My name is Michael Weaver, I'm a professor in the Department of Psychiatry at the University of Texas Health Science Center at Houston, and it is my pleasure to be the moderator for this session, which is The Birth of SBIRT-H, Incorporating Harm Reduction Strategies into the SBIRT Model. And I have my co-presenters here, Dr. Namrata Walia, and this is really her baby, she came up with this, and so she gets the lion's share of the credit for this session. And then she works with me in the Department of Psychiatry at the University of Texas Health Science Center. She is a psychiatry resident, so more credit to her for doing this during her residency. And then we have Dr. Daryl Shorter, he is from across the street in Houston at Baylor College of Medicine, and is the director of the Fellowship in Addiction Psychiatry there, and is an excellent and well-known addiction psychiatrist. So I'm honored to share the stage and screen with these two. And so since Namrata and I are from University of Texas, I do want to put in a shameless plug for the new School of Behavioral Health Sciences that is opening there, so if anyone has an interest in coming to Houston as a faculty member, as a graduate student, or even as a resident, we have some information on the back table there near the door with QR codes if people want to scan for more information or take a flyer with you. All right, and without further ado, let's get started with the birth of SBIRT-H, and I will welcome to the stage and screen Dr. Shorter. Thank you, Dr. Weaver, good afternoon, everyone, thanks so much for being here for us to talk a little bit about harm reduction and some of the ways in which we can begin to incorporate a harm reductionist approach in the care that we provide to folks, regardless of where they are in terms of stage of change, and I'm so pleased and honored to be presenting today with Drs. Weaver and Walia. We have no financial disclosures. So our objectives for today are to discuss and recognize harm reduction strategies broadly, and so I'll be giving a little bit of a historical perspective on how harm reduction developed, and we'll also talk a little bit about the current status and philosophy regarding harm reduction. We'll describe various strategies that would include harm reduction while using the SBIRT model in clinical practice, and then Dr. Weaver will come in at the very end to talk about some of the ethical dilemmas around the use of harm reduction as well. Our hope is that by participating today that you'll have some skills to address the unique challenges of incorporating harm reduction in your specific clinical and administrative settings. So we'll begin with a quick history lesson, and one of the things that I think is really important for us to recognize is that harm reduction is not a new concept. This is something that has been with us for well over 100 years, and oftentimes when I'm talking to people, particularly families and community members, there can sometimes be a lot of surprise that harm reduction, one, exists even today in contemporary society, and two, that it's not new, that it has been with us for well over 100 years. Beginning back in the 1920s with the Merseyside model, which developed in the UK, in the 1920s there was the Ralston Committee, which was actually a committee convened of healthcare workers, physicians, who talked about and pushed for the use of medications for treatment of persons who were dealing with opioid use disorder. So even when we talk about medications for addictionist treatment and how novel that might feel to some people, even that's been with us for well over 100 years. The Merseyside model evolved over several decades to the point where by the 1980s law enforcement was actually involved in harm reduction as well. I think another important thing for us to recognize in our contemporary understanding of harm reduction is that this is a collaborative effort between healthcare as well as other community forces and organizations, and so law enforcement was involved with cautioning. Rather than taking people who might be publicly intoxicated or using substances to the jails or to criminal justice systems, instead they diverted those folks to healthcare facilities so that they could be evaluated and then receive treatment. At the same time that this was going on, we had the development of the Dutch model. The Dutch model really focused initially on understanding that not all substances carry the same type of harm, and the Narcotics Working Party, as well as the Dutch Opium Act, really reflect that change and that shift in perspective. That some substances actually carry greater harm to individuals, to families, to communities than others. Again, a kind of controversial, in many ways, way of thinking, particularly at that time. By the 1980s, there was the development of the junkie bond group, not my terminology, but the terminology that was chosen by this group of people who were either in recovery from substances or really still actively using substances. They were formed almost like a trade union and began a grassroots organizational effort to begin making changes, which ultimately resulted in the creation of the first needle exchange program four years later. One of the contemporary ways of understanding harm reduction is that we have to involve people who use substances. They must be at the table and involved in conversations in terms of the creation of policy, as well as determining the appropriate outcomes for the development of harm reduction strategies. Finally, the U.S. gets involved in the 1990s. We were a little late to the party when it came to the development and really initiation of harm reduction strategies within our country. Much of that grew out of concerns related to intravenous drug use and HIV infection, such that by the time we land in 1995, there were finally official policy statements and recommendations made to our Office of National Drug Control Policy. So early principles of harm reduction really focus on understanding the different models of addiction and recognizing that this is a public health alternative to the more moralistic or criminal model of addiction, as well as the disease model of addiction. Even now, I think it's important for us to acknowledge that we have all been raised and steeped in the moral model of addiction, and so much of the work that we have to do as mental health providers is sort of recognizing when we are ourselves operating from within that model and sometimes stepping back from it in order to provide patient-centered and appropriate care. This early model of harm reduction also acknowledged that while abstinence is an ideal outcome, it accepts that there are alternatives that might help to reduce harms. Even now, particularly when we think about addiction psychiatry, addiction medicine, and more broadly, systems of recovery, it is sometimes very challenging to convince people that abstinence is not the only goal for folks. And so sometimes the work that we have to do is really, again, zooming out, stepping back, and engaging people in conversations about how abstinence is one of several potential outcomes that might be favorable for individuals. As I mentioned with Junkie Bond, I think it's important to acknowledge that this is a bottom-up approach and that we really want to make sure to involve persons who use substances, people in the community that are doing this work in order to help us to create strategies for harm reduction that will have the best impact and hopefully the most uptake within communities. And also, certainly not least, making sure that there's a low threshold for people being able to access these services, recognizing that there are certainly biases, prejudices that exist right now that also serve as barriers. So how can we create services that have a low threshold to access? When it comes to more contemporary approaches, and this, I think, is one that is particularly present for us right now, is the idea that we might need to accept that drug use is a part of our world, and that we, instead of trying to promote solely abstinence, that we choose to work to minimize the harmful effects of substance use rather than ignoring it altogether or condemning it. This is, I think, particularly kind of interesting right now in the age of sort of the fourth wave of the opioid overdose epidemic, where we're having conversations about fentanyl, and we all live in a state where fentanyl test strips are not legal, for example. So my ability to administer those or distribute those to patients or families is we're not able to do that. And Dr. Waver will talk a little bit about the ethics around that when he gets up to speak to you today. And so engaging in conversations with patients and families about access to certain types of things, you know, I acknowledge that drug use is a part of the world, but not everybody thinks that that is the appropriate or the appropriate goal for people, families, communities. I also think it's important for us to acknowledge that drug use is a complex, multifaceted phenomenon. One of the kind of cool things that has happened as a result of just continued medical educational development and curriculum development is the incorporation of our understanding of social and structural determinants of health and social and structural determinants of mental health. And so we can bring to that, to our understanding of drug use, our understanding