Pain Management and Addiction Medicine April Meeting

- Our first set of addiction topics, as we learned a few minutes ago, Rachel is battling her laptop. She is using apparently a hospital-issued PC, so kind of deserve what you get, if that's what... you know, it's like, you know, you kind of get what you paid for. But I'm sorry that this has happened in an inconvenient time. Fortunately, she is so smart on these topics that she needs no slides to educate us. We're gonna talk about some AUD stuff and some stimulant news disorder stuff, which we've already mentioned at the outset of the hour. So our goal here, so Rach, it's 20 after, so I want you try to contain your monologue to 10-ish minutes, and then we'll enter into a 15-minute discussion.

- That sounds good. And I did lose that battle. It wasn't a long battle, but I certainly lost it with the Cooper-issued laptop. The way I sort of envisioned this is I'll start talking, and I would appreciate if people, I would appreciate if people ask me, just kind of interrupt and ask me questions. Again, I'm gonna talk a little bit about, you know, what we have seen and what we do. And I'm very curious to know what everybody else does, everybody else's experiences. So I'm gonna start a little bit with AUD. And obviously, as everyone, well, many of you know, we have a very large outpatient service that we run. And so we do a lot of outpatient AUD. And so, you know, one of sort of the agenda items has been to try and address AUD in the emergency department in a more effective way. And the biggest reason for it, and many of you're familiar with the study, but there is a study that came out of Canada, out of Toronto, I believe, looking at the number of ED visits for alcohol-related complaints and mortality. And what it found is once you hit about five visits in a 12-month period, your mortality is approximately 8.8%. And what we know from opioid overdose data, that is actually not that much less than the mortality from patients that present after an overdose. And so this is a very sick population. Now, do they die of intoxication? Not necessarily, but they do. Most of them do end up dying of... And by the way, this is a one-year mortality. Most of them do end up dying of alcohol-related morbidity. So then the question is: Well, what do we do in the emergency department? And of course we can screen all we want, but if there's no plan for the positive screens, then that's actually not very effective. So we do screen. we actually have implemented NIDA screening at the door. And then, you know, both screening and evaluation. And we've implemented substance use navigators, et cetera. But at the end of the day, there's two big things I think that are important. Number one is, yes, there are going to be patients that are going to be withdrawing. The truth is those are easy. We know what to do with patients that are in moderate or severe withdrawal. We admit them, we treat them. That's, you know, bread and butter. What do you do with those patients that are less acute, right, the ones that are sort of mild withdrawal? Can you send them home, can you send them home safely and get them through their withdrawal period without having to send them necessarily to an inpatient unit? And I think, for us anyway, it's very clear that you can. And there's a lot of different approaches. Many of us do use benzos. And you can use benzos, you can either, you know, load them upfront and taper them, which we sometimes do. You can also do symptom-triggered treatment, or you can just do a taper. And there's data supporting all of them. But the bottom line is you can. A lot of us also will use Tegretol or valproic acid, a supportive medication to help prevent seizures. And lastly, but not least, gabapentin. And again, everybody has a little bit of a different approach to who is mild, moderate, and severe. If you look specifically at the ASAM guidelines, they have a very nice table helping you sort of differentiate. And again, in my slides, I had a table, you know, sort of helping you differentiate, you know, who would go each way. I think one of the most important things, you know, they say you can use a CIWA, but a lot of it is also predicting, right? So if you have somebody who has a history of, you know, pretty severe withdrawal in the past, has comorbidities, is over a certain age, you really do need to think about inpatient stay. If your patients are anything like our patients, many of them simply won't want to stay. And so then you, again, you have to go back to that, can I safely discharge them? It's very helpful if you can have post-follow-up for some of our patients who are able to have the substance use navigators; call them, make sure they're doing okay, and then have a contingency plan, you know, if they need to come back. So I think that's one. And I think a lot of ED physicians still really shy away from, oh, you know, I don't wanna give somebody a or wanna give them all these other meds. They either are really withdrawing and I admitting them, or they should go home and I should tell them to drink less, right? And unfortunately, I don't know that that's particularly effective. So that's the first part. And then the second part is, well, they have alcohol use disorder, and we actually have very effective treatment. So should we be initiating this in the emergency department? And I would argue, yes, it is not difficult. You can set up protocols. We have an entire protocol that involves naltrexone. You can do oral or you can do injectable. You can do, you know, long-acting. And we have enough samples that we are able to do both. A lot of people are not amenable to having an injection in the emergency department, but definitely, it is a little bit more, it is more effective just because the compliance is better. The other part to that is that we do pretty high-dose gabapentin. The data on gabapentin shows that really it's in this 6 to 800 TID-QID range where you actually do have decreased cravings. And again, like naltrexone, and I wish I had my slides, but the good thing about the naltrexone is it doesn't affect cravings as much as it affects actually heavy drinking days, right? So yes, you can quantify it by craving. Interestingly, relapse isn't as affected, but the number of heavy drinking days per month is. There's actually a pretty good reduction. Data past a year isn't very good. So it's really in that first year where you wanna treat the patients. Most effective for males. There are some genetic predispositions that, you know, can help you differentiate who will do better, who will do worse. Like I said, we use high-dose gabapentin. You can use acamprosate. I don't know how many of you are using acamprosate. Super weird dosing. It's like 666, 3 times a day. I don't know who came up with that. It's a little weird. But you can do that. You do have to check creatinine if you're gonna be doing acamprosate. But it is also an option. Careful with the naltrexone, obviously, because if patients do have co-occurring opiate use disorder, et cetera, they do have to be abstinent. We don't use disulfiram. Does anybody here use disulfiram? We absolutely do not. It is very punitive, and the data is actually not particularly solid on disulfiram. And so that's really, you know... But again, you can start these, and we've put together protocols that allow you to start this and then refer the patients to treatment. I don't think Andrew's here, but I think Andrew's team did do a study looking at the initiation and the follow-up rate. I would lie if I said I sat here and had amazing follow-up; our follow-up rate isn't great. But at least you're trying to have an intervention, have a conversation, identify these patients, give them resources. I think that's still a far cry from what we've done pretty much my entire career, which is metabolize: we call it MTF, metabolize to freedom, right? And then you send them out. That doesn't feel like good doctoring. I'm curious to know what other people do in terms of alcohol in your emergency departments.

- Thank you, Rachel. Let's just break there, and let's save the stimulants for a little bit later in the conversation. And let's take this first opportunity to discuss alcohol use disorder. I think a lot of us are really focused on trying to do better for these patients. So I'll open up to the floor. What questions do you guys have for Rachel? I'll ask the first question, which is: Can you remind us what your screening test is? You said it's a NIDA screen, or what is that?

