Welcome to concurrent paper session number two. We have five great articles, papers that are going to be presented today, and I'm going to run through this super fast. We have Dr. Willens for Mass General, co-director of the Center for Addiction Medicine, who will be giving our first paper. We have Dr. Rydberg from the Mayo Clinic in Arizona. Dr. Rydberg is a, well, you're a fourth-year medical student, so soon-to-be doctor. Dr. Gopaldas is a postdoc at Columbia in their T32 track addiction psychiatry fellow as well. And then, rather than Dr. Springer, who is in the audience, we have Dr. Saval, who's an assistant professor of medicine at Drexel, who's going to be presenting the fourth paper. And last but not least, we have Jeff Russell, Dr. Russell, who is a third-year psychiatry resident at Stony Brook. So, it's great to see so many of our trainees, medical students, residents all presenting. Everybody's going to have eight minutes to present, nine minutes just to do switches, and then all questions will be at the end. We'll have ten minutes, so if you have a pressing question, just write it down and save it until the end. Thanks. Thank you very much. So, my name is Tim Willens. I'm going to be speaking about a pilot product, pilot protocol for methamphetamine on inpatient units. Here's my financial disclosures, nothing particularly that's relevant to this discussion other than I do clinical care at the facility that I'm going to be, we cited this at. The objectives are to learn new strategies. It's not advancing. Oh, interesting. It's there. It's on there. You can see it on the screen there. I can see it on the screen, but I can't here. Here, I got it. I got it. Here. You got this? Is that good? Yeah, that'll work. I'll just go after this. Oh, there we are. So meth use, as you know, is a growing problem. It's got a 43% increase over the past few years, actually 2 million people endorsing past year. Probably you know there's been an increase in overdose deaths associated with stimulants. And it's almost all meth related at this point. For those people who work with people with meth, you'll know that the symptoms you see during acute intoxication to withdrawal, during that phase, is things such as depression, agitation, anxiety, paranoia, psychosis, and aggression. This is, by the way, what often gets these patients kicked off of inpatient units, because they get in the nurses' faces, they threaten, and things like that. Behavior-based therapies, not classic behavioral therapies, but behavior-based therapies are effective clinical tools and are considered first-line treatments for both early and late treatment of methamphetamine disorders. And up until recently, all we have are guidelines, just general guidelines. They're actually out of Germany, but no meth protocol. So really what we did was to put together a methamphetamine protocol. I think you'll have to just look off of this. So what we did is, I'm just going to walk you through. We did protocol development, coming up with a protocol, and then we did vetting and revision of the protocol, which was done almost by a whole team. In our case, we were very fortunate with Mass General. They have addictionologists, pharmacists, and all the rest. And then they went through another vetting process through the medical staff at the detoxification center. It went through our Department of Public Health. They reviewed the protocol also. And subsequently, probably one of the most important components was, after we had the protocol, we spent a lot of time doing psychoeducation with our nursing and clinical care staff. Rather than kick the patients off the unit, let's try to keep them on the unit. Let's understand what meth does. Let's understand some of the behaviors, and let's target those behaviors to try to keep them on the unit. That may be probably the most important component of what we did to make this work. And finally, we got implementation and further feedback. So what is the protocol? And you're happy to have the protocol. You can use the protocol. We're using these protocols now at three different units, and it's working reasonably well. I'll show you some data on that. First of all, these are very sick patients, so you need to do a comprehensive medical evaluation. We actually force people to go through and do the standard things. Actual listening to the heart and doing heart rate and heart rhythm to ensure that things sound OK. Check oral dental. Check for skin excoriations. And have all of that treated. The other thing you may be surprised at, I'm a child psychiatrist, do a lot of work with stimulants. And probably you know if you give amphetamines, your nemesis is vitamin C. When people take vitamin C, it reduces absorption, and it increases excretion. And so we use vitamin C to our advantage. We give vitamin C 1,000 milligrams twice a day for two days. These are the behavior-based orders that we use. Here you can see we encourage oral intake of fluids, snacks, and meals. Notice, hold meal for later administration. Our patients will crash. They won't eat. And then they'll get up, and they're hungry and want to eat. So rather than say, oh, I'm sorry you missed your dinner, you get to eat when you're hungry, and you get to drink when you're thirsty. And little things like that have made a huge difference. We reduce stimulation. Get