of addiction, that lens, beginning to see how there are lots of different factors which might predispose someone to use a substance and or develop a substance use disorder. When it comes to the criteria for how to determine whether or not there is a particular intervention or policy is successful, historically we have used abstinence as the only way of kind of understanding whether or not a particular strategy or policy has been effective. How many people have been able to, quote, unquote, get sober? One other way that we have evaluated this is by looking specifically at treatment retention. Are people actually coming back and are we able to retain them in care? But those ways of thinking about whether or not something is successful for an individual don't necessarily take into consideration the quality of life factors that really matter sometimes more to the patients and the families that we're serving. Of course, we want to have a nonjudgmental and noncoercive approach when we are trying to provide these services. And that's something that I think is much easier said than done. I think, again, as we've talked about this sort of bottoms up approach, that it really does become important to ensure that people who use substances have a real voice when it comes to the creation of their programs that are designed to serve them. And in fact, that we incorporate their ideas in the creation of these services, giving people a real stake in the game so that it's not just a sort of lip service that's being paid to them, but rather, what do you think is the best strategy here? How might we assist in the creation of this program that ultimately is designed for and by you? I think it's also important to affirm that persons who use substances really are the primary agents of thinking about how to reduce harms and really empower them to share information between each other, acknowledging that there is community knowledge, that there is community information that can and should be leveraged in order to reduce harms. Again, we want to do this with the understanding of the social and structural determinants of mental health, recognizing that the isms, poverty, class, history of trauma, as well as discrimination and inequality, are also major factors in why it is that someone, again, might initiate or use substances. And at the same time, we want to be able to hold both things as true. We want to acknowledge that there certainly are harms, very real and very tragic harms that can come from substance use, and so that our work can then really focus on how we minimize those. It's also important to sort of acknowledge Housing First. Housing First is an initiative that really focuses on how it is that, particularly among persons who might be unhoused or have housing insecurity, that trying to establish abstinence or really even reduce harms in the context of the stress of living on the street is virtually impossible for so many people. And so can we acknowledge that sometimes just making sure that people have access to the basics can also reduce harms and also potentially substance use? There is more conversation now about autonomous health movements, again, that community-based approach, and really allowing people to exchange that information within the community, recognizing that community actually carries medical knowledge and that conversations between peers and between fellows can also, again, reduce harms. Finally, and I think that this is kind of one of the more interesting aspects of this conversation, is the rejection of legality. Again, how can we as health care providers, as people that work in the mental health field, hold space for people who provide harm reduction services when those services, again, might be illegal in the city or the state in which you live? A list of services and supplies that are currently available, I think it is important to recognize that these interventions now represent allowable costs by SAMHSA funds. So for our treatment facilities and for our grantees that are particularly interested in providing harm reduction services, there are now federal funds that can be used to support that type of work in your various institutions. When it comes to harm reduction effectiveness, there is some data to suggest and to support the use of harm reduction strategies. Now, when it comes to interventions to reduce road trauma, I think historically we've thought about seat belts, for example, as one way of reducing road trauma. But rideshare services, use of Uber, use of Lyft, and really talking to patients about how they might plan their night, even if they're not necessarily thinking about reducing the amount of alcohol that they're consuming in a night, you might be able to talk to them about, well, maybe just Uber instead, ultimately reducing that likelihood of them getting involved in a motor vehicle accident from that standpoint. There is limited research to support other types of alcohol interventions. And when it comes to things like managed alcohol programs where people really try to incorporate a drinking goal and reduction of drinking goals, that data has been a little bit less widely accepted. And in fact, there was a recent Cochran analysis that found that really no studies were even eligible for study inclusion. When it comes to tobacco, I think it's important for us to kind of acknowledge the place in the space of medicinal nicotine products. Now, depending on who you speak to, some people believe that that is a harm reduction strategy, whereas there are those of us that believe that is treatment. So, I think it's important for us to acknowledge that there are those of us that believe that is treatment. We are providing treatment to persons that might have nicotine use disorder. More recently, there's been data to suggest that even the use of electronic cigarettes can actually help to reduce smoking. However, at the same time, there's limited research to support some of these tobacco harm reduction interventions in terms of the tobacco-related exposure, morbidity, and mortality. Importantly, physical activity is helpful not just with other types of substance use, but really in particular with tobacco. So, can we encourage people to get more active? To what extent are you engaging patients in conversations about exercise as a means of using that as a harm reduction strategy for tobacco and other substances? When it comes to drugs in particular, we have a history of supervised injection facilities that have been found to reduce opioid overdose, morbidity, and mortality. Of course, there are overdose prevention centers here in the state of New York that people have been keeping their eyes on these overdose prevention centers in order to get a sense of what kind of impact does it have to allow a safe place for people to engage in substance use and to receive additional services while doing so. Again, we've talked about Housing First. Housing First has shown some evidence in terms of reducing delirium tremens and other substance-related mortality, although more research is needed. We have underwent our understanding of syringe service programs, recognizing that clients may be more likely to seek treatment because you've developed and engaged those individuals in conversation, developed rapport, and from that space have probably created an opportunity to really speak more honestly with them and provide a little bit more support. And of course, harm reduction sites as being places for also providing buprenorphine maintenance treatment to those with opioid use disorder. Just a quick word about barriers and facilitators to implementation. When it comes to barriers to implementation, there are some at the individual level, and the one that I really wanna kind of focus on is mistrust of healthcare systems. So much of the work that we have to do in mental health systems is really about engaging people, talking to them about sort of where they are, and accepting the goals that they set for themselves. Now, I certainly can internally have in mind this idea that like, oh my gosh, I really wish that you would establish abstinence. I really wish that you would get sober. And oftentimes my patients come in and that is not where they are that particular day. Sometimes they're like, I wanna reduce use of this substance, but I wanna keep using these substances, plural. And so in those moments we just take a deep breath and say, okay, well, I'm gonna breathe through that and I'm gonna work with you on your treatment goal. And the reason that we sort of center that as our approach is because it can ultimately help to establish trust with patients, given that there is so much mistreatment and mistrust that so many of our persons who use substances have encountered when they come to see us. Of course, there's the stigma and that includes the stigma that people carry about and within themselves about the behavior that they may be engaging in and all of the shaming that can take place as a result of our society. From an interpersonal standpoint, there can be a number of familial barriers. People in the family or in relationship to the individual might say, listen, I understand that harm reduction may be your goal for yourself, but my goal for you as your mother, father, husband, wife, brother, sister is abstinence. And so that setup actually can mean that sometimes while we are aligning with our patients, the family can feel like we are colluding with the