- So we basically do a brief screen, and then we do... Oh my god, I'm completely blanking. So for nonalcohol, we do the NIDA Expanded. And then for alcohol, we do... I'm completely blanking. It starts with an A. Oh my god.

- Are you talking about like the single-item screener, or which one are you-

- No, no, no.

- AUDIT?

- AUDIT.

- AUDIT-C?

- We do the AUDIT-C. Exactly. So the way it works, we have it built into Epic. And if you screen positive and it's nonalcohol, it automatically puts you into the NIDA Expanded screen. And if you do have, if it is alcohol, then it puts you into the AUDIT-C. And then you fill it out, and then it pops out a score at the end.

- Who gets screened?

- Everybody.

- By whom?

- So the initial screen is done by the triage nurse, and it's just a yes or a no. And then if it is a yes, then you have to do the expanded screens for either one. We have substance use navigators that do those.

- Amazing.

- Any questions for Rachel? I have a few others.

- No, then I can talk about what I do. It's interesting. I work within two different systems. One of them has Epic and we do the screening there, but we struggle with who fills out everything. 'Cause, for years, we tried to get some navigators to help with our patient population there in Jackson. Number one in the state. Woo! The other two sites I work at are in Ascension. There's no such thing in the first-generation Cerner product that they put in, you know, 17 years ago. But we are actually attached to an inpatient, long-term inpatient addiction facility that's owned by the health system. So we deal directly with them. We start treatment in the department, and with direct discussion with addiction medicine. But it's also at the end of the day pending on what the patient actually wants, obviously.

- Yeah, I will say one thing, which is discouraging for us. Our actual screening rate rates are fairly high, but our positives are deceptively low. So technically- Right, so NIDA data says 10 to 15% of adults should be screening positive. Ours are less than 1%.

- I mean, if anybody has a trauma center, if you look at your trauma screening, it's gonna be similar to that, 'cause they all have to screen 'em. And then what they find is they're all going through withdrawal upstairs.

- Exactly. Right.

- And a lot of it's how they ask the question at triage too, right? We've all heard like, "Do you have alcohol and drugs? Are you suicidal or you have weapons?"

- Yeah, or do you do drugs? Do you have a drug problem?

- I think that's an underrepresented concern. Our triage nurses are burdened with like these overwhelming series of screening questions and 1,000 other things that they're trying to do. And those of us who work at triage, and listen to these questions being asked, know that they're being asked in a very rote and perfunctory manner most of the time, because, again, they're tasked with so many questions at once. And there's, you know, 20 patients waiting to be triaged. So I think the place that I would like to get to is having our substance use navigators more ubiquitously involved and doing the screening themselves, with the goal of screening every single patient in the ED; not at triage, but while after triage, once they're sitting around waiting for their CT scan, waiting for the consultant, these patients are really ripe for a variety of public health interventions. And I think that, I suspect, Rachel, that some of what you're seeing there has to do with wrong location really for these screening questions. It's just that triage is just really not about that. It's about trying to figure out who needs to be seen immediately by a doctor. And in fact, I'll just speak for myself, we have put too much on our triage process.

- Yeah, I don't disagree. In fact, some of our substance use navigators are so motivated and so passionate about it that they actually will go through, and they're like, "Yeah, I know. I'm looking at this person; there is no way they're negative." And they will take it upon themselves to go over and talk to them. And sure enough, they will just identify patients that... And also, sometimes you'll hear patients that are starting to act out a little, you know, being very demanding. And, you know, there's definitely a correlation between that and substance use. Are the rest of you guys doing naltrexone and gabapentin for alcohol use disorder at all? Or are you sending mild withdrawal home and starting treatment?

- I'm certainly trying. Yeah, please, Harrison, please.

- Hey everybody, my name's Harrison Pidgeon. I'm at Mount Sinai in Brooklyn. So part of the Mount Sinai system in New York City, but one of the smallest site. We have very little in the way of like support staff, or really anything. So there's no social worker at any time or single-coverage docs for nine hours of the 24. And then we do have a substance use like counselor who's there on some weekdays during some business hours. So it just makes it exceedingly difficult. I'm a young position, I'm a 2022 grad. So I'm just trying to like kind of get my department more up to speed. I came from a tertiary academic center in Chicago where we had tons more resources, including an addiction fellowship. So I'm really just trying to be a little bit of a champion for my own department. In terms of like some of what we're talking about here, we have very little in the way of outpatient resources that are effective, because, you know, I can refer to like the main Mount Sinai area, but that's a full six miles away, which in terms of New York City, for folks that use drugs and alcohol, just becomes unrealistic to expect them to follow up there. There are a few like neighborhood resources that I've made connections with that have been helpful, but even still, they lack like kind of a lot of the medication-assisted therapies that we can do. So in short, it's tough. So I try, and I'm trying to get my department a little better in terms of like making protocols and stuff, but it's just hard. So I'm really appreciative of everything that we're talking about. I appreciate everybody.

- Harrison, thanks for that perspective. I'm not sure if I've met you. I apologize if I have. But I certainly know many of your colleagues. I'm in Maimonides. And I work at Maimonides Midwood, which is two blocks away from you.

- Oh, yeah, yeah.

- So let's connect offline, and I'll be happy to tell you about a lot of resources in the area that you can avail your patients of.

- That would be awesome. Thanks.

- I wanted to ask Rachel, for your question about those people who are in mild to moderate like withdrawal, if they're not other substance users, I still load a lot of those patients with phenobarb. And then I send them home with gabapentin. And that's been my practice for the last several years, and it seems to be very effective, you know? And I try to follow 'em up in our own addiction clinic, with variable success about whether people show up. And our no-show rates or atrociously high.

- How are you dosing it, Don?

- What am I dosing it at?

- Yeah. Phenobarb and gabapentin. Yep.

- Yeah, I'm doing, you know, around 600 T or QID, and I tell patients to titrate themselves. And then for the phenobarb, like, it's usually 260. You know, like usually just two vials or so.

- IV. IV.

- IV, yeah.

- Oh, okay. So you're starting an IV on these patients is I guess the first thing. So you start an IV. And these are like patients, and you give 'em 260 of phenobarb, and then they feel better, and then you send 'em home with gabapentin, 600, 3 to 4 times per day.

- Most of my patients have IVs by the time, like, you know, by the time they either arrive to us, because EMS has either popped them in, or if they're gonna be sobering with me for a while, we usually put an IV in 'em.

