Well, greetings, everyone. Tony Decker here again, and we're going to be discussing special populations in the field of addiction medicine. I'm currently the chief medical officer for the Division of Developmental Disabilities for the state of Arizona. I left after 37 years with the federal government, most recently with the Gallup Indian Medical Center in 2021. Prior to that, I was with the Veterans Administration for five years. Prior to that, the Department of Defense for five years at the Fort Belvoir, now known as Fort Alexander. Prior to that, the Indian Health Service at the Phoenix Indian Medical Center. Previously, I've been the professor and chair of family medicine in Kansas City at the Osteopathic College and on faculty at several universities in the D.C. area, Chicago, Kansas City, and in Phoenix. I graduated from Michigan State College of Osteopathic Medicine in 78, did a family med residency, a adolescent young adult medicine fellowship, and served as a public health servant on Chicago's South Side for 14 years before I moved on to Kansas City and subsequently to Arizona. I have no conflicts of interest to report, no relationships with pharmaceuticals or prohibited donors. I am the past president of the American Osteopathic Academy of Addiction Medicine, which is the sponsor for this course. And although I've been employed by the U.S. Public Health Service, Job Corps, Indian Health, Department of Defense, and the Veterans Administration and the state of Arizona, I don't represent any federal or state organizations. Our objectives for this presentation includes listing the differences in diagnostic and therapeutic issues for addiction care in special populations, recognize special considerations and screening for increased risk issues in special POPs, and implement interventions that enhance recovery in those special populations. So understanding special POPs is important to understand that we're going to use the word culture, and that's the sum total of the shared values, attitudes, beliefs, customs, technologies, environment, and life way that distinguishes a people with a common identity. It may also change over time in the community, and it may change temporally over time in the individual. The different populations that we'll be addressing in this presentation include veterans and military, active duty military staff and their dependents, college students and young adults, the LGBTQ population, the non-binary population, the elderly, those with mental illness, comorbidities, and that is being addressed in another presentation for psychiatric comorbidities, but some special needs that go along with those who are mentally ill and have a co-occurring disorder of substance use disorder, homeless people and people in unstable housing, Aboriginal and Indigenous peoples, physicians and other healthcare providers and professionals, natural and man-made disasters, and we've all just included the post-COVID-19 public health emergency, and then adolescents, women, incarcerated, and psychiatric populations in other sections. So adolescent medicine addictions, special issues in regard to women, incarcerated, and psychiatric populations are in other sections of the board review course. When we look at the military and veteran populations, we realize that there is a military culture, and I was a civilian for five years in the CAPMED section of the greater Washington, D.C. area as the director of addiction medicine for Fort Belvoir, but the military culture is one that honors those who are lost and many times includes a toast. Now, that toast is typically an alcohol toast. One of the things I noticed when I was working at Fort Belvoir is that the PX had three aisles of beer, wine, alcohol, an aisle of baby stuff, and an aisle of snacks, and one of the things that was problematic is that you could buy a fifth or a 750 ml bottle of vodka for $6 because the PX has things that are less expensive. It is an alcohol-based organization. When you look at active duty service members and veterans, the most likely reason they will seek medical care is a pain complaint, whereas in the general population, that is number two or number three in the civilian population. This goes back all the way to the Continental Navy and Continental Army. At the time, Benjamin Rush, who was the only physician that signed the Declaration of Independence, was the Surgeon General of the Continental Navy, and he made a statement that angered one of the suppliers of grog, which was distilled spirits such as whiskey mixed with fruit juices, and it was called grog. If you go to the Annapolis Naval Academy to this day, you can still buy a 16-ounce porcelain-covered cup that has the grog distribution of which they would receive one or two cups, either one in the morning or one in the morning and one in the evening, as part of their pay in the Continental Navy. Benjamin Rush said there's about 10 percent of men who should not get grog, and he said they seem to have a problem controlling their consumption of alcohol, and they would buy grog from other individuals, and they would end up doing things that typically would get them and other people into trouble, such as fighting and things like that. George Washington, who ran the grist mill across the street from Fort Belvoir proper, which was part of the Fairfax site, he also had the Mount Vernon farm, which included the grist mill, which was the distillery and was the main provider of whiskey to the Continental Navy. Remembrances typically include a toast. Anniversaries, especially anniversaries of losses or anniversaries of events, especially battles, is a toast. And when we