Welcome to the paper session one. We have four presentations and each one of the presenter will have about 10 minutes for each paper and then at the end we'll have about 20 minutes for the question and answers. So I am going to start with Dr. Kast. He's going to talk about the effect of specialty addiction consultation on prescribing medication for opioid use disorder during general hospital admission. Then we will have mindfulness-based interventions for adolescent drug and alcohol use, a systematic review and meta-analysis by Christopher Hammond, followed by early changes in irritability, predict longer term abstinence from drug drug use in adults with stimulant use disorder, finding from the stride study by Kimberly Baigward, and the last paper is on carfentanil, a highly potent opioid responding to high doses of naloxone. What can we help? by Sahar Ashraf. Okay, there you go, Dr. Kast. Thank you. Okay, all right, great. Thank you. So I'm going to be presenting on the effect of specialty addiction consultation on prescribing MOUD during general hospital admission. My team and I don't have any disclosures relevant to the talk, and we're going to be describing the utility of addiction consultation in the general hospital setting, particularly as it pertains to addressing the treatment gap. Individuals who fall in that are not currently engaged in treatment. We're going to identify MOUD prescribing rates as a measurable outcome for a specialty addiction consultation service line, something that we can define as a directly affecting patient outcomes, and hopefully get you guys to begin to apply evidence-based metrics to measure outcomes for emerging addiction treatment service lines so that we can really begin to demonstrate to hospital systems the value that we add in these settings. And just to introduce you to the treatment gap, I imagine most in this room are familiar with it. Most of our epidemiologic studies in the United States show that 80 to 90 percent of individuals who meet criteria for a substance use disorder are not currently engaged in specialty addiction treatment. However, they do have high degrees of comorbidity with medical complications that lead to being in the hospital quite a bit. They represent 15 to 20 percent of all general inpatients at any hospital, and their acute care utilization is high after that admission, so they're more likely to experience readmission after discharge, with a quarter to a third of individuals being readmitted within 30 days. And we really see the addiction consultation service as an opportunity to intervene for patients who are in the treatment gap. These are individuals who didn't come to the hospital necessarily to be treated for their substance use disorder, but it is an opportunity and a teachable moment in order to intervene and engage in care. There is some evidence being accumulated as addiction consultation services are rolling out in academic medical centers. So far, we have evidence from single sites showing that there is an association with increased abstinent days and lower addiction severity index scores 30 days post-discharge, a measurable reduction in mortality 90 days post-discharge, increased patient trust as well whenever you engage with somebody who has specialty addiction knowledge. And there's some mixed evidence showing reduction in post-discharge acute care use and some that shows no difference. And there is one prior single site study in a northeastern public hospital that showed six months of data, 300 consults, most of which were for opioid use disorder, that showed about half of patients were getting initiated newly onto MOUD and had a good linkage to care afterwards. But more information is needed for us to really robustly show that this is a worthwhile investment for a hospital system. We also know, in order to demonstrate that that investment is needed, that we need evidence-based metrics that are meaningfully linked to patient outcomes to demonstrate why an addiction consult service is needed in a hospital. And we propose rates of getting patients with a diagnosis of OUD onto medications for opioid use disorder as a reasonable metric because we already know this is first-line treatment, it increases outpatient engagement, reduces the risk of relapse, overdose, mortality, and also we know it is effective when initiated in a general hospital setting and can increase engagement in care. So with that hypothesis in mind, we wanted to compare individuals admitted to our general hospital who have a diagnosis of opioid use disorder and what their rates of MOUD initiation were when they have a consult versus when they do not. We did this as a non-randomized controlled trial over four years since the creation of our addiction consult service and a large tertiary care academic medical center in the southeast. We identified OUD diagnosis by EHR codes. We identified patients who had a consult simply by the order being in their chart during that admission and control cases were those with an OUD diagnosis but who did not have a consult order. And then we identified whether or not they were prescribed MOUD in the hospital or within 72 hours of discharge to show initiation. Our results, descriptive statistics show that this was not a randomized trial. We did not want to set it up that way. It does show that there are differences in patient populations who our general medical teams and surgical teams are identifying as needing a consult. There were over 23,000 cases over that four-year period, 23,000 