So, this is our penultimate. Memorial lecture, so we have 6 or 7 commemorative lectures on a particular topic. The Kenneth Ryland lecture to be on any of our disciplines, and it's usually on a public health topic. That that's that's in a critical need for our nation and for our physicians to be educated upon. Dr. W. Kenneth Ryland, D. O. live from 1912 to 1989. He was born in Camden, New Jersey and his patients included Richard Nixon. And Nelson Rockefeller, I didn't know those guys, but he was the co founder of the New York College of osteopathic medicine and old Westbury, Long Island, New York. He was a personal physician to Nelson Rockefeller for more than 30 years. Dr. Ryland treated a number of nationally known figures. He provided osteopathic manipulative treatment. To President Nixon for several years, and even travel with the president on his world trip in 1969. And this trip to China in 1972. He also provided to Henry Kissinger during his stint as secretary of state. Dr. Ryland graduated from the Philadelphia College of osteopathic medicine in 1936. I think that was the class right before Dr. Bell and soon after settling in Manhattan, he began working part time for the US Steel Corporation. He later became US Steel's chief physician in New York, a position he held for more than 20 years. In 1974, he became a consultant to the company. He was still practicing in Manhattan at the time of his death. Dr. Ryland was co founder and chair of the board of the New York College of osteopathic medicine. Of New York, NYIT and Old Westbury. He was also a founder and 1st, president of both New York Academy of osteopathy. In the American Foundation for Research, Dr. Ryland delivered the 1969 Andrew Taylor Steel Memorial address, the annual AOA house delegates. In memory of our founder of osteopathic medicine, it is considered 1 of the profession's highest honors. I mean, other than this lecture, Dr. Ryland was board certified in physical medicine and rehab and was a fellow of the American Academy of osteopathy and the New York Academy of osteopathy. He served the AOA as trustee and a member of its board of governors, and he was a 1963 recipient of the Academy's Andrew Taylor Steel Medallion of honor. He also served as chairman of the board of trustees of the postgraduate Institute of osteopathic medicine and surgery, which is now affiliated with the New York College of osteopathic medicine. Dr. Ryan received an honorary doctorate of science from Midwestern University, Chicago College of osteopathic medicine, a doctor of laws degree from the New York Institute of technology. He also received a distinguished service award from New York State osteopathic medical society and OJ Snyder Memorial medallion from the Philadelphia College of osteopathic medicine. He was known as a Manhattan socialite. He kept a journal of his life's events, which is now the Rockefeller archive center. At Rockefeller University in New York City, he died of complications from the pluma in 13, March 1989 at New York Presbyterian hospital. At the time of his death, he was 76 years. So today, the W. Kenneth Riley Memorial lecture and medallion presentation is a key feature. At the mid year conference of the American osteopathic College of occupational medicine. Dr. Ryan was a pioneer in the field of occupational environmental medicine. A longtime member of our college, this lecture was established in 1983 by the board of trustees. This prestigious lecture is presented to an individual who has to be very young and good looking and a model of health that looks like he was chiseled out of granite. So, I've never been qualified except for the fact. Right. Right. Exactly. So, anyway, that's kind of explains why I was never invited to give the Ryland lecture, but he could be a member or non member. You can't be a little fat Cajun man, though, and the presenter of the lecture has demonstrated a desire to see the practice of occupational and preventive medicine excel for the public good. This year, Dr. Ben Grant is going to present on our opioid crisis. Benjamin grant MD, MPH received his MD from Tufts University school of medicine, and he completed internal medicine residency at Brigham and women's hospital, Harvard medical school. Received his MPH from Brown University. He currently serves as an assistant professor of primary care at KCU. Where he teaches clinical skills to the 1st and 2nd year medical students and is involved in expanding public health training within the medical school. He maintains an active clinical practice at the Casey care health clinic. His clinical work includes primary care. HIV care and care for patients with substance use disorders. He also serves on the Kansas City, Missouri health commission, where he's active in advocating for change to improve the health of our broader community. Thank you so much for presenting to us. Thank you. All right, thanks so much for having me. This group is fun. I didn't know I was going to be doing a memorial lecture, but I'm honored to do that. Let's see if that works. I don't like holding a mic. All right, so I'm just going to move the Zoom chat out of the way here. I have a little clicker point, too. Is it this or is it this? This is a square. Okay. Perfect. Yeah. Awesome. Well, thanks so much. I'm excited to give this talk. I've never given this to a preventive medicine audience before, but I tried to kind of make it a little bit more public health oriented. I've practiced care for patients with opioid use disorder since I started residency, so for about the past eight years, and I prescribe a fair amount of buprenorphine. The crisis has become worse and worse every year I've been in practice, and so I'm excited to share what I've learned with y'all. I don't have any disclosures. So my learning objectives are mostly clinical, and so they kind of sound geared towards folks who are actually going to be treating opioid use disorder in practice, and I know that may not be everyone in this room, but I think by understanding the treatments for opioid use disorder, you can kind of better understand the big picture perspective and really what we need to do as a society to address this and how the medical profession can help. So I'm just going to start with a little bit of epidemiology. This chart is going to show the mortality from HIV, which peaked in the mid-90s, so in 1990, 47,450 people dying per year from HIV. And this graph shows the number of Americans dying every year from drug overdoses, so this is now far surpassed deaths at the peak of the HIV epidemic. And this problem has really only escalated since the beginning of the COVID-19 pandemic, and the reasons I think are complicated, but particularly at the peak of the pandemic, some of the issues that folks were facing were increasing social isolation, decreased access to care as well for opioid use disorders. I really like this chart. I think it tells a nice story of how the crisis has evolved over the last 20 years. So if you look at it, the first wave of opioid crisis was really related to opioids that were prescribed by physicians. And I don't know if anyone has a Hulu subscription, but if you haven't seen it, this is a really nice series. It stars Michael Keaton, and it tells a story of how the pharmaceutical companies played a role in getting a lot of folks addicted to opioids and a lot