- Interesting, I notice this sort of split in this mild to mod group, which I'm very interested in. We spend most of our time in emergency medicine thinking about severe alcohol withdrawal. But we can probably make a much bigger impact on mild to mod. One of the questions is, you know, how do you do, so there's sort of two parts. There's a withdrawal management and there's an anticraving management. So for withdrawal management there's a variety of options. The main ones that people use are phenobarbital, both IV and PO. And then chlordiazepoxide, which is available only PO to my knowledge. And then some people also use diazepam. You also hear gabapentin being used for this, for withdrawal management, not just cravings management. And so there's just a ton of variability. I've seen very little data. I myself reserve phenobarbital, intravenous phenobarbital, for severe withdrawal. But there's no particular reason for that. I think it's the best option for severe withdrawal. But for mild to moderate withdrawal, it's safe. I think PO phenobarb makes a lot of sense in this sense; administered times one, not sending patients home with PO phenobarb. But I'm interested to hear if anyone has any comments on like chlordiazepoxide, which is my usual choice for mild to moderate withdrawal: 100, 200 is what I use. Everyone gets 100, you know, unless they're like asleep. And then for patients who are showing some hyperadrenergic signs, I give them 200 milligrams. I call that the Librium challenge. Even the ones who look kind of sick, I give them 200 and many of them quiet down. If they don't quiet down after 200, they've announced themselves as needing intravenous therapy and admission to the hospital. So that's sort of my approach. I'm interested to hear others. What are you all doing for mild to mod?

- I don't know if this is bad or not, but it's the truth. I kind of do whatever seems the most convenient at the time. So I think similar to what Don was saying, it's like if they already have an IV, then I will give them some IV meds. I usually lean towards diazepam. But then if patients request certain things, like they've had success in the past, that just like helps to tell me what they want. So I give Librium tapers most commonly. That's my go-to. I think I do, I have it on my phone. I'd have to look it up. I don't do it often enough, but probably 50 TID, or QID, and then it changes as the taper goes home.

- Great, well, I certainly love the patient-centered approach. And the patients will often tell you sort of what they think works best and they often know best. Any other comments on questions, concerns on alcohol? We have like so many substances to cover today.

- How many of you are referring people? And I feel much better about referring people to peer communities, including AA, if they seem leaning toward that, you know? so I'm very, like, hey, I try to do the medicine, I try to do withdrawal, but then I also try to engage them in different peer communities. And I feel that alcohol, like, that's more abstinence-based. I feel much better than saying, "Okay, go to an NA program for opiates." But I oftentimes give that referral as well, and know our local, I'm in a small town practicing rural medicine, but I know our local AA chair who's a nice enough guy, and I'll actually text him if people want, and say, "Hey, could you reach out to this person." And again, I'm practicing very rural medicine. I'm not in Downtown New York. But we've had some successful stories with that as well, and trying to connect with-

- You're sort of deputizing your volunteer community as substance use navigators, in this case.

- You got it, brother.

- I think you have to be very careful. I just think the data on AA is not great. I think it has earned a reputation that is maybe not warranted in terms of actual data. I think there are people for whom spirituality works, and then there's a lot that then end up feeling guilty, because it just doesn't, and that's not their jam. And so I think it's just feeling people out and better understanding, you know, what drives them I just think is really important, because it was interesting, because once I realized NA was not a thing, what did not work, I went back and I looked at some more recent data on AA, and it's not great. So I just think we have to be careful, because I think that's what we've heard for so long, is AA, AA, you know, have a sponsor, et cetera. But does it actually result... Because, think about it, the natural course of this disease is that people get better, right? So is AA help? I don't know. Does it help a handful of individuals that are very outspoken? Maybe.

- I think it's worth separating AA from peer support, writ large. AA has a certain set of principles that, depending on how rigorously they're adhered to, can cause trouble. So the faith-based element, many people are hostile to the faith-based element. And then there's the abstinence, the emphasis on abstinence, which in many cases is contrary to best practices in recovery. And this may not make as big of a difference in alcohol use disorder, but certainly in opioid use disorder, as I'm sure many of you know, the 12-step community is hostile towards medication-based treatment of opioid use disorder, which is directly contradictory to what we think, what we know is best practice. So I think there's a lot of local variation. And then of course there's a variety of other peer support groups that are not faith-based, that will continue to support you regardless of what other medications you might be using, what other drugs you might be using. And I think it's wise to know, like, what is available in your community. But I think it's also hard to argue with the idea that people who have been going through what you're going through and being connected to other people who know where you've been, where you are, is a valuable intervention for many people.

- Yeah. And Don, I hear you loud and clear. I don't think it's homogenous. But that's exactly the crazy part about it, right? If it's treatment, if it's medicine, it should be homogenous, because that's how you control for it, right? But it's not. It's individual and it's who's there, you know, who the group is, who you are. And so, again, I just think we have to be careful. If it works and if it's a good group and if they're, you know, they're a low barrier and their harm reduction is great. But I just think, don't think we can talk about it universally as physicians.

- Yeah, no, I think this is why I kind of threw it out there, because it's a little bit, I'm sure there's a lot of practice heterogeneity and a lot of nuance. So in this type of group of people who think very deeply about this and about the benefits and cons of it, I wanted to kind of get people's perspectives. 'Cause I think that you're right, there's a lot of heterogeneity here and reason for concern, or reason for not fully embracing it. Although I do think that, one of the other things I'd say is, and I did this here when I started this new practice, is I actually just showed up at their meetings for two meetings. I was like, "Okay, what are you guys about?" Like, is this a place that I wanna send my patients? Is as simple as I say I don't wanna send my patients. And again, remember, I'm in a very rural county, so we don't have very many resources. AA for many is the resource. And in general, this small AA group, I find a lot of people have good intent and are friendly toward medication for opioid use disorder. So they are one of the tools that I use, especially for people who have no other friends to hang out with, right? Which in very small communities is really difficult sometimes. So I do think that there's also this interesting discussion about what works in New York City or, you know, Camden, might not work in like where I am in Colorado, you know? And the smaller rural community aspect has an interesting flavor to it.

- 100%, and again, there's just a lot of variation from group to group in how supportive they are of different types of people who want different types of recovery. So the fact that you showed up at one of these meetings I think makes a big difference in terms of your ability to bring the right patient to the right treatment.

- They actually refer patients to me, which is also great, right? When people like show up and they're like, you know, do you think withdrawal management, they'll actually refer 'em to me and that's also unique, you know.

- Nice. Okay. We should pivot to stimulants. Stimulants is a really interesting topic, because there's just such an enormous variation in what we're seeing as opposed to alcohol, which we're all seeing all the time. Stimulant use has a tremendous variability in terms of the types of people who are using it, each community. And I can tell you that in New York, I see very little, but now almost all of what I'm seeing in meth now is as a party drug for gay men. And it's become very prevalent in that group, to devastating consequence. I mean, I don't see the success stories, as it were, but gosh, this drug. If there's one drug I find that people have a difficult time having a good relationship with, its methamphetamine. So Rach, do you want to discuss your thoughts on where we are with stimulant use disorder?

