Good evening, everybody. My name is Elyse Wessel, I am an addiction medicine physician in Illinois. I am happy to introduce Dr. Conrad tonight for another testimony from the trenches, innovations in clinical practice, addressing substance use disorder, MAT in the emergency department setting. Dr. Conrad was born and raised in central Appalachia. He is a graduate of the WV School of Osteopathic Medicine. He completed his residency in emergency medicine at Southern Ohio Medical Center in Portsmouth, Ohio, where he served as chief resident. Dr. Conrad's primary clinical role at present is in the emergency department, and administratively he serves as the medical director of emergency medicine at WVU Medicine Braxton County Memorial Hospital. He also serves as chief of staff at that facility. Dr. Conrad is an assistant professor of emergency medicine at the West Virginia University School of Medicine and is actively involved with clinical instruction of emergency medicine residents and rural health medical students. He serves as a local public health officer and as an EMS physician. He is board certified in both emergency medicine and addiction medicine. He is a fellow of the American Osteopathic Academy of Addiction Medicine, American College of Emergency Physicians, and American College of Osteopathic Emergency Physicians. He serves as a member of the board of trustees for AOAAM and is a member of the American Osteopathic Conjoint Examination Committee on Addiction Medicine. I will turn it over shortly to Dr. Conrad, just some housekeeping items. Please keep yourself muted if you are not speaking and somebody else is, and if you do have questions, feel free to use the Q&A function on Zoom or the chat box. And if you do have a question during the presentation, feel free to raise your hand or unmute yourself and ask. And we will also have time for questions at the end. Dr. Conrad, I'm turning it over to you. Thank you, Dr. Wessel. Good evening, everybody. Thanks for taking time out of your evening to join us. Thank you, Judy and Nina and all the education committee folks. This is the series that we're putting together, hopefully little clinical tidbits that will help everybody just take a little bit of time out of their evening and hear from folks that are practicing clinically in different areas that may be outside the area you typically practice and pick up a little bit. The big thing that we're going to encourage you to do this evening, if you have questions or discussion, anything that you'd like to talk about, just as she mentioned, please let us know. The content itself shouldn't take too long to get through, and we should have plenty of time for discussion. Just to kind of set the stage as to what we're currently doing and my background, I do primarily work in the emergency department, but we've really expanded treatment of substance use disorder and addiction medicine out of the emergency department, primarily since probably 2018-2019. WVU Medicine is about a 20-hospital chain conglomerate medical group consisting of West Virginia, Maryland, Pennsylvania, and Ohio, and it's ranging from a large tertiary practice that has multiple resources, such as addiction psychiatry and addiction medicine, to a very small rural hospital, which there's many of those. So we've basically, as we've expanded our hospital group and our emergency medicine practice, we've really linked up some of our assets at our tertiary care hospital and allowed them to provide services, especially addiction medicine services, at some of our more rural settings. And especially since COVID, you know, some of the telemedicine resources are now available at our smaller hospitals, and then, of course, at the bigger hospitals, addiction medicine is available right there on site. But we'll go through just the general practice, clinical indication for induction of medication-assisted treatment in the emergency department, and some of the issues that go along with it. So some of the goals, we'll discuss some of the current statistics and trends, which, as you all know, are not great. Some of the challenges out of the emergency department, which are very unique, just especially given our isolation and very specific lack of follow-up, we'll touch on the fact that in disconnected rural settings, that presents a different unique challenge. Really try to hit on the locks and administration and distribution as well, and then discuss any other pitfalls and concerns. So some of the local statistics, these are the most recent I could pull from the CDC website. So here in Appalachia, West Virginia, we've actually taken a little bit of improvement as far as opiate overdose deaths, but unfortunately, we're still topping the overdose death per population national average. As you all are very familiar, as the prescribed opioids tend to dry up, we saw a large shift towards heroin, and now, unfortunately, we've taken another shift towards fentanyl, which is now causing the majority of the fatalities. We've actually seen here in this area, a very large increase in methamphetamine overdose deaths as well. And clinically, I've seen a very large increase in the amount of adulterated methamphetamines with fentanyl, leading to overdose deaths or near deaths requiring Narcan rescue. Nationwide, we're seeing actually a little stability there, but still a concerning trend. So