them away from the other loud parts of the unit. Put them in a part of the unit that's quiet. We have noise cancelers for certain patients who get really agitated with the excess of noise. And then here, allow patients to sleep with PRN. Don't wake them up. They can miss groups. They can miss things. We don't enable that activity, but we're monitoring that, and we keep an eye on them. And notice, do not discharge patients for missing groups. Don't discharge people because they're not following the strict rules of the unit. By the way, I'll tell you in advance, did not destroy the milieu of the unit. We were very concerned that other patients would follow suit with that. It didn't do that. We didn't have problems with that. For the duration of the admit, we use three major medication classes. Diphenhydramine for kind of lower dose agitation, et cetera. I can tell you in advance. I wouldn't waste my time with that if I were rewriting. Chloridized epoxide, if you weren't on a, let's say you weren't also receiving other protocols. And if you saw any disinhibition, which you see in a fair number of them, we would stop using it for that reason. Probably the biggest one is Seroquel, good old quetiapine. 25 to 50, TID, PRN for worsening of symptoms. Most of the time, the nurses jumped right to 50. And what did we find? So this is where we cited this. This is Bay Cove Human Services. It's a classic community detox center, one of the first ill-diagnosed detox centers in New England. And this was a sort of QA examination. So we looked at our first 23 patients to see did it do very much. What we found, most of them were male. Most were homeless. 100% were unemployed and single. Most, it's interesting, most started using between 26 to 35 years of age. Some simply didn't know. Most all had opioid use disorders as a primary diagnosis, as well as having methamphetamine use disorders. Part of that is arbitrarily because we didn't have a protocol. You can't bill for the services, right? So a lot of people didn't. And now that we have a protocol, we actually can get reimbursed and bill for patients with primary methamphetamine. Talk about a catch-22. But that's why, for the first time, it was just mainly OUD. These are all patients in protocol. What were the major symptoms that we saw? Were fatigue. We saw a smaller group that were uncooperative, decreased appetite, some with aggression. But all the way over here, if you look at the blue, mainly fatigue. Probably one of the biggest findings is duration of meth symptoms over here. Usually meth symptoms would last about four or so days when we look back at what it was like pre. And what we found is, using the protocol, probably the vitamin C and everything else reduced the intensity of those symptoms to about two days. So it reduced the symptoms. So we had to deal with about two days of symptoms using the protocol. That was a much improvement over what we saw as treatment as usual. So what was paired out? About half of them, we just used the behavior component. Let them sleep, let them eat, kind of manage them carefully that way. And the other half received the behavior component, we found, and the pharmacology. And most of it was the quetiapine. So if you had to go with one, it was quetiapine. What did we use mostly for the behavior? It was letting people sleep, excusing them from group, and going to the bedside with meds. That was helpful, so people would get the treatment. This was remarkable. How many people made it through their stays and their protocols? We had about a, I would say, 65%, 70% early discharge rate for our patients with methamphetamine when it was significant meth. And that reverved. We flipped it, having the protocol. People stay in the unit now and go through their treatments, including their opioid treatments, benzo, if they're also on those protocols. So we felt like it worked in that regard. And finally, we got feedback from the nurses. And I think it was great. I liked that there were options for meth users. Now more and more beginning to be honest about their meth use, because we have a protocol for it. And we're finding that. Since we have a protocol, people are talking to us about it. I like the behavior component, like the different meds we can use. The Seroquel works the best. Vitamin C has been very helpful. It's really interesting. Just doing that, nurses overnight said the vitamin C is a game changer. Just giving vitamin C, look at how benign that is. And maybe it can be expanded to the next level of care. And I'll end with just saying there are a lot of collaborators. It was really fun doing this, putting together the protocol. A lot of really interested people helping. Happy to answer questions at the end, send you the protocol. We're going to be doing more work with it. But I think it's a safe, benign protocol. It's working. And now that we have a protocol, people come and we actually can bill. And it's been, like I said, vetted through our Department of Public Health. Thank you. And which buttons did you push to have it? Oh, right. It's not advancing there, but it is advancing there. Did you see that? Oh, yep. Perfect. Perfect. Thank you. So hi, I'm a medical student and this is my first big presentation. So I'm gonna cheat and have my notes with me. So here we go. Okay, so my name is Anne Rydberg and I'm here to present