Emergency Department-Based Treatment and Harm Reduction Interventions for Opioid Use Disorder | December 7, 2021

February 09, 2022

Information

Edouard Coupet Jr., MD, MS, is a NIDA-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale School of Medicine. His primary research interests are in the intersection between substance use & community violence and disparities in access to addiction treatment. Donald Stader III, MD, is an emergency physician, innovator & entrepreneur. He is Chair of the Colorado Naloxone Project and serves as the President-Elect on the Colorado ACEP Board of Directors and is the former President of the Emergency Medicine Resident's Association (EMRA). He is the is the Editor-in-Chief of their 2017 Opioid Prescribing & Treatment Guidelines and serves as the Senior Pain Management & Opioid Policy Advisor for the Colorado Hospital Association.

ID7436

To CiteDCA Citation Guide

00:35So good afternoon, I'm David Philly
00:37now and I'm the director of the
00:40Yale Program in Addiction medicine.
00:42I want to welcome you to today's talk
00:44in our finding solutions series to
00:47the opioid crisis in collaboration
00:49with the Sandgaard foundation.
00:51We're joined today by Doctor
00:53Edward Coupet and Don Stader,
00:55who will speak on the topic
00:57emergency department based
00:58treatment and harm reduction.
00:59Interventions for opioid use disorder.
01:03Before we get started,
01:04we just want to review a few housekeeping
01:06items on the following slides.
01:10So as a reminder, you can learn more
01:12about the Yale program in addiction
01:14medicine and the finding solutions to
01:17the opioid crisis speakers series by
01:19visiting addictionmedicine.yale.edu.
01:21Following our program in the Sandgaard
01:25Foundation on Twitter at
01:28@YaleADM and @SandgaardFnd.
01:31And by joining our program listserv
01:33and just send an email to emma.biegacki@
01:37yale.edu to be added.
01:41If you will be live tweeting about today's talk,
01:43be sure to tag us and include event hashtags,
01:46#FindingSolutions
01:48and #BandTogether.
01:51Second, as a reminder,
01:53coming up in this series on December
01:5614th will be welcoming Gary Mendell,
01:58who's the founder and CEO of Shatterproof
02:01and who will be speaking about the topic,
02:04stigma and substance use disorder,
02:06the silent killer.
02:07I encourage you to join us for that talk.
02:11So to participate in today's session,
02:13use the chat box.
02:15Please to share comments and
02:16observations with your fellow attendees.
02:19And if you have a question,
02:20please put that in the Q&A box.
02:24Finally, CME credit is available for
02:27today's event and to receive credit just.
02:32Please text the code in red
02:34to the phone number in red.
02:36And this information will be
02:38provided in the chat at the
02:39beginning of today's session.
02:42Now I'd like to introduce and invite
02:45Kyle Henderson,
02:46who's the executive director of the
02:48Sandgaard Foundation to see a
02:50few words unsure about the mission and
02:52work of the foundation, I'll go ahead.
02:54Thank you David and thank you
02:56everyone for joining us today.
02:58It's an honor for the Sandgaarrd Foundation
03:00to align with the Yale Program and
03:02addiction medicine for this
03:04wonderful speaker series. The
03:05Sandgaard Foundation was founded
03:07by Thomas Sandgaard in 2018,
03:09but that story really started 25 years
03:12ago when he founded Zynex Medical.
03:14So it's a publicly traded medical device
03:16company that helps with Electro therapy
03:18for pain management gets people off
03:20of addictive, potentially lethal
03:23painkilling drugs like oxy,
03:25and we started the foundation to really
03:28focus on the opioid epidemic exclusively
03:31to really broaden the impact that
03:33we're already having through Zynex.
03:34So I also run Sandgaard Capital,
03:36which is his private equity group.
03:38And with the foundation this year alone,
03:41we've distributed over 500,000
03:43units of Narcan
03:44around the country in partnership
03:46with direct relief and the Voices
03:50Out Loud project with Ryan Hampton,
03:52who's been a past speaker as well.
03:54And we're also working on a
03:56large initiative with Doctor
03:57Stader who is joining us today.
03:59Doctor Stader is the founder and
04:01visionary behind the Colorado naloxone
04:02project that we're
04:03also honored to be a part of.
04:05So doctor Stader, thank you for
04:06joining us and taking the time.
04:08And I look forward to hearing from.
04:09Doctor Coupet as well.
04:10So thank you everyone for coming.
04:14Thank you, Kyle. We appreciate it.
04:16So I would like to
04:18introduce today's speakers.
04:19Our first speaker is going
04:21to be Doctor Edward Coupet.
04:22Jr. Doctor Coupet is a NIDA
04:24sponsored Yale drug use addiction and
04:27HIV scholar and an assistant professor
04:29in the emergency medicine at Yale.
04:32Dr Coupet graduated from the University of
04:35Illinois at Urbana Champaign completed
04:37medical school at University of Chicago,
04:40and his residency training
04:42in emergency medicine at
04:43Montefiore subsequent to
04:45that he completed a Center for
04:48emergency care policy and research
04:50fellowship at the University of
04:52Pennsylvania. Doctor Coupet's
04:55Research interests are that in the
04:57intersection between substance use and
04:59community violence and disparities
05:01in access to addiction treatment.
05:03We'll also be joined by Doctor
05:05Donald Stader.
05:06Dr Stader is an emergency
05:08physician in opioid expert.
05:10Don works at the Swedish
05:12Medical Center in Englewood,
05:13Englewood, Co,
05:13where he serves as a section chair of
05:16emergency medicine and the Associate
05:18Emergency Department medical director.
05:20Don holds a medical degree with
05:23honors from Baylor College of Medicine
05:25and attended emergency residency
05:27at the Carolinas Medical Center.
05:29He's founder and past chair of
05:31the Colorado American College
05:33of Emergency Physicians,
05:34Opioid Task Force,
05:36leader of the Colorado Cure,
05:39which is an effort to create
05:41multidisciplinary opioid prescribing
05:42and treatment treatment guidelines for
05:45the state of Colorado and he's chair
05:48of the Colorado Naloxone Project.
05:49As we hear about more.
05:51Don is a senior pain management and
05:53opioid policy physician
05:55advisor for the Colorado Hospital
05:57Association and serves on multiple
05:59national local committees addressing
06:00the opioid epidemic in
06:03Colorado and across the nation.
06:05So we're really pleased to have
06:07two expert emergency medicine
06:09physicians to address the what
06:11can be done to address the opioid
06:13crisis in the emergency department.
06:15So Eddie,
06:16with that I'll let you take it away.
06:20Right, thank you. Finish share my screen.
06:30Alright, thank you doctor.
06:32Thank you Dave for that introduction.
06:35Yeah, so we'll just get right into it.
06:39Before I begin,
06:40I should add I have no financial
06:43conflicts of interest to disclose.
06:46I'm going to be covering a
06:47pretty large topic today,
06:48e.g., initiated buprenorphine.
06:50It's going to be a really broad overview,
06:53so there's so many things to
06:55discuss really within this topic,
06:56so I'm gonna touch upon each of these
06:59points at a very high level and starting
07:02off with why the emergency department
07:04is important and then getting into.
07:07Can prescribing and the importance
07:09of protocols lessons learned,
07:11illegal policy updates and then wrapping
07:13things up with disparities in addiction
07:16care and future considerations so.
07:18So I the larger question is you
07:21step back is why should we focus
07:24on the emergency department in our
07:26efforts to really fight and address
07:28this opioid crisis that we're in?
07:30Well, the Ed is open 24 hours a day,
07:34seven days a week,
07:35365 days over the course of the year
07:38and so over that time we see patients
07:41who have overdosed from opioids.
07:43We also see patients who may
07:45come to the emergency department
07:47seeking addiction treatment.
07:49And then we also have the opportunity
07:52to identify patients who may have
07:55been coming into the emergency
07:57department for other unrelated
07:59concerns such as ankle sprains
08:01or chest pain through screening.
08:03And it's through that we can identify
08:06patients with untreated opioid use
08:08disorder and link them into treatment.
08:11So back in 2015 there was this
08:14landmark randomized controlled trial
08:16of Eddie initiated buprenorphine,
08:18which essentially found that
08:20patients who received buprenorphine
08:23are from the emergency department.
08:25The first dose of Jupiter from the
08:28emergency department were twice as
08:29likely to be engaged in addiction
08:31treatment at 30 days compared to those
08:33who had just received a referral.
08:35And so this trial took us into today,
08:38which essentially shows a.
08:40A burgeoning role of buprenorphine
08:43really across emergency department
08:46in emergency departments across
08:48the US and so in this study.
08:51Back in 2002,
08:53refound that there were they found that
08:56there were there were approximately
08:5812 times at which buprenorphine
09:00was administered in the emergency
09:02department per 100,000 PD visits,
09:04and that number is nearly quadrupled to
09:07nearly 43 times per 100,000 Ed visits and,
09:11as you can see,
09:12this is really remarkable in
09:14that how Ed initiated.
09:16Buprenorphine has really
09:17expanded across the US.
09:21With that said, we recognize the
09:24importance of professional organizations
09:27really in establishing standards of care
09:29through specialties and the emergency.
09:32Emergency medicine is no different.
09:34The American College of Emergency Physicians,
09:37our largest or ASAP,
09:40our largest professional organization.
09:42Push this publish these guidelines
09:45recently and within them.
09:47It essentially recommended
09:48that emergency physicians offer
09:50treatment for opioid use disorder,
09:52specifically buprenorphine to the
09:55appropriate patients as well as a
09:57referral to ongoing addiction care.
10:00And so this this paper, I feel, was very.
