Our next speaker is Dr. Philip Eskew, who also, in addition to having an osteopathic degree, has an MBA and a JD. He is board certified in family medicine and OMT, correctional medicine, and addiction medicine, with a CAQ in occupational medicine. He sees patients in both the direct primary care and correctional medicine settings. He also works as an attorney, mostly in corporate direct primary care setting, and he has been a site medical director for YesCare, a correctional medicine company at multiple state prison in Wyoming since July 2015. He joined ProactiveMD, an onsite direct primary care company in February of 2016, and is the company's vice president of clinical development. He has spoken about correctional medicine topics at prior AOCOPM events that he has nothing to disclose. It is my pleasure and honor to give Dr. Eskew the John Gerald Mills DO commemorative lecture. Dr. John Mills has a long and distinguished career of service to his country, medical education, his profession, and our college. He served as a helicopter pilot in Vietnam, and is a 1979 graduate of the Michigan State University College of Osteopathic Medicine. His MPH is from the University of Michigan, and also holds an MS in anatomy from Michigan State University. He completed a residency in aerospace medicine in 1983, and currently serves as an associate professor of community medicine at the University of North Texas Health Sciences Center. He maintains board certification in preventive medicine, correctional medicine, and aerospace medicine. Dr. Mills is a founding member of our college, and has been a loyal and contributing member throughout its existence. His involvement has included service as division chair of aerospace medicine, residency inspector, chair of education, evaluation committee, trustee, and was the college president in 1993. He has been recognized as a fellow in the college, 1986, and a distinguished fellow, 2013. He also served on the American Osteopathic Board of Preventive Medicine, and is a member of the AOA postdoctoral training and review committee. Dr. Mills worked tirelessly on the graduate medical education program standard for fellowship training in correctional medicine. He wrote many test questions for the certifying exam, and was recognized as the founder of correctional medicine by the college in 2014. He has traveled extensively, meeting with other correctional medicine physician provider group, and regulators to raise awareness of our efforts to provide an educational home for correctional medicine professional. He epitomizes the word ambassador. In 2015, AOCOPM honored Dr. Mills by beginning the John Mills commemorative lecture in correctional medicine. It is my honor to present the plaque to Dr. SQ, and Dr. Mills, we would appreciate if you could come up and be part of the picture. No, let's put you in the middle. That's pretty neat to be able to have you with us. Yeah. This is the third time we're sitting. This will be like Saturday Night Live. We're going to do a five-inch jacket. Maybe I'll give him a green jacket. Actually, Phillip's much smarter than I am. Thank you, Dr. SQ. That's all the time we have. I'm going to stop it, and I'm going to see if I can change the mic. Okay. Is this working? Yes. So I'm Phil SQ. I'm a family physician, and once I finished residency in 2015, I headed straight out to Wyoming and thought that I was only going to do correctional medicine maybe one or two days a week, and sometimes life has different plans, and I wound up doing more than I expected, in part because it was closer to direct primary care than I thought it would be. I had more time with patients, could do broad-scope care, had lots of interesting cases. Most of them were very grateful for the care they received. So I've done it in various capacities since that time, sometimes up to 60 hours a week, sometimes down to 20 hours a week, depending on my other obligations. We're going to talk today not about correctional medicine broadly, per se, but about addiction treatment within it and how that is changing. And like many things in correctional medicine, it's not necessarily changing because legislatures are interested in talking about corrections. They rarely are. It's more defined by the judicial system, which is what gave inmates a right to medical care a long time ago. And in this case, it's motivated by the ADA. So we'll get into that a little bit later. And some of this is, in fact, a lot of the withdrawal stuff that we'll talk about, I don't see a lot of because I work in a prison, so not a jail. So when people first get arrested, that's when you see a lot of withdrawal. We fortunately, where I'm at in Wyoming, have not seen a lot of this because there hasn't been a whole lot of illicit substances snuck into the facility, at least not that we've observed. Okay. So the first thing to consider is what are the mental illness rates in the regular community versus the incarcerated population? And they are indeed higher in jails and prisons, which is no surprise. And about 5% of the people living in the community have some sort of serious mental illness, which they could have defined different ways. But no matter how they defined it, the rate was higher in the incarcerated setting. And if you take that a little further and say, what does the substance abuse difference look like, it's pretty dramatic. You're talking about two-thirds of your incarcerated patients have some sort of substance use disorder. And a whole lot of those patients, historically, when they went to jail, they went through a monitored withdrawal, if you will, which may have been pretty dramatic even when you're monitoring it and doing what you can do. That all has changed, and we'll talk about that. And historically, prisons were not treating much addiction with the big three that we'll get into later, and that's going to be changing as part of the ADA as well. And it led to a lot of issues. The two biggest issues that you would see that sequelae from that is that when you would leave prison, you could go back to your old habit pretty quickly if you wanted to, because it wasn't being treated in a way that would decrease those cravings. And number two, you would use your old dose of whatever your substance was, and now your tolerance has changed, and now you have the overdose deaths that are making headlines all over the place. So what if we treated substance use disorder? These are some food for thought. Could we drop incarceration rates by over 50 percent? We're going to talk about one study later in the talk that did just that. Would there be fewer overdoses upon reentry? I think so, as people are being treated. We're