Good afternoon, everybody. Welcome to today's ALAAM webinar, Update on the U.S. Overdose Crisis, Which Drugs, Who is Dying, and How Do We Save Lives by Dr. Chelsea Shover. My name is Julie Kmic and I'll be your moderator for this session. This is the last of our summer webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. I'd like to introduce our speaker, Dr. Chelsea Shover, PhD, is an epidemiologist and assistant professor in residence at the University of California, Los Angeles School of Medicine in the division of general internal medicine and health services research. She completed her PhD in epidemiology at the University of California, Los Angeles and postdoc fellowship in psychiatry and behavioral sciences at Stanford University. Her research focuses on substance use, infectious disease and their shared social and structural risk factors. Her 2019 study on the changed associations between cannabis laws and opioid overdose mortality was named among the year's top 10 proceedings of the National Academy of Science papers contributing to public understanding of science. She coauthored a report published in the Lancet responding to the opioid crisis in North America and beyond recommendations of the Stanford Lancet Commission. Alongside her academic work, she served as an epidemiologist in government and nonprofit positions. Most recently as a supervising epidemiologist for the Los Angeles County Department of Public Health's COVID-19 response in homeless shelters and encampments. Supported by a career development ward from NIDA, her labs current projects include methods to use rapidly available overdose data to inform public health policy, as well as community-based implementation of harm reduction strategies. Using medical examiner data, her team has identified key local drug supply changes and then worked with policymakers and community organizations to improve on the ground overdose prevention. So welcome Dr. Shover. Thank you so much for the introduction and thanks for having me. And I do want to note, I'm happy to take questions throughout. If you could just put them in the chat or I know Julie is also moderating. So either way or unmute, if I'm not seeing your chat, please unmute to ask because I'm happy to take questions throughout. Yeah, we'll have them enter in the Q&A and then I'll announce them. Oh, perfect. Okay, great. All right. Just want to do some funding acknowledgement, funding for the initiative here by SAMHSA. And then I am personally supported by several grants from the National Institute on Drug Abuse. But I do not have any disclosures. So we're going to talk today about overdose data and then we'll talk about some strategies for primary, secondary and tertiary prevention of both substance use disorders and overdose deaths and kind of what these large data trends can tell us about those pursuits. So to start off, we often think of the overdose crisis as having waves. The first wave pretty well, I think we've talked a lot about the first three waves in drug policy world and we're starting to acknowledge and name and describe this fourth wave. So just as a recap, the first wave, we're really talking about the increase in deaths involving prescription opioids that started in the early 2000s based on a large amount of prescription opioids being available through widespread prescribing in the 90s and early 2000s. Then starting in 2010, we start to see an uptick in deaths involving heroin as people switch from prescription opioids to heroin and market switch as well. And then just a few years later, what we think of as the third wave started with the rise in fentanyl overdoses. So fentanyl, as most of you probably already know, is a synthetic opioid that's many times stronger than heroin. It has another key advantage over heroin in terms of production and marketing and that is it is entirely synthetic product. It can be made in a lab. You don't need a field of poppies for it. It's just kind of a lower manufacturing footprint. And because it's so strong, it's also much easier to conceal very strong quantities in a small physical space. So we saw the rise of fentanyl-related deaths really begin taking off in about 2013, mostly in the Eastern US and the Midwest. Prior to 2018, actually, over 80% of fentanyl-related deaths occurred east of the Mississippi River. But then starting in 2019, 2020, you really start to see fentanyl in all markets across the United States. There are some exceptions, but for the most part, everywhere, the drug supply everywhere has a lot of fentanyl. And the fourth wave is what we consider the more recent years when it's really started to be fentanyl plus. So where overdose deaths involve fentanyl plus stimulants or fentanyl plus benzodiazepines. And that was really shortly following the third wave. And I think it's important to talk about them as two separate but related phenomena, just because of, mostly because of the treatment and prevention implications when we're thinking about fentanyl and stimulants in particular, which now account for, next slide, which fentanyl and stimulants now account together or separately now account for the vast majority of overdose deaths in the United States. These first couple of slides are using data from the Centers for Disease Control's wide ranging online database for epidemiologic research or WONDER. It's all of the deaths in the United States and classified with ICD-10 codes. And this is all deaths where the underlying cause of death was attributed as drug toxicity, whether unintentional, intentional or undetermined and a very small number of homicide. And then we're able to see the broad classes of drug involved using the ICD-10 codes for synthetic opioids, stimulants like methamphetamine or cocaine, and then other drugs as well. So this chart, I mean, so the first several charts here come from a paper that my colleague, Dr. Friedman and I recently published about just trying to characterize this fourth wave, like what is happening? And as recently as we can look at with the national data, which unfortunately, as we'll talk about, does still come at appreciable lag, but we are able to see that this rise of where the blue part of the chart is fentanyl without stimulants. It can include opioids or any other drug, but just no stimulants. The purple is fentanyl and stimulants together. And that part has really been growing since 2015. And the red is stimulants