10:05Very critical in terms of scaling up.
10:08Ed initiated buprenorphine as ASAP or ASAP.
10:12Really is instrumental in establishing
10:15guidelines from rule from academic
10:18physicians all the way out to rural
10:22emergency medicine physicians.
10:23So then the larger question is
10:25how did we get to this point?
10:27Well, the emergency department is
10:29quite a quite challenging setting to
10:31really establish standards of care.
10:33In that we see patients who present
10:35in acute illness or extremists.
10:37We also see patients who deal
10:40with multiple social challenges,
10:41specifically housing and stability
10:44and unemployment,
10:45as well as insurance issues.
10:47There's also the pressure for
10:48throughput in terms of seeing
10:50patients as quickly as possible
10:52and getting them either admitted.
10:54Or home safely as quickly as possible
10:57and then now more than ever there
11:00is this issue of crowding as we're
11:01in a national boarding crisis,
11:03and so with that said.
11:08Protocols are really key in terms of
11:12establishing establishing standards of
11:14care and establishing standards of care,
11:17particularly with media initiated
11:19people norfin.
11:20So this study there was a study that
11:24that was across of Ed initiative group
11:27protocols across several geographically
11:30diverse sites and essentially found
11:32that all protocols contain 3 components,
11:36one of which was the identification
11:38of treatment.
11:38Eligible patients,
11:39the second of which was instructions
11:42surrounding human orphan initiation and
11:44then a discharge plan and follow up.
11:47There was some variability between each
11:51amongst each of these components in
11:55that most of them relied on physician
11:57judgment for the identification
11:59of treatment eligible patients.
12:02There was variability in terms
12:03of dosing for group in orphan,
12:05the timing between doses as well as
12:08the Mex first day dose between sites.
12:10And it also found that most protocols
12:13really had very explicit structions for
12:16the discharge dosing for buprenorphine,
12:19as well as instructions surrounding
12:21follow-up care and prescribing of naloxone.
12:26So as we think about scaling up,
12:29Ed initiated buprenorphine,
12:31we recognize that technology,
12:33specifically the electronic health
12:36records and and applications,
12:38really play an enormous role in
12:40terms of in terms of scaling up,
12:43Ed initiated buprenorphine and so
12:45really have the opportunity to leverage
12:47it to really establish and implement
12:50continue to implement standards of care
12:53and so to come there is there will be.
12:56With desktop as well as phone
12:58apps to provide instructions
13:00surrounding buprenorphine induction.
13:02And initiation.
13:04So looking back thus far,
13:07what lessons have we learned as far as
13:09implementing Ed initiated buprenorphine?
13:11Well, as I mentioned before,
13:13make it as easy as possible and that
13:15includes by leveraging electronic
13:17health records and protocols.
13:19As I touched upon before really
13:22identifying local champions including
13:24those in the Ed as well as community
13:27stakeholders who can help guide in
13:30protocol development as well as improve
13:33patient engagement in addiction care.
13:36We've also recognized the importance
13:39of multi level interdisciplinary
13:41interdisciplinary support,
13:42particularly in terms of getting our nursing,
13:46nursing,
13:46pharmacy and social work colleagues
13:49involved as much as possible.
13:52And then we also recognize that
13:54while it's improving still,
13:55stigma still remains a large barrier
13:59to receiving addiction care for.
14:02For our patients so.
14:05Earlier this year we published
14:07this paper identifying Ed patients
14:10with untreated opioid use disorder,
14:12and within it we essentially found
14:15across 4 geographically diverse sites
14:17that most patients with untreated
14:19opioid used to sort of present it
14:21to the Ed not seeking or referral
14:24for addiction care and less than
14:26half of them actually identified
14:29less than half of those who actually
14:30identified as seeking addiction.
14:31Care actually had an ICD 10 diagnosis code.
14:35For opioid use disorder and so it
14:38really speaks to the importance
14:40again of leveraging electronic
14:42health records and protocols to
14:44really identify patients with opioid
14:47use disorder better.
14:48And also we found that many individuals
14:50were challenged by multiple social risks,
14:53most notably housing and stability
14:55as well as unemployment.
14:58In this study looked we looked
15:00at clinician barriers to Ed
15:02initiated buprenorphine,
15:03and we found that only four percent were
15:07of clinicians were trained were received,
15:10a data 2000X waiver training to be
15:13able to prescribe buprenorphine from
15:16the Ed and 21% only 21% at least
15:20reported high levels of readiness
15:22to prescribe you pain or fear.
15:26So as far as looking at barriers,
15:28we found that there was an overall
15:30lack of training and experience
15:32in treating opioid use disorder
15:34from the emergency department.
15:36Many participants also expressed
15:38concerns regarding linking
15:40patients to ongoing addiction care.
15:42And many also spoke up on the challenges
15:46of meeting the other competing
15:49needs and resources within the very
15:51busy emergency department setting.
15:54Some key facilitators we found
15:56were receiving addiction,
15:58receiving education and training
16:00surrounding addiction care.
16:02We also found that the development of local
16:06protocols that can kind of streamlined.
16:09Streamlined Ed initiated
16:11buprenorphine for clinicians.
16:13And we also found that receiving
16:16feedback on patient experiences
16:17from those who have opioid use
16:19disorder as well as gaps in quality
16:21of care was also very helpful.
16:25So now looking at policy updates back
16:30in January on January 14th of 2021,
16:33the outgoing Trump administration
16:35lifted many of the barriers surrounding
16:38procuring an X waiver and over
16:40that time physicians could simply
16:42place an X on their prescription to
16:44suggest that buprenorphine would
16:47be used for opioid use disorder.
16:50It should be noted though,
16:51that for those who did not receive
16:53the 8 hour training course which
16:56was previously a requirement,
16:59we're still we're still,
17:00we're still not able to treat any more
17:04than 30 patients at the same time.
17:06However, as you can imagine,
17:07this didn't necessarily apply to the
17:10emergency department setting where
17:12oftentimes we don't see many patients.
17:15Many of the same patients again.
17:19Two weeks later,
17:20the Biden administration expressed
17:21expressed plans to reinstate
17:23many of these requirements,
17:25notably the 8 hour training course.
17:29And then most recently we the on April 29th,
17:33the most recent guidelines were
17:36established under which clinicians
17:37could apply for an X waiver through
17:40SAMHSA and no longer had to receive
17:43the 8 hour training course.
17:47So the legal Action Center published
17:51this report surrounding some legal
17:54legal ramifications and guidelines
17:56surrounding addiction care.
17:58For me, emergency department and under
18:02which the report essentially stated
18:05that hospital that hospitals should
18:08practice evidence based standards
18:10of care for substance use disorders
18:12in the Ed most notably screening and
18:15diagnosis of substance use disorders.
18:17Offering buprenorphine as well
18:20as facilitating a referral to
18:23ongoing addiction care.
18:25Failure to adopt these evidence?
18:27Some of these evidence based practices
18:30really exacerbated disparities,
18:31and specifically the report touches
18:34upon racial ethnic disparities as well
18:37as disability related disparities
18:39and hospitals that did not adopt
18:42these evidence based practices
18:44were subject to violate many laws.
18:46But most notably,
18:47the emergency medical treatment
18:49and Labor Act or EMTALA.
18:55So touched upon disparities.
18:56Let's look into some disparity surrounding
18:59care for opioid use disorder in the Ed.
19:03So as we as there has been
19:05an expansion of funding,
19:07particularly surrounding Community access
19:10to treatment for opioid use disorder.
19:14It should still be noted that the
19:16adoption of medications for opioid use
19:18disorder still remains low in certain
19:21settings and as a result of that we
19:23still have large gaps in addiction care,
19:26specifically along regional and
19:28racial ethnic regional lines,
19:31as well as racial ethnic groups.
19:34So this study,
19:35basically this was from a study
19:38which basically looked at geographic
19:40proximity to a buprenorphine
19:42treatment provider across the US,
19:45and each black dot represents a
19:47buprenorphine treatment provider and is,
19:49as you can see along the East Coast
19:51there are there are cluster of
19:53buprenorphine treatment providers.
19:54However as you move further out
19:56West you can see there is there are
19:59dearth of areas where buprenorphine
20:01is available to our patients.
20:07In this step, this study was a single
20:10site study of a pro evaluating a program
20:14that administered care for patients
20:17with untreated opioid use disorder,
20:19and it essentially found that young
20:21white males were most likely to have
20:24their opioid use disorder addressed
20:25in the emergency department.
20:30And in this study at another,
20:32in a separate study at another site,
20:35also evaluating a program for Ed initiated
20:38buprenorphine for opioid use disorder.
20:41It found that black patient black
20:44patients were less likely to
20:46receive behavioral counseling
20:48surrounding opioid use disorder in
20:51the in the emergency department.
20:56So now, in touching upon disparities,
20:59one major issue that still
21:02exists is stigma, and last year,
21:05Doctor Nora vocal published this paper
21:07in the New England Journal of Medicine,
21:09which I felt was really impactful and
21:11moving in terms of highlighting this
21:14big issue of stigma and how it remains a
21:17barrier to our patients receiving ongoing
21:20addiction care and really providing the
21:22best care as possible for our patients.
21:24And it really identified.
21:27Many areas of improvement for us as a whole.
21:31In terms of delivering care to our patients.
21:34With your use disorder looking forward,
21:38there is an expanded role for looking
21:41at injectable, VUPEN orphan or
21:43extended release buprenorphine.
21:45It treats.
21:46Addiction addiction symptom for opioid
21:49use disorder for up to seven days.
21:53And currently underway there's a randomized
21:55control trial that that is comparing
21:58the efficacy of extended release.