about COVID-19 treatment outcomes in a cohort of methamphetamine and cannabis users. So we have no disclosures to report and here are our learning objectives. I'll skip this for now, but feel free to review on your handouts. So first, some background information. As is well recognized, the COVID-19 pandemic is associated with a significant increase in alcohol and drug use, as well as in monthly cannabis sales and methamphetamine availability and consumption. We also know that the incidence of the COVID-19 diagnosis is significantly higher among psychiatric patients in general and among those with substance use disorders specifically. Furthermore, poor outcomes of COVID-19 have been reported in older males with medical comorbidities, including substance use disorders. And we know that meth and THC users do tend to differ in many aspects from each other, specifically after recent medicalization and legalization of THC. However, we also know that the use of either substance is associated with a high prevalence of cardiovascular and pulmonary disorders. So we sought to investigate whether there is a difference in COVID-19 treatment outcomes between patients who actively use a common substance such as THC with low perceived health risks and those who use a medically hazardous stimulant such as methamphetamine. So for our methods, we reviewed the EMRs of 56 COVID-19 patients with active meth use and 72 COVID-19 patients with active THC use. COVID-19 infection was confirmed by positive SARS-CoV-2 PCR test and the active drug use was confirmed by positive urine drug testing with confirmatory testing from methamphetamine. Comorbid medical and psychiatric conditions were collected via the patient's discharge summaries with updated hospital problem lists. And if a patient was not admitted to the hospital, then these problem lists were collected from the nearest available visit. And we compared the results between the two groups using two-tailed student t-test or chi-squared test. So moving into the interesting thing, the results. So here are the demographic data for both cohorts of patients. Both patient groups consisted predominantly of middle age non-Hispanic Caucasians with the expected male predominance in meth users compared with THC users where we expected a narrowing gender gap. Most meth and THC users were single, unemployed or disabled with a mean BMI of 27. And interestingly, we did find that the majority of both meth, 78.6% and THC patients at 65.3% did report active tobacco use at the time of positive COVID test. So moving into the comorbid conditions, these were again collected from the patient active problem list. And we found that meth users had significantly more comorbid GI conditions. This was in 41.1% of meth users versus 16% of cannabis users. And the most common GI conditions among both groups were hepatitis C and liver dysfunction. In the meth group, the hepatitis C predominance was at 16%. And we found that THC users had significantly more pain disorders than meth users. So 33.3% of THC users versus slightly less than 15% of meth users. And in both cohorts, these pain disorders consisted of fibromyalgia, chronic low back pain or documented chronic pain disorder. We did not find significant differences observed in the psychiatric history between these two cohorts aside from, as we would expect, reported past stimulant use. 69% of meth users were recorded as having a history of substance abuse, of stimulant abuse, either cocaine or meth, on their active problem lists. Of note, over half of both of these groups had diagnosed mood disorder. So this means prior diagnosis not discovered on admission. So it was 55.4% of meth users and 58% of THC users. So when we looked at metrics for outcomes including hospitalization requirements, we found impressive requirements for ICU level care. At 21.4% of meth users and 18% of THC users and COVID-19 specific medications. At 33% of meth users and 29% of THC users. It's important to note that these medications included remdesivir, steroids, IVIG and convalescent plasma because our study patients presented prior to the use of PaxLavid regularly for patients. So they had to meet a higher symptom requirement or prior condition requirement to merit these medications. And requirements for benzodiazepines, antipsychotics and delirium while in hospital were prevalent in both cohorts. Half of meth users and 31% of THC users did require benzodiazepines during hospitalization. And 37.5% of meth users and a bit over 20% of THC users experienced delirium or altered mental status during their hospital stay. Four individuals out of each cohort actually passed away within 10 months of being seen. So that's a little over 7% of the meth users and 5.6% of the cannabis users. So when we examined the need for psychiatric medication on discharge, we found that around half of each cohort were actually prescribed a psychiatric medication on discharge. That was 48% of meth users and 58% of THC users. The most common of these were antidepressants and antipsychotics. The most common antidepressants were SSRIs. And I think that these findings just really underscore the importance of treating both the substance use disorder as well as the very commonly underlying psychiatric comorbidities in order to give these patients the best care that they can get. And finally, when we