without fentanyl and the yellow is just everything else. So that's all. So in 2010, 77% of overdoses involve drugs other than fentanyl or stimulants, but only 11 years later, that figures down to 16%. So really it's most overdoses now involve fentanyl, stimulants or both. Geographic differences. So I kind of have structured this talk mostly as a really broad like data level overview of what's going on right now and sort of to give, I'm really welcoming questions and opportunities to discuss specific things about it. Because I think that's really in this sort of audience where it's mostly physicians and scientists and experts, I think that's really the valuable part, right? Rather than just stepping through but there are more charts to come. Okay, so geographic differences. So here's another chart. This one's a little bit older. It's from the publication in the Lancet on the report about the North American opioid overdose crisis. This is simply looking at overdoses involving opioids and just mapping it. It's kind of a crude state and province level heat map of which areas have very high denoted by darker red crude mortality from opioid overdose. And that's mortality per population size. So somewhere like West Virginia that has a relatively lower number of people than somewhere like California where I am, the rate in California is much lower just simply because there's more overdoses but spread over a much larger population. So we see kind of the hotspots at a really macro level here in terms of West Virginia, Appalachia, and then the Western coast of Canada, British Columbia, as well as some other darkening, other darker red areas, but this is through 2019. So it would be helpful if I had an updated map of this and I apologize that I do not, but this has kind of historically been areas that are like very, very hit hard. And then as fentanyl has become a bigger part of the drug supply other places, you start to see more and more of this map becoming redder and redder. But there's also differences. You know, when we think about geographic differences, it's not just in terms of overdose mortality, it's also in terms of what drugs are involved. So another chart, this one is looking at the, so this one is only looking at fentanyl related overdoses. And this is from that fourth wave paper I was talking about where Dr. Friedman basically took every state, all of the fentanyl related overdoses and looked at the most commonly co-involved drug by state and how that changed over time. So each of the colors corresponds to a different class of drugs where the yellow is heroin and orange is methamphetamine, light blue is cocaine. But basically I think the broad trends we can see, so we've also broken this up by census region. So the broad things we see are early on, early in the introduction of fentanyl into the illicit drug supply, we see that most deaths involving fentanyl also involve drugs that are legally obtainable. So that's things like alcohol or benzodiazepines or prescription opioids. Now it's important to note that on a death certificate, you aren't able to know where someone got a particular drug. So you don't know if oxycodone that's implicated in death was prescribed to that person, or if it was just taken from a family member's medicine cabinet or if it was purchased on the street. But you get a sense that these are all things early on, fentanyl is showing up mostly with drugs that there is a legal avenue to get. Then in most of the country, starting around 2013, when you really see like kickoff of fentanyl, you start seeing it show up with heroin. And that makes sense in the sense that, initially fentanyl on the East Coast and Midwest was really introduced into the heroin supply as a substitute for heroin. And as fentanyl in the Eastern part of the US is predominantly what's called China white, like a powder product as opposed to black tar that's more common in the Western US, that sort of makes sense where it was just easier to pass off one white powder as another. And that's where you start to see a lot of deaths involving both heroin and fentanyl, which in many cases are attributable to people using them both together, whether they know it or not, if you're expecting heroin and you get some fentanyl, that's going to be a much stronger drug. That really didn't happen in the Western US. And I chalk that mostly up to black tar heroin being predominant here. I mean, we do see fentanyl show up in black tar, but it's just not as pervasive. And there doesn't seem to be as much of a drive to do that, but it does happen. And then in more recent years, we start seeing a switch so that the most common co-involved substances are stimulants. So the CDC data allows us to look at cocaine as one category, and then a category that includes methamphetamine as well as other psychostimulants. I'm saying methamphetamine for shorthand, that is the vast majority of deaths in this case, but technically it does include other psychostimulants. But in more recent years, universally, the most common co-involved, like if you just look at all fentanyl-related overdose deaths the most common co-involved drug is a stimulant. And which particular stimulant, whether that's cocaine or meth differs by place where with the Northeastern US having more states with cocaine predominating and most of the rest of the country having meth predominating. And that to me seems to reflect drug market and preferred drugs at different places, as well as the fact that, yeah, I guess methamphetamine has long been a more common drug in the Western US and Midwest compared to the Northeast where cocaine has just been more common and available. Sorry, I'm having trouble advancing my slide. But I guess this actually might be a good point to talk sort of about the dynamics between the waves. So, when we think about the overdose crisis in terms of waves, I'll just jump back to this other chart that I have if I can. Why won't my slide go back? There we go. Where you can kind of see that this first wave, the green one of prescription opioids, it's gone down over time, but it hasn't gone away. And so in this chart, we're showing only prescription opioids that don't involve fentanyl. And then the heroin wave, this purple wave has also receded, but it's still there. And so, I take that to mean that like, this is a crisis where it's really compounding that just the fact that most deaths now involve fentanyl