opportunities. Well, this presents us a lot of opportunities because there's 20 million ED visits per year. Those are related both to injuries and illnesses. So when somebody comes in for their broken bone, whether it be from a fall from alcoholism or an illness associated with their endocarditis from injection drug use, that presents an opportunity for us to enroll them in treatment or refer them to a program or whatnot. So it's really an opportunity for us to intervene and to get them some treatment that they really need. And actually, if you take the time to screen the patients, about 15 to 20% actually do screen positive for one of the many substance use disorders. And then specifically in relation to trauma, it's pretty staggering, about 25 to 50% of the patients screen positive. So and of course, even a small percentage of those, if we enroll in treatment would be, you know, very life changing. So just some of the evidence, ED initiated, buprenorphine versus SBIRT versus just referral kind of here's where you should go and get treatment. We saw very, very promising numbers. Not only did we see increased engagement in addiction medicine treatment, there was reduced self-reported illicit opioid use, and actually decreased use of inpatient addiction medicine services. And that's just a graph kind of showing that. This was from the 2015 Yale study, which really was a well done. Really the first ER study that really changed the game as far as initiation of treatment in the emergency department. So this is, I think, where really you have to start and you have to take the time to do it. And it doesn't have to be anything super fancy or crazy or complicated. And I didn't specifically just because of I was more concerned about copyright infringement and whatnot. There's multiple EMRs and I'm sure you all have different EMRs that you're comfortable with. But honestly, the few that I currently use, a lot of times these screeners are already built into them. And actually they have screeners linked with order sets. They just have to be used or enabled. So it could be a very complicated screener that's done in triage, or it could be a very quick screener. So for example, have you struggled with pain medication use? Have you had an issue with overdose or quickly unable to assess? And then of course, it could be very, the whole works, a whole SBIRT evaluation. And we know that is useful. The numbers are very positive on that because that's been shown to be beneficial in a variety of settings. But that's very hard to use as just a quick screening, a little more involved than just kind of a catchment of patients. And again, we know that this is useful. And as we discussed earlier, definitely effective, but not quite as effective as actually getting these patients that would benefit from it enrolled in agonist therapy. So it even SBIRT itself reduced healthcare costs compared to the dollars spent. It reduced ED visits and injuries along with the severity of substance use disorder and arrest and incarceration. So you know, and again, like we talked about, a lot of these EMRs actually have these systems built into them already. It just depends in particular based on where you're set up and how you're set up. Larger centers typically have a multi-step protocol to screen. Initially it may be a few questions, screening tests, and triage. And then it may flag and reflex to the peer recovery coaches. But unfortunately, those staff aren't available a lot of the smaller places. It is great if they are. And of course, peer recovery coaches are used in other settings as well. They're great assets if they're available. These are patients that have had experience with addiction. Their life experience is invaluable. They're able to relate with these patients. And a lot of times get very useful information and insight as to what exactly they're struggling with and really help get them enrolled if they so desire treatment. The small sites that we work with now and that we staff typically can't or don't have peer recovery coaches available. And if they do, it is often shared or not directly available on sites. Our larger facilities staff at least during the daytime. So that's a little more streamlined process. So the bread and butter. Medication assisted treatment, especially initiation out of the emergency department, we know it saves lives. It reduces all-cause mortality 50%. Agonist therapy, whether it be buprenorphine or methadone, it not only decreases all-cause mortality, it decreases overdose deaths as well. It improves quality of life and it decreases risky behavior, such as all the things that go along with IV drug abuse. Even reducing that risk itself is fantastic. And one of the things that we've really seen as we go out, we try to get more providers to be open to this and receptive and trained. The ex-waiver elimination has really been something that has prompted them to be more receptive to this. So one of the things, of course, we always look for is, you know, are you here today and are you motivated and willing to receive the therapy? Of course, we always do a Cal score, which is pretty indicative of specifically opioid withdrawal as opposed to just withdrawal from another type of illicit drug, such as benzodiazepines or alcohol. This was a little bit dated, this slide, but obviously benzos are not a complete contraindication. We