admissions that had an OUD diagnosis, 20,000 received no consult, 2,500 received a consult. Of those who did get a consult, they were more likely to have multiple co-occurring substance use disorders, more likely to have more polypharmacy while they were in the hospital, had more likely to have Medicaid or non-commercial insurance, and also were tended to be younger, white, and male. As far as our primary outcome, we were able to show that there was a significant difference in MOUD initiation with an addiction consult. Over 50% of patients who received a consult and had an OUD diagnosis were initiated on MOUD compared to 14% of patients who did not receive a consult. Interestingly, those patients who didn't get a consult, the trend has increased over time. So there is an education effect we hypothesized from having addiction specialists in your hospital in order to educate your teams. And this finding remains significant after multivariate analysis controlling for all of the variables I showed you in Table 1. Additionally, beyond just saying, hey, we're getting more medication into people, we also showed that at 30 and 90 day readmission rates were reduced whenever you get an addiction consult. And the numbers here translate into, for that same 2,500 patients, 399 less readmissions in 30 days and nearly 700 less readmissions over 90 days, which is a very meaningful impact that you can bring back to your hospital system to demonstrate that this is a worthwhile investment. And interestingly, although there was a decrease in readmission rates, there was not a difference in a return to the emergency department, which may actually signal more trust that the patients have in the health care system, but also more stability in being able to discharge back into outpatient care. There were an increase in AMA discharge rates, but this comes with a caveat in that often we are getting consulted as the patient is saying, hey, I want to leave the hospital. And they are asking us to come in and try to work with the patient motivationally to stabilize any withdrawal states, help them complete their medical course. And so this was not unexpected. We also had a longer length of stay associated with a consult. Again, this may actually be a positive finding in that when our patients are largely admitted with complex infectious processes that require prolonged IV antibiotics, having a longer length of stay is more likely to be expected. And getting that length of stay longer actually may show greater engagement in the medical care that they presented to the hospital for. So with that, in the study, we showed that specially addiction consultation for individuals with a history of opioid use disorder is associated with increase in MOUD prescribing and significant reduction in 30 and 90 day readmissions. The associations with the AMA rates and longer length of stay are more difficult to interpret for the reasons I stated. This is important to hold within the context of prior studies looking at readmission rates that have been more mixed. But those studies did not look just at the OUD population. And we do have medications that we know are very effective in really reducing symptom burden and helping patients connect to outpatient care. So it may be the case for this population in particular, we really can have an impact on readmission. And that's important to bring back to our hospital leadership. And then no prior studies have really compared MOUD prescribing rates to a control group. So we're adding that to the literature. So in conclusion, in the single site, non-randomized controlled trial, specially addiction consultation was associated with a significant increase in agonist MOUD prescribing. The evidence, this metric can be considered evidence based and a useful tool in measuring quality of care across hospital systems. And I think this is an important point because if we don't begin to define what quality care is in our hospitals, it will be defined for us. And I think beginning to be able to bring that to hospital systems and also the powers that govern how hospital systems are rated into the future, we really need to be defining that for ourselves. And we hope that through creating these consult service, we're able to expand access to substance use disorder treatment for patients and the treatment gap. And with that, I'd like to thank my study team, including our health IT specialists and our data analysts and finish. And questions will be at the end, by the way. Thank you. All right. This afternoon, I'll be presenting results from a systematic review and meta-analysis conducted by my research team, focused on mindfulness-based interventions for adolescent drug and alcohol use. The slide shows my professional and financial disclosures. I have no conflicts of interest related to this topic area. And this slide shows the learning objectives. By the end of my presentation, I hope you'll be able to at least define mindfulness and be able to discuss some of the components of mindfulness that may make it an ideal intervention to target alcohol and drug use disorders in young people. Focusing on background, the problem. Alcohol and other drug use and related substance use disorders are common among adolescents and young adults in the United States and associated with adverse health outcomes, comorbid psychiatric disorders, accidents, and increased mortality in this population. And our current evidence-based psychosocial interventions, which really focus on three core areas, motivational