Hello and welcome. I'm Dr. Rob Cotez, Director of the Clinical and Research Program for Psychosis at Grady Health System and an Associate Professor at Emory University School of Medicine. I'm so pleased that you are joining us for today's SMI Advisor webinar, Deutilization of Medication for Opioid Use Disorder in an Outpatient Setting. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Today's webinar has been designated for one AMA PRA Category 1 credit for Physicians and one Nursing Continuing Professional Development Contact Hour. Credit for participating in today's webinar will be available until August 15, 2022. Slides from the presentation today are available in the handouts area found in the lower portion of your control panel. Select the link to download the PDF. Please feel free to submit your questions throughout the presentation by typing them into the question area found in the lower portion of your control panel. We will reserve 10 to 15 minutes at the end of the presentation for Q&A. Now I'd like to introduce you to the faculty for today's webinar, Dr. Joseph Mathias. Joseph Mathias, MD, is an addiction psychiatrist and Associate Director of Outpatient Addiction Services at Emory Healthcare. He started to develop an interest in addiction treatment during residency as his local community in Western Massachusetts suffered greatly due to the opioid epidemic. He served as Chief Resident in his final year of residency and helped treat patients with opioid use disorder at the Berkshire County Community Mental Health Buprenorphine Clinic. Following residency, Dr. Mathias completed his Addiction Psychiatry Fellowship at Emory University. Dr. Mathias has a particular interest in the treatment and prevention of substance use disorders in adolescents and young adults. He is also actively involved in residency and fellowship education. Dr. Mathias, thank you so much for leading today's webinar and now I'll turn it over to you. Thank you very much for the very kind introduction and thank you all for being here today and joining me for this talk. It's a talk that I'm very passionate about and hopefully I can exhibit my passion for this topic and help provide some more education on this topic today. Starting off, disclosures, I have no relationships or conflicts of interest related to the subject matter of this presentation. Our learning objectives today, upon completion of this activity, participants will be able to evaluate comorbid psychiatric disorders in the midst of severe opiate use disorder, to practice MOUD to manage patients diagnosed with opiate use disorder, and three, differentiate preferred MOUD treatment based on patient characteristics. Why is this so important and why should this be a very relevant talk? Because unfortunately, our numbers of overdose deaths have been increasing substantially. For the year ending in August 2020, provisional data from the CDC show that overdose deaths have increased 26.8% compared to the previous 12 months to more than 88,000 deaths and more recent statistics have actually shown where numbers have exceeded over 100,000 deaths as well. The highest rates of opiate overdose deaths occur in individuals between the ages of 25 and 54. Some past year illicit drug use among people aged 12 or older. So for the past year, actually in the year 2020, about 60 million people used illicit drugs. I think there's been a lot of attention given to heroin use and absolutely heroin is an incredibly scary substance when you find out that some of your patients are using that, but it is not the most misused illicit drug. That belongs to marijuana at over 50 million people who have used marijuana over the past year, followed by prescription pain reliever misuse. I've seen more and more in my practice that some of the marijuana out there these days is also laced with opiates. People unknowingly are using opiates in their marijuana use, which is also pretty scary. But I also think as much attention as we're paying to the heroin use in this country, we also need to be mindful and pay attention to the prescription pain reliever misuse too. So there's been a lot of attention and rightfully so about when the opiate epidemic first began, that physicians were the one who were prescribing pain medications, which was leading individuals and patients to become addicted to that and eventually leading them to using heroin and eventually them overdosing and dying. And while certainly there is some truth to all of that, I do want to point out that over the past year, the source where pain relievers were obtained too. So while yes, some people did get it from a healthcare provider, about 44% did. Some actually stole prescriptions from a healthcare provider, but the majority of people who misuse opiates were actually given the opiates by a friend or relative at 48%. So while yes, absolutely, physicians were a part of that problem initially, it certainly is not just the case now. This is a study highlighting the co-occurring psychiatric disorders along with opiate use disorder. This was a study done by my colleague here at Emory Healthcare, Dr. Welch, where she evaluated her outpatient substance use disorder clinic. She found a significant association between opiate use and anxiety disorders. Now within the anxiety related disorders, they put in PTSD, generalized anxiety disorder, OCD, and panic disorders. So certainly they saw quite a correlation between opiate use and anxiety disorders. This is even more so important for this talk because we're also talking about severe mental illness and how we can see co-occurring SMI within opiate use disorder. First, we'll talk about MDD. In 2018, nearly 20% of U.S. adults experienced mental illness. Nearly 20% of those with mental illness experienced a co-occurring substance use disorder. Also in 2018, more than 4 million U.S. adults with a substance use disorder experienced a major depressive episode. About 500,000 of those 4 million specifically had an opiate use disorder. Major depressive disorder and substance use disorders have a bi-directional relationship. The symptoms of one disorder increase and reinforce the risk of the other. Patients with co-occurring disorders exhibit poor health outcomes. This is seen with either