- Yeah, absolutely. So again, I'm not gonna delve too much into it, because a lot of it is really not necessarily relevant to the EB practice. Although I think knowing what is out there and being able to speak to it a little bit I think is important. You know, whenever I think of, especially meth, I think of that diagram that shows you the dopamine release. And, you know, the dopamine release of, you know, alcohol and cocaine, et cetera. And then you look at meth, and it's just, you know, it's just so much higher. I think that the effect that it has from a purely neurobiological perspective, it is different. It's a different drug. And like Ruben said it, I think the consequences, unfortunately, are much more difficult to treat. So I think a couple of things. I think that one thing that is important is that the prevalence is definitely growing. We have way more meth now on the East Coast than we ever did in the past. We used to really be very spared. And it was really more of a, you know, Midwest and West US problem. But absolutely now it really has sort of started penetrating the Northeast corridor. Certainly, where we are now, we see a lot more, we've always seen a lot of cocaine, but definitely a lot more meth. Here I think a couple of things about treating stimulant use disorder. The number one, the most effective treatment is still behavioral. So if you look at the data, the number one, the best treatment is still contingency management. It's a combination of CBT plus or minus contingency management. What is interesting is that contingency management, even though by itself it is the most effective, when you stop it, the effect goes away. So it doesn't persist past the actual contingency that is being put into effect. CBT is a little bit different. It is in the short run a little bit less effective, but in the longer run it actually carries through, even when you stop the actual CBT treatment. And I just think that's kind of really interesting. In terms of the medication, there is nothing that is FDA-approved right now. But there are so many studies looking at, and really there's a couple of medications I'm just gonna mention that have been primarily looked at. So when you look at meth, mirtazapine has been looked at, a couple studies, not great data. Bupropion with naltrexone has been looked at. Again, the data is... I mean when you look at the numbers you're like, great, five people benefited, right? It's a really, really, tiny, tiny bit. But there is a positive effect. And then for cocaine, it's topiramate, so Topamax. And then also Wellbutrin. There is one study looking at Adderall plus naltrexone for cocaine. Again, not great, but that puts us into another category which is actually using psychostimulants for stimulant use disorder. And there is some data. And the three that are primarily used are Adderall, dextroamphetamine, Ritalin, and Vyvanse. Those are the three that have been studied and are used in various degrees. I can tell you, from our shop, we use Vyvanse. And really those are the most, the most difficult to treat patients. And we see them every week. They have drug testing. Like, we're on these patients. But for some patients, it is the only thing that will work and the only thing that will keep them away from. And, you know, so then the question is, well, why? If you're gonna be giving them Vyvanse, just let them use the meth. But again, obtaining the meth, the behaviors around the meth, all the risky behavior that goes around it, that is really what we're trying to avoid. So again, very, very difficult to treat. But what can we do in the ED, one knowing that you can send them for treatment? But also, there is data now that shows that, at least for us, that the... Cocaine has been contaminated with fentanyl for a long time, but meth is also contaminated. And so having these frank discussions with patients and saying, "Hey, listen. One, you need to have Narcan. Two, you know, obviously, you know, giving them fentanyl test strips. What's interesting is that there are a good number of stimulant users that really have no interest in opioids, but do overdose because they are not, they don't have dependence, and so their tolerance is much less. So making sure that they have access to that. And then lastly, one of the things that we do is we do offer them naltrexone. And we say, "Hey, we can either give you a shot of Vivitrol, or I can prescribe the naltrexone, and you decide when you're gonna take it." So if you know you're gonna be going out and using meth or cocaine, et cetera, and you're worried about overdose, go ahead and take 100 milligrams or 150 milligrams before you go, before you use, just to protect them from that possible overdose. So have we studied that? No, we haven't, but it makes sense. And again, we are really just trying to decrease harm in the . So that's sort of my, and I'm not gonna go into treating overdose or withdrawal or et cetera. I don't think that that's relevant here. I think we're specifically focusing on, you know, more the addiction and the long-term use disorder, and what to do about that. Because that is the more challenging. Everybody can give benzos for, you know, somebody who's high on cocaine or meth. Any questions? And what have you guys been doing?

- Thanks, Rachel. There's a lot to chew on there. I think of Vyvanse and Adderall for stimulant use disorder is similar to methadone for opioid use disorder. You're replacing an uncontrolled substance of unknown purity, unknown composition, with a substance of known purity, known composition, a reliable dosing schedule. So hopefully, something that you can administer free or nearly free of charge to the patient. And this separates the patients or protects the patients from what I call acquisition harms, injection harms, even if they're still getting controlled substances like another stimulant. So this is replacement therapy in the best sense. I think it's gonna be a hard sell for emergency doctors at the moment, to start throwing dexedrine and related congeners to patients who are using meth. As I'm gonna speak to, as I may speak to, depending on timing, for tobacco, bupropion really is a stimulant. It's a norepinephrine reuptake inhibitor, which is how these drugs work. And I recently was titrating up bupropion for a nicotine use disorder patient of mine. And she had to discontinue the higher dosage because she said she felt like she was high on cocaine the whole day, and she was a former cocaine user. So it just gives you a sense of what dealing with. With bupropion, I think it's probably underutilized. I think there's a lot of potential there with bupropion, and I'm anxious to see more data.

- Yeah, I will tell you, there are several meta-analyses looking at this. And the data on bupropion, it just isn't great. It's so soft. And again, is the dosing, right? Because when you look at the psychostimulant treatment of stimulant use disorder, you have to use doses that are way higher than what we used for ADHD, you know, narcolepsy, et cetera. And so that obviously makes people uncomfortable. So are we supposed to be using much higher doses of Wellbutrin? I don't know that I would want, as a toxicologist, that makes me nervous. It's like not the safest drug.

- Right.

- So yeah. Is there a potential? Possibly. Right now, the data isn't supporting it.

- Mark, you have some comments? Mark?

- Yes. Rachel, I live in Hawaii where meth has been present since 1986. And like multiple generations now of meth. And you know what? I think one of the problems related to treatment that I see is a lot of the patients in the emergency department no longer have phones. They're homeless. The social support, one of the hospitals nearby us does some navigator stuff, and that's probably useful. But just, you know, they end up just kind of wandering around, going from ER to ER. And we do have a little bit of contingency management here, and the people that are using it think it's good. I think there's some state-to-state variation related to how that can be put into place. But I'm not using anything specific in the emergency department, when I see somebody other than just trying to treat their heart failure and talk to 'em about how bad it is.

- Mark, is your meth contaminated with fentanyl at all?