looked at our 3,000 active duty service members that we treated at the Fort Belvoir facility, military sexual trauma was the common denominator, and 95 percent of our female active duty service members received treatment, inpatient treatment for substance use disorder, and about 50 percent of our male active duty service member population. Keep in mind that there are many more men in the military than females, but the abuse rates for military sexual trauma was much higher in the female population. When we look at military sexual trauma, the numbers have been significant in 2012. There were 26,000 that were identified. The number dropped in 2014 and dropped again in 2016. In 2014, the RAM Corporation completed a study and that there was a decrease in the percentage of active duty service members who experienced unwanted sexual contact from 6.1 percent in 2012 to 4.3 percent in 2014. This was with significant efforts by military behavioral health and sexual conduct behavior training for all active duty members. Approximately 72 percent of those who reported their assault said that they would make the same decision if they had to do it again. So, instead of a blame situation, and there have been numerous scenarios and investigations, Coast Guard being one of the more recent ones that was investigated, there has been a significant improvement in prevention, early identification, and interdiction for sexually inappropriate contact. Now, these include barriers to reporting. That's a problem. Failure to hold perpetrators accountable and retaliation against the victims. So, nearly all the women that were treated in the Fort Belvoir Addictions Program were victims of military sexual trauma, as mentioned before. Working with a VA phone number, there is a 877-222-VETS number, which is a hotline for veterans with a history of military sexual trauma or for active duty service members. When we look at the military and veteran population, this is the tattoo of one of the veterans I took care of, and the use of opioid analgesics was actually quite common during the Operation Enduring Freedom, which was Afghanistan, and Operation Iraqi Freedom, which was Iraq. Reconsiderations of opioid use for chronic pain syndrome was strongly emphasized by the military, and in 2022 and 2023, revamping the entire process of intervention for active duty service members with chronic opioids, and the CDC came out with 2016, 2019, and 2022 guidelines for opioid prescribing. One of the things that was very significant is that typically the two Iraq and Afghanistan conflicts, the number of people who had TBI, mild TBI, amputations, and improvised explosive device exposure. These would be essentially bombs and traps that would cause vehicle implosions, explosions, and having a better understanding of how that blast wave goes through a person, and even around blast walls. So mild TBI is typically seen in people who have recurrent headaches. They got knocked down when a pressure wave hit them, but they got right back up again, and continued with their mission for that day. When I asked active duty service members, so the Marines and the 11 Bravos on the combat teams, how many times were you knocked down by a blast? And they say, you mean per day? And so it was a common occurrence many times, several times a day during combat experience. Agonist therapies were used. In other words, mu-receptor agonist therapies were used, and I received many members who were on high-dose opioid therapy, getting people who were on 1,200, 1,500 milligrams of oxycodone a day, which is way beyond a therapeutic range for oxycodone. So the naloxone injector availability was ubiquitous. We had to make sure that others knew how to rescue their partners. And non-pharmacologic therapies, non-opioid pharmacologic therapies, and body work, physical therapy, occupational therapy, and a variety of other interventions were utilized. Moving on to college students and young adults, four out of five college students, about 81%, consume alcohol. Sixty-eight percent have been drunk at least once in their lives, meaning intoxication above 0.08. And approximately 18% to 21% of college students meet the criteria for an alcohol use disorder with somewhere between 8% and 13% as abuse, and 7% to 13% as dependence. Now, it's interesting that leaving that college high-risk environment results in about a 50% drop in significant use. Now, when you look at the studies that are done on college students, 38% admit to being drunk in the past month, 31% have engaged in heavy episodic drinking in the past two weeks. So we do have a cohort of college students that have frequent episodes of intoxication. And like I said, we're talking five standard drinks, 14 grams of ethanol per drink for males and four standard drinks for females to achieve an intoxication level of 0.08% or higher. There's the use of high levels of alcohol is complicated now with the use of legal marijuana. And so you can have impairment at lower levels. And keep in mind that psychomotor speed is impaired with just one serving of alcohol. When they start looking at the college student population, 3% admit to daily drinking, 43% of students diagnosed with an alcohol use disorder during early college continue to meet the criteria after college. Vaping, especially vaping with non-nicotine, in other words, THC, opioids, benzodiazepines, and the use of fentanyl, which typically is smoked because it comes in tablet form, have become significant factors and also the reason for overdoses in the young adult in college setting. Those who sporadically and frequent, sporadically, but frequently binge drink are four to 10 times more likely to report having damaged property than those who do not binge drink. And it's estimated that 50 to 80% of the violence, including sexual violence, that occurs on campuses is alcohol related. 