greater depressive symptomatology, more severe functional impairment, poor recovery rates, increased suicidal ideation and attempt, and higher rates of healthcare utilization. Practitioners should screen for co-occurring substance use disorders in patients who present with either a major depressive disorder or another severe mental illness. Next, bipolar disorder. Substance use disorders are present in up to 70% of patients with bipolar disorder. This contributes to high rates of disability, morbidity, and treatment non-adherence. Tobacco use disorder is the most frequent substance use disorder and bipolar disorder, followed closely by alcohol use disorder, then by cannabis use, and then by sedative, hypnotic, anxiolytic use, stimulant use, and finally opiate use disorders. Substance use disorders increase the severity of the clinical presentation of bipolar disorder with increased impulsive and suicidal behaviors, and this can, of course, result in increased rate of inpatient hospitalizations. Comorbid substance use disorders can produce symptoms that mimic or exacerbate the manifestation of bipolar disorder, which is very important because when we're trying to assess bipolar disorder, we also need to be mindful if they're using substances or not. Can it be a substance-induced mood disorder that they are struggling with? So that's really important to pay attention to and tease apart. There's high rates of mixed and rapid cyclin subtypes among bipolar disorder with comorbid substance use disorders. It can lead to both over-diagnosis and under-diagnosis of bipolar disorder in treatment-seeking patients with substance use disorders. Integrated chronic disease treatment model is a preferred management approach with focus on achieving and maintaining sobriety symptoms and episode remission. So yes, we should absolutely focus on their opiate use disorder or their substance use disorder if they present it to us, but we also need to be mindful that if we're not going to be treating the bipolar disorder, the underlying bipolar disorder, then they might be more at risk to sustaining their OUD as well. Next, we'll talk about schizophrenia. So nearly half of all patients diagnosed with schizophrenia have a comorbid substance use disorder. Comorbid SUD has been shown to reduce quality of life, increase psychotic symptoms, severity, reduce medication compliance, increase rehospitalization, increase violent behavior, increase all-cause mortality, and increase suicidality. Patients with schizophrenia are less likely to seek SUD treatment, and if they do, they are less likely to receive standard of care for patients with an OUD, such as being offered medication for OUD. Cannabis use and opiate use disorders early on in adolescence are associated with subsequent development of schizophrenia. Treatment of patients who suffer from both schizophrenia and OUD should be approached with a dual diagnosis outlook, simultaneously addressing both disorders equally. First-generation antipsychotics, such as Heloperidol, are thought to worsen cravings due to the strong dopaminergic antagonism directly affecting the mesolimbic reward pathway. LAIs, or long-acting injectable antipsychotics, are suggested as first-line treatment for patients with comorbid schizophrenia and OUD. This, in turn, helps with adherence to antipsychotic medication and reducing both OUD and psychosis relapses. An MOUD, such as methadone, buprenorphine, or naltrexone, should be offered as a standard of care for these patients. Very quickly, touching upon the neurobiology with opiate use disorder. The mu-opiate receptor agonists in the brain interact with the dopaminergic system and activate mesolimbic dopamine release. Repeated use of opiates induces neuroadaptation that leads to sensitization of dopamine systems and hyperreactivity in response to drug cues. This is a really important concept to think about because there is a science behind the phrase people, places, and things. For example, I had a patient who worked in a furniture store. He was actively using heroin at that time and when he went into treatment and he was in recovery, he came to my office and he shared, Dr. Mathias, it is really hard for me to ever step foot back into that furniture store because even thinking about it causes me to have those cravings to wanting to use. And this is what this slide is talking about, the hyperreactivity in response to drug cues. So even without using those dopamine receptors are lighting up in the brain, which is leading a person to developing cravings too. It interacts with the neuroadrenergic system and the locus ceruleus. So we're focusing on the fight-or-flight system of the body, right? So if it increases production, it releases norepinephrine to compensate. The additional receptor systems that are also involved here are GABA, glutamate, and the endocannabinoid system as well. So how do we diagnose a patient with opiate use disorder? Well, we turn to the DSM-5 and read the criteria. So there are 11 different criteria for OUD. It doesn't take much to meet criteria, actually only two to three symptoms for mild opiate use disorder, four to five for moderate use disorder, and six plus for severe use disorder. All these symptoms must be within a 12-month period of time and a person must have two or more of these symptoms to meet criteria for OUD. How it's broken down? It's broken down into three different categories. If they have shown a loss of control, if they have consequences, and if there's a physiological effect on their body because of their opiate use. So one of the things that I like to, how I ask these questions in my patient interviews is, one, has your opiate use, has it affected the relationships in your life? Has it affected the relationship with your spouse, with your parents, with your child? Has it taken you away from role obligations as a mother or father or as a son or a daughter? And has it led to you having cravings, to wanting to use? Have you been preoccupied about using when you wake up in the morning? Has it led to any consequences such as, has it led to you overdosing? Has it led to you being admitted to the hospital? Has it led to you developing endocarditis because of your opiate use disorder? And