Welcome, everyone. My name is Talene Safarian, and I'm a Senior Manager of Science and Dissemination at the American Society of Addiction Medicine. And I want to thank you for joining today's webinar, Management of Stimulant Use Disorder, Harm Reduction, and Stimulant Use webinar. Before I turn things over to Dr. Puri, I will go over some logistics and announcements. Next slide, please. This webinar is brought to you through collaboration between ASAM and AAAP. ASAM, founded in 1954, is a professional medical society representing over 7,000 physicians, clinicians, and associated professionals in the field of addiction medicine. ASAM is dedicated to increasing access and improving the quality of addiction treatment, educating physicians and the public, supporting research and prevention, and promoting the appropriate role of physicians in the care of patients with addiction. Next slide, please. AAAP is a national professional society that focuses on evidence-based prevention, treatment, and recovery approaches, particularly with people with substance use disorders and co-occurring psychiatric disorders. Their primary focus is to promote high-quality evidence-based prevention, treatment, and recovery approaches, strengthen addiction psychiatry specialty training, foster careers in addiction psychiatry, and promote addiction psychiatry as a recognized specialty. They also provide evidence-based substance use disorder education to healthcare trainees and healthcare professionals. In addition, they educate the public and influence policy on substance use, co-occurring psychiatric disorders, and related issues. Next slide, please. We begin our session today with a few brief announcements about how to use Zoom features. First, please note that attendees' mics are automatically set to mute. If you have any questions on the content during the presentation, please type them in the Q&A box in your Zoom control panel. We will have time for questions at the end, but you can submit your questions at any time throughout the presentation. If you experience any technical difficulties, please use the chat function to send a message, and ASAM staff will help you with your technical issue. Today's webinar will include opportunities for audience members to engage through Zoom polls. Throughout the webinar, the Zoom poll function will be utilized. The poll will appear on your screen during various points of the webinar, so please participate and answer the poll questions in a timely manner. I'd also like to mention that the slide deck and recording of this webinar will be available on ASAM's eLearning Center by tomorrow. Next slide, please. These are a few ground rules. Please take the time to understand the cases and participate. Embrace diverse experiences, monitor your participation, and seek clarification. Next slide, please. I will now turn things over to Dr. Puri. Thank you. Hey, thanks so much for having me, everyone. My name is Sid Puri. I'm a child, adolescent, adult, and an addiction psychiatrist, and I'm currently the Associate Med Director of Prevention at the L.A. County Department of Public Health Bureau of Substance Abuse Prevention and Control, and that's my picture. Perfect. So today, as we go through this lecture, I want you to understand four main objectives. We're going to talk about recommending actions for individuals who have tested positive on stimulant screening assessments. We want to recognize ASAM's guidelines around stimulant use prevention and harm reduction. We want to identify clear, concrete skills around harm reduction related to risky stimulant and non-medical stimulant use, and then we're going to finally bring us all together into a case scenario. So the agenda, again, kind of we'll talk about screeners, prevention, early intervention, harm reduction, opioid overdose prevention reversals, because we are in our worst national opioid overdose epidemic ever, and then we'll speak more specifically around safer sexual practices, oral health, and other kind of nutritional things that we can do with patients who are using non-medical stimulants, and then we'll end with our case. So let's start with screening. So when I think about screening, I think about the idea that patients are going to tell us important parts of their lives, and we're going to use this information to determine how we can holistically understand what's going on. So we want to use validated screening instruments specifically that involve looking at stimulant use. The three that I've listed here I think are the easiest ones that are publicly available that can be integrated into EMRs, and that patients can also fill out for themselves. So a lot of times I'll have patients fill things out in the waiting rooms so that when they come to me, we can kind of hit the ball rolling and I can be like, oh, you've screened positive on this. Let's talk about more. So we have the NIDA, which is the National Institute of Drug Abuse Quick Screen. We have the ASIST, the Alcohol, Smoking, and Substance Abuse Involvement Screening Test. And then we have the TAPS, the Tobacco, Alcohol, Prescription Medication, and Other Substance Use Tool. The USPSTF, there's so many acronyms, recommends screening at clinically appropriate intervals. So generally when I think about clinically appropriate intervals, however you're seeing your patient, I usually do this kind of on an intake. And then if you're noticing changes in behavior, if your patients are saying, oh, you know, I've started using the substance or I'm exploring recreationally with other drugs, it could be a really good time to do another screen or to understand kind of what's going on in their life. The one thing we want to make sure is that screening by itself doesn't include drug testing without a conversation with the patient. So I'm not going to order annual labs and a urine drug screen on a patient and then say, oh, you screen positive for meth. We need to talk about this. Whenever we actually use drug tests, we want to be very intentional around why we're using them. So if you're using them to get an annual screen or you want to let patients know this is part of an annual screen, just to make sure I understand what's in your body, because that can impact your behavior or even other medications I prescribe you. And you want to make sure you get their consent. The other thing about urine drug screens is positives or negative values don't tell you a whole lot except what's in and not in a person's system at that time, nor does it possibly test for things that they may not be testing for, or sorry, nor does it test for things that the patient may be taking that are other kind of like, you know, black market drugs that we don't test for. When we think about screeners and the results of them, we want to make sure that it can mean we need to do an intervention for the patient or at least start having a conversation around their misuse of psychostimulants, but they're not intended to be like diagnostic and they shouldn't necessarily be the only component of treatment decision making. So these are kind of like the samples of the quick screens or of the screeners generally. So this is your NIDA quick screen. It's nice because this can be done online. If patients screen no for the positive ones, then again, you're going to validate and congratulate them on not using substances. And if they say yes to any of them, then they're taken to a more specific screener around that substance. So depending if it's alcohol, tobacco, prescription drugs or illegal drugs, if they say once or twice on that side of the scale, then they are getting more information, you're gathering that information. And then when you have that, you can be like, let me, let's talk more about, you know, you were saying that you're using methamphetamine, for example, four times a week. Tell me a little bit about that experience and tell me what's going on there. This is the assist screener. So this is basically how the first question basically asks about a bunch of substances that people can be using. If they answered no to all of these, then you're done. And if the answer is yes to any of them, then again, just like the NIDA quick screen, you go into more detail around the substances they're using. And then finally, the