patient and that we're actually working against them. So how then can we manage these kinds of conflicts when they are sure to come up when people have a different idea about the type of treatment that they would like to engage in versus the type of treatment that their family or other people in relationship with them might like for them to engage in. Of course, there's also things related to trauma, gender-based violence, which also can serve as a barrier and really keep people from accessing not just mental health services, but all types of services within the mental health system, within the healthcare system, excuse me. There are institutional barriers that exist, high levels of organizational expectation, a lack of available services. So where in your organization do you refer someone if they are interested in syringe exchange? Do you know where to send someone? And how do you go about making that referral? There's also sometimes limited information or knowledge about the regulations of what I can and cannot say to someone as a provider related to allowing them or sort of encouraging them to access those types of services. Really, what liability am I sort of establishing for myself if I give them Narcan and I also give them the information related to syringe exchange? Can be complicated for some folks. And then at the population level, there are negative stereotypes, many of those social and structural determinants of health and of mental health that I've already discussed, as well as criminalization of substance use and people's very real concern and fear that just by having these conversations with us, that they may be reported and that they may be ultimately experiencing criminal justice consequences as a result of having those sorts of conversations. When it comes to facilitators, the first one is education. And just by being here today, we are actually breaking down barriers to people accessing harm reduction services. So I want to thank you for your harm reduction work. Just being here is an effort in engaging in that type of work. One thing I think it's important for us to, again, kind of center is a spirit of openness and really collaboration with patients, making sure that we check our own sort of anxieties about the expectations and goals that we set for patients. Instead, centering their goals. Again, that's easier said than done. Talking to community, building relationships with community and providing community support, as well as finding support within organizations and helping people to understand and address their fears regarding liability. I think it really is important to think about flexibility when it comes to harm reduction services. And so are you only providing harm reduction services between the hours of 8 to 430 Monday through Friday? What does it look like to provide harm reduction services to people after hours and on weekends? Can we be more flexible in the way that we create these sorts of programs? Is it necessary or would it be helpful to create specialized teams who really understand the models of harm reduction and the services that are locally available or the resources that are available within the community, identifying champions that might also promote the use of harm reduction strategies and employ those practices and policies? And then finally, are there specific strategies that can be created and should be created within your specific organizations? For example, sharps containers. Do people have a place that they might even be able to dispose of used syringes or those types of things? So when it comes to SBIRT for harm reduction, of course, we take this directly from the screening brief intervention and referral to treatment model. But rather than trying to get somebody into a program that is abstinence-oriented or abstinence-based, how can we shift that so that our conversation is not just solely focused on abstinence, but rather focused on harm reduction and getting people into those sorts of services? It involves conversation with patients as well as community members, oftentimes with families. It will require that we collaborate with local partners as well as other healthcare organizations. And really, this will require innovation. How will you need to change the programs in which you work to not only have opportunities to provide treatment, but also harm reduction? And with that, I will go ahead and pass to Dr. Wallia. Thanks. Thank you. So, before we get to Dr. Wollia, we want to make this somewhat interactive, especially for the folks that are here in person, but we'll also include the folks that are watching virtually. You could use the Slido app. It's for asking questions, but you can also submit comments as well, and we'll make those available for other folks virtually, and I can read them out here for folks in the audience. Oh, okay. If it's not picking up, okay. We're going to do some interactive, so if you are watching online, you can submit through the app, and for the folks that are here, I want to pose a question and come up to the microphone if you'd like to make some comments, but what we want to ask and find out from everyone here is, are there harm reduction strategies that you're using already in your practice, or are there any barriers that you have encountered in doing so? So, anyone who has some experience, feel free to let us know so we can share, and we'll also talk about some additional opportunities for things and how to implement this as we go along, but I am interested, and we're all interested in hearing people's experiences, so far in this arena, and again, online you can submit a comment through the Slido app like you would a question. Well, the good news is I guess this is fertile ground for learning, so we appreciate that. All right. So we'll go ahead and there will be time for questions at the end as well, either through the app and in person at the microphones. So without further ado, Dr. Alia, we'll talk about SBIRT. Thank you for being here, everybody. It's always exciting to come to ABA. This is my third year. I started coming here as a postdoc, and it's even more exciting to come back as a resident. Thank you for introducing the topic, Dr. Shorter. We'll switch gears a little bit and talk about SBIRT model. I'm sure as clinicians and researchers, we've either learned about it during our training or use it in daily clinical practice. So as we all know, it's just a quick overview. It's like a comprehensive tool that we use to assess if our patients are at risk for substance use disorder. It includes screening, and then we provide either interventions or refer them for treatment. So SBIRT has been around for a couple of years, tons of years. It started in 1980s, and initially it was used for alcohol and drug use, and then when more research started emerging and we had more data on its validity and reliability, it was started for screening for illicit drug use, for tobacco as well, and for prescription drugs as well. To date, we have a lot of studies that show how effective SBIRT model is, and especially how it yields short-term improvements in people's health. So that's an overview of what SBIRT includes. It's an easy way to assess if our patient needs some specialized help. So we screen our patients for risk of substance use. If they are at low risk, we do not do anything at that time. We just continue to follow them, continue to screen them at every visit. If they are at moderate or high risk, then we either provide brief intervention or brief treatment. Brief intervention is typically like a single or a couple of sessions, motivating them for change. It could be from like a couple of minutes to an hour, where brief treatment, on the other hand, includes many more sessions where you motivate them for change and also could refer them for long-term rehab if they're interested. Lastly, if the patients are screened and they are at severe risk, then we refer them to specialty treatment. The best thing about this tool is it's quick and easy. It takes about two to four minutes. It's validated. We have tons of research around it. Also, it can be implemented by multiple, you know, a lot of clinicians. It could be nurses, social workers, physicians themselves, or any healthcare professional. Can be used in different clinical settings. It could be a primary care provider's office or even ER. It's very easy to use and is very useful. Like I said, there's a lot of research, so I just couldn't put all of them out here on the slides, but the three ones that I found really interesting are here. The first study was done in a primary care setting, and they showed small to moderate reductions in alcohol consumption that were sustained over six to 12 months or even longer. The second study was done in an ER setting. They did the SBIRT interventions and saw reduction in hospital admissions, traumas, and even injuries up to three years post-SBIRT interventions. The third one was done across different settings, across six states, and over a six-month period. They did see 68% reduction in illicit drug use over a six-month period and 39% reduction in heavy alcohol use. They also saw some psychosocial factors improvement, including fewer arrests, more stable housing, improved employment status, fewer emotional problems, and overall, an improved health. At this point, I mean, aren't we all thinking, like, if SBIRT is doing such a great job, what is the problem then? The problem is, even despite