Well, good afternoon, everyone. Thank you so much for coming to our panel. I know you've had a long day and had some wonderful learning opportunities, and we hope that you will find our session today informative and helpful. Please, we will have 30 minutes at the end of our presentation for discussion and questions, so we want this to be interactive. I will also ask you to think about what's going on in your neck of the woods, as Al Roker says, regarding issues around opioid use disorder, overdose, the opioid epidemic, the overdose epidemic, and what we want to make sure we do is have an opportunity to not only learn from us, my amazing panelists, but also learn from you. I am Dr. Patrice Harris. I am chair of the panel today. With me is Dr. Dan Ciccarone and Dr. Smita Das. You may have seen in earlier versions of this panel Dr. Sarah Wakeman, but she was unable to be with us today, so we're going to make sure that we cover some of the things that Dr. Wakeman covered, and, again, we want this to be a very interactive and engaging panel. And so, yes, what lies ahead? After a lot of work from certain people in this room and many others, the X waiver is gone. So now what? Yes, we should applaud that, because that was a lot of work, a long time coming, but now what? And I will say that we have an obligation to be ready and to make sure that we live up to some of the things that some of us said. We said, you know, please remove the X waiver. It was a barrier to physicians and other health professionals offering care, and so now I think we should all take up the mantle, those of us in this room, and if you're in this room, hopefully you're an ambassador as we leave, because we certainly know, you'll see it today, but I think we come to this meeting knowing that most people in this country, actually, who have an opioid use disorder, really any substance use disorder, can't get the care that they need, and so this is an all-in proposition. We can work individually as physicians, as psychiatrists, as clinicians. We can work with our primary care colleagues and collaborative care, and later on in this session, I'm going to talk a little bit about work on the policy level, because, again, it's going to take work in all of these areas. So I am not going to give long introductions. I will let my colleagues give a brief introduction. You have our bios in your background information. So with that, I'll turn the podium over to Dan. Thanks, Dr. Harris. Hi, everyone. How are you all doing on day one? Still reasonably awake? Thumbs up? All right. My name is Dan Ciccarone. I'm a professor here in San Francisco at the medical school UCSF. I've been, for 23 years or so, been doing addiction medicine and a lot of research in the public health dimension of substance use. So my job today is, and I was a proud part of this elimination of the X waiver, both working with the Trump administration and the Biden administration to make it happen. My job today is not really to talk about that, per se, but to set the foundation for what is the problem, the historic overdose epidemic that we're in, driven by opioid pills, then heroin, then fentanyl, and now fentanyl mixed with methamphetamine and cocaine. I'm going to lay all that out so that my colleagues can then talk about more of what's actually in the title of the presentation. So I'm going to talk about the fourth wave of the opioid overdose crisis. In order to get to the fourth wave, I'm going to talk about the three that came in front of it. Here's my financial disclosures. I'm working with Solero Systems on an overdose treatment device. I will not mention it today. And I'm also the voluntary medical director of Remedy Alliance. We are the nation's largest wholesale buyer's club of naloxone, trying to get the price down. All right. Here's the bad news, right? This is US mortality data for the last 100 years. We see a big spike back in 1919 of the so-called Spanish flu pandemic. And then you see this sort of steady progress down in terms of mortality rate, what we would expect. Unfortunately, that's been disrupted by two things. One is the most recent pandemic, which just recently ended in terms of its official declaration. But it's still ongoing, fairly dramatic rise in deaths, as we're all aware of from reading the newspapers and sympathies of anyone who's personally affected. But what I'm going to talk about today is what happened just prior and through the COVID epidemic, which is the drug overdose phenomenon, which is a reversal of fortunes, right? It is so big a phenomenon for a specific age group or specific groups at risk that it's driving US mortality rate up. And related to that, in the inverse, it's also driving life expectancy down, right? Both COVID and the opioid overdose problem. So this has come in four waves. The first wave was deaths due to opioid pills, overprescribing, over pharmaceutical detailing, blind eye to regulatory events that should have happened to keep the supply under control. A lot of diversion drove street pill prices down, street use up, and with that, overdose rates. As we pulled back on those opioid pills, we did a good job, did a really good job pulling them back. But we pulled them back so quickly that a lot of people went hungry in an addiction. That's an official term, right, in addiction? No, they go hungry. Craving, right? So had large amounts of dependency, had choice to either escalate their economy in terms of finding rarer pills or switching to a cheaper, more available, and highly pure product called heroin. So then for a couple of years, we saw heroin use rates and overdose rates go up. Unfortunately, there was not enough heroin to go around. So we get to the third wave, which is fentanyl adulterated heroin. People were not used to the potency of fentanyl, and that drove overdose back up. And we're still in a historic synthetic opioid overdose phenomenon. Fourth wave, deaths due to, sorry, there's a little out of sync between this and that. Fourth wave, deaths due to methamphetamine and synthetic opioids in combination. I've written an editorial on that. We're starting to really wrap our hands around what this means to have yet another wave of this 20-plus year epidemic. All right, here's another visualization from the CDC. This brings us up to present. This is the most recent data, up to December of last year. We see a little plateauing of the overall opioid overdose rate. That's in black. And then the fentanyl curve is just below it. And you can see that not only is it driving it, but it's also flattening out as well. And then if we go down a little bit, down, here we go, methamphetamine cocaine overdoses. This is overlapping data. So a lot of those, and I'll show you another slide, a lot of those cocaine and methamphetamine overdoses are fentanyl related, and vice versa for the fentanyl curve. So what is fentanyl? It's a synthetic lipophilic phenylpipiridine opioid agonist. Very strong, right? Because of the lipophilicity, it's 100x morphine by weight, 40x heroin by weight. We're not talking about diverted pharmaceutical fentanyl. That happens at a very, very low rate. It happens in other countries at a very low rate. We're talking about an illicitly manufactured powder or pill form of the drug. It was largely sold as heroin in the East Coast, but now is increasingly sold as is. So in addition to fentanyl, there are hundreds, I think we're well beyond 200 at this point, 400 maybe, analogs. These are simple chemical cousins where the backbone of the chemical is there, but you've changed a group. It makes potency sometimes higher and sometimes lower, right? And that's a problem, because as they come in and out of the illicit drug stream, those vicissitudes create overdose risk. One day you're using mother chemical fentanyl, then you're using acetyl fentanyl, which is 3x heroin, and then the next day or the next week it goes back up to mother fentanyl. That's an overdose risk, at least on a population level. In addition, we have these super strong NIL fentanyl analogs like carfentanil. This is 10,000x morphine, not meant for the human drug supply. It's meant for large animal veterinary medicine. Where's the fentanyl coming from? This is sort of almost a cartoonish schematic, but it comes from the DEA. It's a DEA report that says all arrows start in China. So illicit manufacturers and distributors in China coming in large quantities at low purity to Mexico to be mixed in with heroin and brought to the United States, coming in direct through the dark web, all sorts of qualities and all sorts of specificities, and then brought to Canada, pressed into pills, and brought south. Those are the main trafficking patterns. Where is it landed? It was a regional problem, sort of setting up a straw dog here, where the Midwest down to Appalachia, over to the mid-Atlantic, up to New England, was the first zone that had this adulterated, this contaminated heroin. It is now spreading nationwide. The fourth wave is that nationwide expansion of fentanyl. It's also a rise in stimulant and fentanyl co-use in deaths. And it's also an unfortunate rise in African-American and Native American overdose rates. And I'll show you all that data. All right. Yes? No? There we go. So no longer regional problem. That picture's going away. This picture's coming in. This is literally about a week old, this graphic from the CDC with the new provisional data release. And it's showing states in blue, overdose rates going down, states in some color of tan brown going up. So the United States is in the transition moment now, where fentanyl deaths are lowering in some places and rising in others. It's not quite the clean stereotype of all blue to the east and all brown to the west. But there's a little hint of that, that Western expansion. We've also concurrently, as this opioid phenomenon has matured, finding increased use of the speedball, the combination of an opioid and a stimulant, whether it's a heroin-cocaine speedball or a fentanyl and meth super speedball, two very powerful drugs being put together, driving the cocaine-related overdose rate up about threefold, driving the methamphetamine overdose rate up 18-fold. Now, about a third of all opioid overdose deaths are the commingling