and a very large proportion involve fentanyl and stimulants, we're still seeing deaths with fentanyl by itself without stimulants. And we're still seeing deaths involving heroin and prescription opioids, just sort of less. And so it's waves that come one right after another on top of each other and really stack up to put us in the situation we're in now where there are lots of people dying and it requires many different kinds of strategies. Let me just go back to this. Okay. But thinking about this historically, it is the case that typically after you have population level rise in opioid use and opioid overdose, it's typically followed by a rise in stimulant use and stimulant overdose. I think probably the most salient recent example would be thinking about heroin in the 1970s followed immediately by crack cocaine in the 80s. And that's just sort of a temporal trend that happens between opioids and stimulants or like between drug markets. Some reasons for that, I think it's helpful to think about that. Like why do we see a rise in opioids and then a rise followed by a rise in stimulants? Part of that is just as a response, right? Where some people start using opioids and then add in stimulants. And that can be to enhance the effect with like a speedball or a goofball, which is mixing heroin, cocaine or fentanyl and cocaine or heroin or fentanyl with methamphetamine as a goofball. But it also can just be as a response to, if you're using fentanyl every day, it can, you know, you can find the need to wake up sometimes and that's when a stimulant becomes, you know, that's when bringing a stimulant on board, people start using stimulus too as a response to, you know, the drowsiness and all the effects of the fentanyl is like, okay, like we take, you know, it's just classic, like uppers and downers take, you might take fentanyl in the morning and, or sorry, stimulants in the morning and fentanyl at night for, you know, as a very simple example. And that is an important thing to remember when looking at this data about polysubstance overdose deaths is that with death data, we cannot know whether someone took, say fentanyl and methamphetamine together, like in a goofball shot, or if they took fentanyl and methamphetamine on the same day, but at different times. I mean, typically like the post-mortem toxicology is going to be able to tell you within a kind of wide timeframe when they took it. So, you know, it's recent, but not necessarily, you know, if you took methamphetamine first and took fentanyl a few hours later, they'd both, you know, have, they'd both still show up and it wouldn't be possible to determine if you took them together. And of course it's also, you know, there's also the case less with meth, I think, but more with cocaine where people take cocaine thinking it's just cocaine and then there's some fentanyl in it. So all three of those scenarios can lead to a death that's coded as say fentanyl and cocaine. It's like intentional use together, intentional use, but not at the same time or intending to use one and having it be contaminated with the other. Oh, so we're still sort of talking about geographic differences and what drugs are involved. And this is pivoting to xylosine. Probably you've started hearing a lot about xylosine. I'm happy to talk more about it. I only have this one chart, but just as a brief kind of orientation for xylosine, xylosine is a veterinary tranquilizer. It is not an opioid, but it is a depressant in the sense that it's, well, it's a sedative and it's a sedative used in veterinary medicine for large and small animals. And it's been showing up in the illicit drug supply around the United States. It really started showing up in Puerto Rico in the heroin supply. And then the second sort of place was Philadelphia. And Philadelphia now has a pretty thorough and mature xylosine market in the sense that a very high percentage of the heroin and fentanyl there also contains xylosine. My colleagues and I use death certificate data to track the spread of xylosine around the United States. And this data was looking at, published this last year, this was looking through 2021 as well, although we only had data from the first half. But just seeing the rise of xylosine in different places, and I think when we talk about xylosine, the kind of the key things to know are, there's a few reasons to be concerned about it. So one is that anytime you're layering two drugs with two central nervous system depressants on each other, of course, there's the potential for increased risk of overdose. So if you're talking about an opioid and then adding a sedative on board with it, you become concerned about them having synergistic effects. The other thing with xylosine is the fact that it's pretty profoundly sedating for some people. And certainly if it's encountered in a street drug supply where you really, it's unregulated, you don't know how much there is, you don't know, you just, there's just so many unknowns about that. It can leave people really like, just kind of knocked out for a long time, which leaves people vulnerable to violence or assault. And just all the things, all the risks that come with say being in public and not being able to, not being aware of your own surroundings or not being able to wake up and do all the things you'd normally do. And then the third big concern with xylosine is the wounds that it causes. So I don't have pictures of the wounds, but I know it certainly has been covered in the media. There are certainly plenty of pictures of those, but the key thing is that xylosine causes, seems to cause these wounds that are difficult to heal. And it seems that the emerging evidence is it's clear that it happens at injection site for people who are injecting drugs, but we're also beginning to see evidence that it happens for people who either aren't injecting or their wounds that are not at the injection site. So say like people who are smoking a product or taking it orally. So basically like that's the other big concern. So yeah, xylosine is extremely present in Philadelphia, increasingly present in other places, pretty limited in a lot of the West Coast, although we are starting to see it. We can talk about the challenges in detecting it, but like one to just sort of signpost a big issue with it is that it's actually not a drug that is tracked by the CDC's database that I was talking about earlier. So it's not