and welcome to another testimony from the trenches. I'm Elise Wessel. I will be your moderator for this evening. And I am pleased to introduce Dr. William Moroney. He is a chief medical officer and medical director at Recovery Pathways, an investigator in a distribution in Michigan, medical director of a drug court, associate professor of family and community medicine and Michigan State University for 23 years and was the program director of family medicine at Synergy Medical Education Alliance and Liaison in the Department of Psychiatry. He is triple boarded by the American Board of Addiction Medicine, American College of Osteopathic Family Practitioners and the American Academy of Pain Management. He's offered expert opinions in addiction treatment and forensic toxicology for 20 years. He has authored the only book on Narcan in America and has done research on buprenorphine and naloxone in pregnancy. He was a Ruth Fox faculty for the ACM Medical Scientific Conference in Washington, DC and an active addiction educator and social advocate in SUD treatment and parity. Dr. Moroney has led child death reviews and opioid fatality reviews in many counting and has been a strong advocate for treatment in jails and prisons as well as post-incarceration overdose prevention and reentry aftercare from 2019 to 2023. I will hand it over to Dr. Moroney and please feel free to post questions in the Q&A box. Thank you. Thank you for that introduction and I'm humbled to be in this group because it is hot topics. It is stories from the trenches and we get to share sometimes really exciting things and very dramatic things and then really confounding things. And this is a great time to be in Addiction Medicine, maybe any day is if you really like what you do is a great time to be in Addiction Medicine. I just, I'll never forget 10 years ago when we were talking about buprenorphine and suboxone, we said, well, that's it, it's all over, it's boring, there's nothing else happening out there. And now look where we are today. This whole lecture is based on the fact that buprenorphine continues to evolve and its need and utility is something that we could have never predicted the safety and efficacy and in different sites, it is performing and it is our systems and our logistics and our people that fail and our governments and our payment systems, but it's never the medicine. We're gonna look at data from the emergency department some adult drug treatment court, principles and data and how that fits the future of telemedicine, mobile units, county jails, prison re-entry and then some of the safety I wanna bring you from my own personal experience with suicides and autopsies being the medical director or the chief medical examiner in five counties and I share a lot of information with other people from my state and other states. These lessons I've learned over the last 10 years. So our system here, we concentrate on suicide, poverty, addiction, criminal justice and forensic science and suicide is a tragedy, but so is poverty. And all these things, poverty, addiction, every criminal justice, it's all linked and we have to begin to see that picture. I got my toxicology training at the University of Missouri, Kansas City School of Pharmacy in Kansas City and I got my forensic pathology, general forensic pathology at the Armed Forces Institute and I'm kind of a chemical geek, I love chemicals. If you're in the wrong place, this is where we're at. This is our webinar tonight, Testimony from the Trenches. I just wanna know that you're in the right place, this is where we're at. I don't really have to give disclosures, you see this all the time, but we're gonna include discussion of investigational uses and I go back and forth between generic names and trade names and it doesn't mean anything. Nobody supports anything because I call it something special, but the slide deck and the data are proprietary. So we'll start with our six objectives. Number one, we're gonna review some of the opiate drivers in these situations and number two, we're gonna try to understand that diagnosis of opiate use in many of these settings and look at some of the barriers to treatment. We're gonna review that treatment and have a laissez-faire broadband attitude towards medication assisted treatment and it really wasn't me 15 years ago. And I want to begin to point out and it's really not editorial where the barriers are in our care in these many different settings because the barriers are never buprenorphine, okay? Uh, if anybody here is old enough to remember Senator Domenici from Arizona, he's the first person to bring up parity. We would have better control on addiction if we have parity. We still don't have parity and there's laws that say, oh, you should be exercising parity and the funding bureaucracy is always confounding, but our hope is that we reach out to each other and collaboratively and aggressively and transparently with nothing to hide, all of our legacy interprofessional team members from the social workers to the therapists to the prescribers. And finally, always humbling, what do we learn from failure? Let's clearly identify failure. One of the problems I have with education today is everybody's too nice. We sometimes don't talk to each other like we need to talk to each other. That definite addiction, this took 20 years to get here is profound and it's really how you're going to change people. You have to feel this, that addiction is defined as a chronic relapsing disorder with compulsive drug seeking use despite adverse consequences. People don't understand that. If you're a provider and you've been doing this for a decade, you know it, you understand it now. And it's considered to be a brain disorder because it involves functional changes to the brain and brain circuits that involve reward, stress and self-control. Addiction is treatable, it's a chronic disease and it's built on neurobiology, genetics, environment and a person's life experiences. And only when you're in an interdisciplinary team and you can get that message out and you begin to see lights turn on in other people that that's really meaningful. Prevention efforts and treatment approaches are generally just as successful as they are for diabetes and hypertension and congestive heart failure and COPD. It's compliance and adherence that are really important. I wanna say that back in 