of pretty nefarious ways that they were able to convince doctors that these substances were not addictive. Really, they infiltrated medical practice in a pretty impressive way. They led us to the whole movement towards asking every patient about pain. Pain is the sixth vital sign, which still is a part of clinical practice, and not wrong entirely, but they were part of that movement that helped us move towards really trying to treat pain at all costs, and a lot of times the cost was medications that had risks that folks weren't aware of. So the state medical boards and societies were also lambasting physicians. If they didn't not take care of the patient's pain, you were at risk of losing your license, and the joint commission, and the joint commission, right? And so, yes, they put doctors in a really hard place, right? In a really hard place, and they're blaming everybody. The doctors for everybody else's screen. Right, so you were doing what your professional societies told you to do at that time, and then you get all the patients on the medications, and then 20 years later, they're telling you to do the exact opposite thing. It's a huge challenge, right? Second wave begins in 2010, and this is a rapid rise in deaths from heroin overdose, and so this is the point in time when folks are starting to be told, when physicians are starting to be told, get your patients off these opioid, the prescription opioids. And then the third wave that we're now in is really increasingly related to deaths from synthetic opioids, and so this is fentanyl, right? And so I just want to zoom in a little on what's going on with fentanyl, which today is playing the biggest role in the overdose crisis. You might wonder, why and how did fentanyl make its way into the drug supply? And the reasons are kind of complicated, and I won't get into the full story today, but in short, it's partly related to the economics of drug manufacturing. So fentanyl is synthetic, it's cheaper to produce than heroin, and it's actually easily made into a white powder that can be combined with other drugs. And so drug manufacturers found that they could basically cut heroin with fentanyl, and they could also cut other drugs with fentanyl. And so fentanyl made its way into the drug supply, not just the heroin supply, but really the supply of any illicit drugs sold on the street. So, you know, what does the data look like now in Missouri? It's pretty harrowing. So drug overdose is now the leading cause of death among adults age 18 to 44 in Missouri. So if you're a public health practitioner, this is the leading issue affecting young people and killing young people in our state. And, right, I'm talking about drug overdose broadly, and many overdose deaths are now involving multiple substances. But even with that, about 70 percent involve opioids, and when they involve opioids, they're probably a primary contributor. In 2020, 1375 Missourians lost their lives to opioid overdose. You all know this, but, right, death is not the only negative consequence of opioid use disorder. There are chronic infections. I practice HIV primary care. A lot of folks contract HIV through intravenous drug use, hepatitis C, lots of serious social and interpersonal problems, and the list goes on. This is a need site, and, you know, I know not everyone here is from Missouri, so I'm not sure if this data is presented similarly in other states. But for folks in the Missouri medical world, this gives a nice graphical picture of the drug overdose crisis in Missouri, and it really shows the role that synthetic opioids are now playing in drug overdoses in the state. And, you know, one thing you can do is you can go to this website and sort of drag back and forth by the year. And if you look back just, like, five years, the circle of heroin, you know, that circle was way bigger, and the synthetic opioid circle was way smaller. So, really, the dynamics of the crisis have rapidly shifted in the last five to ten years. You know, I think a lot of the focus in the popular media has been on how the opioid epidemic has affected white rural folks. And I think that is true to some extent. I think, you know, TV shows like Dope Sick kind of play into that. But just when we're thinking from a public health standpoint, it's important to point out that this crisis is disproportionately affecting Black Americans. And the reason for this is largely due to the same factors that cause other inequities based on race, so things like systemic racism and lack of access to care. So where do physicians come in? I think the key point I want to get across today is that there are highly effective treatments for opioid use disorder, particularly medication treatments. And these treatments are effective in a way that medication treatments for other substance use disorders are not as effective. So I take care of a lot of patients with alcohol use disorder. I don't have a medication. We have medications that are somewhat helpful, but it's not the same as with opioid use disorder, where we have medications that literally save people's lives. And the medication alone, really, without many other supports, is getting people off opioids. The challenge is that these medications are really pretty hard to access, and the majority of Americans who need treatment aren't able to access these treatments. We have addiction medicine specialists that prescribe these. We have psychiatrists that prescribe these medications. But there really aren't enough of those specialists to meet the demand, especially as the crisis escalates. And so, really, we need primary care docs, preventive medicine specialists, folks in other specialties to start looking at opioid use disorder as part of their practice and not just kind of like a specialty referral practice. One of the other things to think about, and I'll kind of talk about this more at the end of the talk, is that there are certain policy barriers at the broader level that are making it hard for docs to deliver the most evidence-based care for opioid use disorder. And for folks who are in that kind of political policy realm or advocates, we'll kind of talk about what policies you should be advocating for that can help get patients access to evidence-based treatments. So I'm going to start off kind of with the more clinical aspects of this talk, and we'll just start with a case. So this is Jane. Jane is a 48-year-old female who's coming into primary care clinic to establish with a new PCP after moving. She had a motor vehicle accident in 2015, and she was started on oxycodone for management of pain by her PCP. We'll say that Jane was evaluated thoroughly. She tried multiple other modalities of treatment, acetaminophen, ibuprofen, other non-opioid pharmacotherapy. She was evaluated by an orthopedic surgeon, and she went through physical therapy. And all that stuff was done before the physician started her on oxycodone. She's now been taking oxycodone five milligrams three times a day for the last seven years. You confirm this with the Missouri PMP, which tells you that she doesn't have other prescribers. She's not doctor shopping. There's no other red flags there. She says the dose controls her pain and allows her to work. She doesn't use alcohol or other substances. And you confirm this on a urine drug screen. And she always takes it as