41% of college students who report the use of an illicit drug in the past year, 38% of students report marijuana, 19% have used another illicit drug other than marijuana, typically a stimulants, methamphetamine, street-derived Adderall, and or opioids. The use of over-the-counter caffeinated drinks are common and that seems to blunt the sedative effects of alcohol. Alcohol is also a very interesting substance because up to 0.8%, it's a sedative hypnotic. But as you go higher than that and you start to get to twice the legal limits of intoxication, in other words, 0.16 or 0.24, three times limit, it can be toxic and activating, causing people to become more violent and uncontrolled as they experience a rise in their alcohol serum levels. Moving on to the non-binary LGBTQ population, and we'll spend a little time in this area because it is a population that is at higher risk. They have significant challenges in regard to access to healthcare and access to health insurance many times because although marriage is a possibility, most people who are engaged in homosexual or lesbian contact are not married. Physical health and well-being is an issue and many times requesting services can be challenging if the primary care provider is hesitant to provide full service care. Mental health issues and mental well-being is a challenge and screening for depression, suicidal ideation, self-abusive behavior are all important. Tobacco, alcohol, and other substances of abuse are more frequently encountered in the LGBTQ population. Not to mean that every person has an issue, but it does mean that it's a common denominator, especially if there's a higher rate of switching partners or changing partners, putting them in a higher risk category from the standpoint of where they socialize. LGBTQ individuals are less likely than heterosexual, cisgender is a term that we use for heterosexuals, to have health insurance. In other words, they're less likely to have health insurance. The LGBTQ individuals are more likely to delay or not seek medical care. They're also more likely to be victims of physical or sexual violence. They're less likely to fill a prescription for medical care. This may be related to financial status and also the LGBTQ individuals are more likely to receive healthcare services in an emergency room rather than with a primary care provider. Looking at that same population, adults are twice as likely to experience psychological distress, which may go back to childhood traumas, and adverse childhood events have higher scores, looking at the FLETI and ANDA studies in regard to the LGBTQ population versus the cisgender population. LGBTQ adults are twice as likely to need medication for emotional health. The youth are more than three times as likely to attempt suicide compared to their heterosexual or cisgendered peers. The LGBTQ adults are more than twice as likely to consider suicide than the cisgender adults. Transgender adults have as much as 20 times greater likelihood to consider suicide. The situation's actually gotten worse for our transgender population with high-profile political issues that have identified and have essentially pushed the needle in the wrong direction of isolation, refusal to receive services, and fear of intimidation and injury. When we look at substance use, LGBTQ adults are more likely than the heterosexual cisgendered adults to have problems with alcoholism and binge drinking. The youth and adults are more likely to smoke cigarettes and vape than their heterosexual peers, and in general, smoking rates are almost double amongst the LGBTQ population. And that use of tobacco products extends into the adult and in later years. And so pulmonary, breast cancer, low birth weight, and go down the list of all the things associated with chronic tobacco use are more likely in the LGBTQ population. We started looking at biological sex. It's typically based on physical characteristics, including both internal and external reproductive systems for the individual and obviously the chromosomes and genetic presentation. About 1 in 100 to 1 in 200 result in a child whose body differs from the standard male or female. The term ambiguous genitalia, which is a very derogatory term, was usually used for this population. About 1 to 2 per 1,000 have had surgery to, quote, normalize the appearance of their genitalia. There's been great debate about this because the sexual assignment for an XY ambiguous genitalia infant could be assigned to phenotypically female but genotypically male. And the individual has no choice in the matter because the decision was made in infancy. About 1 out of every 1,700 births is a child whose genetic makeup is neither XX or XY. And that could be Turner's, Down syndrome, Klinefelter's, a whole variety of genetic disorders that create challenges in regard to sexual expression. Many intersex people prefer the term assigned sex at birth because it recognizes that sex is assigned by others. And so they may say, I was assigned to be a male at birth. But they see themselves as intersex or non-binary. When we look at sexual orientation, the desire for intimate, emotional, and sexual relationships with people of the same gender, which is homosexual or lesbian or gay, with the other gender, straight or heterosexual, either of the binary genders, bisexual, or with all genders, pansexual, including non-binary people. Moving on to elder substance use issues, and I know we're churning