the fact that we can early identify, you know, the patients and send them to specialized treatment, the annual death toll of drug overdose continues to rise in the United States. That's the epidemic that we are facing and continue to face every year. In 2021 alone, there were more than 106,000 people in the U.S. that died from drug overdose. That included illicit drug and prescription opioids. I think the number in 2022 was 110,000, and the projected for 2023 is even higher. Bottom line is, it's getting worse. Since 1999, it's just been going higher and higher, and it affects males and females both. We'll switch gears here one more time. So we've talked about how effective SBIRT is, but there's a little bit, you know, challenges or a little bit problem that we need to address. We'll talk about TTM model of change before we switch to the changes that we're proposing to SBIRT model. Anyone here heard of the trans-theoretical model of change or used them for any studies or any clinical work? Okay. This has been around for a long time, as long as SBIRT, I guess. This was also proposed in the 1990s and revised one more time in the early 2000s, but this theory is based on the assumption that we all go through a common set of changes when there's a change in behavior that's required. So if it's me cutting down on my coffee or my patient cutting down on their alcohol intake, both of us will go through a similar set of changes to bring changes to our behavior. This model includes five stages. It ranges from pre-contemplation, to contemplation, to preparation, action, and then maintenance stage. Pre-contemplation is when patients don't even see that their behavior is problematic. They don't see the negative consequences and they don't intend to make any changes in their foreseeable futures, which is defined as six months. Contemplation stage, on the other hand, is when they do intend to make changes in the next six months. They are able to recognize that their behavior is problematic. They are giving consideration to the pros and cons of changing this behavior. And then the rest, preparation means what it says, preparation, they are making preparations to make that change. Action is when they take the action. And then maintenance is when they are maintaining, they are working on sustaining their behavior. How are we incorporating this into harm reduction is we are targeting the patients in the pre-contemplation or the contemplation stage. When we see patients in the clinic, if they are not ready to make changes or not ready to make changes in the next six months, how about we talk about harm reduction right there? Our goal is to prevent fatal outcomes. Our goal is to prevent the irreversible damage, which is death. How it is done is when you are talking to the patients, understand their motivation to bring changes instead of the traditionally used approach of negotiating a plan to abstinence. This would be like a patient-led approach where we work together with the patients. If they are not ready to make their changes, as Dr. Shorter mentioned, we give them information on the principles of harm reduction, the resources available, local resources especially because that will be beneficial to them, but then continue to motivate them as well. I would just reiterate one more time, there is no recovery from fatal overdose. That's a permanent change that we are trying to prevent here. We must understand not everybody is ready to stop using drugs, and then we have to meet people where they're at. Ever since this concept has come to my mind, I've been trying to talk to my own patients about reducing harm and in what ways we can do that. My co-residents often ask me if there's ever an ethical dilemma in my mind, like I'm promoting drug use. The answer is no. These are the principles we're working on. My goal is to help my patient. My goal is to protect my patient from a fatal overdose. I will have Dr. Weaver give us more on the ethical dilemma and how to work around it with our patients and their families. All right, excellent. Thank you for that very good overview of SBIRT and the trans-theoretical model, also known as Prochaska and DiClemente's trans-theoretical model of the stages of change, and for letting us know about incorporating harm reduction into that. I want to dive back into harm reduction again and talk a little bit about the ethics. Want to set the stage a bit in terms of ethical decision-making. There are some steps that we go through as part of evaluating whether it's ethical or not to do something. You want to identify the particular issue. In this case, with harm reduction, is it ethical to talk to somebody about choosing to continue using drugs, but doing that in a safer manner? Review the various principles at stake, and I'll go over just a couple of them in a moment, and then considering possible solutions. What are the possible consequences, and how can we try to address them, keeping in mind that there may not always be an ideal solution, but we can try to find a solution that at least will satisfy one or more of the ethical principles involved, and take action. And then something that's very important is to follow up, to think about, okay, how did it work out? Was it appropriate? Did it feel right? Was the outcome good, or at least the best possible outcome under the circumstances? So that we can evaluate, would we do it that way again, and if the situation comes up, is there another choice that we would have made instead? So the first ethical principle I want to review very briefly is autonomy. This is something that comes into psychiatric practice all the time. So it has to do with self-determination, and from the clinician's standpoint, respect for persons, respect for the individual that we are treating. So we need to respect their right to determine the action that is appropriate for themselves, whether or not we actually agree with that. And it's their ability to act in accordance with their authentic sense of what is right, what is good, and what is best for them in terms of their situation, values, and prior history. They're the ones who are the expert on their own life and situation, so they are in the best position to determine what is going to be optimal for them in terms of that decision. What we're supposed to do is facilitate. And they have to have the capacity to make that choice freely, without undue coercion. As clinicians, we do have authority, and we can be a controlling influence. Now we can use that for good, in the sense that we can provide advice and we can facilitate, but we also have to make sure that the person doesn't feel coerced. Sometimes that can be difficult, and as Dr. Shorter mentioned earlier, it may be at odds with the goals of the family or the spouse, so we do have to take that into account, and I will talk about that a little bit as well. The other ethical principle that I want to touch on is beneficence. This is the duty to do good for the patient. And in this context, the patient who has an addiction, a substance use disorder that we're going to recommend a course of action for. So it is the responsibility that we have as clinicians to act in ways that provide the greatest benefit for that particular patient. It's not just an obligation to help by being proactive. It's also an obligation to avoid harm by not suggesting options that may actually not be good for that individual. We have to avoid paternalism. We have to avoid the temptation to point our finger and say, you need to do this because I know best. That's paternalism. What we want to try to do is work collaboratively with our patient, allow them the autonomy to make a choice based on their life circumstances. So this is shared decision making as opposed to telling them what to do, because I've certainly found this true in my practice. When I tell someone what they must do, their initial response is, I don't want to do that, even though they know it may be good for them. They also will take the tactic of being oppositional, and rather than trying to have a situation where we're butting heads, I try to have more of a triangle where it is myself and the patient working together against the problem, which is what's going on with their substance use. And then we try to figure out solutions. So is harm reduction ethical, especially in light of autonomy and beneficence? Because there are some folks that if they're allowed to make a choice, they've already been using drugs, so why not continue? So what we need to do is help them to figure out some of the issues that are at play. So by respecting their autonomy in terms of harm reduction, we respect their decision to continue to use, at least for the time being. In terms of beneficence, we want to try to help them to avoid the harm that goes along with using drugs, and we've certainly heard about that. Things like blood-borne pathogens, HIV, hepatitis C, and others, or the social ills that go along with it, because buying black market drugs is expensive, and so that is going to drain resources and other consequences, lost opportunities for schools and jobs and things like that that we know are a part of a substance use disorder. So working with someone around avoiding those kinds of harms as directly as possible. And that will fulfill our duty to inform the patient. Now, as Dr. Shorter said, there may be some opposition, not only by the patient, but from the family or the spouse about, well, we have