tap screener, again, you can get this easily accessible from the NIDA clinical trials network. The first component like the NIDA quick screen and the assist goes through a bunch of questions asking in the past 12 months, how often are they using specific substances, including tobacco, alcohol, illicit drugs, and non-medical use of prescription drugs. So again, this encompasses a lot of stimulant use as well. If they screen positive on any of the taps one, then it gives them into a taps two, where they get more detailed information around what they're using, how often. And so all of these screeners, the main point that I want you to take away is that they set up a really good springboard for a conversation around what's going on in a patient's life. So we're not using the screeners and saying, ah, Sid, you've been using meth, you're a meth user now. It's more kind of like, I'm noticing in the screener, you're using methamphetamine four times a week. Tell me a little bit about that. The screeners are available in Spanish. I use the bam R oftentimes with patients I kind of have relationships with. And if it's part of kind of like their treatment, just to look at things like protective factors, risk use factors, and use factors. I usually start with one of these three big screeners. When patients are using substances consistently, then I'll turn to something like the bam R. Now let's go on to prevention, early intervention, and then harm reduction. When we think about early interventions, the idea of early intervention is when we realize that a patient is using something that could potentially be very harmful to their brain and their body, we want to start understanding their motivation around it. And so the first thing I kind of like want to understand is what's the context of their use. So we'll use a lot of motivational interviewing techniques to understand context. And with stimulant use, a lot of it can be around the populations we're working with. So chem sex, including party and play, and like the LGBT communities, weight loss. A lot of the youth that we see are using it for academic or work performance. People who are taking long graveyard shifts often use them to stay awake at night. So understanding that context can be really helpful then in thinking about ways to keep them safe, reduce risk, and refer them to appropriate care services if they need it. The other thing in all of these early interventions is that you want to understand what the patient's concerns and their goals around their own stimulant use is. And that kind of bleeds into harm reduction. And then in these early interventions, you're going to be talking about ways to minimize the consequences, the negative consequences of their use. So as we kind of go through this lecture, we'll hit on some really key harm reduction principles that I want you to keep in mind. And finally, when our patients are using stimulants, we need to be checking our PDMPs consistently because we know our patients oftentimes don't just use one drug. So oftentimes, they're using stimulants, opioids, or benzos, or things that we can track. And maybe they're getting them from multiple providers. So early interventions could be making sure we're also aware of what they're using and where they're getting it from, and then being able to have conversations with the other providers they're speaking with. When we think about prevention, so there's three big categories of prevention, and we're all going to remember this from medical school and the steps. Primary prevention, ideally, is going to be increasing awareness for the risk factors for stimulant use disorder and limiting access to stimulant use disorder. So we know things like co-occurring mental illness, ADHD, PTSD, a family history of substance use. All of those factors or other kind of substance use are going to increase the risk of stimulant use disorder. So making sure we're having conversations with our patients early and often around risk factors that we've noticed, knowing them, that could increase their use. Making sure they're aware of this is going to be kind of like the goal of primary prevention. And then secondary prevention. So when our patients are screening positive on any of the screeners, we want to identify ways to intervene to prevent it from escalating to a full-on stimulant use disorder. So we want to make sure we're talking, again, about context, understanding co-occurring disorders, making sure we understand if things like housing and food are problematic. And that's a reason they're turning to stimulant use to stay up at night and to be able to care for themselves. We're hooking them up with other interventions and services. And then tertiary prevention. So this, like when we think of patients who are kind of like meeting criteria for stimulant use disorder, and now we're seeing negative consequences. We're seeing possibly like impacts of their heart. We're seeing mental illness, including psychosis, where we're seeing kind of like wound infections if they're shooting up, all of that's coming together and we're making sure we're really managing that. Again, in all of these, we can use harm reduction principles as well. So the first step to a lot of this is making sure, and when we think about kind of prevention and early intervention, these really are the first steps in building rapport for our patients and making sure that we understand context they're using, their goals for both their treatment and their use. And we know that a lot of, unfortunately there's not a lot of direct evidence showing that brief intervention reduces harms to stimulant use, but we know broadly with addiction treatment that brief interventions do increase things like readiness for change, boost motivation for treatment if that's the patient's goals. And then we also know that introducing harm reduction practices has evidence for positive outcomes. So the biggest positive outcome we can think of as a patient not accidentally overdosing from fentanyl that's been contaminating their counterfeit pill powder, methamphetamine, or cocaine, and their ability kind of reach their goals. So we know that combining prevention and early intervention do have positive outcomes on patient's health and wellbeing. Okay. Ooh, poll, who's paying attention? So the first poll is going to be the goals of early intervention, sorry it's popped up, the goal of early interventions for stimulant use include all the following except reducing risks, providing psychoeducation, increasing motivation change, or emphasizing the need for abstinence. Do a couple more seconds. And okay. Awesome. Perfect. Good job, everyone. So the emphasize the need for abstinence. So correct 83% of you were right there. I'm sorry. So yes, the goal of early intervention is all the following except so we do want to reduce risk, we want to provide psychoeducation, we want to increase motivation for change. And then we do not want to emphasize the need for abstinence. Again, coming from a harm reduction lens, our goals are to meet what the patient's goals are. And if they're like, I, I'm not, I'm not focused on abstinence right now. That doesn't have to be what we do in primary prevention or intervention. Good job. Okay, so now we will go on to harm reduction. So harm reduction is really kind of like taken off in the news. And oftentimes we see harm reduction be kind of being talked being spoken of specifically around substance use. And I want us to kind of like telescope back a little and understand that harm reduction is the idea that we're reducing risk for any behavior. So this could be something as simple as wearing a helmet or a seatbelt when we're on a bike or in a car, arranging for another driver if someone's had too much to drink, taking your medications for diabetes, high blood pressure, high cholesterol, getting your annual physical, all of those are forms of harm reduction because we're reducing consequences associated with a behavior that poses a risk. And essentially everything we do in life can pose a risk. When we speak specifically around harm reduction and substance use, the goals of harm reduction at, at its core are, it's that last one, it's meeting patients where they are. It's really understanding what the patient's goals