through all these populations. We have 50 million Americans over the age of 65, and there'll be 83 million people over 65 in 2050. The biopsychosocial realities have a wide variation in the risks and health status of elders. They are less likely to be screened for substance use disorders. Medical exacerbations of chronic health issues may arise. Screening is improved by using genetic-specific instruments, I'm sorry, geriatric-specific instruments, such as the geriatric mast, GMAST, or the CAGE. Tobacco, alcohol, prescription drug misuse and use and abuse are significant. That has gotten better with the decrease in opioid prescribing, but the combination of benzodiazepines with the gabapentinoids and with the opioids have complicated this. Match that with an increased rate of falls and the possibility of fractures, and then again the resultant use of opioids again. So our goal is to protect the population and to do as little harm as possible. Elder-specific treatment milieu and group therapies are debated. There's no evidence of significant benefit with age-specific milieu interventions. Recovery and sobriety brings improvement to several aspects of elder health and people who have a history of substance use disorders. Now, when you look at substance use among older adults, it is a public health concern, and that could increase in the future, especially as the baby boomers continues to age. Older adulthood is not typically associated with substance use disorders. The findings in this report reveal that there are some areas of concern in this population. For example, two of the most common substances in the U.S. in this report shows that, on the average, 6 million older adults use alcohol and about 130,000 older adults use marijuana on a regular basis. That estimate was 2015, and that has gone up, although monitoring this has become not an issue because it is legal, and many people are switching from opioids to THC and CBD mixed treatments. Because prescription drug misuse is the second most common form of illicit drug use in the U.S., prescription drug misuse among older adults is an issue to examine. The National Survey of Drug Use and Health prescription drug questions that were added in 2015 will require pools of data over time. The Drug Abuse Warning Network, DAWN report, which is gathered from emergency rooms, does show an increasing number of older adults that are visiting the emergency room with a history of substance use disorder, including alcohol and subsequent injuries. When we look at elder substance use disorder issues, the DAWN data estimated that there are over 105,000 ED visits by people over 65 that involved illicit drug use, alcohol use in combination with other substances. This is not the chief cause of drug-related ED visits for that group. The use of illegal drugs, the use of combined alcohol and non-medical pharmaceuticals typically resulted in over 300 elder ED visits per day. Now, despite the fact that illicit drug use generally declines after young adulthood years, more than a million older adults had a substance use disorder in 2014, data seems to say that we are no longer calling recreational use of marijuana a illicit activity because it is legal. However, mixing other drugs, including opioids, prescribed street-derived opioids, cocaine, and other addictions continues to see a rise in all populations, including the elder population. Homeless populations are a significant risk for substance use disorders. The Community Reinforcement Approach, CRA, has been found to be a beneficial response to alcohol use in the homeless, adolescent, and adult populations. Now, this has become a real challenge for many communities. We in Phoenix had a zone in which they were averaging one to two fentanyl-related deaths in 2022 and 2023 per day. So there were, we call them forever homes, but there were actually structures that were set up with bathroom, a place to sit, and a place to make food that were given to homeless individuals who were willing to stay in those areas and participate in social support services consistent with the Community Reinforcement Approach. The state of Oregon has decided to make illicit drug use a non-crime, and Portland has been going through a real challenge during 2022 and 2023, and now in 2024, they continue to have significant challenges. The country of Portugal has decriminalized drug use, and they have seen a significant drop in overdose deaths and a significant drop in substance use in all populations. So there must be a sweet spot in this process, and there's also culture issues in regard to who is desirous of support in regard to substance use disorders. Social stability improves versus just treatment as usual, which is catch and release, which is take people, identify them as doing something illicit, put them in jail for a short time, release them after that, encourage them to have ongoing services, but no monitoring. The CRA protocol does improve depression scores. It values the individual, which is a critical part of this. It tries to remove stigma. There's decreased time spent on drinking in the homeless population of those individuals who have that community reinforcement approach. The Buddy System from Neighborhood Enhanced Benefits are one of the benefits of the CRA. Unemployment improves, and non-drinking social club experiences are promoted in the communities and enhanced benefits. This is also seen with special pops in the homeless population, including our transgender populations and our gay and lesbian and our sexually trafficked population. We start looking at serious mental illness in young adults, that's 18 to 25. The 2024 