- Occasionally. Not too frequently.

- 'Cause I see that as a potential in the ED to just, you know, make sure that people are able to either test for it or make sure that they have naltrexone in case, you know, they don't wanna overdose. Otherwise, I don't know how much else we could do in the ED.

- Yeah.

- I start people on mirtazapine. Again, the evidence is pretty shitty, but, you know, we are doing something. And I do send all these patients home with naloxone. And in our small addiction clinic, we do have a contingency management program, which we try to utilize for these patients, with variable success. Yeah, it's such a hard use disorder.

- What's the contingency? What's the contingency and where do you get the funds?

- So we get the funds from a grant through the University of Colorado. So we're grant-funded for that, you know? And then we give gift cards to a local gas station.

- Amazing. How much is the gift card?

- It depends on how good they're doing, is how many pools they get. We still do a fishbowl technique. We've talked about updating it. There's like these kind of new online techniques, but they all charge a pretty significant amount. So we'd blow through a lot of our budget with just the platform. We're still pretty low tech.

- Fascinating.

- Yeah.

- I hate to hijack the talk and go back to another substance, but you reminded me, Ruben, with the discussion about Vyvanse, that I heard there was a facility that was doing safe alcohol consumption sites. And it was really mind-blowing to me, because what happens is that people, like you mentioned, they don't binge as much because they know they're going to get a supply. And so people can just go on a schedule, they get a dose of alcohol, and then they actually get close to recovery, because they're not having this cycle of not knowing where to get it, losing, you know, not having money to purchase it. And it seems like it's healthier just to get people on a routine schedule.

- It makes perfect sense, you know. Again, you're interrupting the sort of highs and lows cycle. That is what destroys the lives of so many of these folks. Yeah, I mean, imagine if we had an alcohol replacement therapy that we could dispense, as, for example, a pill. You know, I know that, I've never seen it, but I know that dehydrated alcohol can be given intravenously. I'm sure Rachel can comment on its use in toxic alcohols and so forth. But you sort of wonder what sort of outta-the-box thinking we need to address again this substance use disorder with so many massive harms that we're just seeing every single day. It's really interesting. So is this like a safe consumption site where people present themselves three times a day?

- Yeah, I don't recall where it was. I think it was San Francisco, but it could be incorrect, but exactly. You just go and you get your dose of whatever, whether it be whiskey or vodka, and it gets people back into a routine. And again, it takes away the highs and the lows, like you mentioned. And I thought that was brilliant. I wanted to get a liquor license for a bridge clinic.

- I was gonna say, you know, I think the bigger thing with alcohol is just how, how poorly it is taxed. And I know here in Colorado we're really trying, like, we're starting to actually launch a lot of advocacy efforts about increasing our excise tax so that we can provide those patients with also more support. And alcohol can fund the rest of our addiction treatment, I'm pretty sure, if we actually get the taxing of it right. And, you know, I think that's something that all of us as addiction docs should be thinking about, is in Colorado, we have a terrible AUD problem, and we're the 47th or 48th in tax. Like, marijuana generates I think something like 40 or 50 times the amount of tax revenue that alcohol does here in our state. And so that's a huge opportunity for us to get the regulation and the legislation right. And then you use that to actually pay for programs for substance use disorders. So that's something that, you know, the beer lobby. Well, the alcohol lobby does not like us as much, and they've delayed the bill till next session. But I think that we're having a lot of positive momentum with how people are starting to talk about the risks of alcohol.

- That's fantastic. And in Europe, the European community is really focused on something called, I think it's called minimum unit pricing. I've seen a bunch of papers on this over the past year. And the notion is that the way that alcohol pricing is currently structured, it incentivizes people to buy very potent forms of alcohol, which is more harmful. And if you paid the same amount per unit alcohol for vodka that you do for beer, we would be incentivizing people to consume less harmful forms of alcohol. And alongside that, certainly, we should be jacking up the price. The risk of course is that if you go up too fast, too high, then you incentivize moonshine. And we don't want that. So black market alcohol, you know, I don't remember Prohibition, but it seems like this was not a good experiment. So that's sort of, those are the pluses and minuses there. But certainly, there's a lot of money left on the table. And then we've learned from marijuana tax what we can do on that front. So it's now at the top of the hour. Thank you, Don. And pleased that Casey's joined us. And we're gonna skip over my slides for now. We may come back to that if we have time in the next 20 minutes. But I wanted Casey to talk to us. And he was generous enough to give us a few minutes on his perspectives on using long-acting forms of buprenorphine in a nonacademic setting, in a community setting in California. Thanks for joining, Casey. The show is yours.

- Yeah, I made some slides here.

- Please.