2016, I wrote an editorial in a Detroit political newspaper and I identified fentanyl as the next demon. And it was right as we were launching Narcan. And I said, this has to be a new strategy where we're getting all this Narcan to the street. And a lot of people said, dude, that's for hospice patients. The fentanyl has got nothing to do with this. It's all Norco and it's all oxy. And when things turned out, things evolved the wrong way and a lot of people died. And here we are 70 years later looking at adulterants in fentanyl. And I think a lot of people just didn't wanna admit that there was something out there they needed to learn. In 2015 and 16 and 17, nobody wanted to say the word fentanyl. And still today, where I say fentanyl crisis, when I'm talking to the media and they wanna talk about opioid crisis and try to focus prescriptions and doctors, I correct them. I have no filter. So we're looking at fentanyl now more than ever. It's being sold as heroin. Heroin's practically gone in many places for months and months at a time. We don't see any heroin in autopsies. Fentanyl is a synthetic opioid and it has a strong affinity for the immune receptor and it's highly lipophilic, which is what causes some of our problems with fentanyl. It makes initiation to buprenorphine problematic and that's due to buprenorphine and fentanyl competitive binding at the same opioid receptor. If you really treat people that are using fentanyl and you're trying to get them on buprenorphine and I don't know why you wouldn't right away because you're stopping them from dying, you see things that other people don't see. There's like this wave of buprenorphine, then there's a wave of fentanyl, then there's a wave of nausea, then there's a wave of clarity. And I saw this years ago and I couldn't put my finger on it but it's actually probably the medicines coming on and off the receptor because they're battling competitively at the receptor like it says they are. Now, fentanyl was always judged to be a very fast acting compound and it is, the only reason we know it as a depo is that's how it's formulated. And people said, well, if you use it, well, then it's gonna be fast on and fast off and if they're using it in drugs, it's fast on and fast off with the heroin. Except that lipophilicity creates an organic depo that then you have to deal with all these people injecting one or two grams of fentanyls going into their fat. And then it releases days, hours later and it's not fat in and fat out, it's fat soluble and then we deal with that. So trying to work with people on the street with buprenorphine, they're experiencing withdrawal and part of our research in the last couple of years coming out of COVID, we try to figure out how to get people on buprenorphine off the fentanyl. It's been difficult and a lot of people have gone into precipitated withdrawal. And if you had a chance, one of the easiest things you can do is put people on methadone because it's not a partial agonist, it's a full agonist and nobody goes into withdrawal and then work with the methadone to try to get them off. Now, I don't like that but that's one of your options, that's not what I do. We try to figure this out and then I listened to a lot of lectures last year about how people at the universities were giving people full agonists. Well, okay, you're in a university hospital, I'm in a clinic, I'm all alone. Well, I have five other providers and 15 therapists but we don't have that benefit of the hospital giving full agonists. We have to try to figure this out in an ambulatory setting. So some of the answers are not ambulatory and most of the treatment is ambulatory. So we wanna match that up. I have always been somebody advocating for treatment and how drugs ruin people's lives. And I was there early on, I put Narcan on TV when Prince died of a fentanyl overdose and we tried to explain that. We had a lot of people say, well, we just don't understand it. It has to be the same message over and over. And we've had some people in government and academics say, well, you shouldn't go on TV. This is a medium, this is how people learn. You have to do this and you have to be transparent and you have to have a history of doing it right. You have to be a provider, a prescriber who can put pictures into words and demystify things. So here's an excellent study that the next step of the future is, I see it revolving around this with fentanyl and buprenorphine. It's a Mariani and Levin and it's that one day transfer. Now, the primary endpoint is to measure how many people they can continue after precipitated withdrawal and to continue to treat them and the people who miss precipitated withdrawal and try to figure that out because it's gonna happen and clinically control those in an observed setting. Now, the third endpoint is that I wanna emphasize is that everything that they do in Mariani and Levin gives us this hypothetical where we need to go, but they skip a lot of the REMS and we're held to a standard of following the REMS. So legally and financially, we cannot just adopt Mariani and Levin and you can't do home inductions this way, but they've worked out the receptors and the concepts. The next step is to try to simplify or disambiguify this critical seminal study. It shows us what we need to do with fentanyl and buprenorphine, but all the providers in America can't do this because it doesn't follow REMS and you have to have a sublocade waiting in a refrigerator and we don't have that. It's a specialty pharmacy function and it's difficult to obtain. But they ask a lot of the right questions. But they ask a lot of the right questions. Now, if we come down to where is fentanyl across America, our county is a sentinel on fentanyl. We show people where it's hitting in autopsies and toxicology and you can see that we had 42 total drug overdoses, 38 of them were opioids and 33 of the 38 were fentanyl. Seven years ago, it wasn't there and now it's the dominant opioid, but I don't wanna say opioid crisis because that dilutes what we need to do. It should be a fentanyl crisis. And we can see that all of our prescription opioids pale in comparison to the damage and the carnage left by fentanyl. Fentanyl is a major public health problem and in opioid use disorder, buprenorphine has shown itself to be very important. One of the places we need to look at is the emergency room and there's