are and helping them get to that goal in, in that way that we would love to reduce overdoses. We want to prevent the spread of communicable diseases like hepatitis and HIV. We also want to offer the resources that they need and want. And this includes things like food, water, housing, medical substance use treatment, psychiatric services, and mental health treatment. At its core, harm reduction is a relationship with a person where you're able to provide the services they need to reach their goals and matching them kind of like, sometimes our goals are like, I want you to stay alive. And that can be a really good goal that you've come up with together. When, when we think about what harm reduction is and isn't, I think there's a lot of resistance to understanding that providing services to people who are using drugs, people can be like, that's enabling your use. And harm reduction, what it truly provides is practical, non-coercive strategies to again, meet people where they are. We have to come to an understanding that people are allowed to use substances and people who are using substances still have the right to have their health and wellbeing protected and their decisions respected. So what we want to do from a harm reduction lens is we want to improve the health and wellbeing of people who use drugs while also reducing the consequences of that substance use. This focus on health though, doesn't require abstinence. And it's truly in this like relationship building with people who use drugs that we're able to understand their goals and help them get there. And again, an emphasis in harm reduction is truly respecting autonomy. What it does not do. So it's not creating a system that enables people to use substances. It's not forcing people into treatment to reduce their substance use if that's not their goal. And this is kind of like a tangent, but Senate Bill 43 just passed in California and that kind of expands our conservatorship laws to include substance use. And so that's kind of a different discussion, but I just want to throw it out there so people know that that's something that's happening in California. Harm reduction does not increase public disorder, does not decrease community safety, and it doesn't take away from healthcare or treatment services. It actually leads people to those services when, and if they're ready to do so. This is my harm reduction wheel. So these are all of kind of like the principles of harm reduction that I want people to understand are services that we should be offering our patients who are using substances. So Naloxone, over the counter now, there's two different formulations for it, easily covered by insurance. This is an opioid reversal medication that saves lives. Stale consumption and supplies. These would include syringes, cookers, pipes, anything to smoke with, all of those. Drug testing equipment and strips we'll speak about later, but this is like fentanyl and xylosine test strips or the FTIR. Medications for addiction treatment. We have medications for stimulant use disorder. ASAM just released guidelines around stimulant use treatment that we'll have another lecture about. Medical psychiatric and substance use care, communicable disease testing, wound care, peer support, and social support linkages. So all of this falls within the realm of harm reduction because we're reducing harms associated with a behavior. When we think about the evidence of it, and again, this is kind of like a lot of people are like, harm reduction doesn't work. It's just enabling. We actually have a lot of evidence that shows it's helped reduce burdens around the healthcare system and made community safety a priority. So within the 30 years of practice for harm reduction, we've shown effectiveness in reducing overdose deaths, which is huge because an alive patient is a patient we can help. Someone who is dead is no one we can help anymore. It reduces bloodborne infections, including HIV and hepatitis C. It's safe and cost-effective. And the kind of stuff that I like to let people kind of like focus in on, the lifetime cost of a medical care for each new HIV infection is $400,000, right? Not a drop in the bucket. That's a pretty substantial amount of money. The equivalent amount of money spent on harm reduction programs prevents at least 30 new HIV infections. So that's much more money that's saved if we can prevent HIV infections, which is what we do in harm reduction. We also have evidence that compared to people who don't access harm reduction services, those who do are five times more likely to participate in drug treatment if that's their goal, three times more likely to stop injecting. And that's helpful because getting people to move from a riskier to a less riskier mode of use reduces overdoses, can reduce communicable diseases, and all of that is helpful in contributing to their health and wellbeing. With harm reduction and stimulant use disorder, now we kind of get into the beef of how this results with how it's related to stimulant use disorder. The first things we want to do is make sure people understand and have psychoeducation on the effects of the non-stimulant, non-prescription stimulant use. We'll go through kind of overdose prevention, reversal, safe sex practices, oral health, and nutrition. The nice thing about this is you can tailor all of your harm reduction methods in principle to the patient in front of you. And that could include safer stimulant use practices and then referrals to things like harm reduction agencies, syringe service providers in your area that can do more direct harm reduction work too. So when we talk about stimulant intoxication, I love these things. Okay, so when patients are like, well, what am I supposed to feel if I'm doing stimulants or this is what I'm feeling, we should all kind of know this. So, you know, they're getting in the brain, they're getting alert, there's euphoria, there's sometimes, you know, insomnia, irritability, some confusion, they're speaking very quickly, they have dry mouth. Physically, they're having an increased heart rate, blood pressure, and breathing rates. They're kind of exhibiting decreased appetite, increased sexual arousal. Generally with the body, we're seeing sweating, increased temperature, tremors, and shakiness. So these are all kind of like the signs and symptoms of what we would expect if someone's using stimulants and they're intoxicated with them. Then on the reverse side, so after that high, and that high feels really good, right? I think, you know, if you haven't seen kind of like the amount of dopamine that gets released when someone is using methamphetamine, for example, is so exponentially higher than any other substance that the euphoria they're feeling drives their kind of like consistency and interest in trying it again. And then avoiding the crash is another reason people are kind of like, God, I really want to get that feeling again. And when we talk about the crash, so these are kind of like the core symptoms of what we'll see with our patients who are struggling and they're crashing from a stimulant use disorder. So we'll see hunger, we'll see irritability, we'll see daytime fatigue, we'll see anxiety, lack of concentration, and kind of just like, oh, well, you know, I gotta feel gross. And during this time, the things that you want to mention with your patient, like when you're in crash mode, make sure you're sleeping, make sure you're eating, make sure you are, you have social support. So like, you know, in this part, parts of like their frontal lobe aren't kind of like woken up yet. And so making sure you're asking someone who can help things like organize you making appointments, making sure you're taking your medications. Can you use alarms on your phone? Like all of those things when people are crashing are really hard to do. So if there's a way to kind of prepare them for that, that can, you know, decrease any of the aftermath of it. When they're crashing again, they can also be lethargic. The insomnia is bad. The dysphoria can be really bad. They can have headaches. The other thing I like to do is, okay, again, we're making sure they're sleeping, they're eating, they have social support. And then encouraging to think about kind of like the ways in