look at chief complaints for admission or presentation to the hospital, we see that the top three reasons are COVID-related symptoms, psychiatric symptoms, including altered mental status and substance intoxication. So active substance users in general are less likely to have reliable access to care. We all know this. And they often present with more advanced illnesses. And so we feel that this actually provides a realistic snapshot of how COVID-19 positive individuals with substance use disorders may present to the hospital. So in conclusion, we saw similar high rates of medical and psychiatric comorbidities as well as high rates of severe COVID-19 illness as evident by ICU admission in hospital delirium, requirement for COVID-19 specific medications, and high post-hospitalization mortality rates. Specifically, the use of COVID medications was required in 33.9% of meth users and 29.2% of THC users. So even in this relatively small study, we're able to recognize trends that are relevant to patient care. As we know that the COVID-19 pandemic has caused tremendous morbidity, mortality, dramatically changed how people live their lives, and transformed how healthcare is provided and accessed. We know that it has changed substance use patterns across the U.S. and worldwide. We feel that it will benefit any physician working with COVID-19 patients to have an understanding of how both meth and THC abuse may affect these patients, particularly given this changing landscape of substance use patterns and the persistent anxiety associated with COVID-19. Thank you all. Thank you. All right, it's great to be here. I'm going to be presenting on one of the projects that I've been working on during my fellowship titled The Impact of COVID-19 on Overdose Risk and Healthcare-Seeking Behavior Among Hospitalized Patients with Opioid Use Disorder. I've listed my wonderful co-authors and colleagues on this slide, some of whom are here today. So thank you. No conflicts of interest to report. Here are the learning objectives for my talk. So one, to examine the perceived impact of the COVID-19 pandemic on overdose risk and healthcare-seeking behavior among hospitalized persons with opioid use disorder. Two, to assess changes in overdose risk perception and healthcare-seeking behavior among persons with OUD over the course of a clinical trial. And then three, to describe the importance of clinically focused research and deliberate treatment for vulnerable populations with OUD during the pandemic. So in 2021, more than 100,000 people died as a result of drug overdoses. And while this is a complicated problem, a problem that was certainly exacerbated by the pandemic. The pandemic, at least, disrupted access to substance use disorder treatment and also contributed to social isolation and an increase in drug use. And importantly, an increase in individuals who were reporting using drugs alone. Many have looked at, at least, the impact of the pandemic on healthcare service utilization and substance use, but we know very little, at least, about the impact of the pandemic on risk and healthcare-seeking behaviors, especially among vulnerable subgroups and those with complex needs. So at least this presented us with an opportunity to look at this in individuals who are enrolled in Project COMMIT. So what is Project COMMIT? So COMMIT, at least here, stands for Coordinating Opioid Use Treatment through Medical Management with Infection Treatment. This is an ongoing multi-site trial funded by the National Center for Advancing Translational Research, or NCATS for short. Dr. Sandra Springer from Yale is the contact PI. And the multi-PIs include Dr. Nunez and Dr. Levin, with whom I work with at Columbia, and then Dr. Brady from MUSC. So the purpose of Project COMMIT is to test a new model of care in which hospitalized patients with opioid use disorder and infections, severe infections, are managed by infectious disease specialists and hospitalists using injectable, long-acting buprenorphine. And this is compared to treatment, as usual. This is the protocol paper which is published. There's a QR code there, so if you have a chance, you can scan it and at least learn more about the study. If you don't get to it now, I have it at the end of this talk as well. So this slide at least highlights the study flow and the relevant visits, as well as the study measures, especially for our descriptive study. So at least participants who are admitted were at least recruited upon admission and randomized one-to-one to the new model of care or treatment, as usual. And then at least all participants received the COVID-19 questionnaire. And what we ended up doing, at least for this analysis, is include data that was collected through the end of August of 2022. And we included in the analysis the measurements of the COVID questionnaire at baseline, as well as week 4, 8, and 12, so the four time points. There we go, okay. So data that at least has been collected thus far has at least allowed us to answer, or at least to ask, two specific questions. So one, what is the perceived impact of the pandemic on overdose risk and healthcare seeking behavior among hospitalized persons with OUD? And then two, does risk perception and healthcare seeking behavior change over time among this particular cohort during the pandemic? So the questionnaire consisted