Surgeon General, Dr. Murphy, has six initiatives. Three of those six deal with behavioral health issues. The rise in suicides in adolescents and young adults, and this is despite the hotline 988 intervention, the rise in loneliness, which was seen initially with the start of the public health emergency, but with the termination of the PAG, we still see a significant amount of loneliness. Some people actually do better with work environments in which they engage their workers. Others do better when they're just at home, if they have a safe environment to stay and work at home. But you can see here, when we're looking at the rise in SMI, serious mental illness, in the red line, actually rising significantly over the course of time to the late teens in the U.S. When we start looking at major depressive disorders, and this is looking at timescales, so 2015, 16, 17, and 18, you can see the 12 to 17-year-olds have had a significant rise. That number went up again in 21, and the 18 to 25-year-olds also went up significantly. Not as much change in the 26 to 49 or the 50 and older populations for major depressive disorders. When we look at major depressive disorders in the 12 to 17-year-old group, you can see again that we've gone from 8.8 to 10.0% with major depressive episodes with significant impairment. We also have severe impairment, and this is looking at the National Survey of Drug Use and Health datasets. When we look at suicidal thoughts and attempts, there has been serious thought increase from 6.8 to 11.0, made a plan for ending their life, and attempted to end their life. We all see increases between 2008 and 2018. Concerning disorders, this would include a substance use disorder and a mental illness. So we start looking at this, when we take cigarettes as an example, no mental illness was in 16.3%. Any mental illness was in 28.1%, and for people who are using tobacco on a regular basis, a serious mental illness was seen in 37.2%. We see the same thing, the same type of increase from any use to daily use, and then we also see a slight increase in binge drinking and co-occurring presentation. When we look at co-occurring on the greater than 18-year-old population, you see illicit drugs, marijuana, and opioid use or misuse, all showing increases over the course of people who have comorbid mental illness in addition to a substance-related issue. And we see that again with prescription pain relievers, and to a lesser degree, with heroin. Now we didn't have much information on Fentanyl until just recently. We look at alcohol use and other substances. So we have alcohol use with past marijuana use, past opioid use, past cocaine use, methamphetamine use, major depressive episodes, and last year with a serious mental illness, you see increases across the board with time. So again, heavy alcohol use is the green. Past alcohol use is the blue, and no past alcohol use is the red. When we look at marijuana related to other substances, no past marijuana use is on the left column with the red, and then if you have people who have a past year opioid misuse and no marijuana use, the rates are low. But then you actually more than quadruple the rates to go to any past use to marijuana, and then daily past use goes up to 15%. So you can see all these are related to as a person ages, as a person is using other substances, and if a person has a cofactor of a major depressive episode and or a serious mental illness. Opioid misuse rates in other substances, the red column is no past opioid use. The blue column is any past opioid use. And for a past year with marijuana use, you can see, this is again looking at SMI, dramatic increases from the red column, which is no opioid use, to the blue column, which is about a 50% penetration with a person who has a serious mental illness and opioid use disorder with marijuana use. Marijuana has changed dramatically over the past 25 years. The marijuana used in the 1970s and 80s was between 4% and up to about 12 to 14% THC. Now we can get hybrid marijuana products that are four times greater, 60%, and you can actually get the wax and the gummies and edibles at as high as 90% active THC. These high-potency marijuana use stimulates the CB1 and CB2 receptors at rates that are much higher than naturally occurring marijuana can do this. So it's created a scenario where we see significant complications with people who have SMI, bipolar disorder, schizotypical, schizoid, and schizophrenia disorders that get augmented pathology because of strong or high-potency THC use. And there's a growing movement in the field of addiction medicine that the person who uses naturally occurring marijuana, you know, 4% to 14%, is a far different individual than the one who's using 60%, 70%, and 80% THC. Unfortunately, the desirable THC in the dispensaries tends to be the higher dose. It captures more money, so you can just follow the money and you realize that people are willing to pay more to have higher-potency THC. Cocaine use related to other substances and SMI, again, no cocaine use is red. Any past cocaine use is blue, and you can see the significant rise of serious mental illness and the use of cocaine. Cocaine currently is being used in the U.S. at a higher level in 2024 than any prior year. The amount of cocaine that is interdicted with three-, four-, and five-ton captures of cocaine liquid and cocaine powder has gone up dramatically, and the DEA openly admits the Coast Guard and the DEA only interdict about 10% of total influx of cocaine. When we look at methamphetamine, we see the very similar situation. Again, methamphetamine use over the past year compared to no methamphetamine use, and