which they've coped with stressful and uncomfortable situations in the past. And a lot of times with my patients who are using non-medical stimulants, I'll ask them to write things down. So like, what are the things that have really helped you manage difficult situations that you could feel when you're crashing? So what's the music you listen to? Write it down. What's the work you want to do? What's the walk you want to take? Where do you want to sleep? So in those moments where it's hard to organize themselves, they have it written down. So we have the intoxication, then we have the crash. And I want people to know kind of like what a stimulant overdose or what a lot of people call over-amping both feels like and looks like. So when someone's over-amping, they've essentially used too much stimulant or unaware of how much they took. And it's, it's much higher. It's a much more intense high. So they feel like their heart is going to explode. They feel like they can't breathe, that their body is hot, sweaty, and shaky. They may have chest pain. They feel like they can't walk or talk. And so it's important again, to educate your patients on this is a time where your stimulant use has gone too high and you've taken too much. If you're with friends and we would always encourage them to use with someone just to be able to, again, use naloxone if someone overdoses, they should know how it looks like in other people. So it looks like they either have a fast pulse or something's happened to their heart and they have no pulse. They're breathing or they're not breathing. Their skin is hot and sweaty. They're confused. And maybe they're, they look like they're in an altered reality or they're experiencing something like visual auditory hallucinations. They're unconscious. They're unable to walk and talk. And in a more extreme case, they're vomiting or having seizures. So providing this education to patients is really helpful because then they can start titrating. This is how much I took last time when I was over-amping. So I know I can't take this much. This is how I felt last time when I was crashing and I wasn't able to do the things that I needed to do. How can I make it different this time if I choose to use? So responding to over-amping, I think this is really important to make sure our patients know about as well. So the first thing you want to do is make sure your patients feel comfortable understanding what is kind of like something that they can monitor versus something that needs to go to the ER. So if it's something like someone's unconscious or vomiting or seizing, those are like the indications that we need medical intervention. You can try managing overheating with ice packs, mist, and a fan. Make sure people understand the risks of stroke and recognize the stroke symptoms. Make sure that they understand if someone's had a seizure, create a safe environment, turn them onto the side, please call 911. And if they have symptoms of a heart attack or cardiac arrest, please recognize these symptoms and call 911. And then knowing your rights when you call 911. So if you're calling 911 and you've had to administer naloxone, the good Samaritan laws will protect both you and the person using substances from any kind of like arrest. So making sure patients are aware of that so they're not fearful of calling and getting medical help. Okay, who's paying attention? So poll number two, which of the following strategies is recommended to encourage individuals crashing from stimulant use? Avoid physical activity, engage in activities, increase stimulant use to counter the crash, or avoid sleep. Okay, a couple more seconds. Okay, perfect. Good job. So the answer is gonna be engaging activities such as listening to music. We don't wanna encourage physical activity if they're super tired and can't, sure, but like get them moving, trying to get their bodies and dopamine up in their brain would be helpful. We don't wanna increase stimulant use to counteract the crass just because if they use more, perhaps there'll be a cardiovascular event and let them sleep, kind of let their bodies recover from this. Good job, everyone. Okay, so now we're gonna go over opioid overdose and interventions here. So hopefully everyone here knows about fentanyl, right? So we are in the worst overdose crisis we've seen in national history and it's resulted from a lot of the fentanyl that's now being cut into our counterfeit pills and powders. The DEA comes out with data annually around how much fentanyl is in counterfeit pills and powders. And so this year they released the information that seven out of 10 pills contain a lethal amount of fentanyl, which is really important for our patients to know because a lot of our patients are like, oh, I'm getting this from a plug online or Snapchat. And knowing that counterfeit pills, powders, including things like methamphetamine, cocaine, Adderall that's coming from plugs or drug dealers or even from over the border in Mexico can have the risk of being contaminated with fentanyl, can change their practices or at least help them practice in a safer way. The thing that I like to present here is also like, so seven out of 10 have a lethal amount of fentanyl. It doesn't mean the other three are like good to go. It means the other three may have fentanyl. And if patients are using multiple substances at the same time, so if they're using like benzos, meth, and pills and powders at the same time, that benzo combination and that fentanyl combination can also lead to an overdose. So making sure patients are aware of this, we never wanna take fear-based messaging, but we want them to be aware so they can make an informed decision. So we wanna make sure in our harm reduction practices and how we approach our patients with stimulant use disorder we're prescribing naloxone. So we want to prescribe and distribute overdose reversal medications as often as possible. So this includes naloxone. We wanna make sure A, they know how to use it, B, they know where to access it. If we can't prescribe it for them, then we wanna make sure they know where in your area they can get naloxone. It's available over the counter now at some major drug stores between 45 to $50, which can be a little steep for a lot of our patients. So making sure that you're aware of at least naloxone access points or community-based organizations that have free naloxone that you can refer to your patients. But I always encourage you to prescribe it for your patients. So these are kind of like the two big ones we have right now. So naloxone, the intranasal spray, the FDA has approved two over-the-counter ones. So we have our good old Narcan at four milligrams and our Revive at three milligrams. Naloxone comes in a bunch of different formulations as well. So we have the auto-injector, the IM injection, the IV injection, and the IM auto-injector. Depending on kind of like what your patients want, it's good to like be able to say this is a range. We also have nalmethine as an IV injection. I just kind of like give everyone intranasal naloxone as much as I can because getting it into the community means that more people have access to it. We're normalizing this conversation. And then if someone does overdose, it's a higher likelihood that someone can intervene and save their life. Perfect. In kind of like understanding naloxone with your patients, there's a few things that I always talk about with my patients who are using stimulants because they're like, I don't need naloxone. Again, making sure they understand that fentanyl is being cut into counterfeit pills and powders, methamphetamine, cocaine. So having naloxone around is a preventative way to save their lives. Naloxone is only gonna work if someone has an opioid in their system. And so if someone has symptoms of an opioid overdose, so they're unconscious, not breathing, their pulse is really slow, their skin is blue, their pinpoint pupil, all the classic constellation of opioid overdose symptoms, that is an indication you should use naloxone. Oftentimes fent and other opioids are cut into the other stimulants that people are using. So making sure they understand that even if someone's passed out and they thought they were using methamphetamine, it's still important to use