a different goal for this person. We just want them to stop. We want them to be part of the family again. We want life to be rosy, okay? But it doesn't always work out that way, especially early on, so we have to keep that in mind. The ideal treatment goal may very well be abstinence, and a lot of us come from that background, and we have to resist the temptation to say that's the only way, and that's one of the challenges of harm reduction or clinicians who really do want the best for our patients. We really want to allow that full effort of beneficence to come into play, but we have to keep in mind their autonomy, and they may not be ready yet. So we can talk to them about these alternatives that we'll go into with some examples to reduce risks to health. So another way that this can be beneficial by just having the conversation is to let them know that we are concerned about what's going on with them and their life and their individual circumstances. And so by making them aware of the risks and our concern, we can actually enhance their motivation to change that Dr. Ovalia was talking about, where we can move them along those stages of change by having them recognize that there is more than one way to approach it. And by having that kind of education, then they may recognize that they want more than just the day-to-day, more than just the harm reduction, and they may be more willing to consider a path to abstinence, even if it's not immediate. So how do we incorporate this into a clinical practice? As Dr. Shorter, as Dr. Ovalia has mentioned, we need to meet them where they're at. This is one of the main tenets of harm reduction, is really finding out what it is that's important to them, what they're willing and not willing to do in the moment. But that doesn't mean we say, okay, that's fine. You can keep using. It's okay. We still have to recognize, yeah, okay, absence may very well be the ultimate goal at some point down the road, possibly. So there are a range of options. Safer use, managed use, less use. So it's not black and white. It's not a yes or no choice. It's not all or nothing. There are various stages to it, just like with SBIRT, where you can see, okay, why don't we talk about safer use as opposed to not using? That way, at least they get initial benefits and they are around to be able to consider the idea of becoming abstinent down the road. We want to address the conditions along with the use. So these are the things I mentioned as consequences, social, medical, psychiatric. And then raise the issue as we go along about evaluating where they are and what their considerations are and have they changed their mind in any way about things that they may be willing to consider. All right, let's talk about some examples in clinical practice. One thing that I talk to my patients about early on is, at a minimum, avoiding use in hazardous situations. So if someone has a job operating a forklift, if they're a dock worker or something like that, making sure they're not using, they're not popping pills right before they get behind the wheel of the forklift or before they go work on the dock. I also treat patients who are healthcare workers, recognizing that those are safety or security-sensitive types of jobs. And you have to draw a bright line between what you're doing recreationally and then what you're doing as your profession. I also talk to patients about going into work after using in terms of just being hungover and being less productive because if you get fired, then that helps reduce your resources and your access. And if they're not willing to consider stopping substances at this point in time, then they at least need to know how to continue to obtain them. And then even from a very practical standpoint, I will talk about not being impaired in a context where you may be victimized. So it could be using in public places, or it could be if someone is drinking at a party, cover your drink, make sure someone doesn't slip you a mickey that could impair you or impair your memory, and then someone could be vulnerable to a sexual predator because they are either disinhibited or because they don't remember afterwards the fact that they've been sexually assaulted. So if someone has a blackout, whether it's from just drinking too much or from drinking in combination with using other substances, especially sedatives, letting them know so that they have an awareness of what could happen. Of course, it goes without saying, but I say it anyway, don't drink and drive. And not only is that for the personal injury aspect, but also the fact that they could have legal consequences related to their license. I have plenty of patients that are already on probation for previous DUIs, and so if they don't want to get more points on their license, it could even mean going to jail. And of course, the fact that you could do something to injure someone else or end the life or lives of others, and people really don't want that on their conscience. It's one thing to make a decision about personal use. It's another when that could impact someone else so dramatically. And then things like if I'm prescribing medications for them, talking about not combining things wherever possible. So let's get a little bit more specific. We mentioned already a little bit about naloxone for opioid overdose. So is there anyone here in the audience in the room who is using naloxone, giving it out to their patients, recommending it to their patients? Okay, I see some hands. That's very good. I'm glad to hear that. And so this is an evidence-based prevention for opioid overdose deaths. We have rescue kits in a variety of forms. You can see in the picture here, the nasal sprays in the bottom there are getting more and more popular. There are now a couple of different dosage strengths available in brand name. And then there are the auto-injectors, which are very simple and straightforward to use. You pull off the cap, and there's actually an audible command that tells you, you just put it on someone's thigh and push down. Don't even need to take off their hat. Put it down. Don't even need to take off their trousers. The needle goes right in and delivers a dose that can be life-saving. So these are designed to be used by folks without medical training, and they can be essential in terms of their life-saving ability. However, the caveat is that naloxone lasts 20 to 30 minutes. Most opioids, their effects last four to six hours at a minimum. Some are closer to 12 or 24 hours. Naloxone is not a one-and-done. You don't give it, and the person wakes up, and everybody goes home happy. This is to buy some time for the naloxone to get someone to go from an overdose state where they're close to death, where they are breathing in the single digits, and they are at risk for hypoxic brain damage, to where they are breathing at a more normal rate in the teens, and they are awake enough to continue to do that while the drug is active, so that the individual who's given the dose or another individual in the household can call 911 so that definitive help can get there for additional doses of naloxone, taking someone to the emergency room for continuing monitoring for the duration of the opioid product. And then, ideally, they will get a brief intervention in the emergency department, and we have evidence that that works as well, including initial prescriptions for buprenorphine in the emergency department setting. So, ideally, by giving someone a dose of naloxone, you are setting off this cascade of treatment that will allow someone to come into more contact with the healthcare system. At a minimum, though, I talk to my patients about having it readily available just in case. I do want to let everybody here know that initially, when this was still a prescription medication, most states had policies in place for what they call third-party prescribing, which basically just means that the medical director for the Board of Pharmacy or something similar for each state said, okay, I'm going to sign all those prescriptions in advance. So it was, for all practical purposes, over-the-counter, where people could go to a pharmacy and request it without a prescription. You could even request it for somebody else, again, without a prescription. Now, it is available over-the-counter. The FDA made that decision last year, and they're ramping up production so that this is readily available. However, that doesn't mean that it is without a cost. So it's still going to have to be paid for. There is a copay if it's covered by insurance, or people do have to pay out-of-pocket if they don't have insurance. With Medicaid, it is covered. So the copay is zero for certain forms, but not all brand names. So for some, you can still be paying $150 for a couple of doses. So it may be whether someone can actually afford that or not. So we still need organizations in the community to make that available and to distribute it. But what we can do as clinicians is educate our patients about get it where it's available. We have some familiarity with those resources in our community. That is fantastic. If nothing else, tell our patients to Google where they can get naloxone from a community organization. So I encourage all of my patients to get it. One nice thing about where we are is that the electronic health record will prompt it automatically for certain subsets of patients. And so that can be very, very helpful. We can just send a