prescribed, never takes more. And she says it doesn't get in the way of her family or work life. It may not sound like a lot of your patients, but I want to just kind of put this into context in terms of diagnosis. Just by a show of hands, who in this room thinks Jane has an opioid use disorder? Okay. And, you know, when I give this talk, I usually get like about 10% or 10 to 20% of the room that says that. I don't ask this because I don't think it's a controversial question. For folks who raise their hands, any thoughts on why you would call this an opioid use disorder? She's dependent on it. She's been on it since a couple weeks ago. So I think it's a valid perspective. I'll talk a little bit about the perspective from the DSM-IV. But I think that, you know, one perspective on this is that, you know, no one should be taking chronic opioids for pain. So this is an opioid use disorder. I'm going to kind of bring in the DSM-V and talk about kind of what their perspective would be on whether this is an opioid use disorder or not. From that perspective, addiction is not simply about the use of substances, but it's the behaviors and symptoms that surround drug use. Remembering that, you know, many people are going to use substances, but only some folks are going to develop addiction. And so they see kind of three Cs of addiction. And so I think about it in terms of loss of control, continuing to use in spite of negative consequences, and sort of having cravings or compulsions for the substance. And so, you know, when we think about this patient, this is the full criteria for diagnosing opioid use disorder. I'm not a psychiatrist, right, so I'm not going to be as strict in thinking about each piece of it. But, like, let's just think in terms of those three Cs. I don't think this patient has lost control around the use of the substance. She's taking a low dose. And she's taking it as prescribed. She's not really having negative consequences related to use. She's not having compulsive use where she's, like, taking it earlier than she's supposed to. She does have physical dependence, though. And, you know, if you asked her, right, if you stopped her medication, she would probably go through withdrawal from that substance. The point I want to kind of get across here, just specifically related to how the psychiatry community defines opioid use disorder, the presence of withdrawal alone or tolerance does not meet criteria for opioid use disorder from their perspective. And the idea here, and, you know, I kind of see this in my practice. I have a couple patients on chronic opioids, you know, some who look like this. It's not a big part of my practice. But, you know, there are selected folks who are on chronic opioids who I would argue don't have an opioid use disorder. And that's not really the focus of this talk, at least today. But I want to talk about a different Jane. So this is Jane number two, right. This Jane is also a 48-year-old female who's coming into primary care clinic to establish with a new PCP after she moved. She also had a motor vehicle accident in 2015 and was started on oxycodone for management of her pain by her PCP. Unfortunately, this Jane started craving higher and higher doses. Her PCP initially kind of went along with it, but then stopped prescribing because they noticed a lot of red flags, right. She then started buying prescription pain pills on the street, and she couldn't afford those. And then she switched to heroin. And so her heroin use has led to loss of her job. She lost her spouse. She's overdosed a few times. And she really wants to quit, and she's tried a few times. But with the withdrawal, it's just been way too hard, and she's not sure how to quit. So for the audience here, who thinks Jane number two has an opioid use disorder? Great. I know these are like polar opposite cases, but this is really the Jane I'm going to focus on for the rest of the talk. I'm not going to focus so much on the gray area patients who are in on chronic opioids for pain management and showing some red flags. That's really not my expertise and specialty. I specialize more in folks who have a clear-cut opioid use disorder and want to stop using opioids. Back to Jane I, and I realize you don't want to focus on that. But I was a CMO for a place in Northern California. And we decided we will start adjusting our practices as a group. And so we started sending people back because we had people on 200 and 300 milligram morphine a day. So as we did that, you find people that are abusing that were more like Jane II. So we had a conversation with one individual. We said, well, hey, you know, if you're all coming back, how come you're not coming back for Mrs. Smith? Well, Mrs. Smith was the little 60-year-old lady who took religiously one, three times a day, had been doing it for 10 years, and obviously doing fine. Looked just like Jane number one. And they said, well, why did you say that? I said, well, half of mine, I use what you give me, and then I also buy from Mrs. Smith. So when they came back in and the question was actually a couple, and they were both getting, said, well, yeah, we take them occasionally. And what we don't use, we sell. And that's how we augment our social security. So just because the person is not, you know, it looks perfectly appropriate, you still should evaluate that on every visit. And could they do fine on two? Maybe they only need it twice a day. But it's so easy for us. Hey, everything seems to be fine. Let it run. So it's not, my point is, it's not just clear cut. There still should be that thing in the back of your mind too. Know what I mean? That's a great point. I mean, this is such a challenging issue. I had a patient that I was taking over from another prescriber who I didn't prescribe because I saw too many red flags. And the front desk staff heard them say on their way out, did you get enough for two? So, I mean, this is challenging, right? And there also is data that for people on chronic opioids that sometimes decreasing their dose can help improve their pain management. So, you know, lots of nuance to the pain management piece. Definitely not my area of expertise. And really props to folks who continue to manage these patients because I think one of the challenges is that no one really wants to do it anymore because of the regulatory environment and all the other pieces that go along with it. So, you know, I think pretty clear that Jane number two has an opioid use disorder based on all of the DSM criteria. Just kind of want to share that, you know, what are some of the additional info you might want to obtain in a patient who's coming in who's interested in treatment for their opioid use disorder? This is what my template looks like in my EMR. And so some of the questions that I would want to ask in a patient that's interested in buprenorphine, for example, you know, want to know when they last used, kind of want to get the story on their opioid use history. You know, what bad things have happened to them in life related to their opioid use? Have they ever had periods of sobriety? And if they did, you know, what worked for them? If they were on buprenorphine before and that worked great, that's evidence to help you form a treatment plan. You want to know if they've overdosed before. That tells you kind of their risk. Other substances