been some very good studies, Gail D'Onofrio out of New Haven did some studies, but her studies were done before fentanyl. So all of her studies are heroin. So let's go back and look at some very specific fentanyl and heroin comparisons. This study was Wakeman et al in 2019. I adjusted it by coloring it and I've modified it to make it easier to read. And you can see that what we're comparing is fentanyl and heroin and retention and fentanyl and heroin and abstinence based on drug screening. Some of the media has made fentanyl out to be a very big boogeyman and it is, it's damaging, it creates a lot of death in its wake, but the simple SUD MAT concepts are used in fentanyl and heroin here. And you can see that you get a response in fentanyl patients that gives us promise in the retention of patients and in the abstinence based on drug testing. Fentanyl and heroin on admission was not significant at sick months for retention and abstinence, but this is where it starts. This is also good data like Mariani and Levin. That's a very specific case on how to do things. This is the data we collect that says we have hope. What's a fentanyl timeline? There's other people that may, Office of National Drug Control Policy or somebody may say there's a different fentanyl timeline, but from what I've seen and how I've worked it, for the second time, the first time was back in 2006, 2007, but for the second time, fentanyl entered a major drug pipeline starting in New York in 13, it went to Rhode Island in 15, it came to Michigan in 16. I wrote my editorial and in 18, fentanyl replaced heroin as the number one cause of death at the CDC from 19 to 54 year olds. And one of the problems that we have all across America that we also see in Michigan is fentanyl is not being drug tested in the ER. 90% of the emergency rooms in Michigan and maybe Wisconsin and maybe Arkansas and maybe none of the emergency rooms in Kansas are testing fentanyl. They run these really quick federal fives. You know there's no fentanyl on that. And then they come back and say, oh, well, there's no fentanyl. That's inane, that's not helpful. So you have to have a test, whether it's a urine test or saliva test. Um, this is a saliva test. That's the fentanyl right there. If you're not testing fentanyl, you're not gonna see it. So you really need to know where it is to do the right thing. Going back to that editorial, looking at fentanyl and saying, this is gonna be important. We should listen to everybody and pass things around. And you know, I think people were just confused. And they said, oh, well, it's a hospice drug. It didn't work that way. I looked as of March 1st, 2023, 16 regional emergency departments, Hills and Dales, Covenant, McLaren, Ascension, my Michigan, Sparrow, Sandusky, Sheridan, Hayes Greenby, all these, nobody was testing fentanyl. There was one hospital that I know that was testing was Spectrum in Grand Rapids. And that's terrible that people wouldn't reach out and do this. So we actually did a study in the ER and we tried to copy Gail D'Onofrio because she was brilliant and it was a really good study. And I don't know that anybody really appreciated her treating buprenorphine in ER. We had some contraindications, you know, like people on benzos, people in custody, people that couldn't speak English, anybody who required hospitalization. We tried, we followed her rule and we got buprenorphine to patients in ER and then we checked them 30 days later, which is a primary endpoint. Her study was published in 2015 in JAMA and it's really clear and it was a lot of hard work because it looks like it was just a quick little study, but she studied her patients from 2009 to 2013. That's how come there was no fentanyl in them. But how, and everybody thinks, well, they were overdosed and then she gave them buprenorphine. No, people came in withdrawal. 52% came in withdrawal, only 8.8% came in overdosed. And the other 34% are people that knew they were addicted, they just wanted help and they walked in and looked for it. This pie tells us there's a lot of people looking for help that don't have to overdose that you can reach out to. And that was the benefit of seeing that you could start buprenorphine. What kind of drugs were people on at that time? More than 50% of them were IV drug use and about 25% were prescription opioids. I'm sure that today IV drug use is closer to 60, 70, 75% and prescription opioids are down to around 10 or 12. The endpoints that we enjoyed in that JAMA study, D'Onofrio 2015, where people were engaged in treatment 30 days, 10 weeks later, that got buprenorphine in the ER. And they were more engaged than the traditional expert or the people referring out, oh, go to community mental health, we'll get you an appointment there in two weeks. That doesn't work. And people self-reported a decrease in illicit use. She was able to take people from 2.9 and 2.4 days of illicit use down to under one day. In our study, we had higher people using per day, higher use per day, and we weren't as prolific. But it's a fast-growing segment of getting these people in. Now, the only difference, we had a tiny little ER, a memorial hospital in Shiawassee County, and she had New Haven, Connecticut, big university hospital. So ours was kind of rural data, and hers was urban data. Later, it was important, she repeated some of her stuff and followed the patients out. And while it's still really important, and it's a classic study, and it earns gold star, the window of helping people turned out to be about 60 days. So if you study them six months and a year later, it's not the same. That's important to know. And these are getting people to ASAM 1.0 continuum of care ambulatory centers. So you have to know that. But her model is the same as David Filene. Interesting, they're both at Connecticut. It's starting people in treatment, the cognitive behavioral therapy, motivational interviewing, or incentives, and then giving them buprenorphine to stabilize their brain. When you take the medicine away, people fall out because abstinence-based care doesn't work. Our treatment worked more by telemedicine, because guess what? We did ours during COVID, but we had the same percent retention as D'Onofrio 2015 and Filene 2014, which is what this graph is from. Now, going in the county jails, I really enjoyed reaching out our key. If there was one word, people are going to