transitioning their care there just like you would for a diabetic patient. You're going to get them their 30-day supply of insulin and metformin and other things and make an appointment for them. Why can't we do that for addiction as well? Might there be better patient behavior while incarcerated? I haven't found anything published here, but speaking with others at NCCHC conferences, that certainly has been the case, that when they're treating addiction, they have fewer other… I'm just going to make this a little louder, or you might… Oh, should I hold it? I can hold it if you want. Back to you. Might there be less hepatitis C to treat? If people are doing fewer injectable drugs, then hep C is not going to spread quite as much as it does right now. Okay. So when you're taking a history from one of these patients, you've got to ask lots of background questions that are going to help you decide how to go about your treatment. So you've got, have you used more alcohol? Have you ever used more alcohol than you initially planned to do, or have your friends or family complained about your substance use? Did you ever want to reduce your alcohol use? These are all questions that you've probably asked before, and so I've got them here for your reference. You have issue with control, compulsion, cravings. Cravings is one of the biggest questions there, and have you used continuously despite the negative consequences, which is often what caused them to come to prison or jail in the first place? What was your drug of choice? Sometimes we've got medications to treat this, and at other times we don't. So that's one of the very critical questions that sends you down different pathways. Have you had behavioral therapy, and what might be available in this particular facility that you're in now? Have you been incarcerated previously? When did you start using? All of these things are relevant. So do you have any opioid withdrawal symptoms right now? They might say no, but you might observe some that would tell you yes, and you've got to be really vigilant about these things, especially in a patient who's underweight. That's one of the most common ways that you can kind of get behind. We'll talk about the cows versus wow protocol a little bit later, but a lot of folks are trending cows when that can sometimes, you know, put you behind the eight ball and make it harder to treat these things. So you want to ask about them early. When I ask the patient about these things, I'll actually display them so the patient knows what I'm going to look for, because this is a team effort, and ask if they've taken suboxone or methadone previously, what was their dose, how recently did they take it, were they in trouble for diverting it either inside the facility or outside the facility, how many relapses have you had, how many prior overdoses, have you ever used naloxone, did you have to use more than one naloxone dose? So all those things can help you. If they have a history of alcohol use disorder, then you've got to figure that out as well. It's obviously treated quite differently than opioid use disorder, and if you look at the DSM-5, how many times in the past year have you had four or more drinks? And if they say even once, then you're going to start looking at those DSM-5 criteria. Have you suffered from seizures, delirium, tachycardia when you stopped drinking previously? And I've got a slide on this later in the presentation, but I thought the seizure rate was much higher than it really is. But the stuff that I learned in med school when I graduated in 2012 is already predated when it comes to alcohol withdrawal or opioid withdrawal. I was taught back then that seizures with alcohol withdrawal were quite common. It's probably closer to 1 percent. And seizures with opioid withdrawal was a never, which is no longer true. People that have fentanyl have indeed used high enough doses that they withdraw from opioids now. So those answers to those test questions have changed. What are you going to look for in a physical exam? I've got sort of a default normal exam here, but it also is prompting me to look for certain things. Look for irritability. Check their pupils. See if they've got some rhinorrhea or diaphoresis. Look for some ascites. It's very common to have liver disease, especially in somebody who is using alcohol and may or may not have hep C from IV drug use. And then get a good idea of their mental status. Maybe you need to check a pneumonia level. Labs that you would commonly order. So I've got these listed here as a reference. I went ahead and included some LabCorp numbers and then the cash price that you would charge for those if you were in a cash price setting. Just as a reference, these are not expensive things, and these are easy to do as a baseline as part of an intake visit. So how do we treat opioid addiction? It's going to vary depending on your setting. So in the jail setting, you've got a lot of people that are maybe coming in for a few days. They might be in withdrawal. Maybe they already had. If you're lucky, they already had their own suboxone maintenance therapy, and you could keep them on that and simply not change the dose. More likely, they didn't have something like that set up, and that's part of the reason they're in jail in the first place. So you've got to come up with a way to go about that, and we're going to—the next slide gets into the timing of the withdrawal and when you would initiate treatment traditionally. And then a little bit later, we'll talk about sort of the plan B that you can go with, which is a microdosing of buprenorphine, which has now become an option as well. So the big three are listed there. You've got buprenorphine, naltrexone combinations, methadone, and naloxone. Those are the three that the ADA is now saying they expect every single facility to offer, which is a challenge, especially the middle one there, the methadone piece. The first and third, as we'll see later, are pretty easy. You don't need any—you've never needed any special DEA registration to prescribe naloxone, not a controlled substance. Buprenorphine, historically, you needed an ex-waiver, but that changed in December of this year, so we'll get into that too. Timing the withdrawal in the jail setting. So if they were on some sort of short-acting opioid, it's probably going to hit them between 8 hours, but it might take as long as 10 days, which is kind of unexpected. A long-acting opioid probably would be closer to 36 hours and could last up to 14 days. And if you look at the guidelines out of ASAM, they do recommend using CALS score because that's what everybody's familiar with. One of the lecturers