approaches, cognitive and behavioral approaches, and family approaches, these types of interventions have modest effect sizes for abstinence. But the reality in our clinical world is that many youth don't engage to begin with and many youth relapse soon after treatment ends. And so, especially for this group of youth who don't engage to begin with, the data is sobering. Fewer than 1 in 10 young people who meet criteria for a substance use disorder ever receive treatment. And the data seems to suggest that that treatment gap is widening over the past decade. Mindfulness really represents what I would think of as a model resiliency factor, which has a lot of therapeutic potential and may be an ideal treatment target for alcohol and drug using youth who are unmotivated to quit. Mindfulness is defined as the ordering and focusing of attention to the present space without judgment. Trait mindfulness is positively associated with psychological health, well-being, and negatively associated with alcohol and drug problems in adolescents as well as in college student populations. Mindfulness has been converted into manualized treatment interventions and tested in psychiatric populations. And mindfulness-based interventions have been shown to improve physical and mental health outcomes across psychiatric disorders, although the results have been mixed in alcohol and drug use disorders as reflected in a recent Cochran review. And so, the primary objective of my current study is to determine the efficacy of mindfulness interventions for reducing alcohol and drug use and improving psychological functioning in alcohol and drug using young people, with a secondary objective to really characterize correlates, mediators, and moderators of mindfulness treatment outcomes in this population with a goal of really better understanding and trying to understand what the mechanisms underlying mindfulness might be. To target these objectives, we conducted a systematic review. We conducted it following standard PRISMA guidelines and we pre-registered it with PROSPERO. Our study focused specifically on studies that compared the effects of mindfulness interventions to either an active or a passive control condition and looked at substance outcomes and psychological outcomes in alcohol and drug using young people. This slide shows some more details regarding the types of studies and the inclusion criteria we used. So, we focused on randomized controlled trials and also looked at controlled human laboratory studies that tested specific mindfulness components like urge surfing against active comparator controls like, for example, distraction. We looked at adolescents and young adults. So, our inclusion criteria there were individuals ages 12 to 25 who reported alcohol or drug use or who met criteria for a substance use disorder. And the main outcomes we looked at were substance use outcomes, looking at reduction in alcohol and drug use and abstinence, but we also looked at what I'd call substance intermediates like drug withdrawal and craving expectancies and psychological symptoms to better understand how these might serve as mechanisms that through which mindfulness may exert its effects. This slide shows the PRISMA flow diagram for my population and for the systematic review. Our search and selection procedures identified 20 peer reviewed published studies that reported results from 18 clinical trials with 2,172 participants who were adolescents or young adults who were using alcohol or drugs. And it's from these 18 clinical trials that the main focus of our qualitative analysis really comes from. Across these 18 trials, there was a lot of heterogeneity. Heterogeneity in how they were designed, heterogeneity in some of the analytic approaches used, the populations. There was also heterogeneity in the types of mindfulness interventions administered. Most commonly, mindfulness breathing exercises as an add-on intervention was used. And a number of studies also tested whether adding specifically this urge surfing focus as a training for young people might be helpful. And very few of these studies really looked at comprehensive manualized mindfulness interventions like mindfulness-based relapse prevention or mindfulness-based stress reduction. And I think that's important to note. In terms of the drug categories that these studies focused on, they focused on a number of different types of drugs with five studies focusing on youth tobacco use, 10 focusing on youth alcohol use, one on cannabis use, and two focusing just on general substance use outcomes. This slide shows really the primary study outcome for this systematic review and qualitative analysis. These show pie charts depicting the proportion of positive studies favoring mindfulness over the comparator condition in orange. And negative or null findings favoring either control or showing no difference between control and mindfulness in yellow. And this is for any substance-related outcomes. The pie chart on the far left shows for all studies. And then the four on the right show by drug category. I think notably over three-quarters of these trials found that mindfulness was superior to either the control or comparator condition at changing any substance-related outcomes. And that there are largely similar effects across the different drug categories. When focusing specifically on reduction in alcohol or drug use, generally a similar outcome was found. We found that about that 71% of these trials showed that mindfulness led to a greater reduction