disagree depending on where you are, but our key in the future for criminal justice is one word, sheriff. If the sheriff doesn't buy into it, nobody's going to buy into it. Got to do your education. Sheriff buys into it, corrections officers line up. Sheriff buys into it, probation officers line up, and the sheriff is the most important person. We compared Midland County Jail to Bay County Jail. We looked at some fundamental statistics, and while I live in Bay County, I work in Bay, Midland, Saginaw, Tuscola, Aranac, and Iosco. What we knew was the Midland County Jail was more friendly to treatment. We had higher numbers of people being seen in Bay County, but when the percent of MAT was delivered in Bay County, based on culture, only 57% of the people that we reached out to completed MAT with a Vivitrol shot. In the Midland County Jail, it was 79% based on a slightly warmer culture with a different sheriff, same politics, same political party, same taxation base, same number of sheriffs, same size jail. Everything's the same, but the sheriff in one case was actually, yeah, come on in, yeah, and then when Sublicate launched, yeah, well, we're not real crazy about Suboxone, but if you want to bring Sublicate in, come on, bring it in. So what that turned out, I actually had the exact same number of telemedicine visits, which is somebody goes into the jail there with the offender, and they call me, or they put me on Zoom. 79% MAT delivered versus 57%. I think that's a big deal. Culture. It's not the medicine. The medicine doesn't fail us. It's always the success and failure is in the logistics and the people. Here's a really excellent study, and this is removed from my hands for forensic overdose death data. The data here comes from Edward Williams Sparrow Hospital, Department of Forensic Pathology, and they're just bought by the University of Michigan. So this is solid. What this shows us is that fentanyl had not yet hit Isabella County in 2014. Isabella County in 2014. Fentanyl hit Isabella County in 2015, and you see the intensity of the overdose deaths. Now, we had an office, and we expanded care, and people from Isabella came to Midland. We didn't have an office in Isabella, and we were able to watch the intensity of treatment go up just one tick from 13 overdose deaths to 12. That's not statistically significant, but the trend is really good because in 2017 and 18, we opened in community mental health, and we were also treating the criminal justice population on the reservation. We were in a healing to wellness drug court for the tribe. In 17 and 18, we were there. That's significantly lower than 13 overdose deaths, and in 2019, we had access. We began sending social workers with telephones into the jail to see me, to get prescriptions, and to come out and be on MAT. Overdose deaths went down to two. Then, for one way or another, the tribe and I separated paths, and the very next year, they had seven overdose deaths, and I think the year after, they may have gone up to eight or nine. This proves getting into the jail was key, and that was exciting to see that happen. That was really exciting to see that happen. How many people are we talking about in jail or prison here? 63,000 in Michigan, 17,000 in local jails, 40,000 in the state prison, and maybe just under 6,000 federal prisoners, and 1,600 adolescents. We gained access to some of those people before they go to jail through the drug courts. In the drug courts, the one word is not sheriff. It's judge. We like judges that are not intimidating. They're personable. They're approachable, and that's what I think we had with our judges. The three treatment court goals from a drug court perspective is to reduce crime and recidivism in the adults, number two, to reduce drug use during program participation, and change their lives to be productive members of a drug-free community, and number three, to be an effective alternative to incarceration, because we don't want to have to incarcerate people. That's why I'm a strong believer in the drug courts, but that's the court's goals. Our goals were slightly different as the providers treatment, eliminate arrest, reduce arrest, eliminate and reduce criminal behavior, reduce relapse, and reduce overdose deaths. These have been more social and behavioral. This doesn't always translate into government and county commissions. They want to see less people arrested. Our information comes from, if you're a buprenorphine prescriber, you recognize this. It's all the trainings, that the general population odds ratio for mortality is one, and IV drug users is greater than six. Then as soon as you get somebody out of being an active IV drug user into medication-assisted treatment, the odds ratio goes to less than two. Teach this. I've been teaching this for 10 years. This is the key, and this is what happens in jail, in post-incarceration release. One of the greatest studies to show this early on was Lee et al., and I think this is out of a New England Journal. This study is done with Vivitrol. A lot of people, if you're a strong buprenorphine fan, you don't necessarily look for this or you see it, and then you pass by and you turn the page. The results here are outstanding that people coming out of a criminal justice system and being started on Vivitrol versus the usual treatments were able to go 10 weeks before they relapsed instead of five. The relapse events were 43% instead of 63%. This is great data, and people were able to show a confirmed abstinence early on in post-incarceration release and adherence in drug screening and self-reports. This is the kind of data that criminal justice wants to see to reinvest in criminal justice. What about when people are in treatment? If you go from drug court to treatment or jail to treatment, where does treatment fit in? This has an adjusted hazard ratio, like an odds ratio, is that while you're in residential care, your risk of overdose death is one. It's nothing, almost practically. It's even. If you get out of residential care and you go to MAT, your risk goes down on buprenorphine to less than 0.2%. This is also really good data. This is a crowd check addiction 2020. If you leave residential care where your odds ratio, your hazard ratio is one, and you leave and you go back to the old neighborhood or the street and you're abstinence-based, your risk ratio goes up to five. Then that's