22:00Buprenorphine to sublingual buprenorphine
22:03across 27 US emergency departments
22:05with their primary outcome being
22:08engagement informal addiction treatment.
22:10And as you can imagine,
22:12extended release buprenorphine has
22:13the potential to really alleviate
22:15some of these real-world barriers
22:17that many of us clinicians face,
22:19most notably treatment,
22:21availability and and insurance issues.
22:28So with that said,
22:29I know I touched upon many, many,
22:32many of the facets surrounding
22:35Edie initiated buprenorphine.
22:36However, I shouldn't should
22:38acknowledge that addiction.
22:39Care is not a one size fits all
22:42approach and that there are many
22:44different facets to kind of managing and
22:47delivering addiction care specifically
22:48out of the emergency department.
22:50And so. With that said,
22:53I'm going to pass it off to my colleague,
22:56Doctor Don Stater, who will touch.
22:58On harm reduction strategies.
23:00I thank you all for listening.
23:03I welcome any comments questions.
23:05Please feel free to email me.
23:07Here's my email address.
23:08Thank you all.
23:12Thank you Doctor coupe.
23:14Appreciate appreciate that that
23:15knowledge in the introduction as well.
23:17I'm going to go ahead and share my screen.
23:19Can everyone see that?
23:21Is that yes, OK, great.
23:23Well, let's go ahead and get started
23:26so so my name is Don Stater.
23:28I'm an emergency physician
23:29practicing in Colorado.
23:30I'm gonna also aborted in
23:32addiction and emergency medicine.
23:34I'm the chair of Colorado
23:35and locks on project.
23:36I've got several other roles which
23:38which we will mention and they do have.
23:41I guess a declared conflict in
23:42that the Colorado and Waxman.
23:44Project has received donated a
23:46loxone from Bio Emergent Solutions.
23:49We've used that donated Milax own
23:51to actually provide free naloxone
23:53to mothers who struggle with with
23:55substance use and opioid use
23:57disorders through our labor and
23:59delivery wards as part of a pilot.
24:01Now I've here to talk with you
24:03about something that is literally
24:05changed my medical career,
24:07which is this concept of harm
24:08reduction and how we actually
24:10introduce harm reduction.
24:112 patients who struggle with opioid
24:13use and substance use disorders which
24:16still remain the number one killer
24:18of Americans under the age of 50.
24:20And what harm reduction is is really.
24:23It's just all in the name.
24:24Harm reduction is just about reducing
24:27harms of dangerous activities
24:29and it's a set of practical.
24:32Knowledge based interventions that
24:33you can use on patients who may
24:36are struggling with substance use
24:38to help make their use safer and
24:40till the day that they're ready
24:42to recover and what it does is it
24:45emphasizes science over stigma.
24:47Understanding the patient rather
24:49than just judging them and doing
24:51so much better for them than we
24:54are doing currently with our with
24:55the status quo because this is
24:57what I learned about drug use and
25:00specifically injection drug use.
25:02In my medical school and residency,
25:06I learned all the complications of it.
25:08I learned overdose.
25:09I learned about hepatitis.
25:11CI learned about the fact that
25:12it's the number 2 cause of HIV.
25:14I learned about abscesses,
25:15which I drained on almost weekly
25:17basis shooters.
25:18Abscesses in the emergency department.
25:20I've seen several cases of
25:22injection related neck fashion,
25:23Botulism about endocarditis,
25:24which which still is driven by Ivy
25:27drug use about spinal infections,
25:30about death.
25:30I learned all these things and
25:32how to deal with the.
25:34Ramifications and the disasters
25:36that Ivy drug use sometimes creates.
25:39What no one ever taught me,
25:41which is actually the most
25:42important darn thing,
25:43is how you discuss these with
25:45patients and prevent them because
25:47an ounce of prevention sure as heck
25:49is still with a pound of cure.
25:51And really,
25:52what I should have learned what
25:55every physician, clinician,
25:56person in who deals with this patient
26:00population should know is how to
26:02inject heroin and how to inject drugs safely.
26:06And while some people like like
26:07wait a second,
26:08I am a medical provider.
26:09Why the heck should I know how
26:12to inject drugs is because you
26:13have to know how to discuss drug
26:16use with patients in a legitimate,
26:18real and scientific way and not
26:20just give people asinine advice
26:23like you should stop using drugs.
26:25'cause that's what I did for the first
26:28five years of my career and whenever
26:30someone came in and they were a
26:31drug user and I drained an Abscess.
26:33My only advice to them was stop using drugs.
26:36Totally neglecting the deep
26:38science behind the neural,
26:40the the addiction and the changes that
26:42occur with the disease of addiction.
26:45And we actually have a great
26:47model to follow when it comes to
26:50implementing this into our practice.
26:52And it's a model that comes from
26:53the 1980s where we had the scariest
26:56epidemic at that time before COVID
26:58that has struck our nation and and
27:01we had a lot of panic around it.
27:04Which is HIV AIDS disease,
27:06for which we had no cures for decades.
27:09And during that HIV AIDS epidemic,
27:12we decided in medicine that we actually
27:14had to start discussing safe sex with
27:18patients and in my medical school I
27:20always taught nitty gritty about safe sex.
27:22About the different HIV transmission rates
27:24between oral sex and vaginal sex and
27:27**** *** and the different risk factors.
27:29So I can ask my patients the uncomfortable
27:32questions and give them the knowledge
27:34that they needed to keep themselves safe,
27:37their community safe,
27:38and to not acquire a
27:40potentially deadly disease.
27:42We need to do the same thing
27:44for our patients who use drugs.
27:45If we ever went to actually
27:48start addressing the HIV,
27:49the continued HIV epidemic hepatitis
27:51C epidemic that is currently
27:54ravaging our country.
27:55Not to mention the overdose epidemic.
27:58So let's do this.
28:00Patient based is one.
28:01You have something we see every single
28:03day in the emergency department.
28:05You have a patient who's
28:07there overdosed on opioids,
28:09and right now fentanyl is of course
28:11driving our overdose epidemic.
28:13We won't get into that.
28:14But besides trying to encourage
28:16the patient to enter into recovery
28:18besides offering buprenorphine and
28:20real legitimate drug treatment,
28:22what else can you do?
28:24You can sit down at the bedside and say
28:26I would never want to see you overdose again,
28:29and these are the simple steps that
28:31practical steps that I want you to take.
28:33If you are to continue with your drug,
28:35use one.
28:36Never use alone because people who
28:38use alone and overdose alone die.
28:42So always use with people that
28:43you know people that you trust.
28:45If you have many people who are
28:47using drugs at the same time,
28:48try to have one person who stays
28:50sober for a period of time so
28:53that they can watch there.
28:54Are there there other friends who might
28:56be using and make sure that you don't
28:58have a potent batch that's been cut with car,
29:00fentanyl,
29:00or fentanyl or something?
29:02That's a lot more potent,
29:03and that's practical knowledge that
29:05you can give to your patients.
29:07Two is when you actually have new product,
29:10you require a new product from
29:12from whatever source you're
29:13getting it from.
29:14Or if you've been trying to to enter
29:17into recovery and have been absent,
29:19either self imposed because
29:20you're trying to enter recovery,
29:21or maybe it's imposed by someone else,
29:23you get admitted to the hospital.
29:25For an infection in your
29:28not getting getting opioids,
29:30or if you've been jailed,
29:31then you'd have to get opioids.
29:32Then your your tolerance is either
29:34decrease or the product you're using.
29:36Might be very,
29:37very potent so user testers shot or use
29:40a smaller dose initially so that you
29:42don't accidentally overdose fentanyl.
29:44We've talked about,
29:45as has infiltrated the great majority
29:48of illicit drug supplies across
29:50the United States and fentanyl.
29:52Test strips are a great way for
29:54people to test whether their heroin
29:55that they may have purchased.
29:57Has fentanyl in it or even other drugs
30:00such as ecstasy or methamphetamine,
30:02which often it's more common
30:04in 2021 and beyond,
30:05are going to be cut if that's all,
30:07because that's always so
30:08ubiquitous and so darn cheap.
30:10So people should be empowered to know
30:13what they're putting in their bodies.
30:15Lastly,
30:16and this is one of the most neglected
30:19interventions that we have in medicine,
30:21as we have an antidote that we
30:23can send home with every single
30:25patient who is at risk for overdose,
30:28which is meloxicam or in our CAP.
30:31You know,
30:31you can send that home with every
30:33patient and it's been shown to
30:35have really beneficial effects
30:36at decreasing overdose deaths,
30:38encouraging safer use, etc.
30:39But we are not using that tool as much
30:42as we should and put the second half.
30:45I'm going to give a broad.
30:46Overview of harm reduction.
30:47But then for the second half lecture,
30:50we'll talk a little bit more about the
30:52locks on in general because the the
30:54current standard of care of just time.
30:56People don't use drugs,
30:58and discharging them after two hour
31:00observation when they present with
31:02an overdose results in people dying.
31:04And we know that the mortality rate
31:07for a young person who struggles
31:09with an opioid use disorder and is
31:11seen in an emergency department
31:13borders on between 5 to 10% a year.
31:16As few percentage in the first month,
31:19so these are people who are amongst
31:21the sickest that we're seeing in
31:23their marriage department and were
31:25failing at basic interventions and
31:26basic knowledge sharing to keep
31:28them safe and decrease death rates.
31:31So we know now how to counsel
31:34patients to reduce their ability,
31:36their their likelihood of overdose.
31:38How about soft tissue infections there?
31:41The classic,
31:41merciless spider that only bites
31:43in the antecubital fossa,
31:46how do you actually discuss with
31:48patients safe drug use so that
31:51they don't get endocarditis,
31:53epidural Abscess, necrotizing fasciitis,
31:56soft tissue infections?