give these together all the time, but very high dose benzodiazepines would be something to consider. PCC is not, you know, the naloxone is the concern there. With the combined product, specifically if somebody is abusing methadone, the concern would be for precipitated withdrawal. If somebody is acutely psychotic, I would be very concerned because number one, they don't have the decision making capacity and they don't have the ability to give you the information that you need to reasonably, safely induce them. And do they have a true allergy, which is always kind of hard to get to the bottom of, especially with the ER population that we serve, because we have a lot of allergies that aren't truly allergies. In a Cal score, we have all been through this, and this is a pretty good tool because it really gets down to the nitty gritty of what's going on and not just, I feel bad. It uses the pulse rate, GI upset, sweating, tremor, restlessness, yawning, which is definitely very suggestive of more of an opiate picture, anxiety, pupillary size, aches, goose flesh, runny nose. As that, those tests are, you can jot them down quickly, either in your EMR or piece paper, and we typically do these serially as we're assessing the patient. This is just an example of one of many pathways. This is the pathway that we specifically use with our buprenorphine induction or impact program at WVU up at Ruby, and our cutoff here is eight on the Cal score. And it's very, very similar to what a lot of people use, and we start our dosage at eight milligrams. And the big thing here to kind of hammer home is we, in the ER in general, and we're always very quick to get people out. You really need to keep an eye on these folks for a while, number one, to make sure they don't have precipitated withdrawal, but watch, observe. And then the folks that don't necessarily need treatment in the ER, but are receptive and ready for treatment, certainly it's a go pack, and a home induction plan is very reasonable even out of the emergency department. The population that I find it honestly most useful in, in the folks that are most receptive is the folks that have had a close call with opiates and have had a Narcan rescue in the field. These patients are often very uncomfortable, and they're in extremis, they're in severe withdrawal. They typically feel dramatically better after an induction. The big, I think, game changer for us to everybody, of course, the big concern with fentanyl, it being fat soluble, is, was precipitated withdrawal a bigger issue with that than heroin and other opiates? And that was the excuse we heard a lot with folks that were reluctant to do inductions in the ER was, well, you know, we don't, we don't know if this is going to be an issue. We don't know if precipitated withdrawal is going to be more, more profound, happen more often. But this study that came out of JAMA in 23 really proved that it's not an issue. In that very large study, less than 1% of their patients had precipitated withdrawal. And that was 70% of those admittedly knowing that knowingly using fentanyl. And then of course, this, and I won't really touch on that, but as you all know, the ex waiver is no longer an issue. Some of the resources that that I've used and I continue to use and other folks have used, you know, Yale has done a lot with emergency department, agonist therapy, ASEP, which is our big governing body and does a lot of advocation for the ER. Actually they have a app that you can put on your phone and of course, just the quick Cal score. These are all great resources, information on treatment plans. They've got the whole sequence of anything you need to look up on those three websites. So something else I wanted to really touch on, I, I find that this probably is even in modern times, it gets done probably a little less than I thought it should. I still have patients that come in and I've had a close call on an overdose and then have required even maybe multiple doses of naloxone and don't get prescribed home kits. So I'd encourage anybody that you can give it to, to just go ahead and get it out there. There is a over the counter preparation available now. I don't know if that's, and I can't really say too much about the cost of it. I wish I knew more, but you know, that's having this, having Narcan in the hands of people that have it available, first responders, family members, you know, it, it makes a difference that we'll see for years to come, especially in very rural areas. A lot of times EMS is so much further than, away than they need to be. So having Narcan available is, is very much needed. So something that has been kind of on the radar that I don't think it's there yet as far as wide use, but I think it's probably coming, it, it was a study with a fairly small end, but it makes sense. And it certainly could, could be out there as, as far as Naltrexone and its utility and use in the emergency department as far as alcohol use disorder and treatment. And it's just, again, it gets back to that, having that opportunity that one patient encounter with the patient to make that difference while they're there, while you can initiate something to improve their life and get that treatment initiated and roll them into treatment. But I don't, I don't think we're quite there yet. I think there's going to be bigger studies to come. I don't