the red bar, the huge red bar. Then the chartreuse bar is leaving MAT. Where do we want to put people? When they're ready, they go to treatment. That's the flat green bar. That's buprenorphine. Just trying to show you that this is real-world setting examples, adjusted hazard ratios for overdose death concerning medication for opioid use disorder and medication-assisted treatment. The different settings give us different risk, different hazards. One of the other options that we had was mobile units. I love mobile units because you can put them out rurally. The problem we had with mobile units is you really can't use narcotics on them because the states want narcotics at an address that they can show up and audit. Mobile units are not a good thing for that. We enjoyed taking our mobile unit to eight to 10 cities every 14 days with a social worker, drug screening, peer recovery coach, and then back again, telemedicine to me. The problem is the mobile unit is micromanaged at the state level by somebody inside of a cubicle, and they don't see what you see, and they don't care. That's what we became victim of. We wrote a fantastic grant, and it went to a committee. The committee decided where we were going to park every day. I had the chance to say, we're going to go to Midland, Michigan, and we're going to park at the Armory, and we're going to see all sorts of vets. We were overturned by somebody in the state capitol that said, no, we want you to go to Oil City because it's rural. Okay, that was Oil City. Nobody showed up. We gave up seeing vets at the Armory a couple times a week in the mobile unit, but you have to fight the system. You have to push back. Let's go back and look at some corrections data and compare Michigan Department of Corrections to Rhode Island Department of Corrections with SUD treatment. In general, what we're seeing in Michigan, and you may be seeing this in other states, is they're trying to take the populations down. Criminal justice reform has got a lot of inertia behind it. Old jails are the subject of millage. Sheriffs are looking for new jails, and we're looking for systems like drug court to give people treatment instead of incarceration. I think some of that's working here, and we see less people incarcerated since about 2006, 2007 down to 2021. In Rhode Island, they had a study where they ran a buprenorphine, methadone, and naltrexone in part of 2006 and in 2017, and then they studied some of the long-term results. Now, Rhode Island is not a perfect example of what you need to do. It's a small example that you can have a lot of control. You may not be able to use Rhode Island as an example, but it gives you a fertile ground to begin to think how we're going to make changes. Everybody thinks we're going to do exactly in Rhode Island what we're going to do in Minnesota and Texas. Well, they're going to be disappointed, but it shows us what can be done, which is a good thing. I'm going to jump ahead on this one. Here's Rhode Island. They began the methadone, buprenorphine, and naltrexone. What they saw, because of the size of Rhode Island, was a 12% drop in overdose deaths statewide. They could get away with that. That made a lot of sense. The focus was post-incarceration overdose deaths. We saw 61%, which was more than half, of post-incarceration overdose deaths. It dealt with approximately 3,000 men and women and 13,000 intakes and releases that year. Prior to that, methadone was only offered to pregnant women, and everybody was put on some kind of active taper. This comes from Clark et al. in American Journal of Public Health, 2018. The Clark study was a classic, and a lot of people went to seminars in Rhode Island to see how it worked. One of the only weaknesses that I think comes out actually is universal to everybody, is you have to have really good education in your corrections officers and in your corrections nurses. They may have done a better job if they had more time to work with educating the system, but they still did pretty good. This is a 61% drop in post-incarceration overdose deaths, and a 12% drop across the state. Rhode Island has a million people in it, and Michigan has 9.9 million people. Rhode Island has 15 methadone clinics, and Michigan has ... It's flexing between starting a clinic and getting a clinic closed down. It's always somewhere between 42 and 45 methadone clinics. The ratio of residents to opioid treatment programs and methadone clinics in Rhode Island is 66,000 to one OTP. In Michigan, the ratio is almost a quarter of a million per one OTP. The ratios are different, so there's different resources. What we saw when they did a similar study, they didn't release their data. When you ask people for data and they don't give it to you, you have to be in a position to wonder why. Well, we were in a position to do post-incarceration follow-ups. We knew that they were getting data. We knew that they were treating people. In that time block, there was no drop in overall overdose deaths for the state of Michigan. In Rhode Island, there was a 12% drop, so we didn't have that. What we also noticed that nobody was coming out and saying we were decreasing post-incarceration deaths. On a personal level, because we're in the center of the state and we looked at what was going on, we had 24 reentry clients come to us. We knew they were giving treatment, and we asked a lot of questions. Out of that 27, 24 of them came into us and said right away, I want off sublucate. I don't want to do sublucate. I want to go back to suboxone. That was the first visit. It was perplexing. We wanted to say, look, we'll work with you, but on your first day, you can't say this. Do the shots for a while, make sure we're stable, and then we can make an assessment. 24 out of the 27 wanted to stop. When we said, work with us, take the shot for another month or two, and then we'll talk about some kind of transfer over, because that kind of data really wasn't given out by the manufacturer or the FDA. There were not a lot of studies on that. Nobody came for their second visit. We probably have three active opioid use disorder patients. There's 63,000 men and women in the program, not 3,000. There are 113,000 intakes and releases, not 13,000. These are unpublished results that we're trying to collect some more data and put some more data and put it out there. We felt there was a problem. The problem was whatever they were doing inside the prison, and nobody was telling us what they were doing, but we could ask the post-incarceration release patient, but they're not always reliable. When you say, I'm not going to give you a suboxone, I want you to take the shot one or two more months and figure this out, and they don't come back, you can't get any answers. 