31:58How did, besides draining an Abscess,
32:00do you actually bridge that gap?
32:01Knowledge gap and it starts with
32:03really getting into the nitty gritty
32:05of how patients are using drugs.
32:07So like I said,
32:08everyone should know how to use drugs,
32:10but you know who's a clinician.
32:12Oftentimes when you buy an illicit
32:14illicit drug that you're going to inject,
32:16it comes in a more solid form,
32:18or black tar heroin attire form that you
32:20have to dissolve so that you can inject it.
32:23So oftentimes you'll take your hair
32:24when you'll put it in a cooker,
32:26which can be a spoon or a more formal cooker.
32:29You'll dissolve the ham with a little water.
32:31You'll. Either mix it up towards dissolved,
32:33or commonly you'll heat your heroin
32:36so that it aids dissolving in Europe
32:39where they have more basic heroin,
32:40sometimes you have to add an
32:41acid here in the United States,
32:42that's not what not as common.
32:44You'll put a continent to help filter,
32:46and then you'll put your needle
32:48and syringe in and you'll actually
32:50drop your drop your heroin and then
32:52you'll find a vein and go inject it.
32:54Or more dangerously,
32:55if you fried all your veins,
32:57you might actually inject it directly
32:59into a muscle which actually has
33:01a much higher infection risk.
33:02So how do we know that you know
33:04how to inject heroin?
33:05Each one of those steps is actually an
33:08intervention point that you can discuss
33:10with your patients to keep them safe,
33:13and some of the most common things
33:14that I do when I go and drain an
33:17Abscess from an injection drug users
33:18as I actually get into the nitty
33:20gritty of how they're using with
33:23the only intent to keep them safe,
33:25and I'll ask them.
33:26And these are common things I'll say.
33:28So tell me how you use and they'll
33:29start kind of walking through
33:31their process and I'll ask them
33:32if they use fresh equipment.
33:34Because fresh equipment of course
33:36doesn't carry as much bacteria.
33:38Once they say, OK.
33:39Well, I've drawn up my heroin.
33:40I'll say where are you
33:42getting your water from?
33:43Because so often times you'll find
33:45people have really bad water supplies.
33:47Some people will use toilet water,
33:49some people river water.
33:50Those are the most extreme cases,
33:52but oftentimes here's one thing that
33:54I've discovered over and over again.
33:56Let's say, oh,
33:56I'll use sink water.
33:57I use bottled water and I'll say,
33:59if we with your bottled water.
34:01Do you actually drink the water before
34:03sometimes you use it and they'll say Oh yeah,
34:05sometimes they'll say that's
34:06why you have an Abscess,
34:07because if you drink water before
34:09you actually use it to solve heroin,
34:11it's contaminated water in the dirtiest
34:13place on your body is your mouth.
34:15The other thing that's a very
34:16common practice is people who lick
34:18needles so often times when people
34:20drop their drug and they start
34:22pushing depressing their syringe
34:23mobile small drop that happens at
34:25the top of the needle and people
34:26often leak the needle before they
34:28find a vein and inject it.
34:30That's how they have an Abscess.
34:32You should discuss with patients
34:34not licking their needles
34:35before putting it in their arm,
34:37and you can prevent people from
34:39developing recurrent abscesses.
34:40Lastly, muscling is a really dangerous
34:43practice because that bacteria is injected.
34:45Into a muscle and doesn't
34:46have anywhere to go.
34:47It's and oftentimes that results
34:49in more danger of infection.
34:51So again, practical information you can
34:53discuss with your patients at the bedside.
34:55So I tell them that the mouth is a
34:57dangerous place of webs that need cough.
34:59I tell them to use fresh equipment.
35:01I'll ask them what they're
35:02doing to clean their skin,
35:04and if the person is homeless or
35:06struggles with resources I reach,
35:08read into my Ed drawer and I send them
35:10home with a handful of alcohol pads
35:12and I'll tell them you can buy these
35:14for a buck at any pharmacy for 100
35:16or get them out of syringe exchange
35:18program if you have access to one,
35:20and I'll instruct them on how to
35:23clean their skin before they inject.
35:25Lastly, if they're there,
35:26if they are cooking product or if
35:28they're scared to cook their product,
35:29which is another common thing,
35:31there's this treatment that, hey,
35:32you're going to boil off all
35:33your heroin or your fence,
35:35and I'll I'll reassure them by telling about
35:37the boiling point of heroin is 400 degrees,
35:40whereas water is 100 or
35:42fentanyl is also much,
35:44much higher than water,
35:45so they can actually cook
35:46and boil their fentanyl,
35:48and they're not going to or heroin,
35:49and they're not going to boil
35:51it off and decrease the dosage.
35:52And by doing that, they'll actually
35:54somewhat sterilize their drug supply.
35:56And then finally,
35:57it's where you're injecting.
35:59We talk about the fact that
36:00injecting in the hands is dangerous.
36:02The fact that mainlining is dangerous.
36:04The fact injecting in the groin is dangerous,
36:06and the fact that they should
36:09always keep one vein.
36:11That's for the medical community,
36:13so I always talk about keeping one
36:15vein that they just don't touch.
36:17So if they ever get really sick that
36:19they can come into the hospital,
36:20tell us where that vein is,
36:22and we can use it to help provide
36:24them the medical care that they need
36:26so we can prevent a lot of these
36:29infections by actually just giving
36:31patients the knowledge that they need
36:33and the consequence of standard care.
36:36And this is all stuff that's been
36:39increasing dramatically over the course
36:40of the last few years is terrible.
36:42Life threatening infections that costs
36:44us billions upon billions of year
36:47and each of which is preventable.
36:49So the third patient we're going to talk,
36:51we're going to talk about how to
36:53prevent viral infections is you have
36:55your favorite nurse who's comes to
36:57you panicked because she's been stuck
37:00with a needle with a person who's a
37:03known Ivy drug user and who's had
37:06multiple visits to the Ed and your
37:09nurses just passed because she have HIV?
37:11Do I need to go in HIV prophylaxis?
37:13Do I have hepatitis C?
37:15And the answer is possible,
37:17so if nothing that I've said resonates
37:19with you about taking actually
37:21better care of these patients.
37:24Here's another reason you want to take
37:26better care of these patients so that
37:28you take better care of your staff,
37:30because we know that patients who
37:31have Ivy drug use often have have hot
37:34hyperalgesia if they're using opioids,
37:36they oftentimes they're difficult.
37:38Ivy starts, and you're oftentimes at much
37:40greater likelihood to have an accidental
37:42needle stick with that patient population,
37:45and if that patient has not been kept safe
37:48and they have hepatitis or HIV, then that
37:51endangers your medical staff as well.
37:53And I've been the victim
37:54of a needle stick with it.
37:55Heavy drug user.
37:56It is not a great situation to deal with,
37:59so we want to keep this medical.
38:02This this cohort of patients
38:04safe not just for their sake,
38:06which is the first duty that we have,
38:08but also for the sake of our
38:10communities and our staff.
38:11So how do you actually prevent people
38:14from getting hepatitis and HIV is,
38:17we know that sharing anything when it
38:20comes to drug use leads to these things,
38:24and we know that.
38:25Hepatitis C.
38:26There's a much hardier virus than HIV,
38:30so here in Denver and I'll just
38:32talk about our local members.
38:33We know that amongst Ivy drug users.
38:36HIV runs at less than 1% because most
38:40people know not to share needles,
38:43but amongst that same cohort of patients
38:46are hepatitis C rate is between 20 and 25%,
38:49so it goes to show you two things.
38:51One hour advice to not directly share
38:55needles is good and has been working to
38:59HIV is a much less virulent disease.
39:02Virulent virus when it comes to or
39:04much less contagious virus when
39:05it comes to injection drug use.
39:07But because it survives outside
39:09the body for only a minute or two,
39:11but hepatitis C has been shown to
39:13survive in a cooker in a cotton in
39:16a needle for up to three weeks for
39:18two to three weeks after last use.
39:21So hepatitis C is like a Navy SEAL.
39:24It's just waiting there and has
39:26infected large,
39:27large populations of people because
39:29it's just such a Hardy virus and
39:31that just goes to show and I'll
39:33discuss all this with patients at the
39:35bedside that you have to be really,
39:38really cautious about saving anything.
39:39Sharing anything, in this case,
39:41sharing is not caring,
39:42so we need to discuss that you
39:44don't share your cooker.
39:45You don't share your cotton,
39:46you don't share a syringe beyond.
39:49Just don't share needles.
39:50The other thing that I often discuss
39:53people is that the need to to actually
39:55know how to inject yourself because
39:57something we want to discuss here,
39:59but which is very,
40:01very prevalent is drug use and
40:03injection use as a way to either control
40:07women who are being sex trafficked.
40:09Or women who are being abused.
40:11And I if you are a woman who comes in
40:13and you are and you have one of
40:15these injection related complaints,
40:17I ask about self sex trafficking.
40:19I ask about abuse because we know
40:21that the numbers are behind.
40:23Those are extremely high and and it's
40:25another way that you can tile it.
40:28Target your interventions.
40:29So let's get back to viral.
40:31Viral infections is you just
40:32have to talk with your patients
40:35about not sharing anything.
40:36You have to talk with them about
40:38going to syringe exchange.
40:40You have to talk with them.
40:41If you don't have a syringe exchange
40:42about going to the pharmacy and
40:44actually getting their supplies and
40:46when patients some patients will say,
40:48well Doc,
40:48I've been to the pharmacy and they
40:50won't give me any injection materials
40:52because I don't have a prescription.