in alcohol or drug use following treatment relative to the comparator or control condition. There was some more variability by drug category with these interventions potentially being more effective for tobacco cessation compared to alcohol use. This slide shows various substance-related intermediate outcomes which may give us some insight into mechanisms. Notable findings here were that a number of studies showed that mindfulness was beneficial at improving self-efficacy and changing drug expectancies. I want to highlight two areas that I think are relevant here. One is on drug cravings. Mindfulness interventions did not seem to consistently reduce drug cravings or urges. Although that may be because we're not actually asking the right question there. It may be that mindfulness isn't reducing drug cravings, but it's changing how an individual reacts to those cravings and relates to them. The same goes for stress. A minority of studies, about a third of the studies showed that mindfulness interventions reduced anxiety and depression, but two-thirds of the studies showed that it changed stress-induced drug choice. And so is mindfulness not necessarily changing mood or anxiety, but is it changing how an individual reacts and makes decisions related to stress and how that influences their decisions about using drugs or alcohol? Four studies conducted mediator analyses and two studies conducted moderator analyses. In focusing more on the mediators, which I think are more salient for mechanisms, these studies showed that change in stress and negative affect, change in impulsivity, and again, change in acceptance and ability to resist drug urges, in some studies, mediated the relationship between mindfulness intervention and a reduction in youth drug or alcohol use. And so really, in conclusion, the findings from this systematic review indicate that mindfulness interventions can result in small to moderate post-intervention reductions in alcohol or drug use and may improve impulsivity and stress reactivity in alcohol or drug-using youth. Preliminary findings with regard to mechanisms suggest that these interventions may reduce alcohol or drug use in young people, in part by reducing negative emotions and impulsivity and changing how alcohol or drug-using youth relate or react to cravings and negative emotions. And regarding future directions, larger randomized controlled trials with additional mechanism-focused assessments, active comparators, and longer follow-up assessment periods, really are needed to move this field forward, but the preliminary results are promising. And so I'll end there. Thank you. All right, hello, everybody, thanks for coming. My name is Kimberlyn Maravet-Bageward, I'm a PGY3 research track resident at University of Texas Southwestern in Dallas, Texas, in the lab of Dr. Madhukar Trivedi. Today I'm going to be telling you about some of our findings that are secondary analysis from the STRIDE study. Irritability is the main outcome that for this secondary analysis, and I'll be telling you about some of our findings which showed that improvements in irritability actually led to a higher likelihood of stimulant abstinence. I have no disclosures. So by the end of this short talk, I hope that you all are able to recognize that irritability is a quantifiable symptom to measure, can consider the connection between reduced irritability and abstinence from stimulant use, and to be able to reflect on how tracking irritability even in your own practices may inform a broader clinical practice overall. So a little bit about the STRIDE study itself. The STRIDE study was the Stimulant Reduction Intervention Using Dosed Exercise study, where it was a multi-site clinical trial at nine residential treatment centers where the participants were randomized either into a dosed exercise arm or a health education intervention. This lasted about 12 weeks, and the participants would attend three times each week to either have the observed dose exercise or the health education intervention, and what was being tracked was the percent days abstinent. We were doing this by timeline follow-back method and urine drug screening. So for the primary outcome, we actually noted no significant difference between the two interventions, the exercise or the education, but what we noted was that there were differences, considerable differences actually, in treatment adherence and baseline stimulant use, so post-hoc analyses that controlled for these factors showed significantly more days abstinent in the dosed exercise arm than in the health education intervention of about 4.8% higher. While modest, it was still higher. So for irritability, by quick show of hands, how many of you have had patients that have presented with irritability? Yeah, exactly. How many of you are tracking the irritability symptoms? Good. Okay. I hope I can get more hands up by the end of this. So irritability, as you know, is the propensity to become easily angered or annoyed and is commonly reported with stimulant use. It's been reported in more research, perhaps in other fields such as depression research where irritability has been shown to correlate with increased suicidal ideation, but we really haven't done much of a deep dive into the trajectory of irritability, especially in stimulant use disorder. So for this secondary analysis, we wanted to look at does irritability even change with treatment for stimulant use, and if so, is there an impact on longer-term abstinence? So in order to do this, we looked at the