of nine questions, which I just grouped into the following domain. So COVID-19 testing and diagnosis, COVID-19 risk behavior. There was a question on social distancing, so how likely or how good individuals are at social distancing. Healthcare seeking behavior, we had three items here, just assessing participants' likelihood of seeking infectious disease care, seeking addiction care, and also receiving medication treatment for OUD. Two items that looked at overdose risk behavior, so likelihood of purchasing drugs and also using drugs alone. And then finally, overdose risk. So in terms of the first question, I'm just going to skip this for now, at least in the interest of time. The sample that we included was 101 individuals. So 101, at least, individuals completed the COVID questionnaire at baseline. And here what you can see is almost everybody was tested for COVID-19, and almost three in 10 at least tested positive for COVID-19. So here this plot, at least what this shows is the relative frequencies of the survey responses at baseline, again, including the population, or at least the sample of 101. So what you're seeing here, at least on the y-axis, are the individual items, the questionnaire items, and then on the x-axis, the relative frequencies for the three responses. So less likely, this is at least represented in blue, a neutral response, so no change seen in gray, and then the orange is highlighting the more likely response. So if you look at at least the first item, looking at social distancing, about two-thirds said they were more likely to practice, or at least were good at social distancing during the pandemic versus pre-pandemic, which is obviously what you would expect to see. The next three items look at health care seeking behaviors. So at least what I thought was interesting here is that more participants were actually rating themselves as being more likely to seek ID care, seek addiction care, and receive medication treatment during the pandemic as compared to before the pandemic, at least also compared to those who said they were less likely to do so. Turning attention to the last three items, looking at overdose risk behaviors, here, at least what you can see, somewhat concerning is that over a quarter, at least, reporting that they were more likely to purchase drugs during the pandemic, and almost 40% reporting that they were more likely to use drugs alone during the pandemic compared to before the pandemic. And then finally, also of note here, 16% versus 5% saying that they're more likely versus less likely to overdose during the pandemic. So in terms of the next question, just looking at longitudinal responses over time, what I did was I just at least selected four of the items of interest. And here what you see, or at least this plot, is showing longitudinal responses by person. And the item here is looking at the impact, or at least the perceived impact of the pandemic on receiving medication treatment for OUD. So here the sample was 65, it included individuals who completed the week 12 assessment. So on the x-axis, you're looking at the particular time points, so baseline, week 4, week 8, and week 12. And then on the y-axis, each line represents one participant. So at least the first thing that I noticed here was you see a lot of gray lines, and this reflects participants who responded with a neutral response, actually saying there was no impact of the pandemic on them receiving medication treatment. But you also see a lot of orange lines, which represents that individuals are saying that they were more likely to receive medication treatment for OUD over time, which is a positive finding. It's something that you wouldn't see. Okay, the next item here, just looking at longitudinal responses in terms of the question item looking at the impact of the pandemic on purchasing drugs. So here again, you'll notice that there is at least individuals who are rating themselves as being more likely to purchase drugs over time as compared to the individuals who are less likely to do so, and this is again seen with the orange lines. The next item here, looking at using drugs alone, again, similar pattern, and you don't see a whole lot of change, at least with respect to the responses. And then just the final item here, looking at the impact of the pandemic on overdose risk. Again, you see a lot of the sample responding neutrally, but you do see a lot more orange, which is also concerning. Individuals rating themselves as being more likely to overdose. So what does this really all mean? You know, as compared to the pre-pandemic ratings, hospitalized persons with OUD rating themselves as being at higher risk for purchasing drugs, using drugs alone, and overdose since the onset of the pandemic. You know, we saw limited variability with respect to risk perception and healthcare seeking behavior, and at least responses remained relatively stable over time. I think also what's encouraging is looking at what we're going to do next with this. So because data is ongoing, you know, perhaps seeing something a little bit different with the patterns as we add a higher N and also the week 24 time point. And I think also looking at, especially with the responses over time, looking at teasing out differences between groups as well as individual level differences among those, especially with