40:55I read them a prescription because
40:57I want to keep that patient safe.
40:59I want to make sure that they don't get
41:01any of these diseases that we talk about.
41:02And finally,
41:03there's big news in terms of something
41:06that's happened overseas and that's
41:07been proven for now going on decades.
41:10Is the fact that that supervised
41:13injection facilities decrease
41:14disease and save lives?
41:16And here in the United States we have
41:18our first supervised injection facility
41:20in New York and we're excited to
41:23see how that plays out over the next
41:25few years because the consequences
41:27of not addressing unsafe drug use,
41:30injection,
41:30drug use with people.
41:31Are you have these tremendous
41:34outbreaks of hepatitis C and HIV
41:37such as what we saw in Austin IN.
41:40Community of 4000 people that had
41:42a problem with sharing a supplies
41:45and and had one of the largest
41:47HIV epidemics we've seen in the
41:49lot in the last last decade.
41:51Where 400 people got HIV from
41:54unsafe drug use,
41:56and that's happened again and again
41:58across the across the country where
42:00we've seen these small outbreaks
42:01all related to too unsafe drug
42:03use that we can 100% prevent.
42:05The last one is a person who
42:07has long term opioid use,
42:09is brought in by the family withdrawing.
42:12Wants to quit and and is begging
42:14you for help.
42:16And before what I did for
42:18these patients is say hey,
42:19glad you want to quit.
42:20Never use drugs again.
42:22And here is a pamphlet of 20 places
42:25you can call to try to get help and
42:28patients would get frustrated 'cause
42:29they start calling these places and
42:31they don't have any access to care.
42:32So we set people up for failure who
42:35are looking for a recovery time and
42:37time again in the past and we just
42:39have to do what we've been trained
42:42to do for every other medical disease.
42:44Treat it,
42:45treat it like a medical disease.
42:47We have lifesaving medications that we can
42:49apply at the bedside beibut ***********.
42:52In some places that are doing
42:54methadone and then referring
42:55that patient to legitimate care
42:57with their relationship.
42:59That you've actually formed with
43:01an accepting clinic and accepting
43:03provider instead of a list of
43:05resources that does absolutely
43:07nothing for people.
43:08Lastly, you can, even if the patient
43:10says you know I went to do heroin.
43:13Anonymous and Narcotics Anonymous,
43:14and they're not going to accept
43:16the fact that I'm on buprenorphine
43:18then send them home with naloxone
43:20and make sure that they that they
43:22have access to a life saving drug.
43:24There's peer recovery organizations
43:26that we need to start figuring
43:28out how to bridge that gap between
43:30the recovery community and the
43:32treatment community in a way that we
43:34can provide patients the best care
43:36possible that aligns with their own
43:38vision of what recovery looks like.
43:40And then finally we have to actually
43:43start affirming humanity in people and
43:45leaving the judgment behind and telling
43:47them that they're worth recovery.
43:48That we're here for you as a medical
43:50community that we're pulling for you,
43:52and that if anything happens,
43:54we want to see you back here.
43:56And that's a message that I give to every
43:58person who I see who struggles with drug use,
44:00whether they're ready to quit
44:01on the day that I see them,
44:03or try to attempt to enter recovery,
44:06or whether they're going
44:07to remain in active use.
44:09We have an open door,
44:10nonjudgmental policy,
44:11but I've worked very hard to
44:13build in a hospital so that people
44:16who use drugs know that we are a
44:18safe place for them to to come.
44:20And the whole premise behind
44:22this is because we know success,
44:24especially in this place in
44:26population is a winding path that
44:28many people have to attempt more,
44:31have multiple attempts to enter recovery.
44:33Some people never get into a period of
44:36absence, but if they're functional,
44:37if they're living what there is
44:39their best life for their function,
44:40then that is a success to me.
44:43Finally, I want to end with just
44:44some parting thoughts.
44:45As is, you know, I was taught my whole life.
44:48That people who use drugs are bad people.
44:51And that's really something a stigma
44:54that drove my own approach to patients.
44:58For the first part of my career.
45:00And every time that a patient came
45:02in and they were a drug user,
45:04what I saw was the drug and I
45:07didn't see the person.
45:09And just like this picture,
45:10that's focused on the needle,
45:12we'd have to stop focusing on drugs,
45:14and we have to start focusing
45:15on the person using the drugs.
45:17If we ever want to provide legitimate,
45:20good, compassionate,
45:22scientific based medical care.
45:25And if we do,
45:26the outcomes are amazing.
45:28They're every bit as miraculous
45:30as curing someone from cancer.
45:32As as as saving a person who's
45:34having a heart attack,
45:36it's it's something in medicine.
45:38It's a miracle that we failed to
45:41actually capitalize upon time and time
45:43again because of the stigma that we
45:46have for people with use disorders.
45:49And I will say that that bridging
45:51kind of that gap to that intellectual
45:54emotional stigma based gap is
45:56when you actually sit down at the
45:59patient bedside
46:00and you discuss harm reduction.
46:02You discuss how to keep that patient
46:04safe in the midst of their drug use.
46:07It takes what is often an extremely
46:10contentious relationship that between
46:11medical providers and persons who
46:13use drugs and it actually helps
46:16provide a therapeutic alliance.
46:18Because that person now knows that I care,
46:21and as a good friend of mine,
46:23Steve Anderson says is people
46:24people won't care how much you know
46:27until they know how much you care.
46:29And that's very true.
46:30With this patient population.
46:31And by actually putting the patient first,
46:34discussing how to keep them safe,
46:36showing them that you're not
46:38judging them for their drug use,
46:40you can build a therapeutic alliance
46:42that actually helps people enter
46:44into recovery and seek medical
46:46care when they need it because.
46:48The world is not black and white,
46:50and that's the other thing that
46:52harm reduction teaches me is
46:54the world is full of color that
46:56there's a full spectrum to people's
46:59motivations to using drugs.
47:01There's a full spectrum to
47:03how to keep that patient safe,
47:05and we in the medical community.
47:07Need to realize that it's not
47:10just abstinence or drug use,
47:13that is just not M 80 or no M 80,
47:16but that we have to accept people where
47:19they are on that path and that every step,
47:22no.
47:22The interventions that we can
47:24take to maximize that patients
47:26help keep them as safe as healthy
47:29as possible and really help be
47:32be good stewards to our to our
47:35patients and and advocates for them.
47:37And the next party that I have for
47:40you is that we have a lot of work to
47:43do and this is a recent publication
47:45that came out just I believe those
47:47last month that talked about the
47:49the rate that we're giving patients
47:52buprenorphine or naloxone in the
47:54emergency department and it compares
47:57it very appropriately to epinephrine
47:59and it what it did is it took people
48:02who had overdosed on an opioid.
48:04So the highest risk patient
48:06population and it looked at.
48:07Which one of those patients was either
48:09prescribed buprenorphine or prescribed?
48:11Duloxetine and the answer is not very many.
48:15We're failing terribly as a nation in
48:18using evidence based treatment for
48:21people with a life threatening disease,
48:24and that should make us all curious.
48:26And when you look at another
48:28life threatening disease which
48:29is anaphylaxis from let's say,
48:31peanuts,
48:32we do a decent job at sending around
48:3550% of those patients home with an EpiPen.
48:38But we do not do that when it comes
48:40to people who struggle with drug
48:42use and a lot has to do with stigma,
48:45both personal stigma and then also
48:48systematic stigma that we've erected
48:50around people who use drugs and
48:52allowing them to access the treatment
48:54that actually saved their lives.
48:56I'm going to provide a.
48:58You know my contact information.
49:00Please feel free.
49:01Feel free to reach out to us.
49:03I want to thank the Sun Gard Foundation,
49:05both with Kyle and Thomas Vanguard,
49:08who have helped fund the next project
49:10that I'm going to just take 2 seconds
49:12to talk about and then I'll go ahead
49:14and wrap wrap it up and we'll do a Q&A.
49:17So one of the things we've done here
49:20in Colorado to try to address that.
49:23Terrible failure we have for now locks
49:26own distribution as we've started a
49:29project that tries to systematically
49:31get every hospital and emergency
49:33department to give out in the locks own.
49:35And what we've done is we've passed
49:38a law back in 2019 that stipulates
49:41that every every Colorado insurer
49:44has to reimburse hospitals for
49:46Norwalk's own dispensed,
49:47and when the locks on when it comes to locks.
49:50And here's a key take home
49:51prescribed the lock zone.
49:53In our patient population
49:55is not a good intervention.
49:57I've got to plot it if
49:59you're prescribing it great,
50:00but it's also an intervention that ends in
50:03failure much more than it ends in success.
50:06Because people who you prescribe
50:08under locks on kit two,
50:10or Narcan or Naloxone 2 don't want to
50:13go and out themselves out of pharmacy
50:15by trying to fill a prescription.
50:17For Narcan.
50:18And that's especially true in small rural
50:21communities where everyone knows each other.
50:23And when you go into the
50:24pharmacy and you ask for Narcan,
50:26suddenly everyone knows that
50:27you struggle with drug use.
50:28If they don't already know it already.
50:31So we have to take that off the table,
50:33and our program asks every single
50:36hospital to dispense naloxone
50:37in the emergency department.
50:39So when patients are identified
50:41at high risk for drug use,
50:42either from chronic opioid therapy from
50:45illicit from from illicit drug use,
50:48or from from even methamphetamine
50:50or Ivy drug use.
50:51I've put Narcan and the lock
50:53zone in their hands before they
50:56ever leave the hospital.