individuals from the study that had the concise associated symptoms tracking for irritability data available. It was about five questions. That is semi-structured interview. And for those participants, we looked at the baseline to two-week data between the two interventions in order to try to see if we could predict what happened in the acute phase of follow-up, which is two to 12 weeks, and then the continuation phase. So through linear regression analyses, we evaluated if these reductions were able to predict. And in fact, irritability did improve significantly from the baseline to two-week. That was about a 1.13 reduction in the score. And again, the two treatment arms did not differ in the change in irritability. Greater baseline to week two reduction in irritability was also associated with a higher percent of days abstinent from week two to week 12. And this was even after controlling for multiple factors, including depression, baseline irritability, age, sex, race, ethnicity, and treatment arm. Additionally, greater baseline to week two reduction in irritability was associated with a higher percent days abstinent from 12 weeks to week 36 as well. Again, after controlling for those various factors. This is just shown a little bit differently. The first slide, you'll see the acute phase. And in the second one, you'll see the continuation phase where you can see the percent days are actually increased with the change in the delta-Cas-IR. So to summarize, irritability did improve significantly from the baseline to the week two with a modest but statistically significant reduction. And that was irrespective of treatment. To me, from a clinical perspective, maybe from a research perspective, we wanted to have a difference on one side or the other. But from a clinical and treatment perspective, this is good news. Patients do change over time when we're doing something with them. And I think that by tracking irritability, you're going to have a better chance to be able to predict which patient might need a little bit extra help. Of course, this is a secondary analysis and a lot more research needs to be done. But it does prove an interesting point that irritability perhaps should be a symptom that we are paying a little closer attention to than perhaps we are. And again, the greater baseline to week two reduction in irritability was associated with higher percent of days abstinent. So adults with stimulant use disorder experience significant improvement in irritability, as I just said, of treatment. And early improvements in irritability are associated with a higher likelihood of staying abstinent during a longer-term follow-up period of time. So with that, I'll say thank you. Thanks to Dr. Trivedi and the others at the group, Dr. Jha, Dr. Manojuddin, Dr. Shabta, our collaborator at UCLA, and Dr. Wakalu. And a special thanks, of course, to those participants who gave their time to come three times a week and be in the stride study. And if you would like to see the primary paper, it's a QR code. And you can scan the code now, and you can get that paper right on your phone. I'll just leave that up for a second for you to do that. All right, super. Thanks, guys. Okay. Thank you. Hi, everyone. This is Sahar Sharif. Oh. Go to the microphone a little closer. Where? It's... Thank you. Thank you so much. Okay. Hello, everyone. This is Sahar Sharif, and we are presenting on carfentanil, a highly potent opioid responding to high doses of naloxone. What can help? I co-authored it with Dr. Nomana Sharif, and we have no disclosures to make. And this is currently another epidemic, which is a big problem. And recently, we had a couple of deaths in adolescent population with this fentanyl and carfentanil poisoning in Texas. So the learning objectives we are focused here at are that we want to increase the awareness of these highly potent opioids, which, unlike the regular opioids, are very potent and have high efficacy. And probably we have to come across some atypical management tools to reverse their poisoning. And Narcan, a nasal spray of naloxone, is found to be very effective in reversing the poisoning, otherwise, which can prove to be deadly. And also, we recommend more research on safety of high-dose Narcan kits between 8 to 12 milligrams. And these need to be available for all those people who can come across this poisoning, either accidentally or intentionally. And also, we need to focus on this poisoning and its management tools and some of the findings which have been so far seen and shown and are published on this poisoning and how it was managed and what were the outcomes. We could not come across much of the data, but whatever we could find, we wanted to bring it to attention to all the providers because I think it can have very important clinical implications. So carfentanil use is emerging as new era of heroin use in USA. Carfentanil use is of most concern among opioid users because it's 10,000 times more potent than morphine, 100 times more potent than fentanyl, although it's also an analog of fentanyl and some people say it's between 50 to 100 times more potent than heroin. Carfentanil looks like table salt, so it can easily cause poisoning, especially in border control people who sometimes sniff some product to identify it or those first responders and emergency personnels who are treating these people. And it has very high affinity for mu receptors in very small amount, which is really concerning. And it can cause toxicity even in extintal exposures, like I