88.89% of our Department of Corrections re-entry no-showed for a second visit that was either therapy or med-checked. 88% no-shows, 88% requests to stop sublicate, 12% retention beyond the first visit. We think that people were going to be using suboxone to pay their rent. People were really on their first visit. They weren't as forthcoming and as transparent as we would have liked. We wish that MDOC would have brought us in. Actually, they did bring me in a couple of years ahead, and then they took somebody else's idea to be a consultant. We weren't given any drug testing from MDOC and these people on release. We felt we had unreliable histories because we felt we had unreliable historians. People were telling us that they were taking the suboxone and jamming it in their chapstick and mixing it up, and they could dose themselves throughout the week or sell it. There was all sorts of other things going on. I think in this case, suboxone may not have been the best thing to film. I really think inside the prison, maybe the subsolve tablet would have been better. Crush it up and use a paper cup, and then they have to dose it, where they were really trying to recreate the ambulatory dosing, which really didn't work. They needed to deliver a buprenorphine powder. They didn't have to use subsolve. They could have used a generic, but I think there was a lot of gaming going on to get strips. Our assessment is that the system has not been transparent, and they needed to build the system backward from aftercare, from treatment. Instead, they just did something internally and didn't care how things went when people got released. So now here's a really good study, like the Vivitrol study from New York. This was a buprenorphine study from Massachusetts. It compared Franklin County to Hampshire County, 197 buprenorphine patients to 227 abstinence-based patients. This is Evans et al from Alcohol and Drug Independence 2021. We saw in the buprenorphine jail, a entire jail that used buprenorphine and an entire jail that didn't in a different location, but their same rule base, same poverty level, same income level, all that. The buprenorphine patients had 32% less probation violations and 48% recidivism versus 63% and 36% less new criminal charges and 21% reincarceration. When you take this argument to a sheriff, he can't say anything other than, what is that stuff? Come in and talk to me, come in and sit down. So we were excited with this data. Everything was the same, except one jail used buprenorphine and one jail didn't. When we look at the non-criminal statistics, let's look at the deaths in the buprenorphine county jail on follow-up post-incarceration. There were six deaths in Franklin County. In the abstinence-based county, there were eight. The average age at death was 42 in Franklin County and 40 in Hampshire. But the number of days until somebody died was almost double, 287.5 days to somebody dying of an overdose after release instead of 141. And the types of death, you could see that they looked at overdose accidents and unknowns and the number of overdoses was very low. Now, after that study, there was a post-study, a debriefing and they went one additional year beyond when that data was collected and Franklin County's buprenorphine group in that post-year had zero overdose deaths and the abstinence-based had six. So recidivism, new charges, probation violations, you can't have an argument against buprenorphine here. Now, there are older studies that looked at things and you have to be very time-conscious. This study was looking at two years before somebody took buprenorphine and looked at the legal records and two years after and said, does buprenorphine make them less arrested? Well, two years before and two years after, there was no significant difference. So if you look at this data and you look at that big gap, you're gonna say, well, buprenorphine really doesn't matter. If you look at the Franklin County data, you'll say buprenorphine is shaking up Massachusetts and it's a good thing. We have a question from Kenneth Brodsky. He asked regarding fentanyl testing, it is my understanding that there are a number of analogs which continues to change, which would make this difficult to test because of potential false negatives. Okay, that's an excellent statement. But if you look at DEA seizures, the fentanyl analogs spiked around 17, 18 and 19, 2021, everything came down and fentanyl, fentanyl, not fentanyl analogs became the dominant player. Yes, you still have a few fentanyls here and there, remifentanyl, acylfentanyl. But if you look at the bulk of fentanyl seizures and you look at the toxicology data, the fentanyl analogs are not sufficiently statistical and significant to change that statement. Bulk fentanyl, it's like they tested them and then they came back and then just reasserted fentanyl. I hope that answers that question. We have to look at NILFIS, National Lagoferential Information System data to see that, but that's exactly what happened. Original data approving buprenorphine said, it reduces drug dealing, prescription fraud and other crimes. This data is in the packet and it's probably about 20 years old. And this is 30 days as opposed to two years. So this is really good. The Denafrio data is 30 days, the Moroni data is 30 days, the packet data is 30 days and the Franklin County data from Massachusetts is 30 days. So looking at our recommendations and treatment, all the opioid use disorder patients should have access, okay, that's a no-brainer. That's a no-brainer, but we need to reduce the risk of overdose and improve functional outcomes. I have to say, point number two, we need more advocates. People in treatment have to be more aggressive and say that abstinence-based care has no evidence. It doesn't have the evidence. I keep running into people at the state of Michigan giving money away to abstinence-based programs. I can't understand it, it's unfathomable. And point number three, these abstinence-based care programs, they get too much funding