that I'll reference on the next slide, who's talked at several NCCHC conferences, his name is Dr. Wilcox. He's not a fan of CALS because he says it always gets you behind. But it is—here is a reference for you of when you would usually see those things. He promotes his own system that he calls WOWS and says that if the patient's underweight, they're more likely to have these electrolyte disturbances, and that's what gets you in trouble. So he'll track their heart rate. He looks for GI symptoms, nausea, vomiting, diarrhea, which are very common, sweating, restlessness, anxiety, yawning. All these things are triggers for him and his nursing staff to do extra things. He always brags about this massive vat of Gatorade that they have that they're constantly filling up, filling up, filling up, and asking people to remain hydrated because that's what seems to send more people to—it historically sent more people to the ER from his jail than anything else—was a lot of diarrhea and vomiting. Because remember what opioids do. They back you up. They constipate you. So as you're coming out of it and going into a withdrawal, all that stuff is reversed. So they had a lot of electrolyte disturbances. A lot of these patients were eating pills rather than eating food, so they were already underweight to begin with, and you could see these electrolyte abnormalities really quickly. And it used to be that you go into jail and you say, all right, we're going to monitor your withdrawal, and you'll go through all this misery, and this misery will motivate you to never go back to that substance again, only that didn't prove to be true. So it's no longer any kind of rite of passage or something. It's something that you do want to avoid, and it's something that does have some dangers with it. As I mentioned earlier, you can indeed seize from opioid withdrawal. So don't put people through that. That's not standard of care anymore. Don't give them water because the electrolyte issues use something better. And heart rate is still your most sensitive finding. So figure out what somebody's baseline heart rate is when they get there, and then start trending that. You're going to see that probably before you even see the GI symptoms or the diaphoresis, and you might notice before the patient does. So lots and lots of vital signs, always a full set of vitals. Alcohol withdrawal tips. So screen the patient twice a day for at least five days, and if you're trending something, trend a Siwa or a Wow's. And the first five days that they're in jail, be pretty liberal with the benzodiazepines. You want to ask them if they have any history of seizures previously with withdrawal because that's a big tell that they might be in that 1% that's potentially going to have them again. Librium tapers are an option, and the rest of that I'll sort of leave there for your reference. It's a big point here that when you're incarcerated, you know, you get lots of different knocks on your door, they're asking you to do various things, and it's pretty common for patients to be irritated about something and maybe refuse to speak with a nurse. If you're worried about withdrawal, keep knocking. This is not a time where you kind of shrug your shoulders and say, oh, they refuse to do vital signs because they could sit there and refuse and fall asleep and something bad may happen. So you really don't let them refuse vitals when you're worried about withdrawal. Okay, so this is from Dr. Wilcox out in Salt Lake City. They started their own program, and they had 1,000 patients that had a history of opioid use disorder. 374 were on methadone, 430 on suboxone, 208 were on Vivitrol. And of the—let's see, they had 138—those were currently incarcerated patients, so I'm not sure how long they've been there or what the timeline was because he hasn't—I don't think he published this formally, but this was in his presentation. They had 138 suboxone patients that were released from the jail, and 59 percent of those followed up in the community. Total patients that returned to the jail in the regular program, meaning without that sort of transition of care, was 74 percent. So the recidivism rate was terrible. Three-quarters came back. But those that had this medication-assisted treatment with suboxone had a recidivism rate at 11 percent. So a very dramatic difference there in recidivism with the jail in Salt Lake City. And since they started that medication-assisted treatment, which is mostly suboxone, their administrative segregation unit population, which is the prison within the prison, if you will, has fallen, and there are fewer behavioral issues than before. So a lot of those co-occurring disorders that might have been managed with other things when the main problem was addiction have fallen off. What about buprenorphine versus methadone? So buprenorphine can be tapered in as quickly as six days if you need to taper it. And it used to be the most common setting you would do that was pregnancy. They've now sort of decided that it's a little bit unofficial, I believe, because I don't think they've changed the category yet. But suboxone actually seems to be safe in pregnancy, so people aren't necessarily tapering it so quickly anymore. But if you wanted to do a quick taper, it is there as a possible option. It's not my favorite way to go because I think that kind of rapid taper still leads to some withdrawal symptoms. Okay, and then methadone, we'll have more comparisons on the dosing later, but you've got to be real careful and start low and go slow there. That's a very long-acting opioid, so you can overdose someone pretty easily if you've got that wrong. What about rather than waiting on a patient to have withdrawal symptoms and then starting buprenorphine, since that's always a little bit of a dangerous game because they might say, I'm in full withdrawal, and if they're wrong, you give them buprenorphine, you're going to throw them in full withdrawal. So you always have to wait until those symptoms are severe enough and then start it. What else could you do instead of trying to balance that seesaw correctly? You could use buprenorphine microdosing. So your regular dose for most patients is 16 milligrams, but you could start out at 0.5, so a fourth of a tablet or a film on one day, go up to 0.5, go up to 1, go up to 2. So you're gradually jubbing off whatever their own opioid is that's on board, but not enough to throw them into a withdrawal. And by the time you get to day 6, day 7, you can start tapering whatever else they were taking and then eventually come off of it as you go up to the full buprenorphine dose. So this is becoming more and more popular because it