think it's necessarily to the point where it would be tough for me to treat a patient as far as opioid use disorder. Of course, because of what we all know about it, but so really discussion, anybody have thoughts, questions, anything anybody wants to chat about? Well, thanks so much, Dr. Conrad. I had, whenever you brought up those resources, I wanted to talk about the one that I find pretty helpful. California Bridge has a lot of protocols on their website. If you just Google California Bridge, you'll see the resources. And they have a lot of different resources like low-dose inductions, macro-inductions, macro-dose inductions, ER initiation, substance use navigators in the ER, peer recoveries, et cetera. But I just found that to be a helpful resource as well. Yeah, that's awesome. And it looks like we have a question from attendee Mary. Can you hear me? Yes. Oh, great. This is Mary Lynn Greeno. I'm a nurse practitioner in Florida. And I have a couple of questions. One, when patients come to the ED, when do ED personnel do screening or maybe urine tox screenings for any drugs? Because when I was in the hospital full-time, I would get patients to me and I saw them with palliative care, pain management, and substance use disorder treatment. So many of them never had a screen done and they didn't have a urine tox screen done. So I never quite knew what they came into the ER already on or whatever was in their system. And I had to kind of go by whatever they told me. And usually, there were heroin issues and opioid use disorder was very common. And of course, I had them in the hospital for five to six weeks if they were there for a valve replacement related to vegetations and IV drug use. So my question is, in your state, what is your protocol when someone comes into the ED? When do you screen someone? Yeah. I mean, I think anytime that you feel like it's going to be helpful to your care. So that would be, in general, that would be part of the initial kind of admission package per se. So you don't typically screen someone who has a trauma or screen someone? Yeah. So typically, say, we have, just for example, like different priority traumas. So a P1 trauma, meaning a severe trauma, those type of patients, the urine drug screen and alcohol levels are on the trauma panel. And that often is questions like, well, why do we need a drug screen on a patient that comes in for a broken shoulder? But that goes back to that very thing. And that allows us to pick up on things that may be unrelated or may very much be related. Okay. And that's just a protocol in your state? No, that's more of a trauma guideline or treatment standard. I think it's more just dependent on the state itself doesn't necessarily have, as far as I know, any state mandated screening. Okay. Unless the only thing I could think of that would come from the state, unless something was subpoenaed or requested by the courts. But I think that anytime we think it can affect treatment, we're pretty quick to grab those tests if we need them in the ER. Okay. Well, it's just, I've had so many problems with people going to the ED and they were never screened. And I'm like, you missed that, you know, all the illicit drugs they were on when they came to the ED and then they just send them home and all of it's missed. So that's for me, because I'm doing community. I was in the hospitals for years and people saw them. So now I'm doing community and helping with palliative care and pain management. And I'll get the records of someone multiple times in the ED and talk screens weren't done. So, I mean, this is Florida, it might be per hospital decides when they will do a talk screen. I've called on patients and said, hi, they're in the ED, please do a talk screen. You know, and I've had to call in and ask for it. I need to know what they're taking. Um, so, and, and that was with the trauma. So I just didn't know if hospitals have their own protocols. Yeah. At least here, not, not in general. So I have some comments on that too, Mary, thanks for the question. Um, so I'm from, um, Illinois and, uh, I, we developed a universal screener and I also trained in Wisconsin and, and we had developed, um, universal screeners for anybody, um, being admitted, admitted to the ED or inpatient. Um, and so it was done by the triage nurse, um, whenever a person, um, um, was, uh, being admitted. And so, um, you know, you have to pay attention to time and not have too many screeners on people, but if you do an audit C and then there's the, um, the one line screener for substance use, or yeah, the one, like the one question screener for substance use, um, that, um, it, those are pretty, uh, sensitive screeners. Um, I would caution on, um, urine drug testing because there are limitations of those based on what the, what urine drug tests are available. If it's immunoassay, um, you know, full opiate, uh, uh, semi-synthetic, synthetic opioids won't be picked up on those immunoassay tests all the time. Um, especially not fentanyl, which is a synthetic opioid. And so, um, verbal screeners like the, um, one question, uh, drug use screening and audit C are very helpful. And to get, get buy-in, um, from your hospital systems, um, you could start gathering data or try to get data on complication rates from not knowing, um, substance use, um, history and not screening, uh, such as like, you know, alcohol