also finally, has it affected you physiologically? Have you developed a tolerance to opiates? Has it ever led to any withdrawals too? So again, it doesn't take much to meet criteria for OUD, but I think it's really important to tease apart some of the symptoms and determine the severity of their use. Some risk factors for OUD. So it's a highly heritable condition. Approximately 50% of the risk is genetic. This begs the point why family history is so important to take in your initial interview. There's also a neurobiological risk. So if you recognize reward, stress, craving, preoccupation pathway of the brain with someone who uses opiates on a consistent basis, you recognize the reinforcing effect of these drugs on the dopaminergic system. Opiate exposure is another risk factor. So people who receive prescriptions for opiate pain medications, they are at risk for developing an opiate use disorder. This is why the government has really cracked down on how long these initial prescriptions are for opiates to manage pain too. If a person is on a prescription of opiates for greater than 31 days, there is a 30% chance that they are going to continue using opiates at the one year mark from when they received the initial prescription too. That doesn't mean they have an opiate use disorder, but it means that they are continuing to use opiates and with that, they are at risk for developing an opiate use disorder. Family history of substance use disorder, we need to be mindful of that. Personal history of substance use disorder. So cross addiction can certainly happen where one individual may be seeking help for his cannabis use disorder. And when he has that under control, develops an opiate use disorder. So we need to be mindful of all of those things too. Trauma, of course, being a big one and other co-occurring mental health conditions, as we've already outlined with schizophrenia, bipolar disorder, and MDD. In terms of pain management and the risk factors there too, so certainly the people who have legitimate pain, whether it's from cancer-related pain, whether it's from musculoskeletal condition, the point of this slide is to show you that people with an underlying mental health disorder are at greater or are more susceptible to misusing prescription opiate pain medications or to require opiate pain medications to manage their pain too. So individuals with the underlying mental health disorder are more prone to being prescribed opiate use to manage their pain. So screening, how do we screen for toxicology? So a regular urine drug screen, which is a five panel, can test for THC, cocaine, opiates, PCP, and amphetamines. Not all drug screens are created equally too, and this is important because we want to be mindful of our patients and advocating for them too. If they say they didn't use fentanyl or oxycodone, are we using the right screens too? Because we do need to advocate for our patients too. So understanding that there are different urine drug screens available and those different urine drug screens can detect different substances too. In our clinic, we mostly use quantitative screens or send-out screens where they're very specific and will show metabolite levels as well because sometimes if you just do a point-of-care screen, you will miss. It may not detect clonazepam use, benzodiazepine use, methadone, fentanyl, oxycodone. Those can all be missed depending on the point-of-care screen that you do use. Some of the screening tools available to assess for opiate misuse are the opiate risk tool. Then there's a revised screener and opiate assessment for patients with pain. There is DIRE, which is diagnosis and tractability, risk and efficacy. There is current opiate misuse measure. There's pain assessment and documentation tool. Again, these are just screeners. These are not diagnostic tools, but it could be of use for an initial psychiatric appointment with a general psychiatrist or at a family medicine appointment or a primary care physician appointment where if you do suspect some misuse, to give them a screener too. Or even if you don't suspect misuse, if you suspect a risk for opiate use disorder or assessing their opiate risk, or assessing their opiate risk, you can do an ORT, an opiate risk tool. These are just some examples of some of the questions that are asked. So for the comm, some of the couple of questions in the past 30 days, how often have you had trouble with thinking clearly or had memory problems? In the past 30 days, how often do people complain that you're not completing necessary tasks? So it's taking some of the criteria from the DSM-5 and putting it into a questionnaire screening tool. Now, some of the more common ones that we use in psychiatry are the PHQ-9, which is a screening tool for depression, and also the GAD-7, which is a screening tool for generalized anxiety disorder. And here are some examples of those two as well. Now, in the state of Georgia, we do have a legislature that was passed requiring the use of Physician Drug Monitoring Program, or the PDMP. This is House Bill 249 in the state of Georgia. Other states have very similar bills. This is important because we need to be checking the PDMP, especially if we're considering prescribing a medication like buprenorphine in an outpatient setting. So when prescribing a Schedule II substance, excluding stimulants or benzodiazepines, we need to review the PDMP. So we need to be mindful that they're not using any other controlled substances, or if they are, how are they using it, who is prescribing it, and making sure that the prescribers who are prescribing it are limited, and our patients aren't going from one practitioner to another. Now, there are three FDA-approved medications for opiate use disorder, one being methadone, two being buprenorphine, and three being naltrexone. All patients with OUD should be offered a maintenance medication because of the risk of relapse, overdose deaths, and other negative associated outcomes, including hepatitis C and endocarditis. Some background about these medications for opiate use disorder, I'll start off with methadone. So methadone clinics originated because of the Narcotic Addict Treatment Act of 1974. Again, I'm not a huge fan of that name. I think it's