prescription to the pharmacy, even though you don't necessarily need one. It sends an order, and then that's a prompt for the patient to pick it up and for the pharmacist to have it available and provide education. A lot of the bigger pharmacy chains have actually agreed to have one pharmacist in each store that has training to teach anyone about how to use naloxone in the various forms and what to look for in someone who may be having an overdose event. I also have conversations with household members, not just the patient themselves. I do have an open door policy for parents, children, spouses to come in with the patient. But I will talk to them, too, about why naloxone. The good news is that when folks do have accidental overdose, most of the time someone else is around. And so that person can interact and can intervene to save a life. I tend to use the metaphor of a fire extinguisher. I encourage folks to use this as well. Most households will have a fire extinguisher somewhere. You don't expect your house to catch fire. You have it there just in case. You hope you never need it. But if you do, you're really glad that it's there. So I tell people naloxone is just like that. You hope you never need it, but just in case you do, it's there. And then after someone uses naloxone, it's important for everyone in the household to listen, to figure out, OK, here's why this happened. What was going on? Why did someone take too much or more than they had tolerance for? What was it that they were trying to accomplish? Was it an accident? And how did it come to that? How did they get access if this was one of the things that's already been discussed? Because the more everybody knows about what's going on, the less likely it is for that event to be repeated. Another practical application of harm reduction that I want to talk about are needle or syringe exchange programs. Unfortunately, it's still the case that federal law prevents use of federal funds to support needle exchange programs. They are still considered paraphernalia, and so they are not legal. And people can be prosecuted for distributing in some states. Others have workarounds, and I'll talk about that in a little bit. But despite the fact that federal funding doesn't cover these kinds of programs, over 500 programs exist in the United States, in 45 states all around the country. And they do far more than just provide clean needles and syringes. There's other paraphernalia as well, so clean pipes for crack and meth and things like that. Because yes, that can also transmit bloodborne pathogens. They do testing for all of those bloodborne pathogens on an ongoing basis, HIV, hepatitis B and C and whatnot. So they can help people to recognize what some of the other health risks are and mitigate that. Naloxone distribution is commonplace in a lot of these programs. And so that's an organization that can be very helpful with this. And who is it that is working in syringe exchange programs? It is folks who are in recovery. So the ones that are there giving out the needles are folks who've been there, done that. They know what's going on. And so they can talk to the people and say, I'm a role model. If you want what I've got, keep talking. So at a minimum, harm reduction. But it is a way to engage people who may be more treatment-resistant, for whatever reason. And for them to see what someone can have that they don't have yet. And that can be a marvelous incentive for them. As I said, a role model for them to realize, oh, you know, that's pretty good. Maybe I should even consider the idea of thinking about maybe doing that myself. Another thing that is very good for needle exchange programs, and one of the original reasons that they were developed, is for reduction of transmission of blood-borne pathogens. But really, with clean needles, you can reduce the risk of all sorts of infections. And that is a significant benefit from a public health standpoint. But as I mentioned, really, the best utility of these kinds of programs is to engage those who don't seem ready to engage. They have said, for whatever reason, I'm not interested in formal treatment. So this is a way to get them to see what the benefits are, what the promise is. And if you want information about where they may be in your community, whether it's here in New York City, whether it is West Coast, whether it's in Texas like we are, the North America Syringe Exchange Network is a great website at the end. And all the slides are available through the app. So you can have those to download. But our last couple of slides are resources, including websites. So we do have links to these in the slide set, if people are interested. So as Dr. Schroeder mentioned, we have to think about laws in our community and how to talk to patients realistically about what are some of the barriers, what can we or can't we say about certain things. And unfortunately, there is a lot of variability from jurisdiction to jurisdiction, from state to state. As I mentioned, the needle and syringe exchange programs may have some pretty significant restrictions. And in Texas, there are lots of restrictions, unfortunately. And as was already mentioned, things like test strips are also considered paraphernalia where we are. And that is a significant challenge as well in terms of making recommendations to patients that are living where we're treating them. And we have to be very careful and cautious about things like that. Now, some workarounds as far as syringes go. You can actually legally prescribe syringes in all 50 states. So at the federal level, that's a standard. And so if you write a prescription for syringes, that can allow someone to have legal access to them if there are prohibitions against needle and syringe exchange programs or for whatever reason they're not readily available in your community. And we do this for diabetics all the time. My background is in internal medicine, actually. And so when I was doing primary care, this is something that is pretty straightforward. You write for a bag of needles. And it's legal, readily available. And pharmacists like this because they can fall back on, well, the doctor wrote the prescription. So it's his or her liability on the line with that. And I don't have a problem with that. Again, it is ethical. It is legal. It is appropriate. So you can do that. And then I mentioned the fentanyl test strips. Fortunately, our own senator from the state of Texas, John Cornwin, has actually introduced legislation at the federal level to try to allow for test strips for fentanyl and xylosine and things like that to not be considered drug paraphernalia so that there will be nationwide access. We have yet to see if that will actually make it into law. It's up in the air for the time being. But we are making progress. And if people are interested, I encourage you to talk to your representatives at the local and at the national level about these issues. So if you have an interest, doing a Google search, making a phone call can certainly go a long way towards having an impact, or at least raising awareness of an issue. And that's something that we can do as individuals. And that furthers the cause of harm reduction. I mentioned already having a conversation with patients. And this is another way to engage with them. But it also helps us as clinicians from a legal liability standpoint. We do have a duty to warn. And we have to keep that in mind. So if we talk to them about the risks, then we have done our duty to warn with the patient, and the ball is in their court. It then becomes their responsibility to act accordingly, to act with due caution. So it is providing them with good, useful medical information, but it is also helping with our own legal liability so that we're not recommending something that is ill-advised or unauthorized. So it's OK to say, yeah, you can get syringes at this place, and that's appropriate. If they've got the permits for that jurisdiction, then it's certainly reasonable to recommend. But if we recommend something for which we do not have a medical evidence base, then that's on us. That becomes an issue in terms of our own licensure. And ethically, as well. So we are open to liability for breach of duty if we recommend something that is not a good idea. So in this particular example, we have evidence. And the Institute of Medicine, now the National Academies of Sciences, came out with a report in 2018 looking at all of the data for cannabis and including things like dronabinol, as well as smoked cannabis and other products, CBD included, and what the research has shown to date about what it's useful for, what it is not useful for, and what some of the risks are. So we know that it can be useful in terms of certain kinds of pain conditions. We know that it can be useful in the form of CBD for certain kinds of anxiety. But we also know that smoked cannabis products don't help to reduce anxiety and can actually increase it. We know that, despite some reports that you see on the internet, that cannabis does not prevent or treat any form of cancer. And it is not useful for things like autism. Either cannabis or CBD has not been shown in the research to date to have utility for that. So if we say, oh, yeah, it's OK to use your medical cannabis to prevent cancer, that is a breach of our duty to provide appropriate evidence-based information. So then the ball's back in our court in terms of liability for a bad outcome. So