you can see the blue columns are significantly higher across the board. And then when you add on, whether it's marijuana, opioid, heavy alcohol use, cocaine use, major depressive events, and serious mental illness, all of them have greater risk when you add other substance abuse to the equation. Additional thoughts, plans, and attempts for young adults 18 and above. Serious thoughts are seen here. I'm going to move my little cursor here if I can. But the suicidal thoughts increase over the course of time and with the presence of substance use disorders in general versus no substance use disorders. So when you look at people who had serious thoughts, made a plan, or attempted suicide, people with a history of substance use disorders have higher risk of higher frequencies of each of these categories. Despite consequences and disease burden, treatment gaps remain vast, and this is a critical thing for all of us to realize that it has been difficult for us to identify avenues that have been successful for people who we serve. So if you look at substance use disorders, nearly 90% have no treatment. For any mental illness, it's about 55% to 57% have no treatment. When we have seriously mentally ill, only 35% have no treatment. So you see we're doing better in that population. Co-occurring, that should be SMI and substance use, about 90% have no treatment. In a major depressive episode, we're looking at about half that have no treatment. Now this is one of the reasons why the 988 telephone hotline was developed, but we haven't really seen a significant benefit. So we don't know if we're seeing the tail end of the COVID epidemic where loneliness was a very significant factor in suicidal ideation, or if we're seeing a population that's resistant to using a hotline. So we still don't have enough data to identify the benefits and the challenges that are facing us. So mental health issues in the US, this is 2018 data from the National Survey of Drug Use and Health, serious mental illness has increased in the adult population. It's increased in the adolescent 12 to 17-year-old population. These findings were more significant than in the population of adults over the age of 26. So it's the young adult and the adolescent that has the greatest risk. There's been a study that was released in 2023 that looked at the 8 to 12-year-old population because there's such a small number of suicide attempts and completions in that population, but there was a dramatic increase in that population. Child psychiatry is looking more aggressively at this population at this time. The use of one substance, alcohol or another illicit substance, is strongly correlated with polysubstance use with major depressive disorder or SMI. Substance use disorders do increase the likelihood of suicidal ideation, suicide attempt and completed suicides. And there is still a huge gap in regard to treatment. 2022, there was some progress, but there's ongoing issues of those living with substance use and mental health comorbidities. So again, a more recent data set that was identified indicates that there's a continuing need to screen people for substance use and behavioral health issues. There's rising rates of marijuana, methamphetamine use, and this is also seen in the adult population. Rising rates of major depression, adolescents and adults. Rising rates of obviously fentanyl use and feelings of escapism being one of the rationales that many people are using fentanyl. Substance use and mental health disorders are closely linked. Mental health is a risk factor for illicit substance use and illicit substance use is also a risk factor for mental health. So when we looked at the Surgery General Priorities for 2024, he had six priorities, loneliness, mental health, especially rise in mental health issues in adolescents, workplace well-being, burnout in all employment categories, misinformation being a significant factor that prevents public health information, and follow-up of COVID-19. It's not gone, but the long-term effects of COVID infections are now being looked at as being contributors to behavioral health and possibly to the substance use epidemic. Aboriginal populations, and this would include our American Indian, Alaska Native, Native Hawaiians in the U.S. carry a greater burden of complications of substance use than any in the majority populations. So cultural and family attachments are many times lost in Aboriginal populations that are afflicted with substance use disorders. One of the things that happens is loss secondary to severe injury and death, loss secondary to legal interdiction, and loss secondary to leaving the tribal areas and going to the urban areas where the sense of continuity and consistency is lost. The colonization process that we've seen over the past 500 years in the U.S. weaponized substances and that capitalize on economic, political, and sexual exploitation. We still see this going on right now. The FBI has identified that the most likely person to physically or sexually abuse a Caucasian is Caucasian. The most likely that is African-American victim is an African-American perpetrator. The most likely Hispanic-American victim is perpetrated by a Hispanic-American. But the most likely person to physically or sexually abuse an American Indian is a Caucasian. So there's a difference in the demography of this epidemic of violence, and there's an ongoing issue of missing women in the indigenous populations that still has not been addressed adequately. Tobacco and cotton were the main drivers of the institution of slavery. When we look at an Aboriginal population that was imported into the U.S., we also have the