very stigmatizing, the way that they called it the Narcotic Addict Treatment Act, but this is just to highlight the genesis of methadone clinics, too, and the term maintenance treatment for opiate use disorder. MOUD doubles abstinence and early recovery. It should be a part of the standard of care for people who have an opiate use disorder. MOUD patients are three times more likely to remain in treatment at three-month follow-up compared to patients receiving just detox. So I'll say this right now, and I'll say it again, detox is not treatment. It is just medical stabilization. The treatment happens after detox. So in order to get these patients to treatment, the research, the evidence shows that MOUD patients are three times more likely to remain in treatment. And here you can see some of the numbers on how effective these medications can be. You know, with thinking about buprenorphine, 60% are opiate-free on medication compared to no medication. So I certainly think that there is a lot of evidence to support that this should be the standard of care for our opiate use disorder patients. Methadone is an opiate agonist with receptor and analgesic equipotency to morphine. It reduces cravings and symptoms of withdrawal. It has a delayed onset of action and a very long half-life. The risk of QTC prolongation and medication interactions is there, so we do need to be mindful in making sure that they have an annual EKG, and also recognizing some of the other medications that they're on and the interactions it could have with methadone. It is federally regulated, and that's why they can only be administered at federally regulated clinics for opiate use disorder. Methadone can be prescribed for pain management, but it cannot be prescribed in an outpatient setting for opiate use disorder. They have to go to a federally regulated clinic for that. In order to be eligible, a person has to be physically dependent on opiates. They have to have a documented one-year addiction history. Some of the exceptions there are pregnant women, because this is still the gold standard of care for pregnant women with an opiate use disorder, for people who are released from prison within the past six months. And this makes a lot of sense, because when people do go to jail, especially for drug-related crimes, they don't necessarily get substance use treatment when they're incarcerated. And they don't certainly get offered MOUD when they are in jail, too. So when they go back into the same environment that they came in from, they are at a really high risk of overdosing, too. And the other exception are people who have been previously treated with methadone. Now, the dose range has been shown to be effective between 60 and 100 milligrams daily for many individuals. However, for those individuals who have used pretty high amounts of opiates or heroin, they may have to titrate above 100 milligrams daily. With buprenorphine, this was made possible in the outpatient setting by the Drug Addiction Treatment Act of 2000, otherwise known as DADA 2000. This act permitted physicians who meet certain qualifications to treat opiate use disorder with medications approved by the FDA, including buprenorphine, in treatment settings other than opiate treatment programs. So this is the first time that a physician could prescribe a medication for OUD in an outpatient setting. And the DADA 2000, the Comprehensive Addiction and Recovery Act, the Substance Use Prevention, Opiate Recovery, and Treatment for Patients and Communities Act, it allowed qualified practitioners to dispense a waiver to prescribe buprenorphine for the treatment of OUD. Now, initially, we needed what we call an X-Waiver to prescribe buprenorphine. Now, there are some new practice guidelines that was released in April of 2021 to provide a greater reach for practitioners, for clinicians to be able to prescribe buprenorphine. So you no longer need an X-Waiver to prescribe buprenorphine. You do have to sign up for what we call a Notice of Intent. So with a Notice of Intent, it can allow an individual to treat up to 30 patients on buprenorphine, which certainly then can expand the reach of a quality standard of care MOUD treatment. Buprenorphine was FDA approved for the treatment of OUD in 2002. It's an opiate partial agonist, so different from methadone, which is a full agonist, it's a partial agonist. And it's a strong affinity for the mu receptor. This is really important because it is stronger than full mu opiates, including heroin and methadone. So if an individual is on buprenorphine and they were to use heroin, the heroin wouldn't connect to that mu opiate receptor because buprenorphine is on there because it has a stronger affinity for it. It has slow dissociation. It's a full kappa opiate receptor antagonist. It used to just require a DEA X-Waiver, but now new guidelines have implemented just a Notice of Intent that is needed. And buprenorphine is the first medication to treat opioid use disorder that can be prescribed in physician offices, significantly increasing access to treatment. And this slide, this graph is just highlighting what we call the ceiling effect too. So where buprenorphine is a partial agonist, it provides what we call a ceiling effect. So if a person overtakes a buprenorphine, it's gonna, they're not at risk of overdosing. There's just a certain benefit that people can see from buprenorphine and typically the highest dose that we would ever see and ever be effective is about 32 milligrams total daily dose. Again, the ceiling effect, as I talked about, compared to morphine and fentanyl, opiate action is mainly at the level of the spinal cord. Buprenorphine is metabolized to nor-buprenorphine, and it later undergoes glucoronidation with minimal urinary excretion. This is important when it comes to, it has very minimal drug-drug interactions, far less than what methadone has with other drugs too. Buprenorphine is seen in a number of different formularies. It is seen most commonly in combination, buprenorphine naloxone in tablets or films. And then there's also buprenorphine monoproduct, which is also known as Subutex, so it doesn't have that naloxone component to it. It's also seen in bucophilms, implants, and supplicate, which is