of stimulants and fentanyl. Of that 33%, 80% involved illicit fentanyl. I'm sorry, 33% are stimulants plus an opioid. Of those, 80% involve a fentanyl. Two-thirds were cocaine and fentanyl, and one-third methamphetamine and fentanyl. This is the CDC SUTRS data. And here's the disparity issue. Let me use the, can I put a, nope, I didn't. We see African-American overdose rates remained low. Why? Disparities in access to pills. But then, as the heroin wave comes in and as the fentanyl wave comes in, no longer protected by either pill supply or by a stable heroin supply in some of our inner-city communities, now exposed to fentanyl. So the rates are now exceeding those of whites. Where this goes next, I don't know. But I'm worried that it only goes up. And it's not just African-Americans. It's Native Americans and Alaskan-Americans. How am I doing on time? Keep going? Yes. All right. So a little bit about what's coming up. Some of this is bordering on speculation. I've been studying the opioid epidemic for a long time now. I do street-based ethnographic work. I have feelers on the ground all around the country. This is what I think is going to happen next. So the increasing use of stimulants plus fentanyls makes sense. People are trying to, believe it or not, they're trying to adjust from the side effects of the fentanyls at this point, including a belief that fentanyl may not be an actual reality or might be a partial reality, that they're protected from overdose when they use methamphetamine. We have some data on that. I'm not going to show it today. I apologize. But whenever we hear a strong opinion on the street, we try to follow it with statistical data. And I think we have a signal there. The other signal that we've picked up is that the methamphetamine that's coming in now is super strong, super potent, super high D-isomer to L-isomer ratio. And word on the street is it's causing people to tweak more, a lot more mental and psychological symptomatology. And we're exploring that also in a statistical way. We also have a signal there that we're working with. Other things that are up and coming, counterfeit pills containing fentanyl, which has me worried because these will have appeal to young people, college kids and young adults. And the other thing that we're actively pursuing, at least ethnographically, is a change in route. The pill to heroin transition also involves a transition from people crushing them or swallowing them to people injecting them. Heroin is mostly an injectable drug. It's not very well smoked. But the rise of fentanyl changes that. Fentanyl salts, hydrochloric salts, and citrate salts are smokable. People have discovered that. It's taking off. And we're actively studying that. There we go. All right. Fentanyl-containing pills. Let me just show you the rise in this. This graph shows the proportion of national seizures according to the High Intensity Drug Trafficking Organization, HIDTA. They gave us all their fentanyl data. And this is the ratio of pills to powder. Pills are going up relative to powder. And the number is extraordinary. So in the fourth quarter of 2021, HIDTA folks seized 2.5 million fentanyl-containing pills. I'll remind you all that US Pharmacopedia doesn't create a fentanyl pill. So all pills that have fentanyl in them are illicit counterfeit. That 2.5, you annualize that quarter to speculative 2022 or the next four quarters. You get 10 million seized pills. If you assume a 10 to 1 seizure ratio, 1 to 10 seizure to supply ratio, 10% is kind of a modest number. It could be we could be seizing better, or we could be seizing not as good. But 10% is pretty good. That means 100 million, an estimated 100 million fentanyl-containing pills hitting the American streets in one given year. This is a problem. Smoking. Smoking is occurring. It's 70% of San Francisco injectors of heroin slash fentanyl have switched over to smoking. There's signals around the country that this is happening. It's kind of the 100th monkey theory. Once one group figures it out, transfers through an oral tradition, or perhaps through harm reduction conferences, or perhaps through the web, that this is a doable thing. So I expect to see more smoking. People are smoking large quantities. That chunk in the middle there is fentanyl. It's probably about a gram. It costs $20 on the street. And some people are consuming a whole gram. And what does that mean? So if I take that chunk and bring it to a spectrometry machine, we have these sort of drug checking programs in San Francisco, harm reduction programs now, and they pick it up as fentanyl, that means it's 5% pure by weight, minimal. Because the lower limit of detection of the spectrometry machines, which are routinely picking up positive fentanyl samples. So that one gram, if that person smokes it in a given day, which is what they reported that they do, they're taking into their body 50 milligrams of fentanyl. Try to wrap your head around that. Lethal doses, too, for a non-tolerant person. So the levels of tolerance and levels of use that are happening are extraordinary. I don't know if this is being driven by smoking. It might be. People use high temperature torches. They smoke both on foil, burning the crushed fentanyl powder. In this case, if it started out blue and the liquid turned is also turquoise blue, some people use bongs and will take quarter grams, flash burn them, and take them in. So they're almost sort of mimicking an IV bolus. So what are the implications of smoking fentanyl? Well, it's hard to know, right? There's some positives we can think about. Reduce risk of hepatitis C and HIV. Reduce risk of abscesses. Reduce risk of other bacterial consequences of injection. Overdose? Hard to know. Other thoughts? Keep going? All right. All right. I want to talk just a little bit. I've just got a few slides left about that pause. This is making the rounds in the newspapers now. I think I had five interviews in the last week, various newspapers, New York Times, et cetera, about what is the implication of this. The honest answer is, don't know, right? We had a pause before in 2018, 2019. You can see that plateau right in the middle there. So I don't know if this is a temporary pause or a real pause. If I was cynical, I would say this is simply regression to the mean. The population is starting to burn out. Deadly epidemics burn out. It could also be post-COVID, and as during COVID, overdoses went up. And now there's a little bit of yin to that yang, and overdoses are coming down. So that's the cynical part. The less cynical part is, there's been an extraordinary effort in tackling the overdose phenomenon in many of those states, including, for example, West Virginia, a couple of states in Appalachia that I showed you earlier, the blue states, overdoses are going down. They've gone from, we have no harm reduction, we have very little buprenorphine, to reasonable levels, right? So my positive, my optimistic brain goes there, that the public health response and the clinical response have been good. Will it continue? I don't know. Harm reduction has taken on new life in this country. So in addition to treatment innovations and expansions, there's also expansion of harm reduction. It is now, I was a proud advocate for this, working with the Biden administration. It is now a pillar of national drug policy, along with demand reduction, along with supply reduction, harm reduction. Harm reduction keeps people alive while they're working through their stages of change and maybe knocking on doors for treatment. I think for that, I am going to end. And thank you all for your kind attention. And we'll have time for questions. It's great to see everybody today. Thank you so much for coming to this panel. And thank you for chairing this panel today and having us be a part of it on a topic that's incredibly important and very clearly affecting our nation and public health here, as well as worldwide. And Dr. Ciccarone did an amazing job of explaining the impact of the overdose crisis and the factors that play into it. I am here as an addiction psychiatrist. My name is Smita Das. I'm an addiction psychiatrist. I'm also chair of the Council on Addiction Psychiatry at the American Psychiatric Association. Furthermore, I'm board certified in addiction medicine. So it's really important to me to be able to treat addiction and also to advocate for treating addiction across psychiatry and medicine. I don't have any relevant disclosures to share related to this topic. And for today, I will be focusing in on that piece of addiction, psychiatry, and the interface. These are the few main points that I'll go over, which include overdose and SUD, or substance use disorder, overlap. Because overdosing is not synonymous with having a substance use disorder, so that clarification and that point. Overdose, substance use disorder, and other mental health. We know that substance use disorders are DSM-5 diagnoses. And there's things that all of us in this room treat in addition to those things like anxiety depression so on and so the overlap and Interface there, and then finally I know that This is a very I think sobering talk this is a topic that is Hitting home for a lot of us whether it be with a patient that we know that we lost or a family member The numbers the numbers are one thing and all of us have been affected I'm sure in some way or another by this topic and So with the the staggering statistics that have already been presented to us What can we do as psychiatrists collectively to make an impact and to really help our patients in public health? So we'll start with what are risk factors for overdose there are a lot of risk factors for overdose again My focus is going to be on things that we may see when it comes to mental health and psychiatry so first in both withdrawal and intoxication so drug use states People may overuse a substance or may be at risk of overdose even in withdrawing so for example someone is experiencing withdrawal from substance a and so they use substance B to try to find relief from that withdrawal and Obviously in intoxication from say opioids then somebody also would be at risk of overdose people in recovery may have less tolerance and be at more at