naloxone. Again, you want to use it, you're gonna squirt one nostril, one dose, wait about a minute and a half to two minutes and then use the other dose for the other nostril. We wanna mention that it only is temporary. So it lasts about 30 to 90 minutes. It should take effect within those first two minutes and advise them that administering multiple doses is okay. When I work down on Skid Row, sometimes we're giving six to eight doses of naloxone. It cannot be misused and it does not cause dependency. So it's not gonna make people high, right? It's gonna take them out of their high. If they're using opioids chronically, it's gonna put them in a withdrawal. If they're using opioids accidentally because it's mixed in with the stimulants they're using, it will bring them back to life. We can use naloxone on any age from infants to centenarians, the older populations. The most common side effects are gonna be precipitated withdrawal, which is uncomfortable and very, but not life-threatening to the point of an overdose being life-threatening. Then we have drug testing. So I think this is a really important thing that we also need to talk to our patients about who are using stimulants. So recognizing safety or recognizing kind of like drug safety equipment is gonna be important because it can reduce overdoses, it can reduce risk, it can help people make more informed decisions around the substances they choose to use. We wanna encourage patients to use comprehensive drug tests. So this is gonna include fentanyl test strips, xylosine test strips, every time they acquire a new batch of stimulants for non-medical use. We want to empower patients to know how to use these properly and why we are gonna crush them into fine powders. And then you also wanna make sure you know kind of what the governing laws are where you're practicing. So in California, for example, fentanyl and xylosine test strips are not considered paraphernalia. We are allowed to hand them out. In other states, some like the fentanyl test strips can be considered paraphernalia. So make sure you're also abiding by your state laws. And I encourage advocacy around changing those laws to make sure these are well and easily accessible to all of our patients. When we talk about fentanyl test strips, and this would be an example of what you would do with a patient. So you have your fentanyl test strip. The first thing you wanna do is make sure that you crush the substance you're gonna use into a very fine powder. The reason we do this, I'll show you in a second. So you crush it into a fine powder. You take out the fentanyl test strip. You take a bit of that powder, mix it with water and dip the wavy blue end in for about like 10, 15 seconds. And then you're gonna lay it flat on a surface for about five minutes. And then you'll see the lines emerge. One line meaning positive, two lines meaning negative. If it's positive, it doesn't tell us A, how much fentanyl is in there. So it doesn't say 2%, 50%, 80%. And it doesn't tell us the type of fentanyl. So it doesn't tell us Sioux fentanyl, alpha fentanyl, car fentanyl. It just says yes or no. Two lines means it's that the substance you've tested is negative for the fentanyl that this test looks for. So there's always a possibility that there may be some sort of like molecular change in the fentanyl that's in their substance that this test does not pick up. So mostly foolproof, but you wanna make sure patients understand. When you're having them start using fentanyl test strips, the reason we wanna make sure that the substance they're using is crushed into a very fine pill or powder is something we like to call the chocolate chip cookie effect. So we have this chocolate chip cookie and fentanyl are the chocolate chips. Sometimes you buy the chocolate chip cookie and unfortunately you don't get a chocolate chip and that sucks, right? In this way, fentanyl sticks to itself. And so if you... So you wanna take that powder, crush it to a very, very fine powder. So you're dispersing the fentanyl. That'll give you the best likelihood of an accurate test. Then we have more advanced drug testing techniques that a lot of our certain service programs in LA County and kind of throughout the nation are using. I can't say that name, but FTIR assesses contaminants and they can also verify the main component of a sample. So this is a really good thing for people to know. It also helps kind of like understand the landscape of drugs in your area. So if you're using drug equipment like this, you can also use this then for public facing messaging to be like, oh, we're actually finding a lot of the cocaine samples have super high rates of fentanyl or the ketamine samples or whatever it is, or we're finding new adulterants. And this can be really useful then for public health and medical practitioners to be able to educate their patients about and result in kind of like changes in behavior. Okay, and then we also wanna make sure patients understand risk factors for overdosing. So the first one is using a loan and using a loan by itself doesn't increase your risk for an overdose, but it increases a risk of a fatality because no one's there to call 911 or administer naloxone if someone overdoses. Tolerance, so a lot of our patients are in and out of carceral settings, hospital settings, or things like treatment centers. And then they have high rates of relapse. And so making sure patients understand if you've taken a break, start low and go slow because your tolerance is not the same as it was, say prior to whatever admission you had. And so making sure they understand that reintroducing a substance in their body may result in an overdose. Drug quality, so again, this is like how much fentanyl is going to be in your non-prescribed stimulant that you're using? Are you testing it to make sure you know that fentanyl or xylosine is present? And if it is, are you staggering use with your group? Are you ensuring naloxone is there or are you using less of it? Multiple substances, so again, if they're using things like alcohol, benzos, and a stimulant and an opioid, all of those things can put a lot of pressure on the heart and cause an overdose or suppress breathing. Mode of use, so again, injecting versus like smoking versus snorting versus eating. So the quicker something gets to the brain, the more likely someone can have an overdose. So making sure people understand that and then can reduce risk by using in a mode that's less risky. So going from injecting to smoking or smoking to snorting or eating. And then age and health, so the extremes. So youth and elderly populations have higher rates and then making sure they understand that any comorbidities, so diabetes, recent COVID infection, cardiovascular disease, all of those things can also put pressure on your body and result in an overdose. And these are the things we wanna focus on in a harm reduction lens. When we talk about kind of making sure people aren't using alone, especially again, with the amount of fentanyl that's in our stimulant use counterfeit drug, we wanna make sure people are aware of resources for that. So if they are gonna use stimulants alone, if they're like, I love doing my math alone at nine, cleaning my apartment, that's fine. But make sure you're calling the Never Use Alone hotline or you have the Brave app open. So in case you stop responding, someone can help get to you and save your life with naloxone or a medical intervention. So these are two really good resources I give to all my patients. Then let's talk about safer sexual practices. Okay, perfect. So we know a lot of our patients with stimulant use disorder have high-risk sexual practices. So we wanna make sure we're doing things like offering PrEP, pre-exposure prophylaxis, because oftentimes a lot of our patients with stimulant use disorder are engaging in sexual behaviors with multiple partners. They're inconsistently using condoms and lube or patients who access PEP, which is post-exposure prophylaxis regularly. All of those would make it a really important conversation to have with your patients. We also wanna make sure we're offering this to patients who are injecting drugs. So if they're injecting their methamphetamine or cocaine. PrEP has not been shown to increase risky sexual