negative or at least on negative trajectories, looking at differences by treatment arm or medication assignment. And does this really tell us something about study retention or dropout? References and acknowledgements. Again, there's a QR code, and again, thank you to everybody involved in this project, including everybody on the team, Project Commit. Thank you. Okay. Very good. All right. Hello, all. My name is Nick Saval. I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine, all in a context of folks who are hospitalized with medical complexity. And I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine, all in a context of folks who are hospitalized with medical complexity. And I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine, all in a context of folks who are hospitalized with medical complexity. And I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine, all in a context of folks who are hospitalized with medical complexity. And I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine, all in a context of folks who are hospitalized with medical complexity. And I'm going to be speaking about a case series from an ongoing clinical trial of patients undergoing low-dose or micro-dose buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of depo-buprenorphine transitions, followed by administration of Terima kasih. It's working on y'all's end. Okay, we're just not seeing it. Uh-oh. So what you might have to do is just talk through it. Look up here. You might just have to look up there, but right now I can't get us back to the beginning. Anybody? Can anybody help? I don't know what to do. Let me just try and see if this... No, it won't do it. Push it there. Put it there. Yeah, now I've lost the cursor. I have not helped. There, we found it. Well, just push up and down. Okay. I hope everyone can hear me. I'm Jeff Russell from Stony Brook, one of the third year psychiatry residents. Let me get synced up. Okay. I'll give you the background on this in a second, but basically our study was a retrospective chart review of patients prescribed benzodiazepines in the Stony Brook outpatient psychiatry resident clinic. So those primarily seeing the resident psychiatrist in their third year. And the purpose of it was looking at patients who might be at elevated risk of adverse effects of benzodiazepines. So there's no financial interests or funding or anything like that. Learning objectives, really it's three-fold. The most important, I think, is identifying the gap in knowledge and the complete lack of evidence-based or protocolized prescribing interventions or tools in psychiatric care settings. There's a few for primary care settings, and that's where basically all the research was done. But when it comes to psychiatric care settings, there's essentially nothing that can be protocolized. And we'll talk about demographic stuff and other patient characteristics. I'm going to go through to here. So basically how this all came about is I started looking at a couple patients I had who were on super high doses of daily benzodiazepines, and I thought, okay, well there's got to be something out there that can help us to get them off of them. So I started looking into the literature and soon realized there's nothing at all. So it was pretty disheartening, and I ended up writing a narrative-style review about some of the history of benzodiazepines and prescription use trends. And going back to the 70s, Valium benzodiazepam was the most prescribed medication in the whole entire world. That's no longer the case, but benzodiazepine prescription numbers still remain pretty high, tens of millions of prescriptions written each year. And there's more evidence about patients who will be at increased risk of adverse effects, people who are prescribed opioids, people who are ages 65 and older, patients with serious mental illness and other substance use disorders, all sorts of stuff that we know about now. If you look at, say, one of the most recent deprescribing protocols from Canada, when you get to the bottom, it mentions if the patient has any sort of anxiety or mental health history or anything, we'll refer them to psychiatry. Unfortunately, we don't have anything that is protocolized or evidence-based when it comes to actually who the best patients are to offer deprescribing to and how to do it. So we think it's a really important topic, and we started by looking at all the patients prescribed benzodiazepines in our psychiatry clinic and trying to see, is it something we actually need? Would it be worthwhile to look into this and try to generate some protocol to help patients get off the benzodiazepines? So we looked over a one-year period, and I did another follow-up more recently just collecting all the information about these patients with attention to some of the risk factors that have been uncovered in the literature so far. So in our clinic, about 20% were prescribed benzodiazepines. Here's some of the basic demographic information. As you can see, nothing stands out too much except a couple figures. 