just seems to be smoother for patients than saying, hey, wait till you think it's bad enough, and then we'll give you this medication, and hopefully we're not making it worse because you called it too early. Which is kind of the old way of doing it. So is addiction a chronic disease? I would certainly say yes. The literature seems to be changing on patterns of Suboxone prescribing over time. Initially, people were taking it for two or three years and then tapering off, and now it seems like more and more patients are just taking this on a chronic basis. So the treating with buprenorphine or methadone following a non-fatal opioid dose reduced subsequent opioid overdose deaths by 59%. So, it's been an effective way to avoid things long term. Patients are functional. They hold down jobs, whether it's inside the facility or outside. And as you can see in Salt Lake City, the recidivism rates fall dramatically. So you're reducing the risk of overdose when they get released. You're reducing the risk of IV drug-use-related illnesses like HIV and Hep C. And you have fewer complications and cellulitis issues, abscess issues, you name it. What about urine drug testing? And there are lots of people who are much more expert at this in the room than me, so in the likely event I've messed this up, feel free to tell me. But amphetamines, you would often see those are positive if a patient's taking Adderall. Other things that can cause some false positives that I read about are listed there. I haven't really seen that a lot myself from Metformin, but it was on the list that I found. Diazepam is long-acting and can be detected for up to 30 days, so morning specimens are more likely to have a higher concentration of drug metabolites. This kind of thing is important because, especially in the jail setting, you want to know what the patient took. They're going to tell you, of course, you're going to seek medical records, but your drug testing is also going to tell you what they were taking, too. So knowing what can cause a real positive or a false positive becomes relevant. Okay. I will say in Wyoming we've had some patients that had snuck something into the facility, and one of the guys already had end-stage liver disease even though he was in his late 30s. And whatever he took didn't show up on any of our drug screenings. And that also happened with a guy who's—we've got dialysis in the facility as well. We had somebody on dialysis who did things. So I don't know if their status as end-stage renal disease or end-stage liver disease somehow played a role in our inability for us or DOC to figure out exactly what those two patients took, but that was interesting. All right. If you're operating as an opioid treatment program under the Code of Federal Regulations, you are supposed to do at least eight urine drug tests per year if you've got a patient who's being treated with methadone or buprenorphine. And some of the larger jails and larger prisons have their own methadone programs. We don't have that. And most jails, I think the rate is around 13 percent, and the entire country currently offer all three of these. It might even be lower than that, but that was one of the numbers I came across. So the rules on this may well be changing. They've changed them with buprenorphine. We'll get into that. I haven't seen any regulations change around methadone or making it easier to prescribe in the incarcerated setting per se. Okay. So what if you have a patient who you're seeing for opioid use disorder and they say they want to either start suboxone or they used to take suboxone? Can you prescribe it to them? You used to be able to say, well, I don't have an X waiver. That's not something I do. That's no longer a reason not to prescribe it. So if you want to treat a patient's addiction, you can do that, which makes a lot of sense to me because we could all—the minute we graduate and have a DEA, we could all start prescribing oxycodone and everything else to cause an addiction, but we couldn't treat it, which was kind of ironic. I think the additional training is helpful, and that eight hours of CME is still, as far as I know, freely available. You don't even have to pay to get it. So that's worth doing. For now, the waiver requirement has been removed, and there's actually no formal training requirement either. But in their regulations, they have stated that they're going to put one back in place probably later this year. And they haven't said exactly what it will be. I imagine it's something similar to what's already there. So state law is behind federal law here, and they're all in the process of reacting to this. So what they will do in each state is hard to say. Hopefully they do something that's pretty transparent and agrees with federal law. The pandemic created some issues here as well because your first visit with the patient for any controlled substance historically always was supposed to be in person. And now, at least—well, for a while during the pandemic, the federal emergency, I think, is going to expire in May or May of this year. You don't have to have that initial drug screen, which you used to always have to have to prescribe it. So I think that's going to go back to where it was, and that's for the better, to have some sort of—maybe if you're doing telemedicine, you could send the patient to at least some facility to get a baseline drug screen or to check that they're taking their medication and not taking things they're not supposed to take. But during the pandemic at the federal level, even that piece was waived. Okay, so again, to kind of reiterate buprenorphine specifically, make sure you start it at the right time, usually around 12 hours if the patient was using heroin or oxycodone. That's if you're doing the old method and not doing microdosing. You're going to start with 4 to 8 milligrams and then gradually up that dose. Some medications can be used to make the patient more comfortable for these other withdrawal symptoms that they might have. You can use Zofran for their nausea, loperamide for diarrhea, so on and so forth. Okay, if you've got a patient who has polysubstance abuse, remember that buprenorphine is only going to address their craving for opioids. It's not going to address their craving for stimulants. There's not a good pill for that as far as I know, and that's unfortunate. So the respiratory suppression and death concerns you can have with opioids, of course, stack with buprenorphine just like they stack with any other if you combine them with high doses of benzodiazepines. So the buprenorphine has a peak effect, but the benzos that are being combined with it, of course, do not. So watch