activity or injection behaviors. So again, it's protective and does not include increased risk factors. We also wanna make sure we're offering STI testing regularly. So generally every three months, that's kind of around the time you would write their PrEP prescription, or six months, depending on kind of like how often you're seeing the patients. We also, in the same kind of vein, wanna make sure we're offering referrals to local sex education programs for harm reduction services. We're making sure we're providing condoms and lubrication or advice on where to obtain them. In the same way, when we're asking about sexual practices, if there's coercive sex versus non-coercive sex, we're making sure you're listening to their patients and understanding if there's other risk factors that are putting them kind of like in the position where they have to engage in high-risk sexual behavior. So are they doing this because they're alone at night and they need a place to sleep and they're using stimulus because they're engaging in commercial sex work? So is there a way we can incorporate case management and housing for them as part of their treatment plan? We also want to make sure that we're not limiting them to contraception and we wanna make sure people of childbearing age are receiving pregnancy tests to kind of like at least let them know and they're aware of pregnancy status. Stimulants also tend to dry out mucous membranes. And so in that way, we wanna make sure they can tend to have longer, more intense sex. So we wanna make sure they're using lubricant. This is especially true of people who are using drugs because they can be using stimulus to facilitate and improve sexual activity. And so we wanna make sure that lube is something they have a lot of, lubricate that. And then oral health. So again, I think all of us have seen these pictures around kind of like meth mouth and the dental complications from stimulant use. So we wanna make sure that in kind of like preventing poor dentition caries and abscesses, we wanna suggest making sure they're drinking water to keep their mouth moist, moistening their lips with their own lip balm, keep chewing gum to reduce clenching, brushing their teeth or using mouthwash when appropriate. And then if they're smoking, avoid infection by using their own mouthpiece. And then nutrition. Again, we learned earlier that people who are using substances, stimulants, have lower appetites. So we wanna make sure that they're eating. So how much are they eating? Can they eat before they use? Can they engage in eating or drinking when they're crashing? All of those things. And if they need help, making sure you're aware of where to link them into services for food as well. Okay, and then we have some specific guidelines around safer practices for smoking. So again, if they're going to smoke their stimulant, smoke in a place where you trust the people you're around, don't share a mouthpiece to avoid infection, keep drinking water to reduce cracks and blisters, moisten your lip with your own lip balms, chew gum, and the pipe is gonna be really hot, so handle it with care because you don't want burns on your fingers. When we think about safer injecting practices and all of our harm reduction technique services have kind of like taught us this for the past 30 years, never share a syringe cooker or cotton. Use a new syringe at every injection. If this is impossible, show them or at least link them to a person who can show them how to bleach and clean their syringe. Rotate their veins. So make sure they're not using the same vein over and over. It can collapse. It can increase risks of infection. Clean the injection spot with soap, water, or an alcohol wipe. Anything they possibly can is gonna be better than any like skin bacteria getting in there. A lot of people will use ascorbic acid or citric acid to break down a stimulant to avoid infections. If they're gonna do that, let them know things like lemon juice or vinegar can carry a fungus. And so make sure that they're aware of that. And then vitamin C powder can reduce the risk of abscesses and infections, but it can also damage veins. So it's really important for them to rotate veins, be very careful with their wounds, especially now that xylosine is in places too, and that reduces blood flow to the skin, worsening infections. So making sure they're all aware of that, and then you know where to send them for these supplies. And then general things, kind of like safer use practices with stimulants. Again, start low, go slow. You can always add more, but you cannot take it back. Choose a safer mode. So smoking or snorting instead of injecting. Avoid sharing your needles and equipment. Avoid stimulants and alcohol or other drugs. Avoid stimulants and other kind of like pills and powders, just given the amount of fentanyl that's in our drug landscape right now. Please remember to take time to sleep and rest and care for your body. Drink water, eat a meal, and then know how long it lasts. So you're like, oh, if I'm shooting up like, you know, an ounce of meth or gram, not an ounce, God, that's a lot. Or gram, that's a lot too. However much they're using that their body can handle, knowing that like, that's gonna take me out for 12 hours. How am I thinking about that? These are all kind of like very concrete practices that I go over with my patients. And then overdose prevention sites. So, or safe injection sites. So these are safe supervised facilities where individuals can consume products and pre-obtained substances under the supervision of trained staff. We currently, so currently in the US, there are a couple of overdose prevention sites in New York. Everywhere else in the country, we're trying to figure out how to kind of do this both legally and safely. The reason that we think this is helpful is we look at European and Canadian models and there's a reduction in overdoses when people are monitored with the substances they're using. So these centers essentially offer supervision when they're using immediate response, but also link people to harm reduction services and provide nonjudgmental support, linking them to the other services they need. And so we're working on kind of like the legality around this right now, but this is something that could also be a really good kind of prevention model in the future and harm reduction. And then SSPs, these are certain safety programs that are in a lot of parts of the country. They link patients to peer teams and services that provide sterile equipment, linkage to medical, psychiatric and substance use treatment. They can work either in foot-based mobile outreach or through storefront locations. Generally, the SSPs cater to low-income, uninsured populations, including people experiencing homelessness. And the main goal is to kind of just increase services to the populations that oftentimes don't come in to see us in clinics. Okay, perfect. We've made it to the case presentation. How's everyone doing? You're all awake, ready to go. This is great. Okay, so we're gonna talk about Mr. X. So this is a patient who is a 34-year-old cisgendered man. He has a history of hypertension and diabetes. He's receiving ongoing care at your primary care clinic. Over the past year, despite being on HCTZ and metformin, his blood pressure has shown to shot upward to from 132 to 81 to 144 over 92. Additionally, you've noticed that his weight has decreased from 184 to 168. You're like, what's going on? It's a stimulant talk. Okay, so then next steps, which of the following investigations would you order for Mr. X? And you can choose more than one. So feel free to... Okay, perfect. So y'all are on the right track. The pregnancy test and the CT scan were thrown in there to see who was paying attention. But yes, so we want to order all of these. We want to know kind of what his mental health is. We want to know a screener. I chose the TAPS here. Basic labs, you know, how his liver's doing, what his hemoglobin A1C is with consent, a UDS and a physical exam, and you're going to review his PDMP. So in all of these, his PHQ-9 screener was high for depression. His TAPS screener was indicative of stimulant use. His CBC and CMP, AST and ALT were all normal. His hemoglobin A1C was 7.4, so still a little