13.6% of the patients were over the 65 or older, which is this classic higher risk group. And interestingly, 72.1% of the patients were women. It's not surprising because there's other studies that have been done about benzodiazepines, and this is a common theme. For some reason, women patients are prescribed benzodiazepines at a much higher rate than male patients. No one quite has given an answer yet. I'm not going to answer it now, but maybe in the future. So just some of the clinical characteristics. Not surprisingly, about almost all the patients had some sort of anxiety disorder diagnosis and some other related conditions, but a pretty fair number also had a history of alcohol use disorder, opioid use disorder, stimulant use disorder, inpatient psychiatric hospitalization, which some would say is also an independent risk factor for adverse effects of benzodiazepines, falls too. So trying to create some visual representation, we looked at the average daily dose that we could figure out by age group, and the 60 to 64 age group had the highest average daily dose, but 65 to 69 is not too far behind. And I think in the 70 plus group, there's even patients up into their 80s, and I think one maybe who was nearing 90 who was on daily clonopin, I think it was. And when we look at the average daily dose in patients who were also on prescription opioids from other people, usually pain management where we're practicing, the daily dose from benzos that we were prescribing was about double that in the patients who had concurrent opioid prescription use, which is pretty concerning, especially now we can back it up by referencing the black box warning from several years ago about benzodiazepines and opioids and the risk of overdose and death when they're co-prescribed. So maybe the most interesting part to us, when we looked at all the patients prescribed benzodiazepines and then looked at the ones who had at least one risk factor, it was 40%. And 18% had more than one or at least two risk factors. So the conclusion we really draw from that is well, there's a pretty good reason, at least at the Stony Brook Clinic and I presume other places out there in the world for looking into how we can actually have a protocolized evidence-based way for helping patients to deprescribe the benzodiazepines. And this was another interesting thing. When we looked at the duration of use, 32% of the patients were on benzodiazepines for four years or longer. Again, now the FDA kind of caught up with what has been known for decades and says, well, they shouldn't really be prescribed for longer than two weeks. So it looks like a fair number of patients are only staying on them short-term, but some of them are sticking with it. And I think we even have some patients longer than eight years, 10 years, who've been on daily benzodiazepines. I'm not saying it doesn't work, but it's hard to prove it from a science perspective that it's helpful or value-added care. So I did look back more recently at the data and there's this interesting number. 54% of those initial patients remained on benzodiazepines at the one-year follow-up after that original period. But I want to clarify the number. The attrition rate from the clinic in these patients was huge. So it's not like they were actually coming off of the benzodiazepines successfully. A lot of the time they would not show up to appointments anymore or there would be a dispute about the benzodiazepine or deprescribing would be offered and brought up over and over because of the high-risk situation. And then eventually they would find someone else, I'm assuming. And a couple of the patients died, too. I think at least the one I'm remembering was also on prescription opioids, but never had a definitive cause of death. So I think the major takeaway is 40% of the patients had at least one risk factor in our clinic. The median duration of prescription benzodiazepine use was over two years. It did vary a lot, though. Another mean daily benzodiazepine dose was twice as high, statistically significantly so for patients with concurrent opioid prescriptions from other providers. So really the conclusion is that we really need to start looking into ways that we can use a protocolized, evidence-based approach to bringing up benzodiazepine deprescribing with psychiatric patients in psychiatric care settings, not just the classic group that's been studied so far, which is people over the age of 65 in a primary care setting with no mental health problem or any known substance use disorder who only took the benzodiazepine for sleep. Because we're not dealing with those patients at Stony Brook, and I'm assuming a lot of you have seen a lot of other cases that are really complicated. So any help would probably be pretty useful. For later. That's it. Thank you. Hello. My question is for Anne. Great presentation everyone. Anne, I was interested in your study. Did you find more ADHD in the methamphetamine use group as opposed to the cannabis group? It's on. Okay, perfect. Sorry. So that we actually did not because we checked very carefully to make sure that folks that were testing positive for amphetamines were only testing positive for illicit drugs. So there was ADHD prevalent in both, but there was no statistic significance between the two. So I just wanted to make sure that if we were not excluding those patients that had past prescription of amphetamines or even were not specifically using methamphetamine, that that may have been higher. Hi. This is about the benzo prescription. We actually are doing that at our clinic at Mount Sinai. We're putting in a protocol for deprescribing