called out as a separate drug. So the only way to really get this kind of information in terms of death data is to look at the actual text on death certificates, which for this analysis, these charts were from jurisdictions that either make that publicly available so that you can download it online or by request, like through public records act. So this is kind of an ad hoc snapshot, but I think the impression it gives is that we've seen a big increase in xylosine in drug markets that represent most of the US. And as we start testing for and paying attention to it more, it's likely we're gonna see it more places as well as it becomes part of a more mature part of the drug supply around the country. And that's kind of an example of like something that has a lot of attention and it's really hard to figure out exactly how big of a problem it is outside of places where it's clearly an enormous problem, like Philadelphia or somewhere like where I'm based in Los Angeles, where it's clearly present, but not widespread. Okay, is there a question? Yeah, I actually have a question of my own. You'd mentioned about black tar heroin being largely on the West Coast and versus fentanyl. Do you think that has any reason or anything to do with the xylosine not being as present there? Is it harder to like mix in compared to with fentanyl? That's a really interesting question. I don't know. So I don't have this information so much in this talk, but I'm happy to talk about it. I also run a drug checking project in Los Angeles where people can bring small samples of their drugs to the syringe services programs we work with, and we will test them with a portable spectrometer and also test strips and then send off testing. And we actually first detected xylosine here in tar heroin, which I've not heard of in other jurisdictions. I'm sure it happens, but I think it could be. Like, you know, I think that could be one explanation, but I do think that the, you know, the ethnography that's been done around this really ties it to, it seems to tie it to drug trade routes and like connect communities that are connected. And so I think it's just that they're farther away from the West Coast too, but like that definitely could be part of the explanation, even though here in LA, we actually, I mean, in our program, we've tested over 300 drug samples and about seven of them have had xylosine, and most of those have been tar heroin. I mean, that's still a very small number, but you know. Right, do you ever see it mixed with methamphetamine then? No. Okay. Interestingly, yes, actually, I'm glad you asked because this is my other like favorite thing to talk about, one of my other favorite things to talk about. So I started doing this drug checking project because I was seeing, you know, looking in Los Angeles specifically, this really dramatic rise in deaths involving fentanyl and methamphetamine. And so I thought, well, maybe there's fentanyl in the meth. That's still possible, but we haven't found it. You know, we've tested about, at my last check, it was, you know, over 75 samples of methamphetamine. We've never found an opioid in any of them. For all samples, we're using three different detection methods. The only other things we've found in methamphetamine were we found cocaine twice and we've found like cellulose. But yeah, we say, you know, we tell people like, you look, the meth is meth. We sometimes do find meth in the fentanyl, it seems like in a trace amount, but not the other way around. Xylazine, you know, I see reports saying that xylazine turns up in cocaine and maybe it does, but we haven't seen that here. And I don't think that's a major concern yet, though it is important to look out for. And the good news is there are xylazine test strips that work really well. The data on them is still coming out, but like we've been doing a validation study in our drug checking program. And we found that they have a really high specificity. We actually haven't had any false positives and they've got a pretty good sensitivity where the only things they've missed have been like pretty low concentration, which I think is sort of baked into how the tests are designed. It's not like fentanyl where, you know, with fentanyl, you want your fentanyl test strips to be able to detect a very, very, very small amount. With xylazine, there's an argument to be made that you don't want it to be too sensitive because you're really concerned about having xylazine that's enough to cause any kind of clinical issues. Very interesting. Thanks. Sure. Okay. Demographic trends and disparities. Just more talking about who's dying. So this is from a paper by colleagues of mine at UCLA on the change in overdose mortality by race and ethnicity. This particular analysis was tied to before and after the COVID-19, the start of the COVID-19 pandemic. So that's what that dotted line is. But I think the, you know, the important things you can see from this graph are that historically, you know, since, and so I also want to point out that all these charts, they usually start from 1999. That's the year that the CDC began using the ICD-10 system for mortality data. And so that's just where the records start, but it's also conveniently, you know, prior to that, it seems like you had like very low rates, but that's the reason it starts in 1999. I wondered that for years and then found that out. I was like, oh, okay. I thought, you know, it's not that there's some like theoretical reason that 1999 was the most important year, just when the data all started being collected in the same way. But so since 1999, death rates have been highest among American Indian and Alaska natives and white non-Hispanics. So I think this graph is white non-Hispanic, yes. So the whole time, like those have been the two racial and ethnic groups that have had the highest population adjusted rates. But more recently, the rates among black and African-Americans have started to creep up and actually surpass those of white non-Hispanics. So this graph just kind of really illustrates that. And then Hispanics and Latin Americans, the slope there is pretty steep, but the numbers are still lower. We'll dig into that a little bit. So like disparities within the disparities. This is a similar figure, but specifically among youth. I know youth overdose has gotten, is kind of, is a topic that's commanding more attention now, I think. And partly that's because