50:57And what we've done is,
50:59as we've passed,
51:00that we've had a concrete push where
51:03we've asked all these hospitals to
51:06join building a collaboration between
51:08over 21 different sponsoring agencies.
51:11We've written guidelines for
51:12hospitals and emergency departments,
51:14and now we have over 110 of our hospitals
51:18and emergency departments enrolled.
51:20And as of January 1st,
51:22we'll have.
51:23Basically 95% of hospitals
51:25giving out Narcan to our highest
51:28risk patients in the hospital,
51:30and that's also tremendously
51:31important because as the study,
51:33there's a study from Delaware that
51:35shows that for 50% of patients
51:38who overdose on an opioid,
51:40they're seen in the emergency department in
51:42the three months prior to their overdose.
51:44And if we on those patients with
51:47overdose awareness education,
51:48and with Narcan in their hand,
51:50it is my thought that we're going
51:52to be able to significantly.
51:54Impact a lot of those lives and
51:56prevent a lot of those steps and and
51:59it's a very hard number to get to,
52:01but it's around 20.
52:02The best studies or the studies
52:04show that it's around 20 to 30%
52:07of people or or more.
52:09Sorry,
52:09no locks own decreases mortality
52:12by 20 to 30%
52:14in these high risk populations.
52:1520 Send people home that
52:17we've given over 10,000 doses.
52:19Of Narcan to hospitals and.
52:22And that's the patients over the last year.
52:25We have a tool kit and we have
52:27videos that are that kind of help
52:29educate clinicians and and educate
52:31patients both in English and Spanish,
52:34and I only tell you about this
52:36because if you want to start a Narcan
52:39or naloxone distribution program,
52:41please use our resources.
52:42You don't have to start from scratch
52:44and we're happy to further develop it.
52:46And last thing I'm going to plug is with
52:49the support of the Scanguard Foundation.
52:51We have a.
52:53Video series that we've also created that
52:58discusses opioid policy around overdose,
53:02especially,
53:02and in the next actually three months.
53:06We're doing a series that does the
53:08same thing that this lecture has done,
53:10which is we discuss harm reduction
53:12and how to actually implement
53:14harm reduction for patients.
53:16So I have the YouTube link there.
53:18Or if you search in the YouTube,
53:19you search the antidote and even
53:21the locks own opioid crisis,
53:23you should be able to find and
53:25subscribe to our YouTube series.
53:27So hope to see a few of you
53:30subscribed and and tuning into that.
53:32Finally,
53:33I want to thank thank yell emergency,
53:36sorry yell at yell for the
53:38opportunity to present with you guys.
53:40I'll go ahead and end so that
53:42we can get to a Q&A.
53:46Thank you Doctor Stader and Doctor Khupe.
53:49We've got a number of questions in the
53:52quest Q&A and in the the chat and I'll.
53:56I'm happy to curate them for you.
53:58The first one was from Lynn Kelly and
54:00I think this was to doctor Khupe.
54:02When you mentioned stigma
54:04as a barrier barrier,
54:06are you referring to the community at large,
54:09the provider community or
54:11individuals with opioid use disorder?
54:13So I think this is the issue
54:15around stigma and the use of
54:19medications like buprenorphine.
54:21Yeah, that's a that's a great question.
54:23I think that particularly a stigma becomes a,
54:26you know, an enormous issue.
54:28Just as Doctor Stayter discussed,
54:30I think that we have stigma,
54:33internalized stigma or self stigma
54:35that many people may call it and that
54:38is the stigma that is self directed.
54:42For people who,
54:43with opioid use disorder and then
54:46there's stigma that may exist between
54:48individuals who both have opioid use
54:51disorder and then obviously there's
54:52stigma at the larger community.
54:54And then there's also stigma
54:56that may exist amongst providers,
54:59and so I think that it exists on many levels.
55:03When I was touching up on it,
55:06I was really touching upon it really
55:09within individuals who with opioid use
55:12disorder as well as amongst providers.
55:15But I think they all have the same effects
55:18in terms of serving as a barrier to
55:20really delivering the best care possible,
55:22particularly in terms of in terms of.
55:28Allowing individuals to receive treatment
55:31and stigma can exist as a barrier
55:35for people to feel like they they
55:37treatment would be beneficial for them.
55:39So yeah,
55:40that's kind of what I was touching upon.
55:44But yeah,
55:44it exists really in many angles.
55:48I agree, thank you Eddie or Doctor Coupe.
55:52The second question,
55:53I think again to you was how many
55:57days of medication or buprenorphine
55:59are you are dispensed at the Ed?
56:01In other words, how long does someone have
56:04to connect with the treatment provider?
56:06Any recommendations from the
56:08guidelines and the protocols and
56:10the practices that you've observed?
56:13Yeah, usually if ideally you'd like an
56:17agreement between the emergency department as
56:21well as a an outpatient addiction provider.
56:26If you have an agreement established and
56:29agreement established to where you will
56:31refer your patients 2, then three to
56:33four days typically is the the standard.
56:36However, if that takes longer,
56:38you know definitely have been instances
56:40where it's been up to seven days where
56:42you may prescribe you pain or fear.
56:44So the real answer is,
56:46as long as it takes to get a
56:49patient into treatment. So
56:53great, thank you, that's very helpful.
56:56Doctor Stayter, let's see.
56:57I think there was a question
56:59that you answered in the chat,
57:01but others may be curious.
57:04Have you created patient facing,
57:07safer injection materials that
57:09you share with patients who come
57:11into the emergency department?
57:16Yes, so it's part of our education.
57:18Our education efforts as we went
57:20to not only discuss drug use with
57:22patients when they're in front of us,
57:24but we want to be able to provide them
57:26information that that they can take home,
57:28share with others,
57:29share with family members and we do
57:31have a patient information materials
57:33that we've developed for previous
57:35project called Yarnall Locks on that
57:37that that has patient handouts for both
57:40injection drug use and then also for
57:42chronic pain patients because those
57:44two patients also see themselves very,
57:46very differently.
57:47When it comes to their risk of overdose
57:50and and we have to have different
57:52messaging for these different patient
57:54populations for it to be most effective.
57:56So I just shared one of those.
57:58We also have this on Noxon
58:00project.com we have.
58:02We have other patient discharge materials.
58:04Here are no locks.
58:05Own has discharge materials.
58:06I also want to address a comment
58:09rough by by Mr or doctor Robert
58:13Heimer which talks about HIV
58:16and hepatitis transmissibility.
58:18Yes, give you warning.
58:19I'll give you a warning there.
58:20He's he's done. A lot of this
58:23work himself so great yeah,
58:24and and I'm looking forward to reading
58:26those I I do say that during these
58:29presentations rather than ranting people
58:31through through kind of the nitty gritty
58:33of of every transmission rate etc.
58:36As I speak in generalities because the
58:38point that I want to make is that we
58:40should be discussing this with patients
58:42at the bedside every single time.
58:44Even if the numbers might be
58:45might be slightly erroneous,
58:46but the concepts there are very, very true.
58:49That HIV is less transmissible than hepatitis
58:52C when it comes to 2 Ivy drug users,
58:54so that's really the point
58:55that I wanted to make,
58:56but thank you for for correcting that.
58:58I look forward to diving into those.
59:00Those resources you shared.
59:02We're indebted to Doctor
59:03Heimer and some of his early,
59:05early early work that he did to
59:09demonstrate the value of syringe service
59:11programs in decreasing HIV transmission,
59:14and this is work done in the
59:16early 90s and late 80s.
59:19And then there's another question in the
59:22chat, and this is open to both of you.
59:24Are you using peer support services
59:26in your emergency department,
59:28and if So what is their
59:30role in these processes?
59:38I'll go ahead and go first is yes,
59:39we have a recovery support specialist
59:41that we have in our mental department.
59:44We we've had one for going on a year and
59:46a half now we use them for all types
59:48of substance use disorders we have
59:51have worked very hard to make sure.
59:53Also and this is a mistake that
59:55I think sometimes is.
59:56I've had a few other colleagues
59:58report back to me.
59:59Which is you have to have a peer
01:00:01recovery specialist who is supportive
01:00:03of medical treatment because.
01:00:05We have heard stories of people
01:00:07who are abstinence only and
01:00:09have been invited into ERS,
01:00:11and then the advice that they're
01:00:12giving a patient might be absolutely
01:00:14contrary to the recommendations
01:00:15of the clinician who says, oh,
01:00:17we should put you on people in
01:00:18our feeder method up so we have a
01:00:20recovery support specialist who is
01:00:22very much in support of treatment
01:00:24for for opioid use disorders and
01:00:27then who follows up with patients and
01:00:29helps form a relationship with them
01:00:31and introduce them into a community
01:00:34of people who are in recovery.
01:00:35And helps change the fishbowl that
01:00:38the patient is hopefully living
01:00:40in and and helps really provide
01:00:42role modeling for for recovery.
01:00:44So the recovery specialist has been
01:00:47a great addition to what we do and
01:00:50really works as part of a multi multi
01:00:53in disciplinary team to provide these
01:00:55patients with the best care that
01:00:57we can and then give this reports
01:00:58back which is also very reinforcing
01:01:00which is our clinicians actually
01:01:02here hey you know James that you
01:01:04referred to me two months ago.
01:01:06He is not used for a month and he's
01:01:08actually really participating in our program,
01:01:10so so our clinicians actually get
01:01:12sometimes feedback that otherwise
01:01:14they would never have gotten.
01:01:17I think that's a really important point.
01:01:19You know, having worked with Doctor Khupe
01:01:21and Doctor D'onofrio and Doctor Hawk on,
01:01:24you know getting emergency departments up
01:01:26and running with prescribing buprenorphine.