- Yeah. So I think I know most folks. But my name's Casey. Greetings from Monterey, California. I gave four doses of Sublocade in clinic yesterday. I'm giving one tomorrow. And I think I gave two on Tuesday. So I use a lot of Sublocade. So I wanted to share kind of my perspective both in the emergency department and then the outpatient practice. But yeah, just so everybody knows, I have no financial disclosures. After years of educating the public on the history of the opiate epidemic, I tend to keep pharma at arm's length. So this is a graphic from the makers of Sublocade, which is one of the two brands of long-acting injectable buprenorphine. And this is the basic pitch, right? Compliance is an issue; if we do a long-acting injectable, the compliance is better. We know this from schizophrenia. It's starting to happen in HIV. And around addiction, it's the same thing. And I'll talk about some of the nuances between the two brands, Brixadi and Sublocade. But again, you know, for my patients, I absolutely love it. I have a 19-year-old that I'm gonna go visit in residential treatment tomorrow. I've been trying for months to get him on buprenorphine, to get him on Sublocade. 'Cause that way, if he has a relapse, well, he's got Sublocade in his system. Given the nature of buprenorphine, I can sleep better at night knowing that he's not gonna have a fatal overdose given how buprenorphine works. And the way my patients describe it to me is if they're on a daily medication, every day's a choice, right? Do I take my naltrexone today or do I drink today? Right? Once they get Vivitrol, that choice is made for them. And the same thing with buprenorphine. So my patients on, you know, bup three times a day, that's 90 choices a month compared to one choice a month, just to come see me and get their shot. So just to be very basic, assuming people don't know much about these, drug number one is Sublocade. This is my preferred. I have maybe 10 patients on Sublocade right now. My hospital does have it on formulary, and we do give it in the emergency department and inpatient setting. And in the office I give it very frequently. Like I said, I gave four yesterday. I can talk about the dosing. There's two forms: 300 and 100. The major issue if you're interested in doing it is that the pharmacy has to come up with a risk evaluation and mitigation strategy, or REMS, and that can be difficult to set up in the outpatient setting. I work in two counties, and in the smaller county I work in, like, no pharmacy has a REMS set up, so we can't even give this in that county yet. Usually, they recommend you take LFTs prior. My experience in the outpatient setting is my patients can remember the appointment, but they can never remember to get their LFTs drawn. And given the morbidity of opioid use disorder in the age of fentanyl, I just say, "You know what? Let's get you on the Sublocade, and we'll figure out your LFTs whenever we can." A lot of them have relatively recent hospitalizations or ER visits, so I usually just log into Epic and see if they have any old labs on file. Sublocade is given in the abdomen, and you rotate in the quadrants of the abdomen. Brixadi is drug number two. It's available as a weekly and a monthly injection. I haven't quite figured out the point of the weekly yet, 'cause if somebody's gonna take the pain of a shot, I want that to last as long as possible. But they have a really nice chart that allows you to take the sublingual dose, and then basically calculate their long-acting injectable dose. Brixadi is a smaller volume then Sublocade; the big Sublocade shot is like two mLs. It's a pretty decent volume. And it's a smaller needle, so it's been billed as less painful. And it's also able to be given not just in the abdomen but also in the tricep, which most of my patients that I've given it to prefer; just seems like this is a less sensitive area. It can also be given in the buttock or thigh. Same recommendation to check LFTs prior. So kind of comparing the two products, Sublocade needs to be refrigerated, so that may be an issue if you're in the clinic like me. Brixadi does not. But one major difference is the tail, and the tail being how long the medication lasts in your system. So with Sublocade, people will test positive for buprenorphine up to like 12 months and even beyond after getting their dose of Sublocade. And hearing from the drug reps, it's not the same with Brixadi. So basically, for me, again, why do I sleep better at night when my patients are on Sublocade? 'Cause if I give them a dose, I know I really have a good two months with the drugs in their system, and maybe even longer. I don't have as much experience with with Brixadi, but the reps were telling me that it doesn't have that same tail that Sublocade does. My experience with both of them is that both injections hurt. All four of my patients yesterday told me that hurt. One of my patients actually puts on EMLA or LMX, like a topical anesthetic ointment, prior, and she puts a Tegaderm. So most of my patients, I choose the site the day of, and she literally like comes in with a Tegaderm and EMLA, and she's like, "You're gonna put it here." I'm like, "Okay." Most of the time, it gets delivered to our clinic with an ice pack to keep it cold. We literally put the ice pack at the injection site for a little cryotherapy to reduce the pain at the injection site. As I mentioned, the longer tail of Sublocade is why I prefer that. There was a doctor on LinkedIn who had a post recently. He's an anesthesiologist that does addiction medicine. Can't remember his name. I think it's David. He does MyMat CLINIC. He had a patient talking about how much less painful Brixadi is. And the Brixadi reps tell you that Brixadi hurts less. I've given one dose of Brixadi. My patient said, "That didn't hurt any less. I wanna go back to Sublocade." The other addiction doctor in the practice who did EM and now does addiction has had the same experience. Most of the patients say they both hurt. If you are managing the patient long term and they have a return of cravings on a long-acting injectable, you can supplement with sublingual, and both meds take a few days to get therapeutic. So I usually have my patients continue their sublingual for a few days after they start and get their first dose. I'm gonna stop there, just 'cause I know time can be a little bit tight, and see if folks have questions. Otherwise I can talk about using Sublocade to taper off of buprenorphine.

- Thanks for that, Casey. Myself, I'm interested in how you got the medications on formulary, how you bill and get them paid for, what administrative support you have to get these drugs available to you and your colleagues; if that's something you had to do, or did your pharmacy team kind of roll out the red carpet for you? I have been so far unsuccessful in getting these drugs in my hospital.

- So two things. So the first is is that I'm gonna talk about the outpatient setting. So we found a local nonchain pharmacy who's amazing, and basically said we'd like to do these. And Monterey County's pretty small. There's only 440,000 of us. A lot of this gets done, kind of like colleague relationships. We've been working with this pharmacy for a decade, and we literally called Jasmine, she's a friend, the chief operating officer, and we told her we'd like to do Sublocade. And she met with the rep and they said cool. They set up a REMS. They delivered to us. And in California, Medi-Cal covers both Brixadi and Sublocade, no questions asked. For my private insurance patients, it is a beast. My office spends hours on the phone fighting with prior auths, trying to get insurance to cover it. One of my patients actually relapsed because I could not get him a second shot because of the insurance barriers. That being said, both companies do offer discount coupons to patients. So if they have a high copay, that can help. For our hospital, we approached the pharmacy and really brought up the example of endocarditis. Somebody comes in, they've got, you know, a severe medical complication of injection drug use; the hospital is the right time to give someone a long-acting injectable medication as they're discharged. And that was really the case. We had a very traumatic case at our hospital of a young man with endocarditis who like broke stuff in his room and was verbally aggressive, and even physically threatening towards multiple staff members. We actually had... I dunno if anyone knows what Schwartz Rounds are. It's kind of like the human side of medicine. We had an entire Schwartz Rounds around this man and how he affected our hospital staff. And so when we said, you know, "Hey, this is exactly the patient that when we get 'em inpatient, we give them Sublocade and discharge them." We are gonna defer, you know, kind of their return to injection drug use for a few months with all luck. And then in the meantime, that gives us time to get them outpatient follow-up. And going back to choice, if they accept the long-acting injectable in the hospital, we have at least a month. Or if they do have a relapse, they're really not gonna feel much. So that was kind of the sell to the hospital to make that change. And then our hospital pharmacy went through the whole REMS thing and figured it out themselves.

- Casey, sorry.

- Oh, go ahead. Please go ahead.

- Yeah, just a quick question. So we also, I mean, we do an unbelievable amount of Sublocade. And we have like 500-and-something patients on it, and a ton on Brixadi as well. We have not been able to figure out the inpatient billing portion, because the problem is that it's included in the DRG. So are are you telling me that your hospital is just willing to swallow it in their DRG? That's incredible.

- So there's a couple of issues here. So one is is the hospital was only able to have one or two doses at any given time in stock. So let's say we had multiple people at the same time that were gonna need to get it; we actually might not be able to. And so that was kind of the sell to the hospital, is that this would be infrequently given medication, and it would be something that would be kind of a return on investment to avoid recurrent visits and the like. So we've only given a handful of doses since we've had it, and that was how we did it. I can certainly put anyone in contact with our pharmacy director who's lovely. I don't know the actual nuance of the billing details.

- Okay.

- So Rachel, you're saying that you can't... Go ahead. Go ahead, Scott, please.

- Different topic, please finish.

- No, no, we wouldn't.