the rates among youth have been going up in the last few years, even though the absolute numbers are still pretty small. And even the rates are low compared to other segments of the population. But we see these pretty substantial racial and ethnic disparities with very high rates among American Indian and Alaska natives. And then among youth, Hispanic and Latin Americans also have a pretty substantially elevated rate. And then over here on the left, this is just the other chart that came with it that just sort of shows this is mostly fentanyl, which makes sense because I think for a lot of youth overdoses, that's really driven largely by counterfeit pills, which are, they look like oxycodone or Percocet, but they contain fentanyl. And so someone uses them thinking they're going to be one thing and there's something much stronger. And so that seems to often be the case, especially for young people. And with older adults, we also see racial and ethnic disparities where the rates among black and African-American adults over 65 are just much higher than other racial and ethnic groups. So higher and rising. And so that tells us that, so overall overdose mortality, among older adults has been growing. Overdose mortality has been growing in most segments of the population. Like you could do analysis like this in most, splicing the population most ways, and you would see that it went up a lot between the early 2000s and most recent data. But for older adults, it's really pronounced among black and African-Americans but it's elevated, it's grown over time across racial and ethnic groups. Oh, this is a analysis that one of my trainees led about changing, basically trying to understand that slope among Hispanic and Latin Americans. We say, okay, well, historically, Hispanic and Latin Americans have had low overdose rates compared to other racial and ethnic groups, but it's been increasing steeply in recent years. And why do we see that? And so this is just showing fentanyl versus like all overdose. And so on the left here, it's showing the growth rate comparing Hispanic and non-Hispanic people for fatal overdose involving fentanyl and other synthetic opioids. And we just see that it's like growing a little bit faster among Hispanic and Latin Americans. And then the same is true for overdose overall. And so that's kind of a flag of like, this is a population to think carefully about where and think about how do we do prevention that is targeted to people who are, maybe historically haven't been as at high risk, but now are, and it's growing year over year. And what do we do to stop this from becoming a runaway line like we have? Kind of across the board and in other groups. And this is just kind of like, this one is probably the most complicated data chart I have. So it's also, I think the last one I have, basically stratifying by multiple intersectional demographics of sex, age group, race, ethnicity, and census region. And so this is particular, this is from the fourth wave study I was talking about where we're trying to characterize this wave of overdoses involving fentanyl and stimulants. And it's kind of a heat graph of low co-involvement of stimulants to red of high co-involvement of stimulants. And basically different demographic groups are more or less affected by this, and that should inform our approach to prevention and treatment. So this doesn't indicate like the relative burden in the sense that, you look at this and you see, oh, the highest co-involvement of stimulants in fentanyl overdoses is among black and African-American women aged 65 to 74. That doesn't mean that that's the highest rate of overdose. It just means that of the people who have a fatal overdose involving fentanyl, the highest proportion also involves stimulants. So, yeah. Okay, now we get to the part that I think is really important, which is like, how do you prevent all these deaths? How do you save lives? What's in our toolbox? What can we do? A few things, I wanna talk about primary, secondary, tertiary prevention, but my pictures are just like naloxone, fentanyl test strips, which also could be xylosine test strips, a mobile unit that's delivering care to people where they're at, and then this like spinner to represent contingency management. Okay, so I know I've been talking about overdose and the reason for that is mostly that that's what we have data about. We have pretty comprehensive data about fatal overdose in the United States. Just in the last year, we've started to have a website by the White House Office of Drug Control that tracks non-fatal overdose in terms of numbers as measured by ambulance runs, but that's a newer data system. It doesn't break it down by specific drug because typically like when there's a response to an overdose and the person survives, they don't do all the testing to figure out, what drug was it? It's just like, okay, great, the person survived, good. So I talk mostly about death because that's where we actually have the data, but overdose deaths reflect also substance use disorders. And the two things are not exactly the same. So I wanna talk about a prevention period for, oh, sorry, pyramid for substance use disorders as well as for overdose. And substance use disorders, of course, meeting the DSM-5 criteria and people with substance use disorders are at risk for overdose, but then there's also people who are at risk for overdose who don't have a substance use disorder. And that's gonna be things like, we mentioned like the student who buys a Percocet from their friend or gets a Percocet from their friend, tries it the first time and it's fentanyl, they die. They might not have had a substance use disorder. Maybe they would have developed one if they survived, but they didn't have one at the time of death because it was just simply a large exposure. The same thing would be if someone uses something, someone doesn't meet the diagnostic criteria but still has an overdose, that's sort of a different thing. But let's talk about treating and preventing substance use disorders. So in public health, we talk about primary, secondary, tertiary prevention, primary being preventing the disease state before it occurs, secondary, treating the disease and tertiary preventing an even worse outcome. I think that's my like extremely layman's term for it. But for substance use disorder, our primary prevention is preventing substance use disorder. And