they're using can sometimes make opioid use treatment a little bit more complicated. Specifically, benzodiazepines and alcohol can sometimes negatively interact with medications for opioid use treatment, but not a contraindication to treatment. Other substances really don't interact. So I have patients that still struggle with meth that I treat for their opioid use disorder as a form of harm reduction. I'll kind of talk about what that means. You definitely want to get folks tested for HIV and hepatitis C. You want to know if patients are pregnant, although the treatments I'm going to talk about are generally safe in pregnancy. And you want to get a bigger picture of kind of their psychiatric and social history, because their success in treatment, a lot of it is going to relate to what other supports they have in life, and also how they're going to fill the space in their life that used to be filled with opioid use disorder. Because people that suffer from chronic opioid use disorder, they spend a lot of their every day trying to figure out how to obtain and pay for opioids. And so once that's gone, they kind of have to figure out, you know, where is that gap going to be filled? Some of you might have noticed this language from the DSM-IV that shifted in the DSM-V. So the old DSMs used to differentiate between a term called substance dependence and substance abuse. And the DSM-V has replaced this with a single category of what they call substance use disorder, and they rate it on a scale from mild to severe. And so you'll notice specifically they've stopped using the word abuse. I know some folks in the room are probably thinking, like, this is just semantics, you know, and this is not important. But I am actually going to make the case that I think the language matters, and the literature supports that as well. So this was a pretty interesting randomized study of mental health clinicians, and it was looking at how language affects perceptions of people with addiction. So what they did, they went to a mental health conference, and they took about 500 clinicians who were attending it and randomized them to read one of two vignettes about a hypothetical patient. And the vignettes were exactly the same, except the vignette on the top described Mr. Williams as a substance abuser, and the one at the bottom describes him as having a substance use disorder. And then after they read the vignette, they asked folks questions about the causes of the substance use disorder, and also about, like, what kind of treatment the patient should receive. Like, should they be put on medication treatment and see a therapist, or should they go to jail for what they've done, right? And what they found is that people who read the substance abuser vignette were more likely to say that Mr. Williams was personally responsible for his addiction, and that punitive measures should be taken to manage his addiction. And so the conclusion, right, is that, you know, language can bias the way we think about patients. And this is even among highly trained mental health professionals. I'm not just talking about lay public, but, you know, folks who manage addiction on a day-to-day basis. You know, this principle about language, I think, doesn't just apply to the DSM and, like, the stuff we put in our medical charts, but it's also about the way we talk about addiction with our patients and with our colleagues and, like, what we write in the chart, too. I actually, at KCU, I recently did a patient panel where I brought in folks who are living with opioid use disorder to talk to our students. They're folks in recovery, and they talked to our students about, you know, what in the medical healthcare system made a difference in their recovery. And the number one theme that came out was stigma and language. They talked about how when they felt stigmatized in the doctor's office, that made them not want to come in and seek care and made them want to continue using. And so we talked a little bit about, you know, what are the terms that you should be using and what are the terms you shouldn't be using. And so this is a pretty helpful list. You know, I recommend against using terms like addict, abuser, alcoholic. You may hear patients use that term, but I recommend not using that term unless, like, the patient brings it up first. Another good example is, like, clean and dirty related to drug tests. You know, patients may use that language, but I don't reinforce that language. You know, if I'm using a urine drug screen for some reason, I present those results in kind of an objective, you know, not value-laden way. So I just say your urine test was positive for x and y, not your urine test was clean or dirty. You know, talking to a preventive medicine group here, my philosophy on this policy would be, how can I do things to encourage the ounce of prevention versus the pound of cure? Okay. Are you going to address that aspect of saying, what can we do to enhance the preventive aspect so we don't have to deal with the people that you're dealing with because they're minimal, not prevalent? That's a great question. I think that, you know, I think that it's hard because we have so many people in this country that are addicted to opioids, and I'll get to this at the end, but I think what we really need are policies that get people access to the best evidence for treatment. So, and I think those things include buprenorphine, methadone. Those are evidence-based treatments that save lives, and people should be able to easily access those treatments without barriers. Like, you have to go see a therapist. You have to go see a psychiatrist. You have to wait three months on this waiting list. I mean, and from my perspective and, you know, from the evidence, that's kind of like saying, I'm going to diagnose you with diabetes, but before getting your diabetes treatment, you need to go to this nutritionist. If we see you at McDonald's again, we're not going to treat you, and we're going to recommend that you, you know, you continue to work on that before we're willing to draw labs and give you your metformin. That's kind of the way we approach addiction nowadays, and I think from a preventive standpoint, that's what we need to do. The other piece, I think, is harm reduction, and so, you know, people that are actively using, we need to get them access to things like syringe services programs, naloxone, you know, preventive medicine folks may be thinking, or have these CMOs, you may be like a CMO of your organization, you know, there should be access to naloxone for in case there is an overdose there. You know, those are kind of some of the things that come off the top of my head. Does that sort of answer your question? I'm not really. It does not. Okay. I'm saying, I want to prevent somebody from getting into a situation where they are abusing drugs, or having a substance abuse disorder, or substance use disorder. And, you know, to begin with, I want them to, I mean, I'll give you an exaggerated example. I grew up in the 50s and 60s in the Bronx, in New York, and kids were immune to that stuff. We never got hit with all of these kinds of drug availability, etc., because the mothers and fathers Italian association didn't tolerate the selling of drugs to children. And that was the way it was. If you were a drug addict, it's about