- I mean, the only thing I I will just add is that the only way we're able to give Sublocade inpatient right now is that we convinced Horizon to take the Sublocades that are almost expiring and nobody showed up for outpatient, and then to reallocate them to inpatient and like de-identify them. And it's a whole big process and it's a whole mass. And it's only for Horizon patients.

- I wanted you to ask.

- Yeah. So we have that. So we do give a lot. We've give hundreds a year. But it's only to Horizon. Yeah, I just feel like we should be able to give Sublocade inpatient. The medicine makes sense, but the insurance, it's not working.

- Yeah, and again, the way did it is it was basically we only stocked the 300 so that the pharmacy didn't have to have more than one formulation. And we would literally just give less than in the syringe. And we let them know that it would be an infrequent occurrence but had enormous medical benefit. And then we also, in order to convince the pharmacy, had to say that no patient could get more than two doses in a year, because we didn't wanna do the revolving door. And that seemed to satisfy them, that this would be an infrequent occurrence, and we would really try to get people connected to outpatient resources so there wouldn't be any misuse of the system. But I can absolutely put you in contact with our pharmacy director who's been very supportive.

- Thanks, Casey. Scott, do you want to take us in a different direction?

- Yeah, just a quick comment. Casey, you mentioned what the value proposition was of the seven-day version, and I actually think that the ED is a perfect environment for that. The pharmacokinetics look like they're really attractive for starting someone on buprenorphine, and you don't have the issues of having to get a prescription filled, and you buy seven days of follow-up time. I don't know if that's the reason why they developed a seven-day formulation. I can't imagine that was the case. But just from evidence that I think is going to be coming out soon, I think it's going to be pretty compelling for us.

- What's the benefit, Scott, over 30 days?

- It basically ends up being like... Well, it's a good question. I mean, the beginning is probably similar as far as like, it's almost like a micro-induction. So you don't have a lot of precipitated withdrawal. I guess it's just deciding what the patient wants. I mean, if they wanna transition to sublingual, they could do that. I guess if you're doing 30 days, I guess you're more prepared. I don't know if patients would be less willing to try something that's gonna last-

- Try it.

- [Scott] Yeah.

- Yeah, I mean, I think my perspective is I want people for as long as possible. So I would say, I mean, I have heard the same, that the seven days could be used in the emergency department for a microdose induction. I've not done it. We don't have Brixadi on formulary at our hospital. They allowed us to pick one. But yeah, I've heard that. But I think my thought would be is if you're gonna give 'em the shot, why not do the 30? 'Cause then at least if they don't follow up or they have a relapse, you have a longer time as far as overdose prevention.

- Yeah, and we're doing 300 in the ED for patients, and it's fine. It's been perfectly fine.

- You talking about Brixadi, Rachel?

- No. Well, we're part of the study, yes, but no, I'm saying separate from that, we do use the 300s that we have reallocated in the ED for patients that are not necessarily withdrawing. Correct. Yep. Yep. But the 30-day.

- Does anyone wanna comment on... Go ahead. Go ahead, Scott, please.

- I was just curious, like, Rachel, if your experience, are there patients that don't want it because of that long-acting effect? Or it's like binary, they either want it or they don't.

- [Rachel] They either want it or they don't. That's exactly right. Like, they either want an injectable or they don't. And I've never had somebody say... And it's interesting, 'cause now, you know, on the outpatient, when I say, "Oh, do you want a one week or do you want 30 days?" they are confused. They're like, "Well, one week, I'm gonna have to come every week." Right.

- Yeah, that makes sense. Thank you.

- [Reuben] Please, Casey.

- I was gonna say, the other addiction doctor in the practice gives a lot more than I do. She probably has like 25 to 30 on this. And it's less of an ask and more of a tell, of the 'I need to get this in you so that you don't overdose and die.'

- [Rachel] Yeah. Yep.

- [Joseph] In Ohio we have to see everyone every week for the first month. So that could be where the seven day comes in. And we use Pain Ease before injection and then right after injection, and it helps with the pain. And then it's not indicated in pregnancy, mainly because of, not the buprenorphine, but what it's put together with.

- Right.

- Nice, Joseph.

- [Rachel] Except that we've given it in pregnancy. Sorry.

- I'm sure it's fine in pregnancy. Joseph, what is Pain Ease? Is that the spray, the ethyl chloride? What was Pain Ease?

- Yep, exactly. Yep.

- Okay, cool. That's always fun. I always spread that on myself before I put it on the patient, just 'cause it's like kind of fun. Does anyone who uses these drugs, or anyone who otherwise knows, have any thoughts on the likelihood of precipitated withdrawal with Brixadi versus Sublocade? Meaning are you less likely? I have heard, but I don't know if this is actually the case, that the pharmacokinetics of Brixadi are slower onset than Sublocade, which on one hand means that the patient is not as well covered for the first couple of days, but with Brixadi, but that you're much less likely to precipitate withdrawal, which from my perspective is a much bigger problem. So I'm wondering if anyone, I mean, have any of you seen any precips? Rachel, I know you've had at least one precip with Sublocade.

- [Rachel] We've had a ton of precip. I mean, honestly, there's an entire element of harm reduction here where you have this conversation: "Hey, you may go into precip." And the patient says, "Yes, and I may also die." Yes, you may also die. So just give it to me. I can say that many of the ones that ended up with precip after getting Sublocade, knew they were going to have precip and chose to have it anyway. So the difference with Brixadi, I don't know because I don't give it in the ED enough, except for the seven-day, and there's not a lot of precip with that.

- Yeah, the other addiction doctor from the practice says there's a couple of patients be like, "I just can't do this. I'm gonna die." Like, gimme the Sublocade and it'll do.

- Yeah, exactly. Yep.

- Wow. Casey, do you want to finish off? You seem like you have another comment you wanna cover.

- I should have realized this was a much more savvy audience. I apologize for being very basic in my slides. I was gonna say, I don't know if anyone else is getting people coming to them saying I want to get on Sublocade to get off of buprenorphine, but I do have some experience with that as well. The first thing is is this was a great study that basically showed that when people are stable on buprenorphine and we get them off of it, within 18 months, 2/3 of them will have either a return to opioids, return to buprenorphine, or an opiate overdose. So my first thing is do we really wanna taper? But if they decide they do want to taper, the long tail of Sublocade works relatively well. I've had now about maybe 3 to 5 patients that specifically came to me to say, "I want you to give me Sublocade so I can get off of Suboxone." And my experience has been, is that depending on their dose, it's somewhere between 1 to 3 injections to get a steady-enough state, that basically that long tail just functions as a very, very gentle taper off of it. They may still test positive for a long time, but I'm not excited about it when people want to come off of bup, 'cause I would prefer they stay on it. But I do have some patients that I've done this with. I don't believe there's any case reports written up of this yet, but I think it's only a matter of time, 'cause patients are aware of it and asking about it. I don't know if anyone else has any experience with this.