how do we do that? I mean, the short answer is sort of that we, I mean, we invest in systems and we almost need to like remake society in a way when you're talking about how do you really prevent it in a population scale? You're investing in communities, treating and preventing the kind of comorbidities that predispose people to developing substance use disorders, having trauma-informed care at all stages. And that's like part of the treating and preventing mental health comorbidities and then education around harm reduction. I think just like knowledge-based, evidence-based education around drugs is a key cornerstone of preventing substance use disorder. I think I, and like probably a lot of us grew up in an era where drug education was just not particularly evidence-based in the sense that it was pretty easy to show. Like if, when your DARE educator says something about the dangers of weed, but you also know that your friends smoke weed and they're all alive, that erodes the trust. And so part of that is like accurate education about drugs and substance use disorder and how to get help and when to get help and things like that. And so that all, I'd put all of that in primary prevention. With secondary prevention, with like treating substance use disorder once it occurs, it's really all about low barrier evidence-based treatment. I would put decriminalization in here and stigma reduction in the sense that, you know, I think decriminalization is an important part of stigma reduction in the sense that the fact that drug use is criminalized is a barrier for people to seeking care for substance use disorders. You know, we have examples of laws on the books in multiple states where if a person is pregnant and admits to using substance, you know, admits to drug use, they could have their child taken away. And there's just these, all these different things where if they could access care, maybe they could enter recovery, but if they can't access care without disclosing something that's gonna expose them to a big legal risk, that's, you know, that's a barrier to getting good medical care. And then evidence-based treatment, you know, for, it sounds like this is an opioid group, so you're all, I'm going to assume you're all aware of the options for opioid use disorder in terms of medications with buprenorphine, methadone, and naltrexone, with stimulus, which as, you know, as we've shown, are a rising part of the current overdose crisis and, you know, substance use disorders also reflects that. Our best, you know, our best evidence is behind contingency management, which is unfortunately really not very available in the United States. So contingency management for, it's basically a type of therapy where a patient is, receives incentives for making healthier choices. And, you know, we know from a long time of research in behavioral economics that people respond to incentives. And it's, the model is often something like a person will enroll and every week they'll come in and provide a urine sample. And every week that their urine sample is negative for cocaine and methamphetamine, they will receive $5. And this has decades of research behind it. It's been shown to work for reduction in stimulant use better than other kinds of counseling. And there's no current approved, you know, FDA approved medications to treat stimulant use disorder. So it's a really good option, but unfortunately it's just not very available. You know, California is currently piloting a program under the state's Medicaid, which we call Medi-Cal, to offer contingency management in some counties. But other than that, it's really been limited to clinics here and there that offer it and not something that everyone who needs it can have the option to access it. I mean, we are not there with opioid, with treatment for opioid use disorder. Now, I think that most recent data shows something like definitely over 50% of substance use disorder treatment facilities don't even offer medications for opioid use disorder. And so that is like, okay, well, if you, you know, if you flip a coin, if you just go to like any random place to get treatment for substance use disorder, it's more than half a chance you're not going to get the best evidence-based treatment for your opioid use disorder. And the picture's even worse for stimulants. I'm seeing something in the chat. Is there, oh, okay. It's just a- Yeah, we're good. Sure. Okay. So yeah, contingency management, which is definitely something I would love to discuss more. Oh, yep. Yeah, actually we had a question just roll in here. Any studies for the use of prescription stimulants in patients with stimulant use disorder? Yes, that's a great question. There are some, there have been some trials and it's, you know, it's not at the level where that's a recommended practice, but I'm optimistic that there will be pharmacotherapy for stimulant use disorder. I'm not sure if it's going to end up being stimulant replacement therapy, which has been tried. And there's also, you know, trials of other kinds of medications to reduce stimulant use, including like some of the meds approved for opioid use disorder. So it's definitely being trialed. There's not strong evidence for it yet, but I am hopeful that we will get there. But yeah, I mean, definitely that's like a high priority for research, right? It's like finding a pharmacotherapy for stimulant use disorder like we have for opioid use disorder. We did have another question. Can you comment on why there is a disparity on the data and evidence-based medicine versus what's being offered in the community? So you'd mentioned about like 50-50 chance that you might get meds for opioid use disorder. Yeah, well, I would attribute that to a lot of things. I mean, one thing is, you know, this pretty pervasive idea that, so using medication for opioid use disorder as an example, it's something that, you know, I think a lot of people in society generally historically views addiction, well, substance use disorder as a moral failing and views prescribing a medication to treat it as substituting one drug for another, which, you know, is not how we view using medications to treat say diabetes or cancer, but, you know, we've typically just viewed substance use disorders as pretty different from other diseases. And, you know, substance use disorder is a tricky thing because it is both a disease and a behavior. You know, I think, you