incorporation of traditional Indian medicine and culturally sensitive interventions. And this includes all, especially the Asian-American and the African-American populations that may be necessary for a beneficial or successful intervention. So getting to know the patient in a stigma-free environment, trying to encourage their engagement, using the levels of change from Prochaska and DiClemente and motivational interviewing to maximize the engagement in intervention strategies. There's a much higher mortality of COVID-19 that was seen in the Aboriginal populations with American Indians, Alaska Natives, and Native Hawaiians, despite all three of those populations having higher rates of the initial COVID immunizations and the bivalent immunization that's been available for the past year and a half, two years. So despite having immunization protection, there was still a higher rate of mortality events secondary to being an Aboriginal. We look at natural and man-made disasters. Substance use disorders have increased after every war since the Revolutionary War. So remember Benjamin Rush? We talked about our military population, and he was the Surgeon General of the Navy. General George Washington was going to court-martial the Surgeon General of the Navy, Benjamin Rush, because he was trying to stop the grog distribution. So Benjamin Rush simply retired from the Continental Navy, but continued to promote the concept that about one in 10 men—it's amazing how accurate he was—should not drink alcohol. When we start looking at the Civil War, massive epidemic of alcohol and opioid use, World War I and World War II were both followed with heroin, marijuana, and opioid use. The Vietnam War also resulted in a large population, along with the sexual revolution and the substance use revolution. And then our most recent experience with OIF and OEF, Operation Iraqi Freedom and Enduring Freedom, we saw a significant rise in opioid use and THC marijuana use in our post-military populations. When we start looking at the impact that COVID has had, there's no doubt that behavioral health issues, loneliness, burnout have become common problems. PTSD and looking at the cognitive impairments from substance use disorder, impaired decision-making, enhanced fear response with increased trauma experiences, lifestyle of those in substance use disorders were higher risk for enhancing dangerous environments and poor decision-making capacity, and anxiety and increased arousal states, especially with the increased use of caffeinated products in a lot of the drinks and nicotine products, especially when you look at the large use, over 60% of adolescents are now using vaping materials with nicotine and or THC in the systems and the stimulants of methamphetamine and the amphetamine analogs and cocaine. Moving on to the physician and healthcare professionals, the general population for a substance use disorder has a rate penetration of about 3.8. With physicians, it's about 7.9. Medical boards are dictated by every state medical society or board, and disciplinary actions are common. The disciplinary involvement for a provider in a review or monitored program has resulted in about 90% to 95% success for navigation through that program, because they incorporate sober support, they support, they incorporate caduceus and fellowship, they also incorporate medication assisted therapies, but they also incorporate monitoring. I also do the talk on urine drug screening, so I highly recommend you get that for the board. Now, 14% of doctors that are in board actions are secondary to alcohol and drug use issues, 11% for inappropriate prescribing practices, likely from the provider's own substance use disorder. The average age for physician characteristics, and this is looking at a data set of over 3,000 physicians that went through a program in Atlanta, mean age was 45, 75% of the physicians had alcohol dependence, 75% of physicians with alcohol dependence had a family history of alcohol use disorder. They were very specific to training, so psychiatry, the most common reason for a psychiatrist to be admitted to a substance use training, a treatment program was benzodiazepine. In emergency medicine, it was cocaine and the stimulants. For anesthesiology, it was the fentanyl injectable, was 50% of all anesthesiologists that went into treatment at the Atlanta program. Smokers have a higher risk, but fewer physicians are smokers right now, a higher risk of substance use disorder. Alcohol was number one, opioids are number two, typical diversion from patients. Cocaine has declined, but new data is needed since there's been such an increase in stimulant use disorders. Amphetamines and benzodiazepines, 20% of anesthesia residents reported using propofol outside of their program. In other words, for non-medical reasons, as residents in one particular study, emergency medicine, orthopedics, plastic surgery, anesthesia, and psychiatry, there was more marijuana use in that population. Mood disorders and suicides, the leading cause of death for physicians between the matriculation into medical school and age 44 is suicide. Of that population, over 65% is related to a substance use disorder. Those who have a complete, those who complete their suicides have a higher history of substance use disorders and family substance use disorders. Physicians who also have a co-factor of suffering from chronic pain or have a greater risk of substance use disorder by self-medication and self-treatment, the Federation of State Medical Boards has questioned if physicians with a substance use disorder should even receive opioids for pain, which is an absolutely insane