elevated. And his UDS was positive for methamphetamines. On physical exam, you noted substantial weight loss and his PDMP review didn't show any stimulants. So you're having this conversation now, right? So again, when we think about early intervention and prevention, understanding what's going on in Mr. X's life is going to help us have a really important conversation around what's going to keep him safe and possibly what's motivating his use, right? Because our goal at this point is we have a patient in front of us who's misusing stimulants. So we want to know what roots are kind of causing the behavior, what his goals for the behavior are, and then how we can kind of help him reach there while protecting his health and well-being. So in the next question that I think I've already answered, what would be important to capture in an interview? So you're going to kind of use this moment to springboard to understand more of what he's doing. Okay, awesome. Y'all are y'all are on fire right now. This is great. So you want to know, like in this in kind of like how we start these conversations, I think is going to be kind of like in the most authentic way you can given the report that you have with your patient. But I think something as basic as, you know, in the both in the screener and in the, in the, in the labs we noted that there was some methamphetamine in your system. Tell me a little bit about what's going on in your life right now and hopefully kind of like, and this comes from a patient, you know that I've seen and so these conversations are really delicate in the way that we want to avoid things like shame and judgment and their behaviors and we want to really understand kind of what's, what's going on there and so asking kind of like when you're purchasing your stimulants or when you're doing them, what are you hoping will happen, what are you feeling when you when you're using them, and you know he was like I'm just sick of being overweight and I really wanted to lose weight. So that is a whole nother conversation like talk to me about your relationship with food and exercise and and what your goals are and why you want to lose weight, all those are really really important for them to kind of talk about. And then kind of like as you're using stimulus what you're feeling in your body and your brain, and then what you're feeling when you're not using them and really understanding kind of his goals and his feelings around that too. In that same way you also want to make sure you're taking a careful history of like prior stimulant use prior like hospitalizations. And then just to kind of like understand medically what else may be going on has he ever had an overdose. And then kind of taking care of all the things we just talked about including fentanyl fentanyl test strips naloxone xylosine test strips, all those things that may be impacting his health in ways that he may not know who his current support system is. And then what they were hoping they would happen if they you know continue the non prescriptions demands. So all this kind of like starts a conversation that promotes health and well being in a way that's much better than kind of being like you are a stimulant use disorder patient, you know, cut off everything. And then maybe in talking to him you're like, I'm concerned that your stimulant use is actually elevated to the point where you know you're not able to do things you enjoy you have tolerance you're having withdrawal symptoms, you're really focusing on getting it. And all of a sudden you're building your social obligations and all of a sudden you're building you're noticing things, and you're able to reflect that back to him and say like maybe this is the time we escalate and elevate services for care to make sure your health and well being is protected for now because you know we're noticing things aren't going well. So these are all kind of like you're all on the right track. And then like our relationship with patients I really kind of like, as you've seen I use a lot of more motivational interviewing around their goals and understanding the relationship to the substances they're using, because these are all patients now we're seeing who are using substances. Our goal is going to be, you know, to reduce risk that may include reducing substance use as well. We want to talk about you we want to use open ended questions so for example how has non opioid. Have you noticed any negative consequences. You know you want to, you want to affirm things in a way, when the patient shares I've struggled with weight loss in the past, you know, but you know he's been able to, you know, eat healthy and exercise more you want to affirm that you want to say you've been able to make substantial changes in your life. And then you want to reflect things so he's tried to quit stimulants so many times then he relapse, you can reflect back like that shows persistence, even in the face of discouragement and then you want to summarize kind of like what you're hearing and making sure it's, it's accurate. So when we think about interventions and you're going to refer things like a dietician mental health to consider psychotherapy and medications for depression, you're going to make sure that they have harm reduction supplies and recommendations. I saw I saw one of the questions the never use alone app number changed. So we'll make sure to update that in the slides before they go out, and then you want to follow up with them. Okay, awesome. Yes. Okay, so we have five minutes for questions I'm sorry that I babbled for too long, but I will start at the top screeners are available in Spanish. Okay. And then we have a common case scenario is where a patient either endorses symptoms of ADHD, a history of ADHD, wanting to get back on meds and the absence of a confirmed ADHD treatment with stimulants what's practical useful screening and diagnostic So there are some adult ADHD screeners and blinking on the name of right now but if you Google adult ADHD screener that's definitely something you can utilize, I would always utilize neuropsych testing so being like, I want to make sure this is the appropriate treatment for you. People can have for concentration in settings of depression and anxiety as well. So I would lean on psychology and making sure they're getting neuropsych testing to be able to do that before. There's also non stimulant things that you can use for ADHD. So if you're thinking there's co occurring depression you can try things like wellbutrin you can try strata. If they're having more kind of like hyperactive ADHD so it doesn't have to be stimulants and if you go that route I'd confirm things with neuro neuropsych testing for patients properly diagnosed with ADHD that asked for an increase in their dose because it isn't helping their energy. Is that misuse. That's a really good question. So, if their ADHD, if their focus and concentration and like their, their core symptoms of ADHD are well controlled on their dose. I would further investigate what's happening with their lack of energy so are they not sleeping enough because their ADHD meds might be too high or they're taking them too late at night so they're not getting enough sleep. So is it a nutrition thing is it a sleep thing. I'd kind of investigate that further before increasing the dose. If you're noticing their ADHD symptoms aren't fully helped with the current dose then increasing the dose would be appropriate. What is the assessment screening you mentioned in the beginning at what level of treatment are the screens used. And is this determined level of treatment needed or reassessment or continual care. So the assessment screeners will be mailed out but it was the night a quick screen, the taps and the assist. They are used at primary care introductions to mental health care, or generally not substance use intakes because then we kind of know, but they can be helpful. During like, you know, a lot of patients will get like an ASAM screener when they enter treatment, and that'll capture a lot of this data as well. I don't necessarily use it while they're in treatment, but I'll use it kind of like if patients are using substances aren't in treatment but I'm seeing them for consistent follow up. I'll usually redo a screener annually