withdrawal. I know it complicates a lot of medical issues. So, um, uh, opiate withdrawal is one of the main causes for AMA discharges. Um, so, uh, and so you could create buy-in that way. Yeah. And just to clarify too, just as Dr. Russell said, um, I think it's just important to clarify what we were discussing as screening, um, was more screening as far as audit C whatnot, like questionnaire screening, as opposed to urine drug screening per se. Um, so it was more asking medical questions and whatnot. Um, but yeah, good question. It's tough because I usually patients I've worked with over the past three years, they're certainly not admitting to anything in an ED setting. They can go in there with even, um, imagine trauma and, and hurt themselves because they want to go in and get medications. Yeah. And that's, that's kind of a tough situation too, because even if, you know, that that's probably a patient is not ready to, even if they have an opioid use disorder, they're probably not ready for, for treatment at that point. If, um, if they're trying to, I mean, that's just, that would be a tougher, tougher case in general. Yeah. Well, it's been a really tough case because it's prescription Adderall, uh, use and misuse. And I've had a really tough time here with, um, patients, um, physician hopping and pharmacy hopping and, um, just totally getting Adderall from multiple clinicians. And, and it's a very difficult to control someone who's doing that. Um, and you know, I don't get it. I, I, you know, here in Florida, people will just go from one psychologist or psychiatrist to another, um, each month and just come away with, you know, 60 milligrams of Adderall a day and all, and four to five milligrams of benzos a day and ambiens and every other thing loaded on top of it. And I'm trying to get these folks into, you know, a treatment program and I can't stop these doctors from prescribing medicines for diagnosis that they don't even have, um, you know, so I don't know what you have in your state, but to me, this has been really tough because it's, it's prescription, uh, drug abuse. Thanks, Mary. Yeah. I'd like to go back to, and, um, talk about how you said patients, um, don't admit to, to substance use. I think that has a lot to do one with stigma. Many people with a history of substance use disorder haven't been treated very well by healthcare systems. Um, I see that all the time. And so they know if they, um, endorse, uh, trouble with substance use, they, they will be stigmatized because they have, and, and also it, it, it has to, to the insight of the person. Do they recognize their own substance use disorder? And sometimes when so people are so far, um, have such severe disease, um, it's not recognizable to them as far as the doctor, doctors, uh, prescribing, um, you know, it's really important to, um, check the, to check the PMP prescription monitoring programs. Um, and you know, most people do not prescribe maliciously, right. Um, as people in the healthcare profession, we want to be useful. We want to help people. Um, and I find that over prescribing, it doesn't often come from a malicious standpoint. It, it, um, I think that having a conversation with the physicians that you see doing the prescribing can be helpful if it's approached in a nonjudge judgmental way. Um, but moving on to the next question by Norma, um, she asks, are you using the same starting buprenorphine dose for patients using fentanyl and you push through with the induction and those experiencing precipitated withdrawal? Yeah. So I I've been really lucky that I, I, I really tend to let them go a little further before, and that just may be me before I do an induction. Um, but I, I have not had a bad precipitated withdrawal. Um, and I do do the, the same starting dose. And, and honestly, I would actually be a little more cautious and maybe Dr. Wessel, who does this more, um, she probably has done a hundred times more of these than I have. Um, I, I would tend to actually use a little bit of a smaller kind of test dose if I had somebody that I wanted to, to get it done, but I was a little concerned and I may precipitate just to make sure I wasn't going to turn the other way, as opposed to using a higher dose. Cause then you may be kind of stuck. Um, yeah, I'll just come. I do do test doses, um, for sure. Like two milligrams. Um, I, um, that being said, uh, I do do quite a bit of, um, low dose cross tapers. Um, I'm in a unique position. I will say to do that. I know I recognize that, um, uh, people in certain clinical situations aren't, don't have that advantage. Um, I've also done a couple macro dosing inductions. Um, and I, and I, um, I typed a response to Paul Steyer, uh, in the question and answer box. Um, so, so for the low dose inductions, I tend to, to use the California bridge, uh, seven day protocol. Now, um, I work in an OTP, so that's where I have the advantage of doing, being able to do a cross taper with a full opioid agonist and, uh, and then starting low dose on buprenorphine. I'll share my contact information if anybody wants to know how I, um, teach patients and manage it. And then the macro dose induction, um, um, I know, uh, one protocol and one, one that I've tried is eight milligrams every hour for three doses. And then if necessary, you can give a fourth dose. Um, there's also, um, instances where you can give like 16 milligrams