comment to make because the provision of opioids for bona fide pain improves the overall success and participation of the member, the physician member in program. So, you know, making physicians with pain syndrome suffer from pain does not improve their overall health. Assessment and treatment of physicians and other healthcare providers, 90% of physicians in state board monitoring programs successfully complete the program. The programs can be one, three, five, or even seven years in length. Physicians may excel in didactic aspects of treatment, but they many times avoid the emotional, the interpersonal, and the spiritual aspects of treatment. The valedictorian of Duke University Medical School that I treated at Brighton Hospital, he read everything that we had to give in a 28-day program in the first night. He said he wanted to leave because he has completed all the educational objectives. I said, well, that's not really the program. And he signed out against medical advice. And four weeks later, he came back in, blood alcohol of 0.4 when he crashed his car in the doctor's parking lot into another physician's very expensive vehicle. I was told by the anesthesia program that he had to get help or he was going to be removed from the program. So, intellect is typically a liability in the treatment of substance use disorders. So, many physicians distance themselves from the somatic and emotional pain inherent in physicians' work. And they use it as a coping mechanism. There's also a perception that their role as a physician does not allow them to be vulnerable. Emergency responders, such as police officers, firefighters, paramedics, EMTs, and now disaster prepared programs, they are exposed to situations that are at risk for development of mental health disorders, especially with large mass casualties, such as shootings and things like that. Amongst the police departments, 18% of males, 16% of females have had adverse consequences secondary to alcohol use. And 8% of that population will meet a criteria for a lifetime alcohol use disorder diagnosis. Female officers had alcohol use patterns that are very similar to male officers and greater for female. And that is much greater than the females in the general population. Male firefighters have a past 30-day binge drinking history of 50%. Now, that's part of that is their lifestyle where they're on 48-hour shifts, and then they're off shift for 48 hours. This is compared with 23% of adult men having a much lower rate, less than half, of the 30-day binge drinking event. Again, that's four servings for women and five servings for men. EMS workers, 36% having depression, 72% with sleep deprivation, 20% of EMTs with PTSD have an increased risk for substance use disorders. Now, when we start looking at this, this was based on several data sources when I put this program together. So, we want continued work with states to address opioid crisis in terms of prevention, treatment, and community recovery resources. When we look at the STR, SOR, TOR grants, these are federal grants, to look at these grants can identify high-risk populations. So, opioid use in the pregnant population, significant issue. Children and adolescents having higher access to vaping systems and to fentanyl products. We're starting to see younger and younger adolescents with overdose events and fatal events. The use of naloxone spray is not ubiquitous to the point that we're, that we have it available whenever needed. Libraries are using more and more naloxone spray because the homeless population may use that for air conditioning or for warmth in the wintertime. And overuse of opioids in that scenario has resulted in librarians being a major administrator of naloxone spray. Block grants to address prevention and treatment issues. These are public health type questions connecting the importance of prevention, treatment, and community supports. SAMHSA, the Substance Abuse and Mental Health Services Administration, has a variety of technology and transfer centers that have information there. And then the National Survey of Drug Use and Health, the Drug Abuse Warning Network, and the publications from the Substance Abuse and Mental Health Services Administration are all free. They're not copyrighted. And they are very beneficial to keep in touch with what's going on in your community. I said earlier that 56 percent of all the fentanyl that was captured by legal authorities in the U.S. in 2022 were captured in the state of Arizona. So there's a dramatic geographic difference. And in states, Ohio is a great example. Severe problems with the fentanyl epidemic in Ohio. And opioid prescribed medications and fentanyl in West Virginia right now. So there's significant variation. You can get that information from SAMHSA, CSAT, and the DEA. I have several hyperlinks here in regard to context you can make in regard to the opioid epidemic and other types of behavioral health and co-factor events with substance use and behavioral health disorders. And then also a definition of some of the issues in regard to specific populations that we addressed in this presentation. I'd like to thank you for taking the effort to go through the training program. And I have high expectations of your passage to become board certified in addiction medicine. My name is Anthony Decker. My email is on the front of this presentation. You're welcome to contact me anytime if you have any questions. And I wish you all well. Thank you very much for participating.

addiction medicine

special populations

cultural differences

veterans

LGBTQ

substance use disorders

emergency responders

opioid crisis

community resources