, we came up with a plan. And that's because in terms of legal liability, not just at the criminal level, but even at the medical board level, at the civil level, we are open to liability for breach of duty if we recommend something for which there is not good medical evidence. So there's a variety of ways, states where cannabis is legalized and there are medical lists for appropriate diagnoses where it's being used, all of this. In those circumstances, patients may say, well, this is something I want to do, but we need to be able to tell them what the evidence supports because if there's a bad outcome, we can still be liable. So that's why it's important to have these conversations with patients, but it can still be used in a harm reduction context. If they're not willing to make a behavior change, we can find that common ground and meet them where they're at. So I will stop there so that we still have time for questions and exercises, some audience participation. Thank you. Good morning and thank you for this wonderful presentation. It's been very useful to hear the various perspectives and how things might be used in a variety of circumstances. I'm a food addiction professional and interested in marriage and family and children households and I'm looking at Maslow and even one basic lower than housing and that's food. And how we can, and my question has to do, how can we intervene in what people are eating to support their mental and physical well-being and that that is so essential. It's before housing. And one of the resources that I found is, one of them is Eric Clapton. If you put in Eric Clapton, the performer, and sugar, you will see a very short clip, less than a minute, about the interviewer asking him, we know about your heroin addiction. Was alcohol your first addiction? And he just whips around and says, oh no, sugar was my first. To eliminate sugar from people's diet or at least harm reduce the amount of sugar in their diets and high fructose corn syrup, we can change the mental states to have more clarity of mind to be able to hear the interventions that are being offered, the harm reductions. This is a much more basic harm reduction. And another one that's available online is about the canteens, the open areas for feeding large populations in Britain in World War II, where they put tablecloths on the table, silverware, had meals prepared by a small number of people to provide for hundreds, and they were healthy food by the standards of the time to help people have a sense of camaraderie and conversation, community. One of the slides talked about the isolation versus community and connection. All of these things, how can we use these things as a harm reduction model in our society? How can we create for even the parents, someone mentioned earlier about wealthy people, and you know, they're feeding their children inappropriately also. So how can we engender this kind of feeding healthy, nutrient-dense food to people in community settings? Is there a way that it can come before the housing? Thank you. Thank you. That's a very important point to raise. I appreciate that. So I treat folks for drug and alcohol addiction, but I spend an awful lot of time talking to my patients about diet and exercise. And like I said, I do addiction work, but I started out as an internist. And so I spent a lot of time talking to patients about these kinds of basic health measures. So I think the first part is raising awareness, educating our patients, letting them know. Because you see all these ads for soda pop and chips and everything else, candy bars, when you go to check out at the grocery store, what is greeting you as you're taking your cart through to snatch on the way home. So talking to patients about raising awareness about these issues is important and how it fits into the overall context of health. And then just in terms of mental health, some of the points that you mentioned about clarity. And finally, in terms of substance use disorders, that can be a trigger. People crave for sweets, and that can actually be a very effective model for working with patients and even letting them know about mindfulness, urge surfing, using examples of food that they can relate to, and then transposing that to be like cravings for a particular substance. So it can go both ways, educating patients, making them aware of resources, including food banks and things like that, but also letting them know that that also plays a role in triggers for cravings for a variety of things that may not be entirely healthy. I don't have an exact answer for that, but I would like to share two resources, again, out of Texas. There are really successful catch programs in Texas that work with school districts. Dr. Kelder is one of the founders. They are working on nutrition, you know, education for children, because it definitely starts at an early age. You know, the earlier they know, the better it is. And then Dr. Sharma, both of them are out of UT Health. She's a PhD in nutrition. She's running really successful food pantries and nutrition programs in Texas again. So maybe you'll find some more information on those two, from those two resources. Hi. Thank you for the presentation. I'm Mark Reagans. I'm a psychiatrist. I