we do have to keep in mind, from an ethical standpoint, that we're up to date with the medical literature. And if we're recommending harm reduction, that we are recommending evidence-based practices. So the kinds of things that we've talked about here are evidence-based. Naloxone, syringe exchange, reduction, safety in terms of blood-borne pathogens, harmful use, and things like that. So we want to keep in mind that you need to keep up to date. And things do change. That's how science works, which is a good thing. And the reason for this is, even though, again, using the example of cannabis, it has been legislatively either legalized for medical use or decriminalized in terms of recreational use. Those kinds of decisions are policy decisions based on the majority will of the electorate, the voters. But we're not beholden to voters. We're beholden to the medical board, or the nursing board, or the psychology board. So we have a different obligation to offer evidence-based recommendations, which is what we've been careful to talk about today. But it's also good to be aware of what are the variabilities in terms of jurisdiction to jurisdiction, state to state. So know what the laws are where you're practicing. So I promised some pages of resources. Again, these are all available in the slides that you have in the app that you can download and peruse at your leisure. So this gives a number of different websites, as well as some peer-reviewed publications. And then at the very end here, I mentioned Needle and Syringe Exchange, or excuse me, North America Syringe Exchange Network. And there is that website. So we wanted to leave time for questions, both from our virtual audience through the Slido app, as well as for folks here, and comments as well. Again, this can be interactive. We can learn from you. And hopefully, you've learned a little something from us. If you want to ask a question and you're in the room, please use the microphone so that everyone can hear. I know sometimes it's an echo. Plus, they are live streaming and recording this. So we want to preserve that as well and allow everyone to hear both virtually as well as in person. And again, for those of you who are live streaming, please use the Slido app. Feel free to do your questions and comments through that. And we'll get to questions. And again, thank you so much for coming on a Sunday and giving us your time and attention. Thank you. I can't tell if it's on. Can you hear me? Yeah, okay. The biggest problem I find with trying to educate alcohol users, abusers, and marijuana abusers, maybe more so than opiate users, about safety with regard to, say, driving or avoiding hangovers, when they use they no longer, their judgment is just gone. In addition, their psychomotor skills are terribly affected, and they have less motor muscle ability as well. So it's like you're working with somebody who just isn't capable of using educated decisions. And they're high and stuff. Or even with marijuana, especially for a long time after it stays in the brain so long. Anyway, just comments on that would be helpful. Yeah, absolutely. I think one of the shifts that had to occur for me as a provider was getting kind of into the trenches with patients and talking with them about their use and how to plan what their use actually looked like. So when I was in training, I recall much more of a just say no, don't do that, here are the dangers approach. And what I recognized was that even though I was giving people information, what I called psychoeducation at the time, and also I would like to add, I would document it as psychoeducation as well, from this sort of medical legal, very paternalistic way of thinking about it, to say that I have discharged my duty by telling this person to not drink and drive or not do this X behavior after they've engaged in substance use. So more recently, what the conversation looks like, okay, well, let's talk about what your Friday night is going to look like. And if you know you're going to engage in use, all right, so how do we plan to do this in a safe way? What does it look like for you to, instead of meeting friends out and you plan on driving, you know you're going to binge drink. We know that this is going to be an episode of heavy alcohol use. Can you plan instead to simply Uber to and from your location? Can we make that the approach from a harm reduction standpoint, recognizing that you still want to drink 10 drinks, which is dangerous, which I also want to acknowledge here. But if what I'm trying to do is to keep you off of the road, let's have that conversation and then keep you alive long enough so that we can continue to do motivational interviewing around goal setting, around values-based living, and around quality of life so that you're here for the later discussion. But in the meantime, just take an Uber or a Lyft. I don't want to seem like I'm advocating one particular ride share over another, so let me, for our people at home and for the video. I almost find that marijuana users are more difficult because it's organic, it's natural, and of course they don't have as many accidents as alcohol users, which is totally not true. They have more in New York State than alcohol users, so it's just really difficult. I have tried to use family interventions if they'll give permission for that. I try to educate patients about some of the things that you have said, which is the effects of cannabis have different phases. So initially they get the giggles and the effects that they're looking for, but when that kind of wears off after a few hours, they are still intoxicated. And I talk to them about the fact that what you mentioned, the motor impairment, the judgment impairment, those last for much longer. And the dangerous part is they don't think that they're impaired, so that's when they get behind the wheel. So I talk to them about planning ahead, just like Dr. Shorter mentioned. If you are going to use, make sure that you don't have to go anywhere or you've got a ride or you've got the Uber, Lyft, whatever app available so that you can be safe because the effects are going to be much longer than you realize for some of the things that can end up killing you. And so I'm very upfront with them about that and provide education about that. If you're going to do this, be well aware of what all the risks are so that they can make an informed decision. And as Dr. Shorter mentioned, the key is planning ahead. I also want to just offer that it's very easy for us to focus primarily on operating a motor vehicle, getting behind the wheel, but there are so many other types of harms that people can experience in the context of substance use. And so really talking to people about, well, should you be considering HIV pre-exposure prophylaxis? Should we be talking about doxyprep? What other kinds of things can we institute that will reduce other types of harm for you? Can we have conversations about going out with friends as opposed to using in a solitary or solo fashion? Or using with friends in a home setting so that you can reduce likelihood of someone perhaps being assaulted or struggling with issues related to consent during times where they are interacting with someone from a sexual standpoint. So there's lots of different types of harms that we actually can and should talk to patients about reducing, in addition to getting behind the wheel. Yeah, talk about start low and go slow. If it's a new dealer, new batch, something like that. Just use a little bit until you're sure how that's going to affect you. Have a wingman or wingwoman. Use with somebody else. Again, especially if it's new dealer, new batch, something that's different. Make sure that there's someone else around just in case. I have naloxone available and hand out the boxes to patients or send a prescription in through the electronic health record so that they can just pick it up at the pharmacy. The pharmacist throws it in the bag with whatever else they're getting, and that can be a big help as well. Just getting down in the weeds with people and how they use forms that bond with them so that we learn about them as an individual human being, and then that allows us to impart information that can be useful to them in those circumstances. I just want to add, I think this conversation will be very like case-by-case basis depending on what the patient is using, how much is it using, and what their overall situation is. But there's one thing I've talked about to my patients is also like drug holiday. Maybe using it daily, maybe talking to them about using it less number of days per week just to reduce the harm by reducing the quantity. That's another conversation that I've had. And also just to acknowledge real quickly that this is not stuff that is taught in a medical school curriculum, that this is not oftentimes covered in a general psychiatry residency curriculum. Oftentimes we really feel as though we are embarking upon new territory. Most of us have not used those types of substances or have that history or could talk about it from our own experience. I think it's okay for us to just acknowledge that sometimes we're coming to this from a place of what feels like a great deal of ignorance and sort of a lack of understanding as well. That's why I think it is important for us to engage in these sorts of conversations here at conferences to exchange information so that we have better harm reduction strategies to offer