01:01:29I think. You know the the challenge in
01:01:33the acute medical setting is that we
01:01:35never or rarely see folks who are doing
01:01:38well after they've initiated treatment,
01:01:41and that's even augmented in settings
01:01:44like the emergency department,
01:01:46and so getting that feedback.
01:01:48Getting to meet patient, you know,
01:01:51in a different frame in a different state.
01:01:55Is really important in getting the
01:01:57feedback that Oh yes, by the way,
01:01:59that person that you referred to me,
01:02:00you know 2 two months down the
01:02:02line they're doing much better.
01:02:03They're back with their family.
01:02:05I've always thought you know we
01:02:07do a lot of cancer survivors,
01:02:10you know events at hospitals,
01:02:12we should probably do some opioid
01:02:14overdose survivor events so that
01:02:15people can can see what how lives are
01:02:17so dramatically changed with the care
01:02:18that that you guys are talking about.
01:02:22Uhm? Question from Mary Ellen Lyon.
01:02:26Are there particular ideas for addressing
01:02:29the differentiating patient willingness
01:02:31uptake of buprenorphine according to gender,
01:02:34race, etc.
01:02:35I'm stuck by the disparity
01:02:37disparity mentioned,
01:02:38such as higher rates of intervention
01:02:40for white males and wondering how
01:02:42it might be addressed beyond our
01:02:43willing own willingness to initiate.
01:02:47Yeah, that's a that's a great question.
01:02:49I think that that that's an area really
01:02:51ripe for research moving forward,
01:02:53but I think that you know this
01:02:56kind of exists at multiple levels.
01:02:58There's some evidence to show that
01:03:00within minority communities they're
01:03:03really dearth of buprenorphine
01:03:06treatment providers as a whole,
01:03:08and that within communities within
01:03:11minority communities, there's also.
01:03:13They're also more likely to receive
01:03:16methadone RV offered methadone.
01:03:18For treatment,
01:03:18and so I think that's you know I we
01:03:21like to move towards this standard
01:03:24where everyone has access to the
01:03:26treatment that works best for them.
01:03:29I think also along those same lines,
01:03:31there's when we touched upon stigma.
01:03:33There's this idea of double stigma
01:03:36that minority groups as a whole may
01:03:40face in terms of also dealing with
01:03:42the stigma surrounding addiction,
01:03:44as well as being a minority
01:03:47with with with addiction,
01:03:49and so these are many areas that
01:03:51are really ripe for interventions,
01:03:53and I think that you know,
01:03:54we can look as large as like
01:03:57the Community approach in terms
01:03:58of access to buprenorphine.
01:04:00Or even a small is addressed at the
01:04:03individual approach in terms of
01:04:05addressing like stigma and stigma within
01:04:08individuals and within provider to
01:04:10individuals with opioid use disorder.
01:04:12So yeah,
01:04:13I think that's an area that we really
01:04:16need to look at moving forward.
01:04:18So great question though.
01:04:20Yeah,
01:04:20that's a great great point.
01:04:21Dr Coupe and appreciate your
01:04:23discussion of sort of intersectional
01:04:25stigma and how that can impact the
01:04:28individual experience and just to.
01:04:29Just a brief reminder that our next
01:04:32talk on December 14th will be from
01:04:34Gary Mandel and address some of the
01:04:36work that shatterproof and others
01:04:38are doing on this issue of of stigma.
01:04:42Uhm? And Linda says thank you.
01:04:45She's in the process of establishing
01:04:47a milax own peer support program
01:04:49in her rural Arizona hospital.
01:04:52So you've provided guidance.
01:04:53I you know, I will say,
01:04:55I'm I'm struck by the success of
01:04:57the Colorado naloxone project.
01:04:59I'm envious.
01:05:00I think we could keep the same acronym
01:05:02and just move it to Connecticut.
01:05:04It'll be the Connecticut null Oxone project.
01:05:08And you know,
01:05:09it's a little bit frustrating to think
01:05:12that I may need to get the legislature to,
01:05:16you know, embark on legislation.
01:05:18Visa V.
01:05:19The the payers.
01:05:20But I that's just more of a
01:05:23point of ignorance for me.
01:05:25I'd have to see whether or not
01:05:26that would be a requirement here,
01:05:27you know so, so there's two ways to do it.
01:05:30Is there's actually an extremely
01:05:32successful in Milwaukee and distribution
01:05:34program that's run out of of California.
01:05:36That's 100% grant based.
01:05:38Which is there's grant purchase
01:05:40Milax own that's dispensed to
01:05:42hospitals and then hospitals.
01:05:44Give it out to patients.
01:05:46And and I think that's right
01:05:48now where we're at is actually
01:05:49a hybrid model where we have.
01:05:53500,000 of donated of of funding.
01:05:56The locks own through the
01:05:57state that we're giving out,
01:05:58but my own bias is that if we want
01:06:01this to be durable and we want this
01:06:03to just be part of medical care,
01:06:06then you got to make it part of medical care.
01:06:08And that means that payers gotta pay for
01:06:11a proven intervention that saves lives.
01:06:14And that's cost effective.
01:06:15And that's been a big push that
01:06:18we've had here in Colorado.
01:06:19We just passed a resolution this year.
01:06:23Between myself and several other
01:06:25colleagues for the American
01:06:26College of Emergency Physicians,
01:06:28and that's going to be something
01:06:30that we're pushing forward.
01:06:31You know, as a as a potential
01:06:34federal legislative effort as well.
01:06:35And I think the more places that that
01:06:38kind of start saying, hey, we this is.
01:06:40This is now.
01:06:41The evidence shows this defective.
01:06:43We should be demanding it,
01:06:44and then we should look at all
01:06:46these regulatory changes that
01:06:48we have to make to to actually
01:06:50implement it and operationalize it.
01:06:53Doctor Heimer also, please email me.
01:06:55I would love to chat with you and learn so,
01:06:58so please.
01:07:00Yeah yeah it's connected to us
01:07:02and Don, I can't under score
01:07:05the the message that you gave.
01:07:08With respect to null Oxone,
01:07:10it's been demonstrated among people who
01:07:14are receiving medications for opioid
01:07:16use disorder and among opioid overdose
01:07:19survivors in the emergency department.
01:07:21If you only write a script,
01:07:24then only up to 10 to 20% of those
01:07:27prescriptions will be filled for naloxone.
01:07:30If you place it in their hand,
01:07:32they will have it when they leave,
01:07:34and so it's it.
01:07:37I applaud as you did.
01:07:39People who are writing prescriptions,
01:07:41but recognize that we're in a state
01:07:43where we need to be able to provide
01:07:45it in their hands to really make a
01:07:47difference at the at the bedside or
01:07:49on the curbside in other places so.
01:07:53Now we have several programs that also have
01:07:55a mess with leave behind the locks own,
01:07:58so they respond to us to an overdose,
01:08:00or they respond to a site where people
01:08:03other people are actively using.
01:08:05We actually have some places that we leave
01:08:08behind several blocks on kits for them.
01:08:10Really, we wouldn't get in the locks
01:08:12own in the hands of the true first
01:08:14responders from most overdoses,
01:08:16which is other people who are using
01:08:18drugs or who are rattler who love and who
01:08:20are around people who are using drugs?
01:08:22And if we do that, we can.
01:08:24We can save alot alot.
01:08:27We have another question in the in
01:08:29the chat from one of our addiction
01:08:31medicine fellows it says has there
01:08:33been a movement in the Ed to initiate
01:08:35methadone for opioid use disorder
01:08:37and when able to immediately connect
01:08:40to an OTP and use what's called
01:08:42the three day or the 72 rule.
01:08:44Our rule to provide methadone and
01:08:46they in the emergency department.
01:08:48So thoughts on that.
01:08:53So I do know a little bit about this,
01:08:55so we do have some clinicians
01:08:58with a deep expertise.
01:08:59They're both Lee addiction and and
01:09:01Ed train to are starting to do this,
01:09:04so there's Rachel,
01:09:05whereas up in New Jersey,
01:09:06there's Eric Ketchum who's out in out in
01:09:10New Mexico who actually are doing this,
01:09:13and trying to also create the regulatory
01:09:15space to do this because we all know
01:09:19how strictly regulated methadone is,
01:09:21and that scares a lot of people away.
01:09:23Methadone we still use sometimes
01:09:25for opiate withdrawal and people who
01:09:28don't who basically, you know, refuse.
01:09:30Buprenorphine will sometimes give them
01:09:32a shot of methadone and that's my at
01:09:34least my practice but but I think
01:09:37that in general beyond exceptions,
01:09:40you know there's very few exceptions.
01:09:41Most easy docs aren't touching method out,
01:09:45but I think that that we all know
01:09:47that methadone works for a large
01:09:49number of these patients and and
01:09:51and is another tool that.
01:09:53I hope we can build as we build
01:09:55this knowledge base and treatment
01:09:57infrastructure into the future.
01:09:59So so you know,
01:10:00I think that it's a really,
01:10:02really great question that you asked
01:10:05Doctor Cohen and and I hope that we
01:10:07actually build this so that we can
01:10:10start utilizing that tool as well.
01:10:12I mean, as as someone who who does that,
01:10:15I think that you should be able to
01:10:17start people on IM metrics on all naltrexone.
01:10:20I think that we should be using methadone.
01:10:22I think that we should be.
01:10:23Using buprenorphine,
01:10:24buprenorphine remains the most
01:10:26appealing lowest barrier.
01:10:28Safest that we should use first,
01:10:30but I don't want any of those off the,
01:10:33you know off the menu for patients
01:10:35who who are good candidates for them,
01:10:37and I think that it really does come
01:10:39to us to kind of build that research
01:10:41and that knowledge infrastructure and
01:10:43really try to implement those if we
01:10:44if we hope to build a treatment system
01:10:46that actually works in this country
01:10:48and provides patients what we need,
01:10:50what they need.