risk of overdose when they go back to using a similar level a Common thing that I see within my clinics is that a patient who may have been using heroin in the past for example Is in recovery is doing really well and as a chronic brain disease They may have a hiccup in their recovery path that might mean that they're faced with the trigger They're faced with something that then opens up the opportunity to use that same substance Now the the amount of heroin that they're accustomed to using if they are to go back and try to use that amount again Their receptors have desensitized and they are going to be more at risk of having an overdose at that point And so while it's really hard to talk about my talk about having those difficult moments with my patients Where they might be faced with a trigger? It's extremely important because we know that the risk exists and we want them to be prepared for that risk having psychiatric symptoms can also be distressing and use of the substance could be there to numb or Even with the the idea of having suicidal intent Almost a third of opioid overdoses may be suicidal in nature And so this is a question that we are asking all the time. Hopefully in our visits a psychiatrist is about suicidality and suicidal intent This sec last point that I have here on the slide Really kind of is jarring for me OUD or opioid use disorder Involving prescription opioids is associated with an increase of 40 to 60 percent in risk of suicidal ideation when controlling for everything else so if somebody has a prescription opioid and that has been associated with an opioid use disorder the risk of suicide Increases so if we are again as psychiatrists were assessing for SIHI. It's part of our usual Language and what we do on a day-to-day basis and it is also very important to go through and do that full Reconciliation of understanding what is somebody using because their risk of suicide may be affected by their prescriptions Dual diagnosis About half of people with the substance use disorder have another mental illness Too often I see these things being treated in silos there might be a Mental somebody who's addressing mental health and saying oh you have you have an opioid use disorder or a substance use disorder You need to get that treatment from someplace else and get it treated and then come and see me or on the other hand There may be say there's a lot of substance use treatment centers that only treat the substance and they say oh no No, we don't treat the mental illness You need to go to somebody else to do that and then if the patient is lucky enough to Have the resources to be able to get treatment from both places if the right hands not talking to the left hand That's a complete missed opportunity And so it's essential for treatment to happen in the same place and we can't just expect somebody to come back to our office After four weeks of not using a substance so then we can treat their depression. That's Unacceptable I think and we need to be able to to have some solution perhaps It's not even with the psychiatrist that is seeing the patient first But maybe there is some other solution because we need to address these things together Among adults with opioid use disorder the prevalence of a co-occurring substance use disorder is high So 26 percent of people with an opioid use disorder has another Alcohol has an alcohol use disorder in addition to that and almost about two-thirds have another mental illness The sad part of this is I said earlier if that patient that I talked about the theoretical patient Who's being told by each treatment center to get the other thing figured out if they're lucky enough to get treatment that was a key point because less than a quarter of these individuals who have opioid use disorder and Another co-occurring mental illness get actual treatment for both. So there's a gap There is a gap and we can have an impact again either within our own Offices and I'll tell us in a bit how we can make that impact but also by partnering with our colleague physicians and psychiatrists Overdose death and substances so for a while now here. I've been talking about substance use disorders I think it's important to also look at other substances that might be implicated So we know this was this is similar to a chart that was shown earlier is that opioids dominate overdose deaths? So a lot of times when we're talking about these staggering numbers 100,000 deaths They're they're drug involved overdoses and usually it's opioids that are the main culprit however Alcohol and benzodiazepines are often co-involved and so it may be that somebody Isn't at is at risk of an opioid overdose from the opioid itself but if they're using alcohol or benzodiazepines that can increase their chance of overdose even more and So here again is another opportunity for us as psychiatrists Say a psychiatrist isn't comfortable treating opioid use disorder We can still make and I'll argue why we should be comfortable treating it but we can still make a huge difference by addressing the alcohol use disorder or the benzodiazepine use disorder and Definitely screening ahead of all of that so that we know is somebody on an opioid Maybe they're they are on a prescription opioid and are they using alcohol or are they also prescribed a benzodiazepine? Because their risk will increase Coming to mental health as an addiction psychiatrist, I do focus a lot on substance use disorders But definitely do treat a lot of anxiety and depression and so on 16% of Americans who have a mental health disorder receive over half of all opioid prescriptions in the US So when we have a patient in our office It is a good thing to ask about opioid prescriptions and check for it in the PDMP as I'll talk about later Because this this is a huge proportion and this is also again a risk factor to to have access is something that we we should be aware of people with depression are at significantly increased odds to screen positive for opioid misuse and Severity of depression is associated with that odds So the more impacted somebody else somebody is by another DSM 5 diagnosis the more at risk they are of opioid misuse Now we have been talking about opioids here a lot and that's the topic of today's session I do want to say though that Opioid overdose and overdose in general is a symptom of a larger issue Not enough attention is given to substance use and substance use disorders I will say I am devastated by the numbers that are shown up here that have been shown up here by dr Scaroni because it is This shouldn't be where we're at and having lost patients This this really shouldn't be happening what I am hopeful about at the same time Is that we have this session here that we are talking about it that there is finally attention being given to this crisis What I don't want to get lost though. Is that The idea that if we do X Y & Z we have solved the problem. It is a step in the right direction and Opioid and overdose those are just a piece of something that is a larger picture Issue that we need to confront as psychiatrists and in medicine There's inadequate assessment and treatment in the system when it comes to substance use Substance use is usually where in our in our charts in our notes. It's it's not in our HPI It's not even in the medical history. Sometimes it gets shuffled into in standard EMRs. It gets shuffled into social history and Then it gets lost and so we are not Addressing substance use as the important topic that it is for our patients and it's not necessarily Any individual person's fault. It's the way that the system has been set up But I hope we know now that that is not something that can continue treating dual diagnosis is Essential and I I tried to make this point earlier when I said that half of people with a substance use disorder have another mental Illness, we need to do treatment of both at the same time Too often I hear well that person they're not really going to benefit from me Asking about their depression or asking about their anxiety while they're using this substance We have a missed opportunity there because that might be the anxiety or the depression might be why they came into our office And if we're at the beginning saying I can't help you until you stop using the substance Then that person's going to lose hope they were lucky enough to one overcome stigma that unfortunately is associated with seeking treatment still But two to get access to care And finally we need to work collaboratively as psychiatrists Physicians governments and communities to address substance use disorders our nation is facing and this is all substance use disorders in addition to opioid use disorder So again, these are been staggering statistics and and numbers And and I think we all know from the headlines how much the overdose crisis is affecting our nation Public health and our communities. What can we do? So on an individual practice level? I've alluded to this already Screening for substance use and asking all of our patients non-judgmentally about all substance use Chances are if I don't ask about something specifically Somebody's not going to tell me I might ask you know if there's a standard question on a on a on an open-ended Questionnaire and it says drug use then a patient might say nothing, but if we actually get to talking about it, okay Let's go through each and every substance and let's do this because I ask all of my patients about it because their lives matter to Me so whether it's alcohol opioids cannabis tobacco Nicotine it's important to include those standardly in our assessments and ask about those things non-judgmentally It's also important to know about dangerous combinations I talked about those earlier for example prescription opiate or opiates and benzodiazepines Opioids and alcohol and dr. Chikoroni also mentioned combining stimulants with opioids as well Check the PDMP. This has become so important that in many states There are there are requirements that if we are going to prescribe a controlled substance For example, then we need to check the PDMP the prescription drug monitoring program before we do that and document that we've done so and providing naloxone I'm so excited to hear about your work in in