patients when it comes to them reducing their own harms in the context of substance use. I do want to bring in some of the comments that are in the app for our virtual audience so that our live audience here in the room can hear. Someone had mentioned that it's good to remind ourselves of the medical oath, for those of us who are physicians, to do no harm with respect towards each other. This is another ethical principle. I didn't go over it here, but non-maleficence is actually a term that was coined that means do no harm. That's another one that can come into play in terms of making sure that we understand that harm reduction is ethical. Helping patients to come to an appropriate decision, but it also means not putting them in a situation where there is harm to begin with, so not offering them options that are unlikely to work for their circumstances or recommending something that they simply cannot comply with because they can't afford the treatment or it's too far to travel or they don't have the child care options to make it realistic. Another comment that was made here is, did anyone else have thoughts on that? Yeah, I was just thinking about how much of our drug control policy and sort of historical way of thinking about this has been really much more instructive, telling people don't do that, don't do this, do that instead. If we even zoom out and think about this, not necessarily from the standpoint of drug use, but really any sort of health behavior, we recognize that people are people and they are going to people. If someone has hypertension and their doctor tells them, you know, you should eat a low-sodium diet, I guarantee you that person is going to have fries at some point in their life again. There are plenty of folks that have diabetes, type 1 or type 2, and on their birthdays they have cupcakes. So the reality is that it's not necessarily reasonable to tell somebody don't do that, don't engage in that behavior, don't do that for the rest of your life. Can we acknowledge that there are different types of conversations and messages that we can and should convey to people that ultimately reduce their harm so that if somebody has hypertension, I'm not talking about anybody that I know personally, if somebody has hypertension, they take a blood pressure medicine and their doctor says, well, you know, you should probably reduce the number of potato chips or french fries that you eat on a regular basis. You say, okay, well, I'm going to do that less. I'll take a Doritos holiday as opposed to eating them every night on the sofa like I might have once done in my life. So the conversation I think just has to change and evolve in order to do no harm and keep people actually engaged in care. Keep in mind that these are folks that are dealing with a significant amount of mistrust of health care systems, which means they don't really trust what you have to say anyway. So your don't do that message actually creates more of a wedge between you and the people that you are trying to provide care to, and it's ineffective. Go ahead and use the microphone. We appreciate that. So our virtual question. What I've learned is that people who use drugs of any sort excessively, which we used to call drug abuse, they of course are experts at BS because they live in that world. And if you take their BS, then you don't have a chance with them. So I have learned to call them out more. For example, if they come in high and you could tell, eventually I'll say, OK, I know you're high today. So there's only a limited amount that we could talk about. So what's the top priority for you today? And then when you come back more sober, we could have a longer conversation if you want. I also have found that they enjoy joking. So I kind of paradox them at times. They seem to appreciate that in some way. I don't know. Just try to make it less serious. I mean, serious, obviously, but less serious in that sense. Very good. I do want to have another comment that came in through the app. So it says, sometimes if you recommend Alcoholics Anonymous or Narcotics Anonymous meetings, patients will decline. And they say, I'm not interested because it's a trigger for me to use again. So what I do in practice is kind of talk to them about what those meetings are really like. If they haven't been, let them know. If you have to drink, if you have to use before you go to a meeting, that's OK. There's no requirement to be sober at a meeting. The only requirement to go to a 12-step meeting, or some of these others, Smart Recovery, SOS, and whatnot, is a desire to become sober. In fact, that's how we know who the newbies are. It's OK to be intoxicated in a meeting as long as you're not disruptive. So I tell them, if that's what you've got to do to get there, go. It can still be helpful. Also, talk to patients about what you're there to do is learn. You may learn from some people, but not everyone. So if someone is giving obviously bad advice or just indulging their own narcissistic tendencies, then that may not be someone you want to listen to. You can be selective about that at meetings. And then just talk to them about other potential barriers, transportation and things like that. Meetings are online. Or if you go to a meeting and you say, I need a ride, hands will go up. It's OK. Once you get to one meeting, you can always get to the next meeting. So talk to them realistically about what to expect so that it doesn't seem so foreign. Or if they say, well, people talking about using, makes me want to use, it's like, OK, that's part of why you network afterwards, why you go out for coffee instead of a drink or to the drug den or whatever. And it's why you look for a sponsor, why you get a phone list so that you can work a program so that you can benefit from it as opposed to just, well, all you do is sit in a meeting for an hour once a week. I think in addition to explaining the way that AA or NA works to people, I oftentimes will step back. And I don't argue with the person. If you don't want to go to AA or NA, I say, fine, don't go. I really encourage people to think about what might really be the best fit for them. I oftentimes talk to people about multiple pathways to recovery. There are multiple pathways. No one's pathway is necessarily the one that you will have to utilize. You really want to find your own way. And can we look at this as a time of exploration? Can we think about this as a time of experimentation? So in addition to perhaps going to different types of AA or NA meetings, can you try SMART Recovery? What does it look like to go to Refuge Recovery, to go to Dharma Recovery, to go to SOS? How about we use this as an opportunity to say, I'm going to try lots of different things. I'm going to throw everything at the kitchen wall that I can't and just see what sticks. And then we come back and have a conversation. You say, what did you like about this one versus this one? You make it sort of a fun exploration for the individual. You talk about lots of different kinds of meetings that people might go to as opposed to just one. And then the person can really kind of pick and choose, well, I like this one. I didn't like this. I like that. I'm going to put those two kinds of meetings together. And I'll try those out. And I'll create something that is just the right fit for me as the individual. And that way is how we can really help people to understand that there are lots of different ways to engage recovery, if that is even really what you're ultimately interested in. All right. I think that's all the time that we have. Well, if you've got one more question or comment, please come to the microphone. I think we've got time for that. Thank you so much for the submissions. I just want to ask something regarding the management of paraphernalia, especially for people where we give needles, ridges, and other things to use. We didn't talk about condom distribution. I don't know if this is something that the policy in this country allows or not, because I think it's also something that really supports prevention of disease transmission, HIV. But I just don't know this. Absolutely. So condom distribution and other types of contraception should be made readily available to folks. I think one of the challenges that we can sometimes find in certain types of health care systems is that people don't necessarily feel equipped or adequately trained to provide education as they are also distributing X. Or they might not necessarily have done what they feel is the appropriate medical evaluation, serological evaluation, assessment to feel comfortable prescribing or providing whichever type of contraception. So I think that this is where our community partnerships really become important, so that if I'm not necessarily doing that particular part of harm reduction within my organization, I at least know where to refer you so that you can seamlessly get access to condoms, contraception, whatever the thing is, even though I myself might not be doing that. All right. Well, thank you so much for the questions and the comments. We appreciate it. Again, thank you for your time and attention on a Sunday afternoon in New York City. And we hope you enjoy the rest of the conference. Have a great day.

SBIRT-H

harm reduction

Michael Weaver

Namrata Walia

Daryl Shorter

opioid use disorders

medication-assisted treatment

patient trust

naloxone

needle exchange programs

ethical considerations

substance use