know, in the Lancet Commission, one of the things we talked about a lot was what kind of recommendation do we make about incarceration and decriminalization? And what we eventually came down to was sort of, you know, no one should be arrested or penalized simply for using drugs, but it also is true that people who use drugs tend to do other things that might harm other people sometimes. And so like that's kind of, so like separating that out, but why, you know, why I think that people see those effects and not necessarily understanding the cause as a disease state, and that makes it politically unpalatable to offer evidence-based medicine, especially when it's something like contingency management in particular is something that, you know, people would view it as, people do view it as, oh, you're paying people who use drugs to stop using drugs. Well, why don't they just not use drugs? And it's like, well, you know, that's a long question. That's a long, you know, something with a lot of answers to it. But the fact is that like this is the therapy that happens to work. And so I think a lot of it is, yeah, stigma. Yeah, stigma. I mean, and that's stigma within addiction treatment too, where there is this idea that, you know, I think one challenge is that it's as humans, it's very easy for us to think like what worked for us would work for other people. And so some people who get into the addiction treatment and recovery world working in it are people who have had a very strong and relevant personal experience, but then maybe generalize that. So like, well, you know, if I didn't need medication to stop, neither should anyone else. But it's like, well, you know, some people do need medication. And so, I don't know. That's kind of my thought. I'm curious what others think. Yeah. Why is there a big gap between what's offered and what the evidence base is? Like this, yeah. Yeah, I definitely think too that it could be, you know, just not having enough people prescribing at substance use treatment programs, because some of them might not even have a physician or an advanced practice provider on board to be able to prescribe MOUD or meds for alcohol use disorder. They might just be more of a psychosocial rehab. And like you said, sometimes you end up in a treatment place and wherever you end up is the treatment that you get. So I could see that being a problem. But I also sometimes think about treatment for substance use disorders growing up outside of the medical field for the longest time. And we haven't until recently, like with the opioid use disorder crisis, I don't think that we've focused on it as much in terms of medications and medicine until, I don't know, I would say since like the 90s. Yeah. Sorry. It looks like we've got more questions that came into here too. So somebody had said, can you comment about veterinarians use Yohimbi to reverse xylosine in surgery? Yeah, I do know that there are several like antidotes to xylosine that are used in veterinary medicine that are generally considered not appropriate for use in humans. I am not a clinician. And so I can't comment very much on the specific ones, but I know like broadly when I've consulted with my clinical colleagues, like, hey, there are these three drugs that veterinarians use. Why don't we use them in humans? You know, one of the issues that came up was, well, you know, we're concerned about it lowering the seizure threshold. I think also, so I think the other like important thing with xylosine is that like currently, when it appears in overdose, it almost universally appears with an opioid, almost always with fentanyl. And so the first line is always going to be providing naloxone. But when there's an overdose that involves both an opioid and xylosine, it's just really important to have that follow-up care where, you know, you're providing naloxone or you're counseling people to provide naloxone and then also call 911. Because for xylosine overdoses, often management with supportive care is the best thing, like, you know, oxygen and other measures like that. Okay. Let's see. How about your thoughts on safe injection sites? The Philadelphia City Council recently voted to ban them from the city. I mean, I think we should have them. I don't think they're going to, you know, I think that safe injection sites are likely to have very positive outcomes for people who use them. I think that physical safe injection sites are likely to have a small impact on population numbers simply because of size. So I think safe injection sites are something that we should try. And I think that's potentially a very promising way to link people to other kinds of health and wellness services. But I think, you know, if we can think creatively about expanding things like the Never Use Alone hotline and things that don't require a physical brick and mortar place where people have to come to every time they want to use drugs, I think that's going to have more of a population impact. But yeah, it is disappointing to see, or it's disappointing to me personally to see bans on them because I do feel like it's something that could have a positive impact, certainly for the people that use them. And if we can think creatively, like even at population level. Okay. One person had commented to you when we were talking about the lack of evidence-based medicine at rehabs and stuff. To expand on what you're saying, many inpatient treatment centers have NA ideology and generally oppose MOUD. That was their thought on that. Yeah, I mean, I agree that that's an issue. I really, you know, another thing we highlighted in the Lancet Commission was the MARS. I think it's called, it's an acronym that stands for Medicated Assisted Recovery Services, where it basically takes the AA model and incorporates meds for opioid use disorder, or I guess NA in this case, model and incorporates medications for opioid use disorder. Because, you know, I think the, I mean, there's absolutely a place for peer support. Like there's a huge place for peer support in addiction recovery. And like, there's very good evidence behind that too, like different models of peer support. It's just like finding a way for all of these things to coexist. And so, you know, I don't think we need to get to a point where every single substance use disorder treatment center offers methadone and buprenorphine and naltrexone, because there are always going to be some