the area of naloxone because this isn't easy This is this is really low-hanging fruit and as naloxone access increases in this country, which is a huge win Making sure that our patients one have it Because what I don't want is for us to all assume that as access is increasing that they have it So we should ask about whether they have it or not. And also do they know how to use it? I've had so many folks who have Not known how to use it and have luckily been able to use it in perhaps even in the wrong way And it has been life-saving But the fact is it would have been much better if we had had that conversation with the naloxone education If somebody has opioid use disorder And is in treatment with you for something and you're not treating addictions primarily consider buprenorphine and seek education Ex-waiver is gone. We we we applauded that at the beginning here I think that it is still very important to complete the required education that goes along with With having the the DEA license and there's excellent resources that have been out there for years That are free to us. So a few examples are here in the slide, but But what I can say is is kind of being on the education side of this I know how underutilized some of these resources are and so use them They're there for you. The APA has excellent resources and PC PCSS Matt also does as well And Treat SUD and other mental health things together in mental health settings. Let's try not to silo things because We're lucky that somebody got into our office. We're lucky when they come back. And so we want to make the most of those visits Systems many of you are here and I know that you're leaders in your systems And so how can you how can you have an impact on the system make screening standard and non stigmatizing? Perhaps consider moving substance use history into a better part of your note or a better part of your systems EHR Don't separate SUD from mental health in your clinics Hopefully there is a dual diagnosis treatment center available and similarly don't just treat the opioid use disorder very important to treat opioid use disorder do assess for the other things and and use those resources that I mentioned in the previous slide to get acquainted with how to Treat those because we do have life-saving treatments. We do have treatments that work. They're just highly underutilized and Avoid punitive policies that discourage seeking care we don't want our patients to feel like we're gonna wag our finger at them if they do something that is again a part of the chronic nature of this this illness if there is you know use or a Relapse we want them to feel comfortable to come back to us. And so our systems can set them up for that comfort on a legislative front We can do a lot as an individual psychiatrist. We can work with our district branches we can work with our advocacy arms to make a change and I have been fortunate to be a part of those things at The local and national level and I know there's people in this room who have also done some of that So advocating for harm reduction policies as has been mentioned expanding access to treatment and again encouraging treatment over punishment substance use disorders are chronic brain diseases and they deserve the attention and The same sort of treatment that we would offer to any medical condition any psychiatric condition and our patients deserve that Thank you Thank you, so as we Change over slides. Let me ask you how many of you in this room had gone through the process to get the waiver? Yes, we X the waiver, but how many of you very good very Very nice audience. And so you did all that hard work and now your hard work will pay off. So now we no longer have the waiver and So now the only requirement is Requirement is Starting in June the next time you renew your DEA license is my understanding that you will just have to attest to the fact that you've completed eight hours of training now beware of Attestation because if somebody ever decides to audit you I'm sure you will have to provide proof but no longer will and thank you by the way. Thank you To all of you who did go through the training for the waiver requirement We know those those Requirements were a bit burdensome The the documentation was burdensome and finally again through a lot of hard work We no longer have to do that But we now need to encourage as many of our fellow physicians as possible both psychiatrists and of course non psychiatrists To treat in their office or work collaboratively with you Treat patients who have a substance use disorder because as we've seen the need is great. So yes, we've X the X waiver I'm glad smita really ended her talk talking about policy because we've I think had a great Deal of information regarding level setting from Dan where we are of the scope of the problem Some things that we need to do and Dan one of my first questions for you is going to be to tell us a little Bit more about what you guys are doing in San Francisco regarding harm reduction and this meter talked about policy And so I'm going to really expand on the policy from my work at the AMA. I am Patrice Harris again I'm a child adolescent psychiatrist forensically trained psychiatrists in Atlanta done a lot of work in addiction former president of the American Medical Association third psychiatrist and so happy to represent a Psychiatry at the AMA and I was the AMA's first chair of our inaugural task force opioid task force And so I'm going to give you a little bit of the work that we've done some challenges and some opportunities for the future here So I'm not going to go through a lot of these Dan did a wonderful job he talked about the four ways, but I think it's very important that we Begin to think more broadly than just opioid as has already stated and one of the things I think we are there's always Going to be another substance as long as we have a brain. There's always going to be another substance so I think it behooves us to step back and stop chasing substances and specific treatments and Really broaden the access to treatment no matter what the substance and that's why I think you heard up here and it's subtle but we really no longer talk about the opioid epidemic as Much as we should be talking about the overdose epidemic because again, we've seen the data around the different substances So we are in this a fourth wave and I don't know how many of you saw just last month the Biden Harris administration With dr. Rowe Gupta who's from West Virginia, by the way, I'm from West Virginia talked about xylazine so now we have another substance that is involved in overdose and misuse and Addiction and so we really have to make sure that we are broadening our approach and making sure that folks have adequate Access to treatment no matter the substance and of course along with co-occurring mental disorders Dan again has already talked to you a little bit about the data I think the take-home message from these slides is let's not forget special populations Let's not forget our adolescents and our young folks Let's not forget people of color We I think I hope learn through kovat that Disaggregating data is important I mean I'm old enough to know that a lot of our studies when we read our studies and you looked at who participated in the studies they were mainly white males and So now we have to make sure and ask about that when we are reading literature When folks are coming to us With policies we have to make sure that we are Getting disaggregated data by race by ethnicity by age by gender And then we can tailor our treatment approaches, which will be different a Dan I used to say a long time ago that maybe the treatment approaches we used in rural West, Virginia My home state will be different than Marin County And so it's important to understand where we are locally and making sure that we disaggregate the data So I think really that is the the take-home message of these slides. You already pointed to the increase in Overdose deaths or do we do see some? Plateau and we have to make sure We appreciate how it's affecting Folks of different races and ethnicities and this slide again drives home the point Looking at quarter by quarter over the last several years Making sure we appreciate Access to treatment because I think that's a in large part What is happening in some of our communities of color now? You also mentioned Regarding the beginning of this wave and the pills and I think you're right But I was having a conversation at the very beginning and a woman said well, you know, I think it's good that we are seeing less African Americans who are dying from overdose from pain medications and I understood that but we and we're not Talking about pain necessarily today in the flip side of that an undertreated pain But clearly one of the reasons why folks did not have a communities of color did not have access to pills as they were being Undertreated for pain So I always say we have to make sure that we are pulling in that data and understanding that context as we have these conversations, but of course with the illicitly manufactured fentanyl, carfentanil, xylosine, and all of what you mentioned is on the street, this is affecting everyone and as you said becoming a nationwide problem. So in 2014 I was on the AMA Board of Trustees and of course we were in the midst of this opioid epidemic. The CDC had declared the epidemic and there was one narrative if you recall, you have to go back and recall the narrative, it's all doctor's fault. If doctors would just quit prescribing these medications we would solve this problem and clearly no question, you mentioned some of the other, the marketing and some of the other issues, clearly physicians had a role to play and so we said at the AMA we did not want to shirk our responsibility for leading on this issue. So the Board of Trustees developed the task force and I was appointed chair and we brought representatives from 25 national, of course APA was involved, national specialty societies and state societies. We started with some states that were particularly hardest hit by the opioid epidemic and so we're going to lead on this issue and we are going to start at home. And so our first report was issued in 2015 and it