at a time, um, a couple of times. Um, I also, um, work with a, uh, or one of my colleagues is, um, in, in Chicago, one of their health systems, they use IV buprenorphine to, um, to, uh, uh, start buprenorphine in the setting of fentanyl or, um, um, you know, trying to meet patients where they're at, if they're agreeable and, um, but can't stay long and wait out their withdrawal. Um, there are some protocols for IV buprenorphine and, and also, uh, transitioning to extended release buprenorphine, um, which the brand name is supplicate. Um, and, and, um, I can give you more information about that, but that's interesting too, because, you know, when I learned about supplicate, the, the protocol was give, they need to be stable on sublingual buprenorphine for at least seven days prior to, to supplicate initiation. Um, but there are quicker inductions onto supplicate, uh, that, that have been working very well. Sorry, go ahead. Oh, I was just going to say if anybody else wants to share their experience too, I think that would be helpful. Yeah. And I, I think you'll find that everybody has, um, just as she said, their, their own, um, protocols that have worked best for them. But, um, I think all those resources that she mentioned are great. Um, and I, I'm just looking at this one question. I, I apologize. It took me a second to get over this. Um, I typically, I mean, if somebody's, as far as the Zofran and the Clonidine, I don't typically give, so one of, so one of the, uh, larger community hospitals that I work at, not the primary site that I work at, um, I really struggle. Um, I'll just kind of put this out there. The dual diagnosis, um, psychiatric facility attached to the hospital takes everybody off buprenorphine. Um, they use no suboxone. So even if they're on it and stable, um, and they're admitted for SI, um, they take them off. So it's, it's kind of a, it's a weird situation. So, especially if they come in with, in a withdrawal, then we tend to use other agents. So in that setting, I, I use a lot of Clonidine and Zofran. I've never used them both together. Zofran, I think would be great. You know, you're certainly not going to run into any issues, um, with, with that, uh, and bup. Um, unless there's issues, I don't see anything wrong with Clonidine and buprenorphine. I don't know if it necessarily do a whole lot of good, but, uh, it may be something to try. And just to piggyback back off that, um, you know, I, I think you're referring to pre-medicating people. Um, sometimes when I do outpatient, um, um, inductions, I mean, not sometimes, but a lot of the time I'll, I will send them home, um, with, uh, orders for Clonidine or Lofexidine. Um, sometimes like Lofexidine, we don't have prior authorizations for those anymore and it's covered by Medicaid. So in Illinois, and so I tend to use that, uh, because I see a lot of, um, Clonidine misuse. Um, and so, so I prefer Lofexidine and, you know, maybe people, maybe Lofexidine will have some, it does have sedation. So I assume it could potentially develop misuse. Um, but I do prefer, uh, Lofexidine for that reason. Um, but Clonidine is fine too. And, and so I will send them home and, um, but we're talking about the emergency department too. So I think that's a reasonable yes. Um, and then I know Richard Andrews, you had your hand up. Can you hear me? Yeah. Yeah. Uh, Richard Andrews, I work, uh, at an OTP in Texas and, uh, I wrote a comment there. I I've tried to, uh, do, um, low dose, a very low dose bup, uh, initiation with patients on methadone, several of whom I think would do much better on buprenorphine for various reasons. Uh, but our, our leadership at the OTP kind of freaks out and, uh, and they, they haven't let me do it thus far. So, uh, I, I, and I think that's pretty common. Um, well, Richard, I am doing a talk next month on OTPs and I will tell you that I do the low dose injections and the cross-staple with methadone buprenorphine all the time. And we will definitely have a conversation about that at least next month. I don't want to take too much time away. Thank you. Yeah. Dr. Conrad, I had a question about, um, about if you, what your experiences with xylosine in the ER, if you're seeing that and how you manage it with overdoses or not. I, at least I've not, we haven't seen too much. I know it's out there. Um, I, I haven't seen anybody that, you know, that we've known has been that as a primary source of that. Um, it may just be that it's not saturating our particular drug market right now. Um, but, uh, yeah, I mean, it's another one of those things that's kind of scary and hopefully another thing to knock on wood about. Is anybody from the, the audience seeing, um, xylosine? And just something else to mention that I don't think I touched on earlier, you know, the more, especially from the emergency department to the, I, I'm a, I work with the health department quite a bit as well. I'm with EMS. So what we discussed earlier about, you know, potentially some So what we discussed earlier about, you know, potentially some aberrant prescribing or, you know, some drug seeking behavior, what I'd, I'd encourage everybody to potentially even have a relationship with the local drug task force. Um, just because, um, you know, you may get tipped off to something that's coming into your area that you may need to keep an eye out for, or it may be useful if you