saying no. I mean, look, you know, there was the man with the golden arm in the 50s with Son Acher. There was, you know, Valdemar Dahls with, excuse me, what's her name's book, turned into the movie 66, etc. These were very dramatic things, but again, depicted the society and the issue in the society as minor as it was, as something to be avoided. And it was a chilling effect of that. We now have things where it's the movies glorify it. Are you talking about the language, how the language could be helpful on someone who's not, that can be preventive, like you don't want to be a junkie kind of a thing. You don't want to be an abuser and use that as a preventive way. No, I'm not actually saying that. I'm not saying let's go back to Nancy Reagan's idea of just saying no. I'm sitting there saying, okay, these are terms that we're using. I'm saying, what do we do and how do we actively as physicians, preventive medicine physicians in particular, to prevent people from ever getting to the point where they're now in these situations where we even have to consider what language we use. I don't want anybody to be on the stuff that doesn't need to be. So good question. Let's pardon me about that. And then let me finish. That's what I asked him if he was going to be talking about it. He then asked, no, the question about it, and I was trying to operationalize it. Yeah, let me get to the end and we can try to have a conversation then about it. It's not my expertise, honestly. I think there's so many people that are addicted and I would share that I'm trying to address that on the ground. But also, I think we know the things that don't work. I think we know that trying to control the drug supply has not worked. And we also know that putting people in jail for using drugs also has not worked. And so I think I'm going to talk about some kind of preventive medicine solutions, but they are more at the level of secondary and tertiary prevention, unfortunately. And I may have to park that one too, what primary prevention for opioid use disorder looks like. So this is just a statement from the American Osteopathic Association that supports what I just said about what language we should be using to talk about folks with opioid use disorder. I'm going to kind of get into talking about what evidence-based treatment for opioid use disorder looks like. Does anyone here prescribe buprenorphine or methadone in their practice? A couple of folks. Okay. All right. So we've got the same Jane number two who wants to, she wants to quit, but she doesn't know how to. And thinking about Jane, I don't want to pose a question to the audience. Which of the following treatments are going to give Jane the best chance at long-term success? And I want to define success in terms of reducing her opioid use disorder associated morbidity and mortality. So how many folks would say A, detox? B, buprenorphine. C, methadone. D, naltrexone. E, therapy. A couple of folks say therapy. How about F, B or C? Okay. Yeah. So I'm going to try to make the point that really the answer is F, and the data for therapy is not that good. I know that sounds counterintuitive, and I would never say a patient shouldn't get therapy. But the reason I point that out is because one of the biggest barriers to treatment is places that say, well, if you don't get in therapy and see a therapist three times a week, we're not going to give you this medication treatment. And I'm going to make the argument that that's the wrong answer, at least for this particular substance use disorder. So what are the options for treating opioid use disorder? Behavioral treatments. We've got opioid agonists. That's buprenorphine and methadone. Antagonists. That's naltrexone. And then detox. So to really understand the different treatments, you've got to understand why people use. And so big picture, this is how opioid addiction develops. People start using to feel good. Eventually, they develop tolerance. And then they're basically constantly every day going into withdrawal, into periods where they're not using, and they'll tell you why. Just use heroin to feel normal again. And I feel like crap when I don't use. So how does medication treatment work? Basically, it's going to treat the withdrawal symptoms that make it hard to break that cycle of opioid use. And then it's going to help people maintain recovery by decreasing cravings and restoring the normal opioid, the normal reward pathway in the brain that's been disrupted by chronic use of opioids. You've got to understand a little bit of pharmacology to understand how these different treatments work. So methadone is a full opioid agonist, right? So it's like morphine or oxycodone. But what makes it unique is that it's very long acting. Buprenorphine is a partial agonist at the mu opioid receptor. And we'll talk a little bit more about what that means. Naltrexone is an antagonist at the mu opioid receptor. I'm really going to focus on buprenorphine because I think in outpatient practices, it's the one that folks have the most access to. And I think people are considering changing their practices. This is the one that you could write a script for tomorrow. And Naltrexone, you could as well. But I'll make the case I don't think it's quite as effective. You had to do any TAs lately? The nurses helped me with it. For Missouri Medicaid, it hasn't been too much of a challenge. Most of the folks in Georgia and the Atlanta area, they were abysmal. With the PAs for buprenorphine? I think they want to keep. I don't know if I totally disagree with that. What are the goals of medication treatment for opioid use disorder? Relieving withdrawal symptoms, methadone and buprenorphine are going to do that for you. And then all the treatments are going to do three other things. So block the opioid receptor, reduce opioid cravings, and restore that normal reward pathway. So let's talk a little bit about buprenorphine. I think the pharmacology is really important in understanding how the drug works. Basically, the key here is that buprenorphine has a very high affinity, but a low activity at the opioid receptor. And so with the low activity, it's going to treat withdrawal and reduce cravings. It gives you enough activity to treat withdrawal and reduce craving, but it doesn't get people high. Basically, you can function day to day with it because basically it has a maximum effect. With the low activity, that's the ceiling effect, right? So you can take more and more buprenorphine. It is very unlikely that someone will be able to overdose on buprenorphine. And really the only overdose risk comes if people take other substances along with it, like benzodiazepines and alcohol. Even if someone was taking those other substances, the overdose risk is still way less than if someone is mixing heroin with alcohol or benzodiazepines. And so that's why we probably even still should be treating people that have a comorbid alcohol use disorder, at least considering buprenorphine for those folks. The other key is it has a really high affinity for the opioid receptor. So basically, it's going to block other opioids from stimulating that receptor when the patient is taking buprenorphine. So if someone's on buprenorphine and they use heroin, they are not going to feel very much effect from the heroin because the buprenorphine is locked onto that