was really five recommendations of what physicians could do. We said we're going to start with us, we're going to take ownership of this and lead and that was our first report. Also one of the statements I had to put forth was a statement regarding the CDC's recommendation. If you look at that report in total and their prescribing recommendations, most of them were reasonable but there was one that we warned that payors and states and pharmacies would misuse and we were right. And in this case, by the way, I hated to be right but we knew that what was going to happen was payors were going to use those recommendations for coverage determinations and people in pain who really need these medications were not going to, were going to have less access to these medications and that is exactly what has happened. Now again, this is old news now. We know the CDC revised their recommendations but that is one of the first policy pronouncements we put out. And I can tell you as chair of the board, I got a little bit of heat, chair of the task force, I got a little bit of heat on that but, and again, unfortunately we were right about that. It was important to point that out because as physicians we've seen that time and time again for other issues. Now again, on the, not necessarily the flip side but in the context of these issues we realized that we had to talk about pain and subsequently the AMA developed the pain care task force and then a year after I rotated off the board, they combined both of those two task force, task forces. But a lot of good work occurred and really at the AMA we focus on policy and Smita said this and I realize that not everyone is enthralled about being active in policy but I encourage you at the very least know your own legislator, your psychiatrist, how many psychiatrists in the room or physician or healthcare and by the way, you see firsthand up close and personal the impact of policies that legislators pass every day. And so it's important, again, you don't have to necessarily go to the capital every day. At one point during the course of my career I became a lobbyist and as you all know, very active and involved at the AMA but at least let your legislator know what you're seeing every day in your practice and that your patients can't get the care that they need. So again, policies. Now what we have seen for many years is legislatures will pass what I call feel good policies. There's a crisis, there's a problem and they are well intended, right? They hear from their constituents and they want to do something about it and so they'll pass a policy and that's exactly what they did. They passed what I call feel good policies, policies that were not necessarily rooted in science and they decided that again, physicians were the problem and they were going to first of all restrict access. So how many of your states have laws where your five days of opioids, now by the way, I'm not saying that necessarily that's a bad thing. Physicians do want to be judicious. We do need to be judicious in our prescribing but just arbitrary limits not based on science, not a good idea but yet they still pass those restrictive policies. They also mandated the use of the PDMP. By the way, great tool but again, they thought if they just got physicians to check that PDMP, this problem would be solved. We've seen that's not the case. I'll show some more data on that and then mandate education. Again, well intended and all of these things are the right thing to do. It's just in their execution and some of their mandates. For instance, most of you already as you noted already had the training for the X waiver. So to require you to do additional training, this one size fits all blunt policy was not necessarily going to get them the outcome that they wanted. And so I said and been saying for years that when it comes to policy, we should inspect what we expect and we did that at the AMA. We said we're going to hold ourselves accountable as physicians and legislators and regulators. We're going to hold you accountable to your policy to see if your intended outcomes were achieved and of course, again, with the numbers that you've already seen, of course not. Restricting prescriptions has not led to reduced overdose deaths. Again, the current legislative environment, they started enacting these no laws in 2017 and again, it did not get their intended result. What about mandating PDMPs? Physicians started checking PDMPs. By the way, physicians were doing this before. Many of these mandates, this slide shows you how many times physicians check PDMPs over the course of the last 10 years or so and again, the overdoses have not decreased. By the way, as you see, prescriptions did decrease but again, overdose deaths did not. Mandating education also has not given our legislators their intended impact. It has not reduced overdose poisoning or death but we see the number of states that have mandated either CME for pain, for substance use disorder. Again, all of those good ideas, the mandates that didn't make sense, the one size fits all blunt approaches that they use but of course now, we have the new act, the X waiver is gone and some of you, if you already have your waiver, you won't have to do this but those that have not will be able to prescribe buprenorphine with just an additional eight hours of education. Medical students who receive X waiver training during their training will also not be subject to that additional eight hours. One more failed policy, there have been a lot. There have been a lot of failed policy but this is a big one and that is the war on drugs and I think we all know that. 50, 60 years now, well, I actually don't know the intended effect and sometimes I wonder. The price of drugs, the disavailability. And I'm a little bit cynical because we know that as a result of this war on drugs, when at the time, most of the folks who were using heroin were black and brown communities and as a result of our war on drugs, we've had mass incarceration of black and brown people. So that was racist, discriminatory, structural problem and it has not worked and I would say the X waiver did not work but we got rid of this so we really have to continue to fight on so that we don't have this punitive supply side approach that you mentioned. We've already had mass incarceration perhaps going forward. We will reduce that and we will be always on the lookout for policies that are racist and discriminatory. And again, Dr. Gupta just said last month that every day we are losing enough people to fill a Boeing 757 passenger jet and if that happened, the FAA would change their rules and so we have to be a part of the change to make sure that folks have adequate access to treatment no matter the color of their skin, their gender or where they live, their socioeconomic status. So what can we do regarding policy? We can work and continue to insist that payers remove all prior auth. I know that prior auth is the bane of our existence for so many things but clearly the step therapy and prior auth protocols just put barriers to care for those who have a substance use disorder. We can ensure and Dr. Angela Shannon is in the back and has done a lot of work in correctional settings. We can make sure that those in correctional settings, pregnant women get the care that they need, the special populations that I mentioned earlier. Parity has been on the books since George W. Bush but it's still been regionally evaluated and assessed and we know that insurers in some states and of course this is regulated at the state level. Some states have not had any action towards evaluating their payers. One of the recommendations that came out in I believe in the task force second set was to have states really look at the payers in their states, again inspect what they expect. I was at a meeting once and one of the state officials said none of our patients are asking us to do this work. None of the patients know how that all works. They don't know that the state has authority to evaluate whether payers are adhering to both federal and state parity laws. Again easy access to Naloxone, we can talk more about that in Q&A. We have good Samaritan laws on the books. We have to make sure that people know that. We still see those stories of folks who are too afraid to call the police, call 911 because they are afraid they will be arrested. So it's a matter of making sure that those laws are on the books and people know about that. We do have to continue to protect patients with pain from these arbitrary dosage and quantity limits. I want to hear from the audience and my panelists about overdose prevention sites, somewhat controversial. What should we be doing there? Syringe services programs, again you mentioned blue states but I think you were not talking about politically blue states but blue states on your, yeah. But clearly we know that some states are not supportive of harm reduction, although as you note that's getting better, but still there's some controversy, shouldn't be, around syringe services programs. And we certainly now need to think about technology and I'd be interested in many of you and I'm talking about actually technology beyond tele-psychiatry that is a start but we need to think about what else can we think about using technology and digital methods. We saw that during the pandemic it was a lifeline to be able to prescribe these medications without an in-person visit and you've seen the recent rules about that. We've got a grace period but we have to figure that out. On the other hand, we also saw when people misused technology and over-diagnosed ADHD and over-prescribed stimulus and here we are again. So we have to figure that out and by the way, we in this room are the leaders on that. We're the thought leaders on that. So we cannot be silent. We have to raise our voices and participate in those conversations back in your hometown. And the fear is real. You know, we've got pharmacies not stocking buprenorphine. We've got high cost of even though naloxone is now over the counter but who can afford it? So is it really accessible? So again, a lot of problems that we need to continue to solve but absolutely we all have a role to play as physicians. We