for that combined use with either benzos or alcohol. And as we talked about earlier, buprenorphine, of course, can precipitate a withdrawal if you start it too soon. Okay, and it's Category C. I mentioned that a little bit earlier too. I tend to get ahead of myself in pregnancy. You can't have neonatal abstinence syndrome here as well just like you would with methadone, and you're going to taper the child after birth. Okay, what about methadone if we're comparing that to buprenorphine? It's only initiated pursuant to 21 CFR Code Section 1306.07c. So there's an incidental adjunct expansion argument and a 3-day rule expansion that can apply in either emergency settings or in jail settings that can allow people to prescribe it even if they don't have a formal program. But those are for brief time periods. So when they're starting the medication, it's usually 30 mg, and it's increased by as much as 10 mg depending on patient side effects and tolerance. And a lot of people are told to watch for torsades, watch for QT prolongation with methadone. Most opioid treatment programs don't even do a baseline EKG now. So apparently there wasn't much QT prolongation there compared to what I was taught in medical school, which is interesting. Okay, what else about methadone? Of course, it can cause respiratory suppression. I tell these patients they can't drive on this medication, and I've got that on here twice because it was just such a big point to emphasize. It's a CNS depressant, and we talked about the QT interval risk, although it's apparently much lower than originally thought. So if that's the only medication they're taking and they had no history of QT prolongation, you don't tend to see baseline EKGs. All right, FDA pregnancy category C, and it used to be what you put everybody on when they were on buprenorphine, but now that trend is changing and there doesn't tend to be a medication transition. Now Trexone, of course, is an opioid reverser, and there is a long-acting extended release formulation. The trouble is it's incredibly expensive. For a while, we had grant funding to offer that to patients upon release, and that money lasted about 6 months and ran out. So we can prescribe the pill form, but then you have to take that pill every single day, and the adherence rates for that are much lower than with getting a once-a-month injection. If you're going to do the injectable form, you want to make sure the patient has enough body mass to actually take it. So it's designed for a 2-inch needle to get into that intramuscular space, and hopefully their body habit just fits that requirement. Okay, if you're going to do a tablet form, you start at a 25 and then do 50 milligrams daily. And the tablet, and I suppose the injection as well, actually, they both can be used for opioid use disorder, but they're also helpful for alcohol use disorder, so they tend to decrease cravings for alcohol as well. So this is a nice one for somebody who had both of those addiction processes going on. You want to watch it if the patient has liver disease or renal impairment. And in women of childbearing age, it's contraindicated in those patients, which unfortunately is a fair number of people who've used controlled substances for some time. Liver disease is quite common, either from hep C or from alcohol. Okay. Good question. You're asking a lot of the criminal-slash-prisoner between injections, testing. What if I'm refused? I mean, do I have the ability to be refused? I mean, I'm not getting stuck with this stuff. I'm not being handcuffed. Where is the ability to find out for their own health, but also in the system? If it's an acute withdrawal state, their refusal rights could be a little bit limited because it's creating an emergency, and you could have compelled medications in that case, just like you could have for a variety of self-harm issues and any number of psychiatric illnesses. If it's in more of a chronic condition state where they say, I don't want to take this, I don't want to take naltrexone upon release or any kind of buprenorphine while you're here, then they can certainly refuse that, just like we have diabetics that refuse insulin and have an A1C of 11. Yes, Dr. Mills? Well, you know, I haven't worked in correctional facilities for like 25 years. I can tell you the court will mandate a psych state. When you start talking about meds that aren't psych meds, definitely blood pressure medicine and treatment for opioid addiction, they won't work. I've seen people with blood pressure over 200, and they refuse medicine, and that's just the way it goes. The comment about methadone, typically... I think you're probably switching, but there was an exemption for methadone. If you were pregnant, make sure you know what your opioid use is. You don't have to go through any special stuff. You can give a pregnant woman methadone maintenance during pregnancy. There's an exception, it's not a black box thing like the other one. There's much less restrictions on taking care of pregnant females. So Dr. Mills commented for those online that it can be difficult to get a court to compel any medications outside of the psychiatric realm, and that methadone was commonly continued during pregnancy. I would agree with that. You don't have too much red tape when you're trying to continue that during a pregnancy. I had one patient a few years ago who came in on Suboxone and was insisting that she wanted to taper it while pregnant, which was interesting. So I talked with some others, and we actually did do that successfully, but it's not something that you really want to do, but that's something she insisted on doing. Okay. Also about naltrexone here, it is a pregnancy Category C as well, but animal studies have shown some problems, so we tend to try to avoid that if the patient's planning a pregnancy or actively pregnant. Okay. And if you're looking at pricing of these different medication options, most of them have become much more affordable. The problem with the long-acting version of naltrexone, which is Vivitrol, or the long-acting version of buprenorphine, which I actually don't have up here, is Sublocade. They're incredibly expensive. Sublocade was anywhere from $1,000 to $2,000 when I was looking that up as well. So those are once-a-month injections, which theoretically would be much easier for everybody, you know, the nursing staff, because remember, if we have a—if I prescribe lisinopril to somebody, that's what we call a KOP medication, keep-on-person. So they'll come in these pre—these dose packs with 30 pills in them where you punch out each pill, and those are given to the patient by the nurses once a month. That's pretty