said, in first responders, doctors, and border control people. Carfentanil, like most fentanyl analogs, has intrinsic efficacy. By intrinsic efficacy, we mean that once they bind to the receptor, they can produce their effect, even if the receptors loses its function. So it does not cause tolerance, unlike the other opioids. And it can produce its response in presence of very small number of receptors left in a person. This helps carfentanil escape the heroin-induced tolerance and thus it can also cause toxicity and morbidity and mortality, eventually, in people who are otherwise tolerant to heroin. The potency rate of onset, bias, muscle rigidity, unlike heroin, low susceptibility to naloxone reversal, and lack of cross-tolerance makes it a very lethal drug. So this is also very important to note that unlike heroin, it does cause muscle rigidity of chest muscles. So it causes even more respiratory morbidity as compared to heroin. It does not cause the, you know, it does not affect or impair the movement of muscles of chest wall. So the effect of carfentanil is even more morbid for chest muscles and respiratory function. First responders should be educated on the interventional care of affected individuals with possible carfentanil overdose. In Ohio, many programs are developed, like REACT, Rabbit Response, Emergency, Addiction, and Crisis Team, to expedite access to naloxone kits and the training of caregivers. So Ohio is already, you know, working on it, and we need other states and other parts of the country also to become aware of this, to reduce the mortality and morbidity by this compound. It is, because it's out there, people are using it. So we did a literature search by using some relevant MeSH terms, and we used the databases PubMed, PubMed Central, Medline, and Cochrane databases, and we identified all the published relevant articles until June 12, 2022, and after doing the screening of abstracts, we come down to 18, and finally we came down to 11, but now when we are going into detailed paper writing, it has come down to nine. So carfentanil poisoning has been associated with potential lethality, as we have been discussing, and this came to attention of the world in late October 2002, when it was used in Moscow during the rescue operation in a terrorist attack. So this gas was used to, you know, decapacitate those terrorists and just rescue the hostages, but it caused the death of 15% of hostages, because there was not enough naloxone available to reverse the toxicity that was caused. So that is a lot, and Bardsley et al. presented two cases of carfentanil in 2019, where one patient received 12 mg of naloxone, and other received 10 milligram of naloxone to be successfully resuscitated. So now you see, this is like high doses of naloxone. When we talk about Narcan kits, they come in the nasal sprays of two milligram and four milligram, but here you see that one needs almost 12 milligram and 10 milligram of naloxone to reverse the toxicity and poisoning. So we need to have enough naloxone ready for these cases, and also, by default, we need to be aware that more dosage, which is not relevant with the low levels of carfentanil in the blood of patient, would be required to reverse the morbidity and mortality. There are risks with high doses of naloxone, but its benefits outweigh its risks in reversing respiratory depression without the need of intubation, which has way more risks involved. Another pilot study on two patients coming to the emergency department also showed some similar results. A public health investigation in West Virginia in 2016 of a case of opioid outbreak showed that 16 out of 20 cases were treated with repeated naloxone doses, and they finally successfully treated the patients. So the studies that we came across, there was one study where they took the blood samples of patients, and they saw that you cannot make any relevance between the amount of naloxone that needs to be administered in these patients with the blood levels, because even if the blood levels are very low, the patients still need high dose of naloxone to reverse it, and you need to give it, because naloxone so far is quite safe, and even some people say that it's very safe, and only if a person has allergy to it, they can have side effects, but that's also not entirely true. We do have some side effects, because since it reverses the opioid action, so you can have all the symptoms which are similar to withdrawal symptoms, but still, they are not that common, and we can safely use this much of 10 to 12 milligram as default of the naloxone to reverse the toxicity. So carfentanil is among the most potent opioid and can cause toxicity at a low dose. This puts doctors versus responders and others at risk of poisoning, and it is reversed using high doses of naloxone, which are not associated with low blood concentration, as I just mentioned, and this was the conclusion. And also, narkin, we have two forms of naloxone. First is intravenous, and second is the nasal spray, which is narkin, and that comes, I told you, in two milligram and four milligram packages. So intranasal is more the recommendation that we have made in this paper is for narkin nasal sprays, because those are so easy to administer. You don't need any formal training for it, and you don't need any blood work or training or any phlebotomy training for it, and even bystanders, if they are aware of it, if they are educated on it, they can provide this relief to the patient or caregivers who have some loved one who has