work on with street medicine teams in Los Angeles, and the huge problem that we have and the huge majority of what we do is actually harm reduction. We carry around needles and crack pipes and speed pipes and safe sex kits and Narcan and Suboxone and wound care together. We're supposed to be doing primary care. So I have two questions about it. One is, you guys talk about studies that show that harm reduction for any given person reduces the damage. I have some question in my back. Is that also true on a population or public health basis? If you have a community and you added harm reduction, does the amount of drug abuse in that community go up or down? Because you certainly see newspaper articles that says, oh, you have that place where they could shoot up and look like a party, and so more people are likely to use if you're handing out crack pipes. Do we have any population data whether it improves a community's amount of drug use overall or not? So in doing the research for this talk, I was not able to come across anything related to that where the presence of harm reduction seemed to promote greater drug use among populations. It is interesting to me in thinking about how we define treatment success and what is it that we are ultimately trying to accomplish by implementing harm reduction strategies and services. As I sort of alluded to during my portion of the presentation, we're not even really doing a great job of collecting data about overdose, both nonfatal and fatal overdose deaths. That's just one type of outcome that we could be tracking. So it's not always, I think, about abstinence. It might be that treatment success for someone is that they take their diabetes medications more regularly and that their A1C is under better control. I mean, we, I think, have historically thought very narrowly about what constitutes success, and sometimes maybe it's really just keeping the person breathing for another year or five or ten or what have you. But nothing related to population level findings. Whether it makes them go up or down. The other question I have, so I'm a psychiatrist, and so I've wondered, all right, I make all these ethical switches. Are there other tools I should be actively adding into this, ranging from we have huge piles of meth in the group. Should I be adding in Welbutrin so they can stay awake if they stop meth for a few days? Should I be adding in Abilify so that they have less psychosis from the meth? Should I even be considering doing prescription Adderall? Which I never do, but should I be? Should I be adding in, for people with alcohol or, like a guy was taking a huge pile of Xanax and he was getting off the streets, wanted to get down, and I didn't, he wanted, hey, if you give me some free Klonopin, I'll switch over to that, and maybe I'll use it. And I didn't do that. Should I be doing that as well? Where's the, it seems like I have a bunch of possibilities that would fit within this same ethical framework that I was certainly taught not to do, but I was taught not to do any of these things. That should I be expanding what I'm doing? If so, is anyone doing it so that I'm not like the first one trying this shit? Yeah. I'll just say, like I said previously, all ethics is situational. It's a negotiation with you and the patient. I will say, though, that they studied Ritalin maintenance for methamphetamine use and it didn't work. They've also studied Valium maintenance for alcohol use disorder, didn't work either. Even things like Dranabinol for cannabis use disorder, none of that's panned out as well as things like Methadone and Buprenorphine for opioid use disorder. So we do have some evidence that, okay, that sort of issue probably isn't going to work for a population of patients. But if you do have a patient who is particularly prone to psychosis from methamphetamine use, then talking to them about the two sides of the issue, if that's an ongoing issue, I can help some with the symptoms, but at the same time, we also know what the underlying reason is and can work on that aspect of things too. So trying to find that common ground is the best way to approach it in terms of, well, is this something I can do legally, ethically? It's more about, okay, what does the patient in front of me need? How can we best meet those needs while still staying within the bounds of the laws and morality? Yeah, and I'd like to piggyback on what Dr. Weaver just offered. I think, again, it really does depend on how we ultimately define treatment goals and treatment success. So when we think about how medications like Ritalin have not worked for treatment of stimulant use disorder, it depends on what you are talking about. Are you talking about trying to help someone to establish abstinence? Or are you maybe talking about, well, this is someone we are better able to retain and care because they are coming back for their weekly prescription and it gives you another opportunity to have a conversation with that individual about their stimulant use? Or, you know, mirtazapine is a really great example of a medication that doesn't necessarily reduce methamphetamine use, but it has been shown to reduce HIV risk behaviors among MSM who use meth. So that, to me, is a worthwhile