models of, like some models of care for people who either don't need those things because they're, you know, working with a different substance use disorder or they don't want them for whatever reason, or it's, you know, more of a, you know, just a different model of what people need or want. I think that's fine. We also need to get like well beyond 50%. It's kind of my thing. Right. Okay. Somebody said, I think you hit all the issues I would have in the prevention pyramid. I like the idea of treating societal trauma and reducing adverse childhood experiences. Yeah, me too. I agree, yeah. Oh, here's my little prevention period for overdose, which is like mostly the same, but I think the key sort of things when I'm thinking about differently, like overdose versus substance use disorder is, you know, again, tertiary prevention, trying to prevent death, again, naloxone, clinical management of overdose for something like stimulants. You know, if it's just stimulants, what you're concerned about is the other clinical sequelae of, you know, acute stimulant toxicity and then that's figuring out better ways to manage that or prevent that. For secondary prevention, again, it's this evidence-based treatment. Also harm reduction education, like for people who aren't going to stop using drugs or aren't quite ready to stop, you know, you can prevent overdose by going slower, like very simple, you know, getting, you know, I think as clinicians and as people who work in healthcare, I think it's important to think about like, what are our patients not sharing with us? And like, what do patients not share and how can we provide guidance and counseling that might meet people where they're at currently? And part of that is around like, look, like it's better, you know, you're more like, you're less likely to overdose if you start with a little bit and go slowly. Of course, you know, you prevent overdose entirely by just not using drugs. But like, I think I can agree that like abstinence-only education is like not effective for everybody and for mostly. And I put like prevention of overdose. So it's, so the tertiary is like, once an overdose has happened, how do you keep it from being fatal? It's kind of like, yeah, just like naloxone and medical care. But for secondary prevention, how do you prevent overdose in the first place? You know, I think drug checking has a role here where we're actually testing people's substances so they can know what's in them. And that includes like personal drug checking, like using ziozine or fentanyl test strips. And then I just put decriminalization in here too. I mean, there's some interesting work out of Brad Ray in Indiana's lab around finding that areas where there was drug enforcement, finding then like an increase in overdose in that geographic area, just which makes sense to me in terms of disruption of a drug market, then you've just got more unknown quantity. I mean, that's the thing, you know, especially with fentanyl, the margins are just so much smaller in the sense that a small error in dosing or a small increase in the purity of your batch one week to the next is the difference between a high that you're expecting and a death, unfortunately. And then primary prevention, it's, you know, all this stuff we talked about, investing in communities. Yeah, we're trying to reduce adverse childhood experiences. You know, there's some supply side interventions that absolutely come in here and then, you know, healthy alternatives to drug. I mean, that's all sort of part of the same thing, I think, but this is, yeah, the primary prevention is always the hardest piece. So that is my last slide. Some references, my contact info. Yeah, so anybody else? We have a couple of minutes left. Anybody else have questions, please enter them into the Q&A. I think this is really interesting, especially looking at different parts of the country and the, you know, who's dying from what there, and also looking at the data for race and ethnicity, very important. So let's see. I got one question here. You had somebody comment, superb work. And then, not a question, but I'm happy to share a few perspectives as a doc working in Massachusetts jail, if you'd like. Thanks for a great talk. Yeah, if we have a few minutes, I'd love to hear, and I'm sure others will benefit too. Yeah, and I don't know that we can unmute how we have it set up, but if you want to enter something into the Q&A as far as your perspectives, Christopher, that would be great. And then, oh, somebody's also just saying thanks for the series, and it's been very valuable. One of the things I noticed too was, just in my state where I'm in Pennsylvania, is that over the past several years, it was really hard back like around 2011, 2012, if somebody was on a medication for opioid use disorder for them to get accepted into a rehab, partly because of methadone, you need to have gas dosing and everything set up, but then our state changed things. So if you are accepting Medicaid money at your rehab, you have to accept all people on these medications. And so there's a lot more access. If somebody's struggling, they're on methadone, but they are using cocaine and they want to go to rehab so they can get that more intensive treatment if they wanted to. That's great. I see someone asking about access to materials. I'm fine with you distributing them, or the slide. I mean, you know. Okay, yeah, they'll be posted on the website for sure, where you're gonna all go to claim your CME credits too. So go back to that education page on AOAAM and fill out your surveys. If you haven't done them yet to fill out the surveys, or if you missed part of the sequence of webinars, they are archived there and you can watch them and still get Enduring CME for quite a while, we have that set up. So, well, I guess, you know, it's almost around six. So I want to thank you so much for presenting today. This was very interesting work and really liken the work that you're doing too with the drug checking. That's very interesting. Hopefully, you know, you'll be able to publish some stuff on that too. Yeah, we're working on it. I've been on maternity leave, so coming back. So thank you. Okay, thank you. Bye. Bye everybody.

overdose crisis

prescription opioids

heroin overdoses

fentanyl-related deaths

primary prevention

secondary prevention

tertiary prevention

racial disparities

targeted prevention

safe injection sites