and all of our leaders are uninformed. We need to reframe the argument. It has to be more aggressive lobbying in that area. So let's take this summary down and we can answer more questions or I have a couple other slides, but I'm gonna wrap this summary up for the top of the hour. The emergency department initiation of medication for opioid use disorder has data. Our unpublished data copies Gail D'Onofrio, 2015. It increases engagement, but it doesn't increase it as measured for the entire year. It's a window, but it's a good window. It's a two-month window. What makes it difficult working out of the emergency department like that is some of the same things that we talked about the Mariani and Levin. That's a fantastic article, but nobody's gonna have a refrigerator full of sublucate to start giving it immediately. And in the emergency department, the billing and the special pharmacy insurance issues behind sublucate prevent us from using it in the emergency department in an ambulatory setting, outside of a major hospital that's gonna have hundreds of thousands of dollars and say, put it over here in the refrigerator. We can't treat people that way. It just, the cost isn't there and it's outside of DEA guidelines. So number two, adult drug treatment courts follow the abstinence precedent of the courts is what we're seeing and not evidence-based. So I have one court that has now embraced MAT, but until we took it over and the legacy provider left, they embraced abstinence. That was just a couple of years ago. How can people continue to embrace abstinence? It's because in the legal system, the judges look for the precedence of previous courts and they try to follow that instead of evidence-based. And I talk to judges all the time. I speak with them, emails, we teach together, we're on stage and this precedence of prior court activity is way too important because it ignores evidence-based. But that's where we need to make some adult treatment court movements is people are hung up on precedence. In telemedicine, I'll tell you that we were able in telemedicine to equal Gail D'Onofrio's data in ER and David Filene's data in an ambulatory psychiatric clinic. That's really important that you can see telemedicine and face-to-face are very strong and they're linked. So telemedicine is underused and coming out of COVID, the telemedicine rules are gonna change, but you always have to have that capacity because guess what? They're still not gonna let you see somebody face-to-face in many jails and nobody's gonna let you go to prison and see people. That's all gonna be corrections officers doing the work. They just discharge them and then you inherit them. So that face-to-face on a regular basis, I can't be in six jails in one day, but I can be in one office and have a therapist go to six jails and they show a patient on telehealth. So mobile units, mobile units are fantastic. They equalize the transportation barrier. If you look at barriers to people getting treatment, the number one barrier is people said they didn't know they were ready. Number two barrier is that people say, I didn't know where to get it. And the number three barrier is, well, I knew it was there, but I couldn't get there or they didn't have the money, I didn't have the transportation. So it's like in the top three barriers and you eliminate that with mobile units, but we have to change the way we work grants. They can't be reimbursable sub-grants. You have to give somebody a stack of money and say, go save your seats, I'll see you in a year. That has to change the way we do grants. The cost of mobile units, you always have somebody micro manipulating it, micromanaging it because of the cost and give the grant to somebody you trust, give them the money and let them go. That makes a lot more sense. Our local jail programs, it all comes down to one word, the sheriff. The culture of local jails leads us to a fractured condition and we need leadership. And my answer to that is, if you go individually to the different jails, you're gonna have to deal with all these different personalities. I was talking to Shelly Erdrichen, who works for the governor in Louisiana. And we decided that instead of trying to work with all the different jail systems and sheriffs, we were gonna go to the State Sheriff Association. And everything could come down from that. And it makes the most sense, but you have to have a good speaker and you have to have data and you have to be polite and you have to go on and meet with the Sheriff's Association. Prison re-entry, I don't know of any good published prison re-entry that shows the data about recidivism, re-arrests, deaths, puts it all together. The Clark article showed a reduction in post-incarceration death, but people wanna see less arrests. And you know what? We see that in the jails. We don't see that in the prisons. And prisons and jails are two totally different beasts. The jails are run by the sheriffs and you can reach them. The prisons run by MDOC, that's difficult. Go ahead, yes, another question. Yeah, we do from Marcus Cooksey. Can you speak more to the efficacy of buprenorphine crush tabs versus film for success? You said earlier that the sublingual film was too easily diverted. So the data was poor, at least in one setting. Study, is one medium better than another for correction settings? Yes, I will. But before I answer that question, I have one take-home message at the bottom of this slide. In case we didn't get there, I kinda showed it to you early on. Buprenorphine is not in suicide data, it's not in overdose data, and it's really not a part of medical examiner reports. That was part of our title is looking at autopsies and suicides in medical examiner data. So now let's go back and answer that question. In a criminal justice setting, people are already in a controlled environment. When you have a tablet, I'm going to look real quick. All right, a crushed tablet in a paper cup dissolves under the tongue. A film put under the tongue dissolves under the tongue. Now, if anybody at MDOC is watching, they're really not gonna like this. I'm not gonna have friends here, okay? When you crush a tablet and you put this tablet under your tongue, it dissolves and it turns into a solution and you can't spit it out right away because it's crushed. Inmates were using their undershirts and their overalls and spitting their films out