an extended-release injection of buprenorphine. So why, what is the difference between just buprenorphine monoproduct and the combination of buprenorphine naloxone? And in all reality, it is to prevent abuse and diversion of this medication. Individuals who use suboxone or buprenorphine naloxone correctly, they will not have any adverse reaction to it. If they choose to inject it, they will go into withdrawals too. So this is more of a protective factor for individuals who you might have suspicion could be using or misusing, or excuse me, abusing or misusing their buprenorphine naloxone prescription. Buprenorphine monoproduct, otherwise known as Subutex, is equally as effective. However, we need to be mindful about the diversion or street value of this, because it does have a higher street value than the combination of buprenorphine naloxone. So typically what I would do is I would always start off with buprenorphine naloxone for my patients. If there is some kind of sensitivity to the naloxone component, which can sometimes be seen with increased high levels of nausea or increased headaches, then that is when I would switch to buprenorphine monoproduct for my patients. One of the most satisfying parts of my job as an addiction psychiatrist is doing an in-office induction of buprenorphine. This is typically when a patient is not feeling so great, is in moderate opiate withdrawals at this point, and they are looking for something that can really help them just feel normal, too. So some of the things that we do for an in-office induction is make sure that they have been opiate-free for 24 to 48 hours, leaning towards the 48-hour mark, and in moderate withdrawal, or in moderate opiate withdrawal. And then we would also be mindful that they have, besides medication support, that they have psychotherapy support, that they are connected with a sober support network in the community, or at least offer those connections. And then we also do basic lab work, such as CBC, CMT, HEP panel, and STD screening and pregnancy test, if appropriate. And also, of course, a urine drug screen as well. Why we have to be mindful that they are in a moderate state of opiate withdrawal, because if we give buprenorphine too early, it can actually precipitate withdrawal, and that is a really, really uncomfortable feeling, which can ultimately lead them to relapsing and returning to use, too. So this is why I share with my patients. I know it's gonna be uncomfortable, but the greater symptoms of withdrawal that you present with in my office, the greater response you might have when we start buprenorphine. And when we do start buprenorphine, if they are in a moderate state of withdrawal, the response to them feeling better is literally within minutes, too. This is the withdrawal scale that we use, a clinical opiate withdrawal scale, otherwise known as a CALS, that we use to assess withdrawals. So we're checking their pulse, we're checking their pupil size, we're checking their bone or joint aches, if they have a runny nose, if they have increased anxiety, tremors, stomach upsets, all of those things, which, if they are in moderate withdrawal, they might have to some degree, too. So for the first, and this line looks a little bit intimidating, but after you do your first induction, you will recognize that it is actually a pretty easy medication to prescribe. So typically, I will either do two to four milligrams on the first, in our first meeting, with the option of doing another two to four milligrams at home for them, too. So usually a total daily dose for the first day being eight milligrams. By the second day, possibly going up to eight milligrams in the morning, another four milligrams in the early afternoon, and seeing how they do with that, too. Typically, I've seen a therapeutic dose for a lot of individuals being anywhere from 12 milligrams to 16 milligrams a day. And how I assess if we need to go up on the dose is ask them about their cravings. If they feel like their cravings are well-managed, and if they feel normal, then you have a pretty good dose, too, and you're probably at a good therapeutic dose at that point. So again, this is not a hard medication to prescribe, but it does take time to make sure that a person is on a therapeutic dose. And I truly believe that this is a life-saving medication for a lot of people. Buprenorphine also comes in a long-acting formulary, such as Suplicade. So this was FDA-approved in 2017 for opiate use disorder treatment, and it's a once-a-month injection of time-released buprenorphine. And it is something that can certainly help with medication adherence to this, as well. Here you'll see the comparison between methadone and buprenorphine. Both are very long-acting. Buprenorphine has a little bit longer-acting half-life. Both you would take daily. The biggest difference is methadone. You would have to go to a special federally-regulated clinic every day versus buprenorphine, which can be prescribed at an outpatient physician office. And lastly, there's naltrexone, which is an opiate antagonist, so it blocks the opiate's reinforcing effects. It is FDA-approved for alcohol and opiate use disorder. The big key is that you cannot start this if opiates are still in the system, so a patient must wait seven to 10 days after their last opiate. That is incredibly difficult for a lot of people with an OUD to do, to go seven to 10 days without an opiate, especially if their body is dependent on it. So if we are considering this medication, we need to be understanding that they have the proper supports in place. Maybe this is a time when you explore with them engaging in an intensive outpatient program where they have that additional support during those first two weeks when they are transitioning from their opiate abuse to naltrexone. It can be taken daily in oral form or monthly in an IM injection, otherwise known as Vivitrol. We also should, of course, check baseline LFTs, or liver function tests, to make sure that they are at least within three times the normal limit before we would start this medication. And this is just to highlight Vivitrol, which is a long-acting version of naltrexone, and so once a month injection. Some of the big signs of opiate overdose, so