this issue, they can have it handy. And also, there was another study that was in the literature review that I wanted to mention. It was some part of Europe where they were encouraging those people who use heroin that if they come and they get it administered at a proper, in a supervised setting, then they might be educated on it and they might take this in control, because sometimes people who use these intravenous drugs, they are also administering those other fentanyl analogs and other carfentanil knowingly or unknowingly along with the regular drugs. So that is also a way to keep everything in check, because they have regular blood works and they have counseling done and they have it done in a clinical supervised setting and they also can prevent the other risks associated with unsupervised administration of drug use. So that was all about this paper. And any questions? Thank you. Regarding the Vanderbilt study, have you presented the data to TenCare or those other public agencies in an effort to get some money because of the reduction of readmissions? That's a good question. That is our plan. It hasn't yet happened. We do hope to bring it to their attention and also to expand our own services at Vanderbilt because we know we're only seeing a small fraction of the patients that we might be able to. Right. Or even extending it to Memphis and UT. Regarding the irritability study, what was the instrument that you used to measure irritability? I think I missed it. That was the CAST IRR, the Concise Associated Symptoms Tracking. Part of that has five questions that are specifically for irritability. And what are they? Oh, I do not have those memorized, but I could look them up and tell them to you if you'd like. And should we be, we as a professional organization and other addiction organizations, be pushing for naloxone to be standardized at eight milligrams rather than at four? That's the recommendation we are making in our paper. And is it, are you passing it up to the bureaucracy here for the public policy committee to be looking at? Yes. That's a very, very good point. Thank you. Thank you all for sharing your studies with us. I have one question for Dr. CAST. In your data, I don't know if you looked at the retention on MOUD and the correlation with readmissions. We weren't able to track that because patients were often being referred to community partners. It is a goal of ours to be able to do future studies where we're working with state stakeholders to integrate the data warehouses that exist, particularly for patients who have Medicaid in Tennessee and be able to track better how retention occurs. We do know about half of patients who are referred to our bridge clinic, which is our low barrier appointment within a week of discharge from the acute care hospital has about a 50% retention rate or show rate at that first appointment, which is very similar to other findings. So we know that this population experiences high social determinants of health burden. They often have a lot of barriers to getting into treatment, but we're still getting about half of those patients into the clinic and retaining them in care over those three months and getting them into some stable recovery. So not everybody is going to be able to respond, but we're still rescuing a large number out of this treatment gap population. Thank you. And for Dr. Bighorn, the health education and the exercise, do you have a protocol or a guideline that you can share? Yes. So both of those are published in the primary paper that I cited at the end. They are, they were both observed. So the health intervention was a one-on-one conversation that occurred three times per week. The health exercise was actually, was an observed exercise so that a certain duration, that's all right, so that a certain duration based on the patient's health that they were able to engage in was achieved for each of those. Sure. That's all right. Do we control for the positive cannabinoids? I don't, I would, I'm not sure that we did control for urine positive cannabinoids. We were... Right. I'd have to look back and I believe all of the different positive screens that we did have were all tracked, but I don't know that we had a specific like statistical method that we used specifically for the cannabinoids themselves, but that's a great question. All for your presentations. For Dr. Hammond, I was wondering about the heterogeneity between substances that you found for the mindfulness interventions and why that might be. Is there a social context possibly or another explanation? That's a great question and I don't really have a solid answer for it. There weren't enough studies to really do too many sort of thoughtful sub-analyses there. I would hypothesize that some of that signal that we may be seeing where there may be a better effect for tobacco cessation compared to alcohol, which in a reduction of substance use may be related to how young people commonly use tobacco on a daily basis and with sort of nicotine levels going up and down during the day and so it's being more helpful to target that specific pattern of use compared to alcohol where the pattern of use, especially in a youth population, is more variable and sort of binge episodes as opposed to, for example, daily alcohol use that you might see in an adult with an alcohol use disorder.

addiction consultation

opioid use disorder

mindfulness-based interventions

irritability

stimulant use disorder

carfentanil

naloxone

first responders

healthcare professionals