need to hold ourselves accountable to some of the practices and approaches we talked about today. We have to hold our payers accountable. We have to hold our employers. If you are in the C-suite, some of you in this room are in the C-suite, it can impact what your employer does regarding coverage and health benefits. We have to make sure that we are in those rooms as well and I think I've already made the point about policymaking. You can go on the AMA website and just type in opioid pain care task force. We have lots of resources as well just like the APA. And we really highlighted what people are doing, right? And here are some of the folks that we highlighted in that toolkit. And you can see that we wanted to make sure that we were practicing what we preached and looking at programs across this country and programs that were led by a diverse set of folks. I commend that report to you and other AMA resources and best practices. And I want to end with this framework. I spent five years of my career as a public health director. And it's a long story, maybe over a vodka tonic about how a psychiatrist became a public health director. But I do think as we think about actually mental illness in general and substance use disorders, we need this public health framework. We need this data. We need the hotspot. And we need real-time data to figure out if we see a cluster of infectious diseases from needle use or overdoses, we need that data quickly to hotspot, have teams go in. And that's why I think we really need to look at this from an overall public health approach, make sure we are looking from the promotion and prevention side all the way up to the treatment side and then to the maintenance side. So again, partner with your public health, and this is a slide from Well-Being Trust, but partner with public health officials along with your other physician colleagues in your communities to solve this problem. Looks like this audience doesn't need the eight hours of training. But if you do, again, in addition to the APA resources, you can go to the AMA EdHub and also get resources. So now, thank you very much. And we will open the floor for questions and comments. »» Testing. Check. doing. My name is Dr. Lopez. I'm a board-certified psychiatrist. I'm practicing here in California. I'm currently also licensed in Nevada and Virginia. I spent a good deal of my time in the Navy. I've been out for about four and a half years. So Suboxone and its treatment are one of the most important things in my current career, but a few very important points to make, especially based on the presentation that I've seen today. But the first job that I had when I got out of the Navy was in Las Vegas during the very quintessence of that methamphetamine epidemic with the new onset fluorid psychosis as a result of the kind. It's not a type of methamphetamine or its production, but more of the environment that I found around the methamphetamine that causes that reaction. So that comes from inpatient settings and street experience in Las Vegas, especially during the most difficult... Las Vegas had one of the most difficult lockdowns in the United States, London-style. Everything was shut down for many, many months. So a little bit of a laugh line, but if you've ever wanted to be an aspiring filmmaker and getting footage of the Las Vegas Strip or anything else in Vegas for free with the streets empty like that was pretty interesting. But it was like that for many, many months. But the most important points, I think, were made and set by an author named Sam Quinones, who I think is quite popular in PR, that level of things. His book, The Dreamland, was about the opiate epidemic and its underpinnings. And his newest book, which is called The Least of Us, is about the methamphetamine epidemic, and that's the one that I was serving. And a good portion of it is in Las Vegas during the time. But his points are well made because in 2006, when I was in medical school, or yeah, that was the year, that was the first time that I felt it curious that the physicians around me were prescribing OxyContin and these things to patients with long-term health conditions. And this was well before any of the information about the epidemic would come out. And it seems that the basic methodology and base scientific principles of addiction medicine and pharmaceutical use were being ignored. And that was when I was a child and a student. So, sir, do you have a question? Oh, no. What I wanted to say was that with the suboxone waiver being removed, I'm afraid that this suboxone will become an endemic epidemic, much like Valium did, and that those aspects of its use are being ignored, much like the pill mills and things we're doing in the past. So being in a position, yeah, and so in the position, and I think it's very good that psychiatrists, since psychopharmaceuticals, even the street ones, are our baby as a specialty. So if you could address that, because ultimately that's what I see as being the major public health crisis that comes out of removing the waiver. And sorry for standing up. I just wanted to make sure people knew Sam Quinones's name and those books, because they're absolutely practice necessities. So thank you. No, I had the honor of meeting him. We hosted him at the AMA. And by the way, those of you, if you don't already know, at the end of the convocation, the author of Dope Sick is going to be on a panel, and I'm going to moderate that panel. So both of those are great books, Sam Quinones. And I am blanking on a colleague who wrote Dope Sick. I'm blanking on her name. Beth Macy. Beth Macy. So come on Monday to hear that. You know, I've heard a lot about people said, oh, if we make Suboxone easier to get, then people are going to divert that, and then that's going to be a problem. That's a fair point to raise, and I think I will give my thoughts. But what are both of your thoughts about that worry? Currently, among people who have X, or previously when people had X waivers, or were required to have X waivers, the rate of prescribing was so low. We just didn't see people prescribing buprenorphine. My concern is that even with the X waiver next, that we're still going to have low rates of treating OUD. And I'd also go back to the idea of harm reduction. Like, people can get buprenorphine now for non-substance use disorders and prescribe that without an X waiver. That's been the case for years. And so we haven't seen this, you know, a rise or substantial enough rise to be concerned. Again, I'm really excited that now hopefully there can be more access to buprenorphine. And at the same time, we didn't see that many people with the X waiver prescribing to begin with. So I don't think, I think it's a step in the right direction and not enough, and certainly not enough at this point for me to be concerned about, kind of, widespread misuse. You raise a valid point. Anytime we liberalize access to a drug, you will see both positive and negative effects from that. We, to the same degree that we hope that more people prescribe it, is the same degree that we will be concerned about diversion. Let me tell you two things about diversion, though, because we do have data on this. One is we can use, look at the French example. So the French did this already quite a while ago. And you're absolutely right in that as they made buprenorphine an utterly normal pharmaceutical for any physician and their equivalent of nurse practitioners to prescribe, or mid-levels to prescribe, diversion went up. But the overdose rate in France plummeted at the same time, right? And the diversion, to the degree that it was young adults, it was people who sort of, you know, experiment, you know, they're in their experiment phase, it was considered not problematic enough for them to go back on the policy. So we do see diversion in this country. Most of the studies that I'm aware of, both quantitative and qualitative, say that it is occurring. And what's really fascinating is that most of it is periclinical appropriate behavior. People are sharing it with others who actually need it. And so there's very little of even the French phenomenon going on, and that is diversion to people who are opiate naive and therefore creating yet another addiction, you know, minor addiction problem. So I'm relatively reassured by that level of data. What happens next? Don't know. Have to track it. Surveillance is key. But I'm relatively reassured. All right, sir. Oh, yes. I'd like to say thank you for an awesome talk. I did want to bring up the point, I think in all your talk, there's a level that I didn't see addressed very well, and that's your state mental health authority, okay? I live in one of the, and I'm a state mental health authority in one of the blue states there. We have driven a ton of things. Everything you mentioned up there, we are doing very significantly. Our overdose rates have not budged a whole lot, but we have 160 opiate treatment programs in our state. We have, I saw the numbers, we have 80,000 people on buprenorphine, okay? Yeah, I don't know who's taping. It's from Ohio. I'm state medical director of our department in Ohio. When you mentioned talk to your legislators, legislators are okay, but if you talk, you got folks that are psychiatrist addiction trained in that. We have a state strategy. We work with our, you talked about a public health response. We have a very close relationship with our department of health. We have naloxone distribution. If you want to get naloxone in Ohio and you can't find it, you're not trying. We give it to people every day, all the time. I see real time reports in locales of overdose deaths, and we still have an incredibly hard time moving that needle. All I want to suggest is there's other routes to go. We have, we got $100 million in SOS funding per year. We spend that, you know, so there's a lot of resources there at your state level that I would suggest people tap into and get to know your state medical director and all that sort of thing, because I would agree with you. There's 5,000 deaths a year, okay, and we see suicide deaths. That's a couple thousand. I don't know how many of those are. I get it all the time, because we talk. I talk to every county board