01:10:52Yeah, we always.
01:10:53We often refer to the no no
01:10:55wrong door policy and that that's
01:10:56that's the goal of our program,
01:10:58is to make General Medical
01:11:00settings as responsive and that
01:11:02there is no no wrong door.
01:11:04Just a brief clarification on the 72
01:11:07hour rule for those who are unaware,
01:11:09it allows for clinicians with DEA
01:11:13registrations or settings to dispense.
01:11:16Not prescribed,
01:11:17but dispense methadone over a 72 hour period.
01:11:22As long as the intent is to get
01:11:24a patient into a more definitive
01:11:26treatment and the the key there is
01:11:29that the patient has to come back,
01:11:31for instance to the emergency
01:11:33department or to the hospital,
01:11:35or to the clinicians.
01:11:36Practice each day and have
01:11:37that medication dispensed,
01:11:39not quoting prescribed and filled it,
01:11:41a pharmacy.
01:11:42Just a clarification so
01:11:43that folks are aware
01:11:45and just for the emergency
01:11:47department folks in general we did.
01:11:50There was a law that was passed.
01:11:52I think it was now a year ago.
01:11:54That says that that's a small
01:11:56small amendment to the three day
01:11:58rule that says that we should be
01:12:00able to prescribe or dispense.
01:12:01Poop in orpheon 2 patients who
01:12:03can then take it home and not
01:12:05have to return to their marriage
01:12:07department for repeat visits that
01:12:09has not been the regulations for
01:12:11that have not been finalized,
01:12:13so we're still waiting in the regulatory
01:12:15realm for that to be finalized so
01:12:18that it can actually be implemented.
01:12:20But we did actually advocate for
01:12:22and pass a law and I can dig that
01:12:24out at somewhere in my very deep in
01:12:27my emails from a year or two ago,
01:12:29but that we should be able to
01:12:30actually send people home.
01:12:32With those medications or supplies
01:12:34and not have to inconvenience them
01:12:37with returning to a COVID infested ER.
01:12:40For three days in a row.
01:12:44And then a final comment?
01:12:45Terra Kerner says at home,
01:12:47or what we call an observed
01:12:50inductions or so important,
01:12:51and she hopes that Eadies will soon do that.
01:12:56And I will say that that
01:12:57is standard practice,
01:12:58at least in our emergency department,
01:13:01that, if patient is not insufficient
01:13:04withdrawal to receive their first dose
01:13:08of buprenorphine in the emergency.
01:13:10Apartment, then the since everybody well,
01:13:14they prescribed the doses and
01:13:15are provided instructions so
01:13:17that they can do and observed,
01:13:18or at home inductions.
01:13:21To that, can I comment on that is that
01:13:23is so important and it is something that
01:13:26you need that we're building toward
01:13:27in a lot of places because you know,
01:13:30I think we're getting some of
01:13:31those early adopters and asking.
01:13:33OK, will do Ed induction,
01:13:34but then they miss the opportunity for
01:13:36the person who's not actively withdrawn,
01:13:38and moreover, fentanyl is changing the
01:13:40game when it comes to how long you have
01:13:42to wait for some of these inductions.
01:13:44Then we have seen multiple cases of
01:13:47precipitated withdrawal that I'm much
01:13:48worse because fentanyl is so lipophilic
01:13:50and sticks around so much more.
01:13:52So, so the fact that we now have,
01:13:55you know, we should be developing tools,
01:13:57we have a patient says I use fentanyl 12
01:13:59hours ago and they're in mild withdrawal.
01:14:01I went into an induction for that patient.
01:14:03I would.
01:14:03I would give him more time and I try
01:14:06to get them to be at least 24 or 3648
01:14:09hours after last use and they can either
01:14:11come back to see me or we can give
01:14:13them a home induction but but that is
01:14:16oftentimes really missed opportunity
01:14:17that we have to to induct patients
01:14:20and and initiate them on treatment.
01:14:23So,
01:14:23so I'm very glad for your comment.
01:14:25It's right on the right on the ball.
01:14:30Doctor Schnoll says the increase in
01:14:33prescribing buprenorphine in the Ed is great,
01:14:35and maybe this is to you Eddie,
01:14:37but fewer than 50% of waivered
01:14:39clinicians have written a prescription.
01:14:42Question how do we change that?
01:14:45Yeah, I think 11 I guess.
01:14:49Easy target I think is increasing
01:14:52education and training amongst clinicians.
01:14:55I think that we found that as clinicians
01:14:58we brought the training to them and made
01:15:00it as easy and accessible as possible.
01:15:03Physicians were and clinicians as a
01:15:05whole were aware that many clinicians
01:15:07still not aware that this is an option,
01:15:09and so I think as we make that as
01:15:11easy and accessible as possible,
01:15:13I think we we will see.
01:15:15Increase in in prescribing of
01:15:17buprenorphine and I think that
01:15:19also goes along the lines of.
01:15:22Educating about opioid use disorder
01:15:24and and and kind of teaching.
01:15:26That addiction is a disease
01:15:28and not a moral failing.
01:15:29I think these two kind of go hand in hand,
01:15:31but I think as we see that happen I
01:15:33think we will see I'm I'm hopeful
01:15:35and optimistic that we will see
01:15:37an increase in prescribing.
01:15:40I think the other thing that that's probably.
01:15:44You know, hidden in this discussion,
01:15:45and I think you both alluded to it
01:15:48as having these ready connections.
01:15:49I, I think a number of physicians say
01:15:53I'm happy to start the medication,
01:15:55but I need to know that there's some
01:15:57place that this patient is is going to be
01:15:59able to go, be it an aftercare clinic,
01:16:01be it an OTP that has, you know,
01:16:05the ability to see patients on the
01:16:07same day that those resources is very,
01:16:10very widely around communities
01:16:12across the country and.
01:16:14You know some some.
01:16:16Locations have you know very readily
01:16:19accessible low barrier programs,
01:16:21but there are many parts of the country
01:16:23where those programs just aren't available,
01:16:25and so thinking about creating not
01:16:29not over creating but creating to some
01:16:32extent that infrastructure so that you
01:16:35know folks can have some place to follow up.
01:16:37But the reason I say don't over create
01:16:39is 'cause you don't want the perfect
01:16:40to be the enemy of the good, right?
01:16:42So you don't want everything has to be in
01:16:44place before we even think about doing this.
01:16:46But you do need to think
01:16:48about what the follow up is.
01:16:49And in the Ed is just sort of 1 slice in
01:16:52in care in the trajectory of the patient.
01:16:56One thing that I've seen,
01:16:57which has been actually very cool and
01:16:59in this community is there's actually
01:17:01been several examples of ER docs who
01:17:03who have looked around and said, well,
01:17:05we don't have anyone to refer to,
01:17:07and they've actually started addiction
01:17:09clinic, which is just a just a huge.
01:17:13A huge tribute to to those docs who've
01:17:15seen that community need who have
01:17:16looked for someone else to do it.
01:17:18And then when they didn't have anyone
01:17:20step forward, they said, well,
01:17:21well, if no one is going to do it,
01:17:23I'll I'll go ahead and do it because
01:17:25these patients need care somewhere.
01:17:26So Reuben Strayer is an example of that.
01:17:28Up in New York,
01:17:29there's there's many other ER docs
01:17:31who who have done the same thing
01:17:32and it's led me to when I give
01:17:34lectures to people who are in rural
01:17:36places and I say and it won't do.
01:17:38Don't you have a program that said,
01:17:40well, no one will prescribe
01:17:41people norfin after let's say wow?
01:17:43Look yourself in the mirror.
01:17:45Are you willing to have a
01:17:46clinic once a month?
01:17:48And and we're actually doing
01:17:49something very similar to this.
01:17:51I work in, you know,
01:17:52a big county ER,
01:17:53but I've started buprenorphine programs
01:17:55in two rural hospitals as well,
01:17:58and we're starting just a one day
01:17:59a week addiction clinic because
01:18:01there's no one else to prescribe.
01:18:03So so really.
01:18:04We have to.
01:18:05We have to be much more proactive
01:18:06if we want to create this treatment
01:18:08infrastructure and it's not hard to do.
01:18:10People know if you need an
01:18:12extremely easy drug.
01:18:13So if I think that that
01:18:15were probably doesn't exist,
01:18:16you have to demand that at it does and
01:18:18figure out some schmuck who's going to say.
01:18:20Sure,
01:18:20I'll I'll do it.
01:18:23Well and and I often say it's the
01:18:25most rewarding thing I do in in
01:18:26primary care and in general medicine.
01:18:28So it's it's very reinforcing and I
01:18:32appreciate the opportunity to do that
01:18:33and to work with colleagues like my
01:18:35colleagues in the emergency department.
01:18:39So with that, I think we'll wrap things up.
01:18:43I want to thank again,
01:18:44the Sandgaard Foundation I wanna thank you.
01:18:47Doctor Coupet and thank you
01:18:50doctor Stader reminder.
01:18:51We'll be back on December 14th with
01:18:55Gary Mendell, who's the CEO and
01:18:57founder of the Shatterproof Foundation,
01:18:59and he'll address the issue of stigma,
01:19:01and I think our last slide just reminds folks
01:19:04of about how they can stay in touch with us.
01:19:06If you have questions, we're happy
01:19:08to connect with you afterwards, so.
01:19:10Thank you very much and have a great day.
01:19:15Thank you bye bye.
01:19:16Thank you.
01:19:19Thank you. Take care.