- [Joseph] Yes, we use that for helping people taper. And we've also had a lot of trouble with people absorbing, that have no body fat with Sublocade. And the Brixadi seems to work better with that.

- Yeah, absolutely.

- [Casey] Are you saying that they absorb too fast or too slow?

- [Joseph] Too slow, they have like four big lumps by the time their fifth injection's coming.

- Interesting.

- And their levels are low.

- I've had the opposite. I've had several of my very skinny patients feel like they get kind of overmedicated within the first few days. Has anyone else had that experience?

- No, I'm on Team Joseph. We have the same thing with patients. It just sits there, and their levels are really low, and we end up not being able to continue it.

- Hmm.

- Maybe Casey's delivering it in a different way than Rachel and Joseph. Casey, I think it's supposed to be Sub-Q and not IM. Maybe that's what's-

- I hit it IM .

- So I have another question. One of the things that has been hard for us is that we have patients on Sublocade, but it's not enough. And so we give the Sublocade, and I still have people on two or three films a day. And you can say, right, they're probably selling them. But we specifically, we never do Subutex. we always do Suboxone, so that I can at least see their naloxone in their urine. And they do, they have very high levels of naloxone. And it's crazy to me. But I guess, really, Sublocade first came about with heroin, right? That's the initial studies. So I would only think that there may be a pharmacokinetic component to this, and you probably do need more. But I don't know if anybody else is doing that. But we're giving so much. It's crazy.

- Yeah, so it's very interesting. So I dunno if anyone else is doing this. My urine tests in the office are all quantitative. So I don't get any qualitative: only quantitative urine drug tests. And so it's very interesting. One of my patients who I gave like three months in a row of 300 of Sublocade, and was giving BuTrans and was giving sublingual, his buprenorphine levels were only like 120. And one of my patients who was only on two milligrams, a half sublingual twice daily, had the same level. So I've been pondering over why one person's level is so much lower despite their dose than the other. I haven't figured that out yet. But my experience has been yours, is that some people I maximize whatever I can, and it seems like they still don't get a lot actually absorbed and therapeutic.

- I wonder if some patients deserve double-dose Sublocade.

- I don't know if insurance would cover it, but certainly worth considering.

- Yeah.

- [Casey] in my fridge for the patients that haven't followed up.

- I'm telling you, reallocate that.

- Joseph, did you have a comment?

- [Joseph] We had been able to get a few people to get every three weeks instead of every four.

- Okay, that helps. All right. And I imagine after a couple of doses of Sublocade, if you're giving it every three weeks in particular, given the pharmacokinetics, it would start to accumulate. And that the therapeutic levels might get higher and higher over month to month.

- [Joseph] Yeah, the Sublocade people say four doses and you're at a plateau. And Brixadi says three doses and you're at your plateau.

- Mm-hmm.

- Yeah, I don't know if anyone else is doing this, but for some of our patients with higher opioid tolerance, we don't make the drop on Sublocade; we just stay at 300.

- [Joseph] Yeah, we try to keep at least 4 to 500 with people that have been on fentanyl: exactly.

- Yep.

- Great, well, thank you, Casey, for sharing your experience. I'm optimistic that we're gonna see more of this done out of the emergency department over time, as these medications become more prevalent, as the price falls, as more and more insurances will cover it. The advantages are just overwhelming. And the notion that we could take someone with OUD who comes to the emergency department for one thing, or they come for help, and give them a month's worth of coverage out of the ED is just really exciting.

- You know what I really wanna do? I wanna give Brixadi on the ambulance. I wanna give it after an overdose in the field. I don't know that I can do it. I don't know that we'll be able to pull it off, but that's sort of where we're heading.

- Rachel, if anyone can do it...

- I don't know, I think this one is a big one. Yeah.

- [Joseph] We're working to try to get Sublocade on discharge from the jail through the opioid settlement monies in Ohio. And they really keyed on getting out of jail and prison, having things set up. I don't know what it is for your other states as to where the priorities are for dividing the money.

- Yes. So we did that also. And what's interesting is that they let the jails pick. So several jails said yes, we do wanna do Sublocade. So here's what's interesting: less so upon discharge, but more so while they're in the jail. And the reason was purely financial. Because in order to administer the sublinguals and have them brought down to the room, observed, et cetera, it just takes so much personnel. And so moving to Sublocade and being able to administer Sublocade, while they're in the jail and then upon discharge, just ended up being financially better. Some jails just absolutely chose not to. But we have the local jail that is doing a crap-ton of Sublocade.

- Incredible.

- The only other thing that I think we've run into is we have one faith-based kind of abstinence-focused drug treatment program, and they don't have any clinical personnel and cannot manage any medications. And they were previously just kind of making people withdraw. And we've compromised with them, that if we manage the meds and the meds are in the skin so they can't be diverted or misused, then they'll let us use long-acting injectable buprenorphine, which has been great for their retention.

- That's a huge win.

- Huge.

- Guys, it's 6:25. Thank you all for giving us some of your Thursday afternoon. Sam, are you... Yes, Sam is still with us. Outstanding.

- Thank you. This is gonna take a minute. Just a few administrative things. ACEP Scientific Assembly is gonna be in end of September, October. As soon as I get the information for the in-person meeting, I will let the section know. There will be a reception at the first day of the evening of Scientific Assembly, which is gonna be an all-section reception. I will send out all that information to the engaged.

- Oh.

- Yes, sorry.

- No, that was inadvertent.

- Okay. Council is coming up. I know we're a few months away, but council resolutions will be due end of June. June will be here before we know it. The pain section actually has had a lot of success in the past, so please think about it. So if it's the resolution that you potentially would like to run through the section, just remember, we need at least two ACEP members for every resolution. Course proposals are closed for the CME track for Scientific Assembly. However, non-CME proposals are still open and can be submitted until June 30th. If you would like the section to sponsor or support your proposal, any member can submit a proposal. Please run that past the section chair, or just email me and I would loop the section leadership in. But we do need to get approval from the section leadership to sponsor the proposal on behalf of the section. Just a few items. Thank you so much. I will send all of this out in an email. I know it's 6:30 in the evening, Eastern Time, but I will follow this up in an email.

- Great. Thank you, Sam, for facilitating. Thanks to all of you for your attendance and for your thoughts on this Thursday afternoon. Looking forward to ongoing discussion on the Listserv, on Engaged. And I'm hoping to see as many of you as possible in Vegas in a few months. Thanks, everyone, for your attendance, and we'll see you soon.

- Thank you.

- Bye, everyone.