and a group of us. That wasn't just me, but we ask in your county, are your deaths, you know, are your suicide deaths, how many do you attribute to opioids, and we got a very low response, but I think we all know that those determinations are not, you know, all that accurately made. All I'm suggesting is you got your Boeing 747. I think we've got it down to 20 excess deaths in our state a day, yeah, due to this. So did you say, so you said we are or are not moving the needle on overdose deaths, and thank you, so Ohio. I think we're, you know, as you show a small trend downward, but 5,000 is still way too many. Yeah, it's too high, but it sounds like you could be a model for what other folks need to do, so thank you for that. Absolutely. I just would ask you get to know your state mental health program director. Absolutely, absolutely. So we have in the back and then up front. Did either of you have anything to add? Yes, sir. So as far as I've been prescribing buprenorphine for 20 years, and it's a very, very safe drug. I think there have been a few hundred overdoses on buprenorphine over the last 20 years or whatever compared to 100,000 a year for opioids. So I'm not worried about diversion, because most of the diversion that I have seen has been somebody giving their suboxone to somebody else who's going through withdrawal. I haven't seen anybody go out on the street and buy buprenorphine to get high. So as far as I'm concerned, we should have buprenorphine prescribed by every physician. I used to teach medical students, and when they saw me treating opiate addicts in the office, they said, you can treat heroin addicts? I didn't know that. Their total exposure to treatment was seeing overdoses come through the emergency room. They thought these people are hopeless. They're just going to go out there and use until they overdose and die. So we're doing a very bad job of convincing physicians out there to treat this drug just like any other drug. No physician says, I don't treat heart disease. I only treat other organ systems. We are allowed physicians to say, we don't want to treat these addicts. Give it to somebody else. And it's not until we get a complete buy-in by the medical profession to say, we're going to treat this. Somebody comes in with depression or somebody comes in with diabetes. They got an opioid addiction problem. You treat them then and there in the primary care clinic or wherever they happen to be. Thank you for that. Yeah, we do have a lot of catching up to do. And by the way, Smita, when you said, because I'm old enough to know that when we used to do the HPI and substance use in the social history, just think about that. Think about how stigmatizing that was. And so we have a lot of catching up to do from all those years of stigmatizing it, not training physicians. And also let's talk about practical. Because again, I'm at the AMA. I said, all right. I was around the table with colleagues. And again, in our own house, there is stigma. But also, let's be clear that our primary care colleagues are overwhelmed right now. I called the other day to get an appointment. I will admit, I haven't been a good patient. And so I've been going for other things, but not my primary care. So I called. And so I haven't been for a while. So I called to get an appointment. The first available was a year. A year. And I didn't use the, I'm former president of the AMA. Can you squeeze me in? I didn't use it. But yeah, it's a year. So we have to do it. But I was just talking to someone last night. And again, we're on our journey. Someone mentioned to me, this is what you can do, by the way, in your states. Go to the family AAFP meeting. Offer to do a session, right? Either at the county medical society or your state medical society. Offer to do a session. These are the things that we can do. And I heard that a lot of meetings of our family medicine colleagues and our internal medicine colleagues are including this. But you're right. We have a long ways to go to catch up. So did any, do you want to? I'll just add briefly that I think so many people here are psychiatrists and we are leaders in this field and space. And so I love what you just said about going out to AAFP and offering to do sessions and educations. When I was at the VA, a lot of, there's a lot of fear of, I don't, even something as simple as naltrexone, I'm going to other substances, but something as simple as naltrexone for alcohol use disorder. There was a lot of fear and hesitancy and again, siloing and going out into the primary care clinics, talking about how easy it is to just use this medication that less than 10% of the veterans who have alcohol use disorder actually get. Like it just partnering with them, being there for a little bit, helping increase confidence of primary care went a long way. And I know the same, we're doing the same things for buprenorphine. And so I would encourage all of us as psychiatrist leaders to do that in our communities and systems. Sir, you were next. I just didn't want to block everybody, but my question is about pain and Spox and wrapping this all together because a lot of my patients come to me and they'll be in withdrawals and I treat the withdrawals, but then, you know, they're like, Oh, I'm still in pain or whatever it is. Right. And I'm just like, Oh, I'm a psychiatrist. I'm not a neurologist. I didn't do a pain fellowship. I don't treat pain. I treat addiction, but inevitably I am treating their pain. And so my question is legally, right. How do I document that? And how do I navigate those waters? Because I am. And if their pain isn't treated, they're depressed and they're going to use and they're going to go find, you know, and the pendulum has swung it, you know, at one point in time it was like, you know, you can't undertreat their pain. You don't know if they're in pain or not. Right. Like, so we passed out opioids to everybody and now we're cutting them off, you know, and most states, like you said, do have like, you know, two weeks for this, like a dental surgery, you only get like four days. Um, but many people suffer from like lupus or, you know, degenerative, you know, disc disease or whatever they've got going on. Right. So they're chronically in pain and that affects their mood and that, and it's one of the main reasons why they go and use. So again, as a psychiatrist, I didn't do a pain fellowship. Right. So how do we navigate that legally? Well, the first first suggestion is that buprenorphine is a wonderful pain medication. I will just add this, like my patients tell me their pain is treated better. And OUD with buprenorphine. Yeah. And I, and I talked to my patients about that. And, um, because most of my patients tell me that the buprenorphine, the Suboxone actually does treat their pain better than any other opiate does. And so I, I really talked to my patients a lot about it. I'm just like, you know, there's no reason for you to stay on Roxy's, Oxy's, Oxycodone, and then you go to the dirty thirties, whatever. The only dilemma is that, um, uh, buprenorphine is very interesting molecule. It has, it has some unusual characteristics. So it's, uh, there's evidence that it's, uh, better as an agonist in the pain system, uh, at lower doses. So hence you see all those products that are, that are, uh, micrograms, um, as opposed to what we would typically use, which is milligrams. Um, so that's, that's the only dilemma. I've actually worked in a clinic that, that is at the intersection of pain and addiction, and we use buprenorphine a lot. And that's our, that's our only big dilemma is who's a microgram patient and who's a, who's a milligram patient. And then of course there's people who that buprenorphine doesn't help with the pain. So what do you do with those? Uh, that, that, that's an interesting dilemma as well. I mean, you raised a good question and maybe, I don't know, is there a session here, um, on, um, you know, psychiatrists and treating pain? Uh, because I, you know, I, I was reminded of, um, uh, when I worked for an ACT team in Fulton County, Georgia, and patient came in one day and his blood pressure was, I can't remember the exact number, but maybe 200 over 160. And, you know, I said, I need to figure out, um, how to at least initiate, um, treatment for blood pressure. Because here's what I knew was going to happen. If I send him to Grady, which is our huge, you know, of course didn't have any insurance, send him to Grady. First of all, he wasn't going to go. I doubt he was going to stay in the emergency department for eight hours for hypertension. And then, and I'm a physician, right? Yeah, I'm a psychiatrist, but I'm a physician. And so these are the things, so it might be. So one of the things we did in Georgia, and we haven't done this, I don't think a while, Angela, is, um, we had a joint meeting with AAFP and it was like, um, you know, hypertension 101 for psychiatrists and we did sort of mental health 101 for family physicians. So that's, that's an interesting, um, dilemma because I, I wouldn't feel comfortable, I think, treating very complicated pain. So I did actually look up on Wednesday, there is chronic pain for the general psychiatrist or review of shared mechanisms and treatment strategies at 1030. There you go. Very good. Legally you could perform surgery, but I wouldn't recommend it. No, I'm sorry. Not to be. Yes. I mean, within your scope, I mean, what you feel comfortable, but maybe we could go to that session and, um, and figure out, but legally you can, I mean, you know, the issue gets in if something happens and you're not trained and there's a bad outcome. So you want to be protective and you want to talk to your malpractice carrier about that, but yeah. Hello. So I was one of the individuals who obtained the X waiver, took the additional CMEs or 24 hours, whatever it was to obtain the X waiver. This is when I was working in, uh, what do you call that? Uh, yeah. Emergency psychiatry, uh, ops unit, you know, inpatient, you know, that sort of deal. Uh, I've since transitioned into more of a consult liaison psychiatry, uh, in, uh, long-term care, subacute setting, you know, a 14 day, uh, physiological, you know, medical, you know, uh, rehab facility where, you