easy. But if they're on any number of—let's say even like duloxetine, for example, which is not a KOP medication, then they've got to go to PillLine each and every day. And if they're on something like clonidine for blood pressure, which is terrible, but sometimes that happens, then they're going to PillLine three times a day. So with buprenorphine, if you're going to start doing this, then it's almost always a BID medication. So you've massively increased your PillLine. And with the films, you know, they're going to put that in there, and it's going to dissolve. It's harder to cheek and divert than, say, a pill would be. But it still creates this big PillLine burden, and you have to up the staffing because of that. If you can get grant funding for the injectables, it's much easier because you just show up once a month. There's really no risk of diversion at all. And so that's hopefully where some of this will go. But you can see the pricing on the different options there. Okay. Could the patient have alcohol withdrawal? They certainly can. If you're suspecting that, look for dehydration. Look for early symptoms and follow the CYAR, which is modified a little bit for patients with alcohol withdrawal. As I mentioned earlier, the seizure rates are actually much lower than we originally expected here. But you do watch for hallucinations. They can be auditory or visual. So if a patient's in the cell by themselves and they're talking, that's a good sign you've got a withdrawal concern. Look for sympathetic overdrive. So your heart rate is going to be your guide here as well. They may have hypertension and they never had it before, that kind of thing. Okay. Being facetious, now we have alcohol. Good to give them. We give them everything else. All these medications. Two beers a night, I'll be in Madeline. Well, maybe if they had auto-brewery syndrome, they would still have their own. Otherwise, I don't think it's going to happen. So most of these patients can be treated in the outpatient setting, which is nice to know, especially if you have somebody who has a—because a lot of patients with substance use disorder just don't want to be admitted, even if you think they're high-risk. So if you've got somebody who wants to be assisted with alcohol cessation and doesn't want to be admitted, then hopefully you would consider doing that. The one thing that might convince you otherwise is if they said they had a history of seizures when they did this two years ago, then you'd be more likely to admit them. But apart from that, it is something that should hopefully be done more and more in the outpatient setting. Thank you. Bessie, what did you think one should consider doing with that? Just now, your statement, I'll guess what you did. If they were wanting assistance but not admission, should you consider? Oh, consider treatment. So a lot of patients who have an alcohol use disorder or any number of addiction issues, they're used to hearing the sort of, I guess, the really maybe conservative approach of if you've used this heavily for this long, the only way for you to come off of this is to get admitted to a psychiatric facility or some other facility of some kind or be incarcerated, which in many ways is a psychiatric admission for patients. And there are it's easier and easier, I think, between the buprenorphine micro dosing and between some of the newer literature around alcohol withdrawal as well. You can treat these patients, treat their withdrawal on an outpatient basis. So they are going to need, I think, to have access to you with your cell phone or some other number that you would choose to share, and you can sort of tell them what to do with each step because they do need close follow up. But maybe you start this on a Monday rather than a Friday so that they can follow up with you in your office kind of each day and see where they are. But these kinds of things can be managed in the outpatient setting more than more than we thought. When you say outpatient, you mean you mean in general population and corrections or do you mean like go home? Yeah, I mean, like, yeah, but this is assuming they're not incarcerated. This is just for yeah. Yeah, the facilities I work at, people don't get to go home. But to your point, there's a there's a I don't remember the name of it, but there's a Netflix documentary that surprised me because they cover these these prisons around the world. And there are several where you where you're in prison, but you can still go home, which was interesting. So there are a few that do that do interesting things like that. That particular one, I think, was in Greenland. Okay, Benzo's for alcohol withdrawal. Very great. Yeah, not very far to go. So Benzo's for alcohol withdrawal. If someone's drinking more than 10 standard drinks in a day, then you're probably going to go or on the side of using a higher dose of diazepam on day one. You might go with a 20 milligrams every six hours. If you don't have that, you can you can discuss chloride as epoxide or gabapentin that can be used adjunctively. So if somebody is drinking less than 10 drinks in a day, maybe you do 10 milligrams every six hours. And basically, you're doing close monitoring on these patients because, as you can see, you're you're guessing you're guessing how much they were drinking. You're guessing how much of a benzodiazepine dose they needed. And you're going to monitor your vitals to tell you to go up or down on that as you taper. Okay. What about non benzodiazepines for alcohol withdrawal? Benzo's are still your first choice, but other things can be considered. Gabapentin is a decent long term medication for alcohol use disorder because it can reduce the alcohol kindling phenomenon. Arbamazepine is less commonly used here, but it is used overseas in Britain. And then phenobarbital is a consideration of alproic acid, especially if they have some sort of seizure history. But they don't have a lot of supportive data by themselves, and you're mainly treating some symptoms there. Okay. What if the patient was abusing stimulants? I don't have anything FDA approved or a stimulant use disorder. There are some nuances we can talk about here. If they were doing cocaine, which is pretty rare these days, it seems like everybody does methamphetamine rather than cocaine. But topiramate may help some with cocaine, but doesn't seem to have any beneficial effect at reducing cravings for methamphetamine. Mirtazapine, naltrexone, bupropion are all considered because there's a decent chance if a patient was just trying to use a stimulant like methamphetamine or cocaine that they're getting fentanyl. Because fentanyl is used by drug dealers