to see if there's any changes, or if they're telling me their changes in their behavior or their substance use. I'll ask about that and can use a screener. The law that was passed in California was Senate Bill 43 and that expands conservatorships to include substance use disorder. It's only going into effect at San Luis Obispo County in San Francisco County in 2024, but all the other counties are in preparation I think they'll be entering it in 2025 and 2026. I think it's an interesting moment to consider at what point does a substance use disorder require kind of like mandated conservatorship treatment and monitoring. The stats were given for harm reduction those were kind of general harm reduction stats not just similar use disorder. Crash from cocaine and methamphetamine can be very dependent on the person and how much they took and how often they take it so what their tolerances. Generally kind of a crash from cocaine be a handful of hours like maybe like four to six hours across from math can be much longer. I've seen patients crash from math for like 12 to 14 hours. Naloxone does not help in a stimulant use disorder but because what we're seeing nowadays is there's so much fentanyl cut into our stimulants, that if people have overdosed with the symptoms of an opioid and they've tried to take methamphetamine or cocaine, giving naloxone is helpful. Giving naloxone and someone who has a stimulant overdose will do nothing to them, because naloxone again only works on the mu receptor in the brain, and it doesn't work on any of the other receptors that stimulants are working on so it won't hurt them, but it will help them if their overdose. It has any of the fentanyl in it. Overdoses associated with stimulant use disorder on the rise. Yes, they are. Do you think that is due to the direct effect of stimulants or more like a co occurring substance use or adulterants. The way that I'm seeing it with my patients at least as a lot of my patients who are overdosing are saying they're trying to use a stimulant and it's just being cut with fentanyl. So that's what that's what I'm seeing in a very select population in Los Angeles County. What do you recommend for managing acute psychosis for unhoused people who have been using meth PTP Okay, so this is, this is, it's tricky if they've used anything that has helped work in the, in the past I would start with that. The quicker ones that I've used in the hospital tend to be kind of like olanzapine, Ativan. If they need an injection, you know, haloperidol, Benadryl and Ativan work well. A lot of my patients who kind of like have persistent psychosis aftermath, or kind of like subclinical psychosis, I will get on a medication and say let's start you on this because this can be protective for your brain, if you're going to continue using stimulants so I'll get them on a long acting Invega injection or something like that or Haldol to reduce kind of like the severity of their psychotic symptoms when they use methamphetamine. Those are kind of the routes I take. Okay, who's the contact for system testing. I'm not sure what system testing means, but if there's a way to clarify that question. Are you aware of the practice of olanzapine prescribing five milligram doses to add yeah okay so prophylactically. Yes. So, um, we we sometimes do this with a lot of our unhoused patients as well. And so I will give them this to kind of like keep in their back pocket and I'm like if you're using math and you're noticing that reality is shifting in a way that's uncomfortable pop this in. So this is again a protective way that we're giving patients tools. Again, like I said earlier, my patients with persistent or subclinical psychosis, I'll try to get on an antipsychotic to again, reduce things like acute hospitalizations ER visits or positions where they're putting themselves in risky places like running into traffic. What are your thoughts and harm reduction groups, learning how to provide oxygen, especially in the setting of dollars and I am for it so one of our harm reduction agencies homeless healthcare has an oxygen project and skid row where they drive around and golf carts providing oxygen to people who are overdosing so they, they can at least get oxygen to the body that they don't they can either dose the naloxone so they don't put them in a precipitated withdrawal. I think this is really important and if your organization has the funds and capacity to do that I'd recommend it. Okay, perfect. It does administering six to eight doses at a time increase the chance of putting someone in a precipitated withdrawal it does but again, precipitated withdrawal or death, and like I know precipitated withdrawal sucks and they're going to hate you and they're going to feel But, you know, less likely they're going to die from it and then making sure they have access to kind of like quick start bupe or something along those lines can reduce the intensity of that precipitated withdrawal. The legality of administering xylosine test strips so I would look into kind of like network law for your state to see if there's anything that's been written around xylosine test strips. Does one pill have fentanyl and another not same batch, totally so we see this a lot in like when friends have like split a Xanax into kind of like four pieces and three of them overdose and one does not. That means like the fentanyl was was not you know properly mixing that pill. We've also seen it with like individual pills in a batch. So again, it's really important just to test anything you're going to use. Fentanyl and xylosine test strips are not CLIA waived so we can't use them in our healthcare settings you know if this might change you know what I don't but I'm happy to look into it and kind of provide follow up for that. Do fentanyl test strips test for analogs or just fentanyl? So some of them will test for analogs as well. The BTNX one I sent you does test for some analogs. There's a few other ones out there that increase that have like more testing for analogs so I just encourage you to look and see what's available. How quickly does someone lose tolerance for opioids? So within kind of like I would say like within the first like three to five days their body's kind of recalibrating so again, any admission, I even say to my patients who are admitted for like two or three days and are still kind of going through withdrawal symptoms that your tolerance has reduced. So start low and go slow. Do you have contacts for test strips maybe available for addiction counselors? I'm seeing a lot of questions around test strips so maybe I'll work with ASAM to put together some like FAQs on accessing test strips so we can send that out too. Okay, perfect. Sorry, I like recommend a patient handout that discusses oral health nutrition and safer sex practices. Ooh, no, I don't have one but again, when we follow up I'll look to see if there is one. I imagine like Vancouver or like New York sites may have had something like this but I'll look around. We have a like Los Angeles County Public Health has a really good wound care sheet that I can also send for you too. I see we are five minutes over. And so I wanted to also respect people's time and see if there's anything. I will continue working through these questions though. Yeah, thank you Dr. Puri. If you can just switch over to the next slide I'll give everyone an overview of the upcoming webinars. So to claim a CE credit you will need to log into your ASAM account and complete the valuation through the eLearning Center in order to claim the credit. You will also be receiving an email tomorrow regarding claiming that credit. Next slide please. So these are all the upcoming webinars for this series. You can register again through ASAM's eLearning Center. And these are the dates and the times for those webinars. Next slide. Should you have any questions at all you can always reach out to the Education Department at education at ASAM.org or call 301-656-3920. Next slide. Okay, thank you everyone so much for coming and we hope to see you at our next webinar on February 21st.

stimulant use disorder

harm reduction strategies

early intervention

prevention

screening assessments

appropriate care

psychoeducation

safe sex practices

oral health

nutrition