receptor and like, hey, sorry, heroin, you are not welcome here, right? Basically, three phases to opioid use disorder treatment with buprenorphine. You start with induction. And basically, what you do is you have the patient wait until about 12 to 24 hours after they last used. And then you basically start the medication and help titrate it. Second stage is stabilization. That's when you're kind of getting them on the correct dose. And then the third phase is maintenance. That's when they're already on the medication and you're just kind of maintaining them on the treatment to prevent them from relapsing. And I think that's the other piece to prevention is that people get on this and they stop using opioids. And really, the prevention comes with the medication treatment. Basically, before one of the keys with starting buprenorphine is that you have to wait for patients to withdraw from their full agonist before you can start. The problem is if you start, you know, right after someone injected heroin, you're going to get this thing called precipitated withdrawal. And basically, what's happening is, you know, someone injects heroin that, you know, they are getting euphoric from the heroin. They take a dose of buprenorphine, and the buprenorphine has a really high affinity for the receptor. So it's going to hop onto that receptor and be like, bye-bye heroin, and the patient is going to feel really sick. So that's why you—that's why—and that's kind of the tricky thing about starting buprenorphine is that you have to make sure your patient's in withdrawal before they start. I won't talk too much about this, but you might have heard of the trade name suboxone. Basically, that is buprenorphine co-formulated with naloxone. You might wonder, you know, what is the reason for the co-formulation? Naloxone is an opioid antagonist, right? And so that's like the medic—that's Narcan, right, what we use to save someone's life if they're having an opioid overdose. The reason we co-formulated is that the naloxone isn't orally bioavailable, but if someone were to crush and inject the buprenorphine, it would block them from getting euphoric from the crushed and injected buprenorphine. You know, I think this was a safety mechanism that the manufacturer built in, you know, although the abuse potential of buprenorphine is really not that high, especially compared to full agonists. This slide, I'm really excited to put a red X through because I used to have to talk about how, you know, you had to have a special DEA license to prescribe buprenorphine, what was called an X waiver. And so the crazy thing was that, you know, if you just get your regular old DEA license, you can prescribe any Schedule 2 or Schedule 3 medication, right? So you could prescribe fentanyl, morphine, oxycodone without any additional training. But in order to prescribe this harm reduction treatment that saves people's lives, you have to do a special eight-hour course, you know, track your number of patients, limited number of patients in the first year. Thankfully, in December 2022, the omnibus bill that was passed by Congress and signed into law, the president removed this requirement. So now, basically, any prescriber that has a DEA license that lets them prescribe Schedule 3 meds can prescribe buprenorphine. There are apparently going to be some new training requirements that everyone is going to have to do around opioid use disorder, but they haven't clarified what those are. But as of today, if you want to prescribe buprenorphine and you have a DEA license, you can just write the script. And just because we're short on time, I'm not going to talk too much about these other substance—these other opioid use disorder treatments. I'll just say methadone is very effective as well, but it's very highly regulated. So unless your patient's going to a methadone clinic, they really can't access that treatment. Naltrexone is an opioid antagonist. There is not as good data to support its efficacy. I have prescribed it from time to time, but I don't think it's as core a part of the opioid use disorder response. So what's the data to support medication treatment for opioid use disorder? This is a systematic review from JAMA psychiatry that found that treatment with methadone or buprenorphine was associated with a lower risk of all-cause mortality compared with no opioid antagonist use, and the relative risk of 0.47 had a really good 95% confidence interval. I think the data is impressive. I could show lots of different studies on this, but one thing I always point out is, like, how many treatments do we have in primary care or preventive medicine or occupational medicine where you have data showing a lower risk of all-cause mortality, right? I mean, this is good data that these medications save people's lives. A lot of people ask me about detox, and I think that a lot of federal and state dollars have gone into funding detox. I think the problem is that detox really just doesn't work. Basically, the idea—you know, and it works probably better for alcohol use disorder, but not for opioid use disorder—the idea is that you give people medications to help them get over their withdrawal. So as an example, like, I just talked about buprenorphine. It can help people with their withdrawal symptoms. So why don't we just give people, you know, put people on a detox, give them a week of buprenorphine, help them get off the medication, get off their, you know, get through their addiction, and then send them home without medication? The problem is that the data shows people just relapse, and so, you know, that's why you really need maintenance therapy that's longer term to help people with opioid use disorder. People who you do a detox and then you don't link them to ongoing medication care really generally don't get retained in care, and there's also actually some data showing an increased risk of overdose after detox because the problem is people lose their opioid tolerance, and then they go out on the street, and they use, you know, heroin that's mixed with fentanyl at the same dose they used to use, and this time when they overdose, they do die because they've lost their opioid tolerance. Let's talk about counseling. I think this is an interesting one because a lot of people raise their hands, you know, wondering that this should be a key part of the treatment. Unfortunately, the data doesn't support counseling as a key part of treatment for opioid use disorder, and, I mean, data, right, evidence- based medicine has its limitations, so, like, I'm not going to ever make the argument that people shouldn't be engaged in counseling, but in the patients I take care of, a lot of patients, like, can't afford counseling. There's all these systemic barriers to getting in. They can't, you know, spend an hour during the day during their work week every week to engage in it, and, you know, basically, and there are plenty of patients that basically their only, you know, psychiatric therapy is seeing me once a month or so and checking on how they're doing and kind of strategizing around, you know, what they might do if they were at risk for relapse or something like that, and that's enough for those folks. For some people, it's not enough, you know, especially folks that have comorbid psychiatric disorders who have other substance use disorders, but