that's your respiratory drive, so breathing is very slow, blue skin, lips, nails, loose cyanosis, weak pulse, pinpoint pupils, drowsiness, vomiting, passing out, and one of the things that's very distinct about an opiate overdose is this gurgling or snoring noise that you might hear, too. At that point, they are at very, very imminent risk of overdosing and dying, and they need to be administered naloxone. So some of the more common risk factors are changes in tolerance, post-detox, post-incarceration, changes in physical health, mixing opiates with other substances such as benzodiazepines and alcohol, so this is why it's so important to make sure you check that PDMP that you have the accountability factor there with your patients by having them do urine drug screens. If they've had a previous experience with a non-fatal overdose, that puts them at a greater risk of having an opiate overdose, there's also a variety of strength and content of street drugs. So many times we don't know what's in those opiates that people buy off the street. It could be fentanyl. It could be cart fentanyl. It could be really, really potent opiates that can lead to overdoses. In the years that I've been practicing addiction psychiatry for individuals who have used heroin I have yet to see a urine drug screen that did not show fentanyl in it. And that was a surprise to a lot of my patients too who were using heroin, but they didn't know that there was fentanyl in the heroin that they were using. So with opiate overdoses, absolutely call 911, call EMS services, and administer naloxone. So naloxone is the antidote for an opiate overdose. A little bit about naloxone. It is an antagonist of the mu-delta and kappa opiate receptors and is used to rapidly reverse effects of opiate overdose. It has a short half-life, 30 to 90 minutes. This is really important because if a person is very close to overdosing and you give them Narcan, you still, and this is something to educate your patients on, you still have to call emergency medical services because there is a risk of the naloxone wearing off and the opiates still being in the system and connecting to the new opiate receptor and causing a person to re-overdose even though they haven't used any since the last time that they used to. In the state of Georgia, and I think in other states as well, there is a medical amnesty law. So for individuals who have paraphernalia around them and one of their friends overdoses and they administer Narcan, in the past they used to run away because they were at fear of being charged with drug-related crimes. Now there is a medical amnesty law in place to protect them, to allow them to help out individuals who are overdosing without the consequences of incarceration. The CDC recommends that you co-prescribe naloxone rescue kits for anyone who's had a history of overdose, anyone who has a history of substance use disorders, even taking benzodiazepines or at risk for returning to a high dose to which they are no longer tolerant to. This is what Narcan naloxone rescue spray looks like, very, very simple to use, very easy to use, and something that I try to educate all my patients on about how to use and framing it in the way of hopefully you'll never have to have this used on you, but perhaps just by having it on hand, you can also help save a life too. Now there are different levels of criteria when we're thinking about levels of care and how much support a person might need when they are seeking treatment too. So ASAM or the American Society of Addiction Medicine has a set of guidelines for determining level of service on a continuum. So this includes placement, continued stay, transfer, discharge for patients with co-occurring substance use disorders. It's a multidimensional assessment, and it was developed first in the 1980s. So it takes into account the whole person rather than just one aspect of that person. It eliminates failure at lower levels of care for placement into higher levels of services, and it's a continuing service rather than just discrete levels of care. So very quickly, you can kind of see that there are four primary levels of care. Point five is early intervention. This might be something that a primary care physician does in their office when they suspect any opiate misuse. Maybe that is when you provide that early intervention. Level one is strictly outpatient services. So what I provide here at Emory, I'm strictly outpatient. Level two is intensive outpatient. So where they have to attend programming for at least nine hours a week for anywhere from five to 12 weeks. Level two also includes partial hospitalization program. Level three is a residential level of care where they need that added support of a different environment, of a safe environment for them to really build a foundation of their recovery and sobriety. And level four is when patients need an inpatient medical hospitalization because their withdrawals can be life-threatening. Typically, this is more so reserved for individuals with an alcohol abuse disorder or a sedative hypnotic anxiolytic use disorder. Then there are different dimensions that ASAM has provided that helps us assess what is their likelihood of being successful in that level of care. So understanding dimension one, is there any acute intoxication or withdrawal potential? If so, perhaps they do need an inpatient medical hospitalization. Dimension two, understanding if there's any co-occurring medical comorbidities that we need to be mindful of. And they have really bad uncontrolled diabetes or uncontrolled hypertension that we need to be paying attention to. Dimension three being any emotional, behavioral, or cognitive complications. Dimension four, assessing their readiness to change, how motivated are they to change? Dimension five, if there's any relapse or continued use or continued problem potential. And dimension six, understanding their recovery or living environment too. So SONATO is a linear progression between level of care and intensity of services. Many IOP programs actually provide more intensive counseling and case management than residential programs. And even medically managed programs provide less intensive counseling than services seen in an outpatient