medication to use in that population, especially if what you are trying to do is maybe reduce HIV risk behaviors among folks that use methamphetamine. So I do think that a part of the conversation can be about the goals that the patient sets for themselves, as well as some of the goals that we have in maybe retaining people in care and addressing some of the behaviors around substance use, even though you may not necessarily reduce the substance use itself. Thanks. One last comment or comment. Let's let someone else ask some questions, and then if there is time, you are more than welcome to come up. Good morning. Good morning. Thanks for your conference. I am a psychiatrist. I am from Lima, Peru, from the National Institute of Addiction. Well, what about the ethical dilemmas with the family? Because it's very easy to speak with a patient, but usually, for example, in Latin America, almost, it's very rare that the patient comes alone. And the problem is that he is in a pre-contemplation or something in some stages, and the thing is what to do with the family when the family begins to come two, three, four, five times, really begging, what can I do for my child or for my husband, and how do you manage these things? Because this is really, really hard, the dilemmas that we have with impact in the family, depression and everything of things. How do you manage the things? So first, acknowledge it. Let the family members know that they're being heard and that they're welcome. And then I try to give them resources, so things like Naranon, Alanon, so for loved ones of someone who has a substance use disorder that work on 12 steps for the family members for dealing with the issue, whether someone is in recovery or not. So those can be very, very good resources for family members, and the only drawback is that they're not focused on family members helping get that individual into treatment. But you can also recommend family counseling, especially if it's parents coming about, a young adult, and those concerns, couching it in terms of, you know, well, let's open up family communication, let's learn how to better talk and understand one another, maybe more palatable than saying, you know, we want you to get into drug treatment or you've got to quit and we're going to tell you how. It's more about, okay, let's communicate around, you know, what is appropriate and how do we respond to use, how do we respond to not using and reward that. So educating families about what their options are so that they can feel less frustrated and get some practical tools is very important. I appreciate you bringing that up, because addiction is a family disease. I would also recommend the community reinforcement approach in conjunction with family therapy. It's also referred to as CRAFT, and finding providers in your city, in your town that are well-versed in CRAFT and trained in how to work with the families. These are relational disorders, and I encourage the family members to get into their own care, get into their own treatment. Are they involved in individual therapy? Because yes, there is a part of the family therapy where perhaps the individual with the substance use disorder and the members of the family are in the same room and doing work together. But there has to also be, in my opinion, a part of this work that is done by just the family members sort of on their own. And then they can learn the skills that either promote, that are pro-abstinence, that can kind of promote change versus those that might contribute to the individual's ongoing substance use, especially if there's some enabling behaviors that the family members are really struggling with. But CRAFT is always a great place to start. I want to add destigmatizing it as well, because outside the United States, I understand, like I'm born and brought up in India, I understand how medical decision-making is a family process rather than the patient itself. So just destigmatizing addiction and harm reduction so that family is more open to the options and understands it better, because there's so much social pressure as well. So making them understand that it's not a stigma. It's just like another medical issue. So working on that as well. We can have one more question, sure, thanks. Thank you very much for a wonderful presentation. I'm a psychiatrist from Sweden, and I do some work in this area, and I would like to call this an existential approach to addiction, which is really the highest level of appreciation, I think. Thank you very much. Thank you. So, when we categorize our patients using the lens of stages of change, we could get easily discouraged and then we hear these numbers like 106,000 deaths and large amount of money which has been utilized to help our patients with drug dependence, with the sense of therapeutic nihilism, but today Dr. Schroeder, Dr. Valli and Dr. Weaver and all of you have gifted us with ray of hope and some concrete skills and competencies and strategies with the ultimate goal of saving lives. Thank you so much.

SBIRT

harm reduction

drug overdose

substance use

needle exchange programs

naloxone rescue kits

bridging clinics

addiction models

SBRTh

patient autonomy

ethical dilemmas

opioid crisis

healthcare providers