for patients that have been on long-term benzodiazepines, and we have policies in place and stuff, so stay tuned for that. But come talk to me if you want to ask questions. For Ann, I had a question just to, and maybe I missed this and I apologize, but did you control for who was on SNRIs or especially fluoxetine or fluvoxamine? I'm hearing that those are pretty antiviral. Just wondering about your clinical course there. We did not, but that is an excellent point, and I think that's definitely something that we're considering now. Especially, I did collect the data about which different SSRIs were used, and we're actually just doing the, kind of redoing the multivariate analysis. We've added another group of alcohol users, so that will be definitely something that we could consider. Thank you. Any other questions? This is for Dr. Russell. I work with a lot of, several patients I inherited from a previous prescriber in my clinic at the VA in Milwaukee who was more comfortable prescribing a lot of benzodiazepines and a generic veteran would be a Vietnam veteran in his 70s who's been on it for PTSD for 20 years and used to their dose and can't see any problem with the benzo. They're getting older and they don't want to budge on it, and so they might be on suboxone or another prescriber might be giving them opiate, but there's nothing wrong with it, I want to stay on it. And so, I mean, sometimes they're aware of problems that, you know, as things come up, they have falls, we can talk about it, but sometimes they're not aware of it and they also have problems and it can be really difficult. One thing that I've found helpful is kind of focusing on a least effective dose, you know, continuing to educate them, build a relationship with them. You can't do anything without engaging them. You can't just spring a taper on them right away. You have to engage them, understand them, work with them through time, and sometimes educating them, hey, you're getting older, you know, your body your level of benzos in your blood is going up, it's not the same. Educating them on the risk factors with MI principles, asking permission, and then sometimes what I find is people are mostly afraid of that first reduction and kind of looking at, hey, we're not going to cut you off, we're not going to stop it. Maybe let's talk about going to a least effective dose, reassessing, and kind of the way you approach it and frame it, I've found I've been able to bring patients down in dose. Some of them get off and some of them I'm, I don't know, it's kind of like containment, the U.S. in the Cold War with Russia. It's like I don't want them to disengage, but I don't like, so I'm just going to document my informed consent risk benefits, have that conversation, continue to educate the patient, but it's not easy. I think a protocol would be helpful to just have a standard, so thank you for your talk. It was very helpful. My name is Jared Weiss. I'm a fourth year resident at Zucker Hillside, so not too far away. I also just had some thoughts. I think one of the challenges in the resident clinic is that maybe more so than in other settings, we're getting turnover. We might inherit these cases as third year residents and then be handing them off in a year. I think, and particularly because resident clinics may skew towards sicker patient populations, at least that's the case where I am, there's often an interest in getting to know the patient, assure that they're stable before we start trying to taper, and then by then, we may not have that much time before we have to hand the patient off again. I think that that's something that needs to be looked at carefully. There is that tension you're both alluding to between what's the greater sin, keeping people on benzos and then they stay in care, they keep coming back, or try and taper and have them withdraw or go elsewhere. It sounds like that had some real adverse outcomes in your case. I try whenever possible. What is the fear? My anxiety is going to get worse. Are you on an SSRI? Are you on an SNRI? Many patients aren't. Or have they tried other safer short-acting agents? And if I frame it as, well, best practice is that these medications are meant for short-term use while you're getting stabilized on something else and that part never happened, let's do that first. I'll wait to start tapering the benzo until we've done that, but we kind of need to do this in order to allow for that because I can't prescribe this safely to you indefinitely. And I set a time frame. I say, okay, let's spend the next three months of treatment focused on getting you on other pharmacologic options. If you choose not to do that, that's okay. It's your choice, but I won't prescribe a benzo indefinitely unless you're accepting some other pharmacologic treatment. And then I don't care how slowly we go down. Half milligram, quarter milligram every month, two months. Setting those expectations, laying that roadmap months in advance can facilitate the partnership so that when it comes, even if it's not their preference, they at least might stick around in treatment. So that's what I've got.

addiction medicine

COVID-19 pandemic

methamphetamine addiction

behavior-based therapies

overdose risk

opioid use disorder

low-dose buprenorphine

retrospective chart review

benzodiazepines

deprescribing approaches