setting. And finally, this is a slide that I want to highlight before we finish our talk, is addressing the stigma. Because words absolutely matter. You know, I think there was a time when it was acceptable to use the terms clean when describing someone's sobriety date. And now we are getting away from using that type of language because it could be stigmatizing. Because what is the opposite of clean? It's dirty. And we're never calling them dirty too. So instead of using clean, not currently using substances, instead of dirty, using a statement like a person who is currently using substances. So I think this is the first step for physicians to help destigmatize addiction treatment. And that can be as simple as changing the language that we use in our everyday practice. In summary, opiate misuse is highly prevalent in the U.S. There are identifiable signs and symptoms of opiate intoxication and withdrawal. The DSM-5 defines opiate use disorder on a continuum of mild, moderate, and severe. Urine drug screenings, use of PDMP, formal screening tools can mitigate risk. All patients with an opiate use disorder should be offered maintenance medication. ASAM levels of care can help guide patient placement. And when in doubt, give Naloxone. Thank you very much for your time. All right, thank you so much, Dr. Mathias, for such a great talk. And thank you for all that you do in providing excellent care for individuals with substance use disorders in the Atlanta community. So before we shift into Q&A, I'd like to take a moment to let you know that SMI Advisor is available from your mobile device. Use the SMI Advisor app to access resources, education, and upcoming events, complete mental health rating scales, which I actually did yesterday, and even submit questions directly to our team of SMI experts. So now let's jump into the Q&A. So a couple of things I was wondering. One was, do you have any tips for folks in the audience on differentiating substance use disorders from someone who might have like a primary bipolar disorder or schizophrenia spectrum disorder? Right, absolutely. So one of the things that you need to be mindful of when kind of teasing apart those symptoms is assessing how long has a person been off of a substance, too. So if you have suspicion that someone has a bipolar disorder, doing the urine drug screening and seeing are they using opiates or taking a good history, too. How I typically do it, if a person has been absent for at least a two to four week period of time and they're still displaying those symptoms that are indicative of either a manic episode or a psychotic episode, then more than likely they have a primary psychotic disorder or a primary mood disorder, too. So making sure that you take a really, really good history and a really good substance use history when kind of teasing those symptoms apart. One thing I wanted to ask you a little bit about is, do you ever have any reluctance from your patients about people providing a urine drug screen? Yeah, you know, I have that all the time and part of what I share with them, and maybe I have a little bit of luxury because I'm an addiction psychiatrist and I typically treat individuals with a co-occurring substance use disorder. So they are there to see me for that particular reason. But I also frame it in the way that this is for accountability. I never use urine drug screens in a punitive way. This is just a part of having a conversation about what is going on, too. And if there are ways that I can help you, right? For example, with individuals who use opiates, but they also use marijuana, too, asking them what their goals are of engaging in treatment. Is it just to be abstinent from opiates and not wanting to have much motivation to be abstinent from the cannabis? Okay, find out what their goals are and we'll work on that together. So having an initial drug screen show opiates and marijuana, and having the subsequent drug screen only showing marijuana, that is still considered a success because we are meeting the patient's goals there, too. Yeah, that's great. Framing it as an accountability measure. One thing I wanted to ask you a little bit about was sort of given the overwhelming evidence for MUOD, you know, there seems to be like there's often a general lack of beds available for people who are seeking, you know, maybe residential treatment options. And some residential facilities actually may not even allow people to use medications. That may be the minority of places nowadays, but is there anything that we can do to address this on a systems perspective? That's a great question, and that has honestly been one of my big frustrations, too, because not all treatment is equal, and that is unfortunate because MUOD should be the standard of care no matter if you have MDD, bipolar disorder, schizophrenia, if you don't even have any co-occurring psychiatric disorder, if you have a severe opioid use disorder, MUOD should be standard of care. And I think this is something that needs to be brought up to the higher ups and needs to be something that we need to address on a systems-based level, too, because for an individual to go to a treatment facility and not have the option, not even have the option of being offered MUOD after all the evidence supports that, that is really discouraging for me as an addiction psychiatrist, for me as a physician, for me as someone who wants the best possible outcome for their patients, because this is honestly a matter of life and death for these patients, right? And we're seeing over 100,000 Americans died of an opiate overdose in the past year. That's 15% above last year, too, which is a remarkable and horrible statistic to even conceptualize, too, when these lives could certainly have been saved if they were even offered MUOD. Yeah, I think some excellent points there. You know, Dr. Mathias, I was wondering a little bit about, I know you do a lot of work with the residents and with the fellows and very involved with education. Like, I'm kind of curious, because there does seem to be a lot of, you know, for some people, maybe guilt or shame about using substances. Like, for some people, how do you even open the door about a conversation like that? I'm sort of curious about any