for patients that have an opioid use disorder, have a good social support system, and, you know, have other things going on in their life, a lot of times the medication treatment can really be it without counseling or other treatments, and I have plenty of patients in my practice that kind of prove that's the case. You know, so how long do patients need to be on this? Basically, you're just weighing their risk of relapsing off the medication against the long-term benefits of the treatment, and so it's kind of a case-by-case decision with patients, but, you know, really, we're talking months to years usually. I think I've gotten into a lot of these myths, so I'm just going to skip this slide, but just, you know, do want to point out that a lot of folks will say, well, you're just substituting one addiction for another, and I would just kind of make that corollary to say, like, you know, saying that someone is dependent on their insulin for their diabetes does not mean that they're, like, addicted to insulin treatment for their diabetes. I think of this in kind of the same way, and that's what makes this really a chronic disease model of care. You know, I think of opioid use disorder as a chronic relapsing illness. My patients do sometimes relapse, and, you know, we can just like patients with diabetes sometimes, you know, like have a bunch of Halloween candy and go into DKA and end up in the hospital, right, and we continue to manage their care and, you know, counsel them and kind of work through harm reduction with them, and maintenance medications are part of the standard of care, just like metformin or GLP-1 agonists are the standard of care for diabetes. Some patients will relapse, like I mentioned, and you shouldn't stop their treatment just because they relapsed, you know, and actually I do have patients that struggle with continued use, and if someone is continuing to use opioids on a regular basis, you can give them this medication to reduce the harm associated, because just remember the pharmacology. It's on the receptor, and it's preventing them from having as much euphoria and also preventing them from being as likely to overdose from the medication. I'm sharing this with permission. This is from a patient I take care of who's on buprenorphine, who has intermittently struggled and, you know, had cravings for opioids, has also intermittently struggled with cravings for benzodiazepines, which I told her she can't use with her buprenorphine, and she recently relapsed, and I asked her to go home and come up with a plan about what she's going to do the next time she has a craving, and she made this very thoughtful flowchart and brought it in and showed me, and I think I'm at the bottom of the flowchart, but there's a bunch of other things that where she does. There she, like, listens to music and thinks about the consequences of using again, goes for a walk, and I just point this out because I think it's really important to recognize that our patients are resilient and capable, and if you engage your patients thinking about their own capacity to help heal themselves, you're going to be a better partner in their care and you're going to be more likely to be successful. I want to talk a little bit about harm reduction, which I think gets a little bit, you know, at a different kind of secondary prevention for opioid use disorder, but really the goal of harm reduction is to kind of meet patients where they're at, reduce harm, and prevent death, and so some of the interventions we've seen that work are educating people about overdose, prescribing naloxone, syringe services programs. Patients can also get fentanyl test strips at those syringe services programs so they can know what's in their drug supply. I think a lot of folks' reaction to that is, well, you're just encouraging substance use, you know, by providing that stuff, and what I've seen and what the data shows is that basically what you're doing is meeting people where they're at. They may not, you know, just like with smoking, people may not be ready to quit, but, you know, one way to handle that is say we're going to put you in jail for doing this. The other option is to say we know that you're actively using, but we're going to help keep you from dying while you're using, and we're going to engage with you, and when you're ready to stop, we're right here and we'll get you into treatment, and that approach really works even though it is not the approach that we as an American society have generally decided on. One thing about naloxone is you want to prescribe it not specifically just to people who use opioids, but friends and family of people who use opioids because people usually can't Narcan themselves and save their own lives, right? People are going to have to give naloxone to a friend or family member who is overdosing, and so, you know, folks—and really, naloxone should be available without a prescription and at no cost. I mean, that's another public health measure we could do to save people's lives rather than create barriers to a treatment that is really only life-saving and there are no risks associated with it. Dr. Green, as far as the deputy sheriff, before opioids, it was rare to see a deputy that had a life-saving treatment. Now every single deputy has one, and they only give you one because most people are doing this once a month. They're saving their life, but you only get one for your first use of Narcan, and then, so if you have Oakland clusters, it means that you saved a life not using some other technique, you know. Anyway, just for kicks and great giggles to show you how much impact that's had on our law enforcement. Yeah, that's a great example, and it's also— Too grateful that your daughter saved your life. Right. That was a different substance, but that was chocolate tea. Well, I know I probably didn't save enough time for the public health pieces, or I hope I did for the pieces that you all want to talk about, but I'm going to kind of talk about what I think a public health approach to opioid use disorder looks like, right? So, you know, most of our for the non-preventive medicine physicians, and I mean, I do practice preventive medicine. I'm one of the medical directors of the health department, and so I do do that, but my clinical practice is one-on-one patient care, so I'm really focused in the little orange bubble at the bottom, but really, you know, folks who have a public health background know that you have to address all of these different levels in order to come up with a comprehensive response to any kind of public health problem, and so what are some of the solutions to this crisis that address these different levels, knowing that, you know, we need to get to the outer circles to really address this more effectively because, like, just training doctors to prescribe buprenorphine is not going to be enough, right? So what are some of the solutions? You know, one we've already solved. We removed that X waiver, but unfortunately, that doesn't solve everything. You know, a lot of docs don't want to use this. Their stigma is associated with treating opioid use disorders. People say, I don't want those patients in my clinic. We have to do more to address that so that folks can actually get access to treatments that they need. Another, you know, another concept that you'll