like salt is used like a chef, they just put it on everything. So even if that's all they wanted, a lot of times patients are positive for fentanyl and they thought they weren't using any opioids at all. So sometimes that does play a role, even though you don't expect it would based on what the patient tells you. Okay. The other thing to note here is that you want to push the pause button before you diagnose a variety of different psychiatric conditions when patients are first admitted, and especially in a jail setting because they may appear to be psychotic and they might meet DSM criteria for all kinds of things, and a lot of that is really more of an addiction issue and a withdrawal issue than it is a true psychosis. A quote about cannabinoid addiction, try and treat the underlying source of anxiety. There aren't any medications that you can say will clearly reduce the cravings here. There have been some studies around N-acetylcysteine, though. What's younger? Younger than what? You said in younger patients. Most people are younger than I am, but that doesn't mean anything. I think that study was looking at 20 or under, if I remember correctly. Okay. Thank you. And, of course, I didn't put it on here, but the other thing that we'll see fairly frequently is cannabinoid hyperemesis syndrome. Is everybody familiar with that? Yeah. Okay. Some say no. All right. Well, the cannabinoid hyperemesis syndrome, it's a bit of an ironic disorder because a lot of patients who use cannabis are doing it initially for any number of what they view as positive effects, and then they might actually, when they start to come off of it, when they have their own kind of more minor withdrawal from that, they'll have this nausea. And, of course, cannabis is used by cancer patients specifically to treat nausea. But there is a condition called cannabinoid hyperemesis syndrome where whatever was going on there has changed, and instead of treating nausea, it's now causing nausea. And it's often in people who have used it for quite some time, and it can linger for a while after they stop using it. So these patients often spend $10,000 going into the ER, getting CT scans, getting scoped. Nobody's finding anything. And then finally somebody asks probably the most critical question in the history, which is a weird one. Does your nausea go away when you have a hot shower? Why? But having something hot on the abdomen actually reduces the symptoms of cannabinoid hyperemesis syndrome. So since you can't tell somebody to stay in the shower for 24 hours a day to get rid of their nausea, one of the things that's being printed up that's being used for that is actually topical capsaicin on the abdomen. So go figure. But it can really fool you because it can linger for months. So it's not like you quit smoking marijuana and now two to three days later your symptoms are gone. Marijuana hangs out in the system, I guess, for a while, and whatever it's triggering with this cannabinoid hyperemesis syndrome can linger for two, three months. And I have had a debate with one of our patients about this specifically. She was insisting that this couldn't be the answer because she'd last smoked like two and a half, three months ago and was already in prison from a jail, and it was the answer. Okay. If you don't treat addiction, have you violated the ADA? And this is a new one that Dr. Mills and I heard discussed this year at an NCCAC and ACCP meeting. The answer out of the Department of Justice is yes, that addiction is indeed something that is covered under the ADA. And you've got the citation there. And we'll dig into it a little bit more here. Why is this considered a disability? Just like any other chronic condition, basically, it can be covered as a disability. And there is an exception within that USC citation there that if they are actively using, then it's not considered a disability, which is important certainly in the employer setting where they're going to often terminate people for using for a variety of reasons because it affects their safety and the safety of those around them. But in the incarcerated setting, and this is to be litigated, but from the expert that we heard from earlier this year, that's more of a, you know, healthcare setting where they literally can't go anywhere. It's almost like being admitted in a psychiatric facility. Then even if you have somebody who's been using something illegally, getting something snuck into them, there's a legal argument that they're still entitled under the ADA to medications for opioid use disorder. So lots of changes are needed here. So most jails and prisons have not offered any kind of Medicaid-assisted treatment. And the new DOJ rule says not only should we be offering that, we should be offering all three. So if everybody comes into my facility and there was a jail nearby that said, hey, all we've got is methadone, so anybody who's got opioid use disorder, we're putting you on methadone. And then they get to prison, and we say, oh, all we've got is Suboxone, so we've got to switch everybody over to Suboxone. That's going to be an ADA issue. So you've got to find a way to do all three, which is a challenge for a lot of facilities. And the Department of Justice is making this an area of emphasis this year. And when they did a survey in August of 2021, 12 percent of facilities had any form, let alone all three. So a lot of movement to be made here. And hopefully the pricing and the access along with it will come way down for the injectables, which I see is the only viable solution if this is offered widely across the country. If you consider the high volumes of patients who are probably going to request treatment, they need to find a way to do that efficiently, and that seems to be the most efficient way. Okay. Many, many facilities do have these outdated blanket policies that they're going to have to adjust. This can hit skilled nursing facilities as well. And if they say we're only going to prescribe one substance, that will get you in trouble. I think I already kind of discussed all these. Transition of care to the community. Hopefully you have recent community programs in place if a patient is leaving your facility. If they have a 12-step program, they want to be enrolled in that. Have a job at the ready, some sort of motivation to help them avoid going back to whatever that controlled substance was. I don't have the data in here, but I do remember seeing some discussions about physicians specifically that had substance use disorder. And their rates of going back to that addiction were much lower than the rest of the population, presumably for a variety of reasons, maybe better