feel like that there's something dangerous that maybe, uh, you know, potential prescriber is putting out there too. So it's just, um, it's nice. We, I actually get, um, usually it doesn't happen very often, but once every couple of months, there'll be a bad batch that's coming through, um, that I'll get an email or a call about. So it's, it's nice to have that relationship with them. I know that, um, just as an aside, again, I know that the there's xylosine, um, testing strips coming out, um, from what I recently saw there on 89 cents, a, a strip. Um, and, um, so I don't know, I, I'm trying to get the, my organization to purchase them. I know we have some opioid settlement funds that, that could potentially go to that. So, So, one, one, another question. Oh, I think. Oh, can you spell that. I'll put it in the chat box, and Paul. Let's see, it's referred to as drink dope and the CDC put out a, like a warning flyer about it for for patients to. So, I mean, as far as I know about the pharmacology of it. I would at least initially try things that we try like with catapress or quantity and overdoses and children, like initially Narcan. Sometimes you have some transient response with that. And even, you know, kids can get sick as a dog with that. Sometimes you may need pressure support. You know, I just hope that we don't get anything super super bad. But again, all those, this stuff is so much is often some adulterated with so many different things. It's hard to tell which toxiderm to really to really chase. I guess do. I'm curious for any of the ED people on here to do or Dr. Conrad and do you call the poison control center. And you're like if it's something very straightforward. Generally, we still alert them. So the toxicology service is often very helpful in undifferentiated overdoses or something exotic. Generally, somebody comes in, even with a reported overdose. It, at least the statistics, even if you handle it, you know how to handle it. The statistics may help the next person that overdoses on the same thing. So I still think it's important to notify poison control of anything. I always try to take the time and encourage people to take the time to do it. And there's some things that, you know, I had a patient in residency that was a hydrofluoric acid exposure that sounded, you know, it looked pretty benign. It was a cutaneous exposure that they didn't think too much about and of course got really sick. So it's always a good idea to just get an expert involved with anything like that. So I'm curious if this has been implemented in anybody's local EDs. When the three-day medication dispensing rule came out, either three days of buprenorphine or methadone from the emergency department, in Illinois, some hospitals were looking into implementing that to help bridge them to a prescriber or treatment center. And so I know that without additional funding from one of the hospital systems that previously worked, they weren't going to do that because it was such a cost. But I'm curious if anybody else had that implemented. Yeah, we've been, with what, again, the small kind of rural hospital that I primarily work at now, honestly, we just got suboxone put on formulary about a year ago. So that's how long it's taken even to have the ability to continue the inpatient dosages. But at the tertiary care facility, of course, things are way past that. But we, there is the ability where we can dispense a little bit, but it's still a fight with pharmacy. As far as the dispensing pharmacy, the logistics of it, I don't think it's as much as the cost. There are just concerns about the legality of it being a dispensing pharmacy, or at least that's what I often get with them. But we do have the ability, if you're doing a home initiation, we do have take-home packs. It's not anything where we can really tailor the regimen. But we can give, it's essentially, I think, I think it's two days, like two strips, where you do four milligrams. So two, they cut an eight milligram strip in half. So a little bit of an ability to give some. But we haven't been super successful in being able to give them a whole lot out of the ER. Okay. And I'm just going to put the bill in the chat. We do have some time left. Anybody else have any questions, comments, experiences they want to share? And just for everybody, I'll go ahead and take a take a second to remind everybody. So we're doing this monthly, Dr. Wessel will be presenting on July 13th. As we talked about, specifically about opioid treatment programs, it Thursday at 6pm. So that'll be a good one for everybody to attend if available. So we look forward to seeing everybody that can on that call as well. Norma, does the patient have to return to the ED for additional doses? Yes, they have to come. They can come daily for three days. No, actually, no, I take that back. They can be dispensed three days worth. Yeah, yeah. Anybody have any burning desires? Well, thanks for for the conversation. Thank you, Dr. Conrad for your informative presentation. I think working in the emergency department is interesting and takes a special kind of person. And so I appreciate what you do. And thanks, everybody, for attending. Thanks, everyone.

substance use disorder

medication-assisted treatment

emergency department

rural areas

screening protocols

buprenorphine

naloxone distribution

Naltrexone

collaboration