because they weren't being observed. And then on the inside of your shirt, your undershirt or your overall, you have a buprenorphine film and you let it dry and you bring it back to your cell and you can sell it. When you put this in a crushed paper setting, you crush it in a paper cup, you have to put it in and it dissolves. You can't reconstitute this. The benefit of the buprenorphine film was the FDA said to the manufacturer because buprenorphine came out as tablets 21 years ago. Make the buprenorphine product impossible for children to take and die. That's the history behind buprenorphine. As long as it was this tablet and was this pretty peach orange, it looked like Pez, people liked it. And kids got into it and the FDA said, figure it out. So they went to the cold, cough and flu medicines and they made that buprenorphine tablet, a film that could go under the tongue. So when I say the wrong product was used, it's because in an MDOC setting, people could spit the film out and dry it and sell it. That allows diversion. There should be no diversion in a criminal justice setting. If you wanna allow diversion in your clinic and figure you can get a handle on it, that's one thing. You cannot have diversion in a drug court, in a county jail or in a prison system because recovery just breaks down. Now, does that, when you talk about duration of action, whether it's a film or it's this tablet, buprenorphine has a 17 hour half-life. So it's not about the half-life, it's about the diversion of the format. I need to know, Dr. Wessel, that that answered that person's question. And we can wrap up. I'll take it. It seems like it. If you wanted to put it in the chat or in the Q&A, but I thought it was an excellent response. And as Cooksey says, so definitely tab superior to film in these settings. Yeah. I think buprenorphine film is a fantastic formulation and it's been earth-changing. It's saved millions of lives, but in a DOC setting, insanity, it was dumb. My mother told me never to say dumb. It was not smart. So, these summary points are based on the emergency department, adult drug treatment courts, telemedicine, mobile units, local jails, and prison re-entry. And I didn't put a lot of effort, but I'm telling you that buprenorphine, it's amazing how little buprenorphine is in overdose death data. And it's really not buprenorphine, it's norbuprenorphine. It's people who stopped taking it to go do fentanyl. So, if there's any other questions, I'm really excited. This was a lot of fun. This is close to my heart. And dude, it's 7.05. I'll hang around a little bit. Thank you all. Sorry, we don't have any questions right now, but thank you so much for your expertise and insights and sharing that with all of us. Yeah, it's been a lot of fun. Please consider joining the American Osteopathic Academy of Addiction Medicine. We're a smaller group than the other guys, but we have a lot of fun. And what you get with a small group is rapid change and response. We can do things as a little organization that don't have to go to really big committees. And you just meet all sorts of people. Today, I can still thoughtfully think about the two people, Dr. Tony Decker and Dr. Steve Wyatt that fired me up like 25 years ago and got me addicted to substance use disorder. They're fun guys and I own everything. Have a good night. Dr. Maroney, we did have just one question pop in from Cynthia Lewis. What do you think the barrier is for testing fentanyl, cost or ignorance? Well, right now, Cynthia, we don't have a clear waived fentanyl testing. Do you have any other insights into that, Dr. Maroney? Yes, I think it's a three part. Cost is one of it. Number one, the hospitals want to be compensated if they're gonna do a fentanyl test and they're not gonna do a test that they're not gonna get paid for. Ignorance, instantly people in the emergency department became addiction experts. Instead of calling people to come in and help them with programs, they just sat in a room and pointed to each other and said, we're gonna do this whether you like it or not. And they really don't have the experience. Yes, they know how to do emergency advanced thoracic life support and suturing and congestive heart failure, diuresis, but you gotta be in addiction for a decade or two to really understand what's happening because it's happening so fast. And then the third part that Dr. Wessel brought up is people are really uncomfortable doing a lab test that may not be clear waived. So we get around it by all of our testing is done in clear waived cups and the fentanyl test is a separate dip. And then when we send it out for confirmation, because these are completely useless unless you do confirmations in ambulatory care. When we send out our fentanyl dip that's either positive or negative, the CLIA test that comes back that gives us nanograms per ML is perfectly fine, but you kinda need like a pregnancy test, like a barometer, is there fentanyl or is there no fentanyl? What is it? And that not being CLIA waived, having people that think they're addiction experts and then hospitals and healthcare systems wanna get paid, they don't wanna do it for free. Those are our three main barriers. You know, I'm going to look up here real quick. Oh, I do see somebody who worked in a methadone clinic said that methadone was useful in the transition to new patients to buprenorphine, which I kind of suggested because straight to bupe, it's partial, you precipitate withdrawal. And then the same person talked about that avoiding precipitated withdrawal is one of the big benefits of a methadone clinic. Methadone clinics, I think are highly underused and people don't understand them. And if you're going to be a buprenorphine provider, you really have to have a methadone clinic as a friend. Yeah, I was going to say I just did a talk on OTP programs. I work at OTP and we kind of addressed all of this in that talk. If you want to go back and listen to that, but totally agree, Dr. Maroney. Excellent. All right. Thank you, Dr. Maroney. Thanks, everybody. All right. I am going to stop sharing my screen. And if you have any questions, send them to AOAAM. Good night, everybody. Thank you so much. Good night.

Dr. William Moroney

addiction medicine

buprenorphine

opioid use disorder

treatment

access

telemedicine

medication-assisted treatment

recidivism

fentanyl testing

evidence-based treatment