support, maybe additional insight into their disorder and motivation to keep their license and keep their job. It often comes with the medical board sort of monitoring them closely. And for a lot of other patients, that's not the case. They don't have necessarily as much to lose in their mind, and they may not have that close monitoring that we seem to get either from our employer or from a medical board. Patients are up to 40% more likely than the general public to die of an opioid overdose upon release. So these are incarcerated patients when they leave. They don't realize how much their tolerance has fallen. Are they educated about that on this journey? Yep. And, you know, when we got rid of the—we had that Vivitrol financing for a while. We do offer them naltrexone and any number of other prescriptions as they're leaving as well. So we try to avoid this as much as we can. In general, whether we're treating addiction or hypertension, patients leave the facility with a 30-day supply, and then they have a prescription through a mail-order setup where they'll get medications for another 90 days that way, which gives them a window of up to four months to establish care somewhere else. Do they get some kind of counseling that encourages them to not go back to where they were using for getting away from those individuals and that type of situation? Right. I mean, we certainly do. They need to go right back to that environment. Sure. Yeah. We talk about that, and that's easier said than done. Oh, sure. You know, their family is their family, and their friends are their friends, and if everybody else was doing something we don't want them to do and they're going to go back in that environment, it's challenging. And that's true, you know. That's true not only for this. It's true for smoking. That's true for bad eating habits probably for a lot of people. So the environment plays a big role, and we educate around that as much as we can. And the parole board does factor that into their consideration in when they parole people. And oftentimes they're paroled to a treatment program rather than going directly back to where they came from. And we've had other situations where, you know, never mind the addiction we've just discussed, but we've got patients, you know, we're basically running a small nursing home in the facility as well. So when those patients kill their number and have to be released, finding a place to put them can be challenging for the parole board. Okay. So we've got some recommended resources there. And that was my last slide, so I don't know if I'm over time or under time here. Okay. Well, that was a very good lecture. I think if anybody's taking care of people, particularly in jail, you have to be extremely careful because most of these people are abusing Xanax. Okay. And so your nurses are doing the screening. And they'll say, oh, well. And so they'll put them under monitoring. And then, you know, symptoms for like four days, you know, and they take them off. Really good facilities. I've never trained them at all. Go around and see these people twice a day and check vitals on them. Where will you find somebody who's taking care of them? That's acting for like 96 hours. So they don't start withdrawing until they're, you know, five, six, seven days. And so you can take them off. They're all wired protocol all once you have somebody see them. So you don't see it too often. When something gets easy to miss, it can get you in trouble. You know, you mentioned fentanyl. Last year we lost almost 108,000 marathons of opioids over. Most common form of overdose is fentanyl. Fentanyl can help with all overdoses. But the most common drug they were overdosing on was fentanyl. The DEA has already confiscated enough fentanyl to kill every man, woman, and child. Probably several times. And you only need enough fentanyl, like the naive person, which most of the people who are overdosing are naive, like 80% of them. So you can go from prey to prey. There's fentanyl out there called carfentanil, which is like 10 to 100 times more potent than fentanyl. And if I ever had someone go up to me and I was looking at dust in their face, it was an immediate respiratory arrest. The problem with the cartels, it's not a problem. It's a business to them. Fentanyl is completely synthetic. There's no agricultural overhead. Since 1913, most of the precursors of fentanyl come from China. You know, the cartels, the cartels, the man-attacking. What he was saying about meth is absolutely true. Because the cartel, I mean, I sat on the opioid containment council for the state of Texas. That kind of stuff. And the cartels have spent a lot of money on pill presses. So they can make a pill that looks exactly like a Percocet. Same color, same number, same size. I can put two in front of you, one from the pharmacy, one from the cartel, and you couldn't tell the difference. Adderall, Xanax, doesn't make any difference. So when I talk to people about this, I say, I'm not too worried about Dr. Bershka. You know, he's like a pretty sorted white guy. Outstanding citizen and all that. But your kids, your teenagers, your grandchildren, it's when they go to school and somebody says, oh, I got a bad headache in high school. I'm like, Francis, I got a Percocet. Those are the people that are dying of overdoses. We had two college students in Ohio who thought they were taking Adderall because the thing looked exactly like an Adderall. When the respiratory arrest died, they were just taking Adderall because they were cramming for an exam. And you can go on the DEA website, and they've got a thing they call the fentanyl wall, and there are literally thousands of pictures of teenagers who died inadvertently because they thought they were taking a Percocet or the Xanax. They don't have any anxiety or time. They have a transcancer, something that looks exactly like a Xanax drug. I just heard an NPR stimuli going over the border. A lot of us Americans go to Mexico for cheaper, and they just pull the exact same medications that they would be taking and it's placed with Xanax. I mean, that's right. That's right. I think that helps. Yeah, and I think the cartels are lacing all the drugs of abuse, meth, cocaine, heroin. They're lacing all the fentanyl. Why do they do that? It's a business decision. They're trying to switch you over to a cheaper drug of abuse. Fentanyl has an intense choreographing product. That's what I call good business. Yeah.

addiction treatment

correctional medicine

substance use disorders

opioid use disorders

medication-assisted treatment

ADA compliance

microdosing buprenorphine

recidivism reduction

community care integration