know, broken hip or, you know, that sort of deal. A lot of those individuals, uh, coming in, you know, with, you know, it may have been substance use disorder that led to their, you know, uh, pneumonia, broken hip or what have you. And so I find myself in a situation where I definitely a strong advocate for the use of Suboxone for individuals who may need it within that setting. Uh, those situations don't come around often enough for me to have a great familiarity and experience with using it. And it's been so many years that I'm freaked out about starting it, you know, starting it, where to go, how to obtain, you know, uh, just regular treatment management to know the nuances of it. And within that setting, not having colleagues or a mentor, uh, to be able to play off of, to go about utilizing it, uh, even though within that setting, uh, I'm looked at as the psychiatric director or specialist with how to, you know, you know, support my, uh, you know, colleagues, the, you know, physicians, the attendings in managing of all things psych and behavioral health or what have you. And so in theory, I'm an advocate for, yeah, this person should be on, you know, Suboxone. We could really help them with, you know, this and that while they're coming in for their medical recovery, what have you. In practice, it's like, uh, you know, I don't know how to go about this. So what would you recommend as the best way to go about, you know, equip, equipping myself with the resources and my team with the resources to go about managing this, uh, intermittently when the circumstance comes about? So I often refer folks to this excellent question. Um, and I'm so glad that you're motivated to, to kind of get back into this in your new setting, um, or your newer setting. Um, PCSS now, it's one of the resources that I had mentioned. Um, they have taught all sorts of talks. Um, so for example, managing, uh, opioid use disorder in people who have a lot of dental procedures, um, was one that I just, I just glanced over managing, uh, buprenorphine or opioid use disorder. One of the most recent ones that I watched was on, um, in people who are using fentanyl. Um, and so I'm sure I didn't, I didn't have a chance to go through everything, but to, to look at those like chronic care settings where people are, um, rehabilitating, um, there's, there's, there's probably a presentation on that. If there isn't, they have an ask, ask a clinician, a clinical question and, um, and they offer mentoring and support through, through their website. Trying to get to your slide here. Perfect. Thank you. PCSS now.org. And here's another resource for you. The, um, uh, here in San Francisco, there's the national clinician consultation center. Uh, it is a warm line. So when you have, uh, a patient who's maybe just a little bit more complicated than the, than the training guides you with, you call them, they'll walk you through it. Good. Thank you. And they're very accessible. It's actually underutilized. You want to repeat that resource? Yeah. So it's the, uh, I had to look it up. Sorry. Even though it's my own university, national clinician consultation center. I'll remember. There's that plus UCSF and you'll get phone numbers, email address, that kind of thing. So I think we have a time for two questions. I can't remember. I don't know. Sir, are you in the back? I think he's standing first. Yeah. All right, sir. Yeah. Hi. Uh, I'm a long time, um, had a long time interest in substance abuse treatment. And, uh, so I have a specific question for you. Um, many years ago during residency, uh, they asked us to do a paper. And so I went down to the Menlo Park VA and said, look, I want to do a paper on cost versus benefit on substance abuse treatment. And I'll never forget the, uh, the expert down there scoffed and kind of laughed at my naivete. And he said, well, first you're going to have to show some sort of effectiveness before you talk about, um, cost benefit. And that question remains. Um, and through the years I've had a variety of levels of responsibility and so forth. Um, but I've kind of feel there's intransigence in the medical community because they're not convinced really that there is an effective solution. So they get reimbursed for detoxes, but then they want them to go over to the psychiatry department anyway. So my question is, is there anyone really addressing that crucial issue of cost versus benefit? Sorry, I didn't hear your, the last piece of your question, but I, I thought that it was interesting that you went to the Menlo Park VA. I was, uh, most recent prior to my, this position that I'm in now, I was director of addiction treatment services for the Palo Alto VA system, which included the Menlo Park VA. We do see the benefit. Um, we expanded our treatment greatly. Um, and we're very proud to have not just medication clinics, but our residential programs and tents about patient there, there was a clear benefit and, and it was seen by the veterans. And, um, and that's why we, we continue to have more access to our programs. Now, you also might be talking about maybe an individual physician, primary care reimbursement. And that, as we know, is very complicated. And for many years, if you were primary care, you couldn't get reimbursed. You couldn't code right for some of these, but some of those barriers are being, um, reduced, but as the cost benefit of treating a chronic, uh, treatable disease, I think just like diabetes and hypertension, I think we, we have that data. Well, so you're the person that I should be talking to. Actually, I'm somewhat speaking on an institutional level and I know at NIH, they'd always lead with these statistics. Well, alcohol abuse costs 138 to $145 billion a year, blah, blah, blah. And, uh, with your many years, thank you very much for your service in this area. But, um, what statistic or what facts would you lead with to say, okay, well, if we spend, you know, you know, if you go to Washington, you spend $10 on lobbying and get a hundred dollars worth of benefits. What's your leading line about if you spend $10 on treatment, how much does it save? Not sort of society, but actually the medical system, maybe the HMO or whoever is, is insuring this person or the BA for that matter. Well, I'll just say this. I don't know. Each system would be different, but part of the issue, and actually I've been talking to a lot of folks lately because everyone, a lot of employers want to do something about mental health and, um, in their own closed systems, they always talk about the mental health budget, right? And if they look at it in silos, they probably won't see the benefit. And one of the things we have to encourage them to do is look at their total cost of health, uh, because I can tell you, and I bet you anyone in this room knows that untreated substance use disorders, mental disorders, depression, anxiety drive costs in the med surge budget. And that's been a hard thing to convince them of. And I think they're just now realizing, I think a Cleveland clinic, um, I think it was Cleveland clinic did a study and they showed that untreated depression prolong the hospitalizations after cardiothoracic surgery. So I can't remember the citation, but more and more studies are coming and they are seeing that yes, if they just look in this silo over here, it may be expensive, but they, if they look at their global health spend, um, which candidly some payers don't want to do, but if they look at their global health spend, they are beginning, but there's a problem in how they've been looking at this. I don't know if you, I just look to see, I, you know, the, you bring up a very good point. Like we need to have that leading statistic. And I wasn't aware of it. Um, I didn't have the exact numbers here, but, and this is about eight years old, I believe, but, uh, every dollar spent on substance abuse, say abuse, change it. Now substance use treatment saves $4 in healthcare costs. And $7 in law enforcement and other criminal justice costs. Okay. Last question. Thank you all for staying. And we know we're two minutes over. We won't be offended for those have to go on to the next thing. We know the opening session is five 30. So sir. Yeah. Mike does, uh, Boston medical center, VA Boston, um, and VA Boston, we've been trying to create a rapid access clinic and a QI project related to the fentanyl problem and, um, getting the word out itself isn't enough. So the question is, how do we give clinicians, all of our prescribers have waivers. So we've got a wealth of waivers, but there'd been real resistance to training and to treating the folks. So we've been really thinking hard of how to do that. So a comment, and then a question for the group and for APA as a whole one is, um, how do you give clinicians the option? So we're thinking of actually templating in our medical record system, high dose, low dose, you know, consultation, a whole range of different options, and then looking at that over a period of time and seeing how we do it, because we've done, you know, we've getting the latest literature in terms of case series of high dose, low dose. And there's two CTN studies that are underway that should inform this in the next year or so, all that sort of stuff, but thoughts from the audience, APA in general, maybe even for when we, uh, have other meetings in the meeting to pass that on, but how do we get clinicians who have the training to actually take that step? That, that's the question for the group. I think in a system like the VA, uh, where, or time is precious, creating the infrastructure, I mean, being, you know, as a leader at the VA, I would love to, uh, to know more about incentivizing that infrastructure. I think there's a lot that's squeezed into a lot of these, the clinics at this point. Um, and so having that framework, um, as Dr. Harris said, there's, our primary care colleagues are, are managing so much at this point. Okay. Thank you so much for staying. It was our honor to present before you today.

opioid epidemic

X waiver

buprenorphine

opioid use disorder

fentanyl

stimulant combinations

harm reduction

psychiatric conditions

integrated treatment

over-prescription

evidence-based practices

policy changes

addiction treatment