particular phrases you may have. I like the idea of using the screeners that you talked about, but are there any sort of ways to open the door that you like to utilize? Yeah, you know, one of the things that I like to do for at least an initial visit, too, is just understanding who they are. And one of the things that has always stuck with me, that one of my mentors has always shared with me, and he was like, Joe, you need to find the person and the patient, right? So understanding what is their life like? What is their day-to-day structure like, right? And usually within that conversation, if they do have a use disorder, some of those things will start to come out naturally, right? Dr. Mathias, I'm really having a lot of difficulty with my wife. You know, I tend to drink too much at night. She gets mad at me. And then, you know, that leads to me just not wanting to go to work in the morning and me not performing my best, me missing out on some of my kids' activities. So already, you kind of notice that you are assessing some of the criteria for DSM for a substance abuse disorder. Also, using motivational interviewing, something that I try to use in all of my sessions. So helping the patients come up with some of the problems that they see and helping them connect that with their use of substances, right? Helping them create that discrepancy and helping them come to the conclusion that I need to make a change. And maybe when they first came into my office, it wasn't necessarily about changing their consumption of substances, but maybe it was about helping them feel better, right? They're seeing a psychiatrist for a reason because they are struggling and they want to feel better and helping them link that. Well, maybe their substance use is causing them or at least contributing to them feeling not so great. Yeah, excellent. Excellent. I love that idea of, you know, for everybody that we see seeing the person within the patient, that's really powerful. I know that you have an interest in working with young adults and adolescents, and I'm wondering, you know, are there some specific considerations for individuals with OUD specifically around, I mean, maybe just sort of general considerations when working with adolescents and then also maybe some more specific ones for that interaction with the person and their family slash support system. Yeah, no, absolutely. And this is something that we've encountered, unfortunately, quite a bit more in our adolescent substance use treatment program here at Emory, where we have 15, 16, 17-year-olds using pretty, pretty high amounts of opiates, too. Some have overdosed and thankfully have been saved by naloxone rescue kits. Others have overdosed and died, which is really, really horrible when we're thinking about that they're 15, 16, 17 years old, you know, and they had so much potential in their life and it just ended so quickly. But some of the considerations to take into that is helping them understand the severity, too, because one of the things that I've quickly realized in working with a younger population is that they feel invincible at times, right? And they feel like they, that nothing can stop them and providing maybe some reality testing that this is, this can lead to you dying, or this is a matter of life and death. And I think that's a really powerful conversation to have with a young adult and helping them understand and providing that psychoeducation, too, and allowing their families to be a part of that conversation as well, too, because I have a pretty low threshold when it comes to family involvement with some of the younger patients when it comes with an opiate use disorder, because that can mean life or death in that instance, right? So allowing families to be a part of that discussion and helping support that individual into one, getting treatment, and two, maybe even considering MOUD as well. Buprenorphine is FDA approved for individuals 16 and older. So in some cases, we can actually start prescribing buprenorphine to help stabilize them as well. Okay, terrific. Well, Dr. Mathias, I wanted to thank you so much. This has been really, really excellent. I know I learned a lot today. That's all the time that we have for in the Q&A. So if there are topics covered in this webinar that you would like to address with colleagues in the mental health field, post a question or comment in SMI Advisor's webinar roundtable topics discussion board. This is an easy way to network and share ideas with other clinicians who participated in the webinar. If you have questions about this webinar or any other topic related to evidence-based SMI care, you can always get an answer within one business day from one of our SMI Advisor national experts. This service is available to all mental health clinicians, peer support specialists, administrators, and anyone else in the mental health field who works with individuals with SMI. It's completely free and confidential. SMI Advisor is just one of the many SAMHSA initiatives that are designed to help clinicians implement evidence-based care. We'd encourage you all to explore the resources available on the Mental Health Addiction and Prevention TTCs, as well as the National Center of Excellence for Eating Disorders and the Suicide Prevention Resource Center. These initiatives cover a broad range of topics from school-based mental health through the opioid epidemic. So to claim credit for participating in today's webinar, you'll need to have met the requisite attendance threshold for your profession. Verification of attendance may take up to five minutes. You'll then be able to select next to advance and complete the program evaluation before claiming your credit. Please join us next week on June 23rd as Anita Madley presents Dialectical Behavioral Therapy for Serious and Persistent Mental Illness, a Skills-Based Approach. Again, this free webinar will be available, this will take place on June 23rd from 3 to 4 p.m. on Thursday. Thank you so much for joining us and until next time, take care. you

Dr. Rob Cotez

Clinical and Research Program for Psychosis

Grady Health System

Associate Professor

Emory University School of Medicine

SMI Advisor

opioid use disorder

outpatient setting

APA

SAMHSA