see that, you know, Kansas City probably hasn't done very well that other cities have is what's called low-barrier buprenorphine, which is basically the idea that someone walks in, and they get buprenorphine on the same day, and there's not a lot of stipulations around the care. Like, you know, you have to get a whole bunch of labs first, and then you have to keep this appointment with a counselor, and if you miss one appointment, we're going to cut you off. That stuff doesn't work, just like it doesn't work for diabetes and hypertension treatment, right? We need access to maintenance opioid use disorder therapy for incarcerated persons. So people who are incarcerated need access to methadone and buprenorphine, and then when they get out of prison, they need to be linked right into that care afterwards so that we can break the cycle of incarceration that is related to continued use of opioids. Another piece is thinking about policy barriers for harm reduction, right? So there are lots of policy barriers at a state and federal level that prevent syringe services programs from getting set up, that prevent those programs from having fentanyl test strips, that prevent people from getting access to naloxone. You know, from my standpoint, it should be over the counter and should be a very low cost. It's not there yet. You know, a lot of states have standing orders so that people can buy it, but there's a cost associated, and people who maybe need it most are probably still not getting access to it. Kind of other solutions, you know, we really need to decrease the stigma so that folks can get access to treatment, and that has to happen at multiple different levels. You know, people with addiction really avoid care either at an individual level or a public health level because they're afraid of how they're going to get treated because of their addiction, and I've seen that time and time again in clinical practice and in my teaching, too. Another piece, though, it's kind of like broader societal level interventions that we need in order for people to get care for opioid use disorder. So I know Medicaid expansion doesn't seem like it would necessarily be linked to opioid use disorder treatment, but a lot of my, you know, my patients that struggle most to get on buprenorphine are patients who can't pay for the care. So, you know, they will come in, we'll try to get them treatments, you know, where they're paying cash and they're getting good Rx coupons and they're paying 50 bucks a month and paying their copay to come to the community health center I work at, and then, like, they just can't keep it all together because they can't pay for it. And if they just had Medicaid, then they would be able to stay engaged in opioid use disorder treatment. And, you know, the broader social determinants or political and economic influencers of health also matter, right? I know it's, you know, you might think, like, how is homelessness linked to opioid use disorder? But I've taken care of many patients who tell me, you know, I ask, you know, what is the biggest barrier to you getting off heroin? And they've told me housing, right? Same thing with meth use disorder. I've seen a lot of patients who when I ask, you know, what do we need to get you off meth? And they've said housing. And a lot of that is related to what homelessness looks like. You know, patients will use drugs while they're homelessness to deal with their PTSD from, like, living homeless, which is really challenging. People, and I've had patients that tell me they take heroin to go, they use heroin to go to sleep during the day, and they take meth to stay up at night so their stuff doesn't get stolen and so that they're not subject to violence, you know, at the middle of the night. And so, I mean, it's hard to, we don't sometimes think of it this way, but in some ways, you know, there are aspects of substance use that can be rational for populations that are highly marginalized. And we need to address the reasons that they're marginalized in order to really get a handle on this public health crisis. I only left a minute for questions, but yeah, I know there's probably a lot of thoughts. Yeah. Well, I have, like, several comments. I sit on the whole Bureaucratic Committee on Counsel for the State of Texas, and so I'm immersed in this all the time. I'd say, like, fentanyl test tubes, that's good. Mexican cartels have really crappy quality control. That's one part of the tablet. It can be negative, and then press the tablet, and it's like a Pococet or Oxycodone or anything else. So it's helpful, but it's not a real medicine. I've interviewed several thousand addicts, because I used to be a chief medical officer in a 4,000-bed jail that arrested 160 people every 24 hours. It's just half of them were involved in some level of substance abuse. And what I learned from that, I had some patients who are on methadone, but I was always dumbfounded by it, because they were on high-dose methadone for years, and there was no effort on the part of the methadone clinics to transition them anywhere else, because they were compensated by the number of patients there. They had a financial drive for keeping people on methadone at high doses for years, which was somewhat troubling. And in addressing all these people, the most common thing I found was they hadn't graduated from high school. They had a complete lack of education. So when you talk about a lot of these interventions, you're not really getting at the root problem. You know, if you drop out of high school when you're 16 and you're in a bad neighborhood, your career options are limited. And after you get arrested, your career options are even more limited. Association management has worked out well for many. It's not a rough solution. And the other thing is, almost none of them knew their father. And so it's a double whammy. They have no education, they have dysfunctional families, and they're in poor neighborhoods. So you get, you know, I support expanding Medicaid to anybody who has a diagnosis of opioid use disorder. I think it'd be quite helpful. But in society, in the long run, you've got to go way downstream. The other comment I had is Leroy Young sits on the licensing board of the great state of Oklahoma. And I had a long discussion about this. And he said, one of the pathways they found into addiction was oral surgeons. Because you take your teenage kid, get their wisdom teeth out, and then give them like a couple weeks of hydrocodone. And they dropped the hammer. They said, two days. Now all my poor kids, when they get their wisdom teeth out, I told them, you can give me the hydrocodone prescription, but I'm going to spread it because they're going to go home and take multiple. And yeah, you're going to hurt. But if you never take hydrocodone, you're never going to get addicted. So that's my comment. Yeah, that's a great point. And I mean, the thing is, you never, if it's, you know, one in 20 people that are going to get addicted from those two pills of oxycodone, you don't know who those two people are, right? And so the risk is high. So that's really interesting about the fentanyl testers too. Thank you so much. This was a fun group.

Kenneth Ryland series

opioid crisis

Dr. Ben Grant

opioid use disorder

fentanyl

buprenorphine

methadone

harm reduction

Medicaid access