All right. Hello, everyone. I think we can begin now. My name is Dr. Muhammad Adil. I'm a psychiatry resident at Rutgers New Jersey Medical School. Thank you for joining in the paper session of the AAAP annual conference. And it's going to be five presentations going to be done today. And at the end of those five presentations, there's going to be a Q&A session for 10 minutes. If you have any questions, you can put it in the Q&A section with the name of the presenter to address. The five presentation I have here, the first one is going to be by Dr. Amy Yule, Provider Experience with Overdose Death. The second one is by Dr. Brian Furlan, COVID-19 Vaccine Administration and Hesitation Among Psychiatric Emergency Patients. The third presentation is going to be by Dr. Suparno Mitra, which is going to be presented by Dr. Arun Prasad. It's on Long-Term Opioid Prescription, LTOP, a survey and retrospective chart review on the efficacy of long-term prescription of methadone at an inner city opiate treatment program. The fourth presentation is by Lana Buffenstein, Systematic Review of Recruitment Bias in U.S. Addiction and Substance Use Phase 2 and 3, Randomized Clinical Trials of Adults, 2008 to 2019. And last presentation is by John Westenberg, International Consensus on Prevention, Treatment, and Management of High-Risk Substance Use and Increased Risk of Overdose Among Youth. So let's begin by the first presentation by Dr. Amy Yule. So I'm really excited to be here to talk to you about provider experience with overdose death. To begin with, I have no relevant ACCME disclosures. I do want to note that this work was supported by the provider clinical support system. So I'm going to talk about a survey that we conducted a year ago. And by the end of the presentation, you'll be able to describe how prepared providers feel to cope with patient drug overdose deaths and how prepared they feel to support a colleague after a patient drug overdose death. But you'll also be able to identify resources that providers found helpful after experiencing a patient drug overdose death. And then you'll be able to describe how patient drug overdose deaths influence providers' future clinical decision-making. So this conference with this audience, I don't need to belabor this point, but we've seen a record number of drug overdose deaths in the past year. They have a really profound impact on families, on the community in which an individual lived. And then also we suspect that there's an impact on providers. And over the past two years, there's been increasing research describing the stress associated with patient drug overdose deaths and the opioid epidemic on first responders, and then also community health workers that are doing overdose prevention outreach. There's been less literature, and to my knowledge, I'm not aware of any, really describing the experience of providers and clinicians that are working in more formalized medical settings. And that's who we're going to focus on today. And in constructing the survey that we did and administer, we looked at the literature on provider experience after a completed suicide to really inform the survey's development. And in December 2020, a year ago, we sent an email invitation to the provider clinical support system membership directory to complete an anonymous survey. We used largely descriptive statistics to describe the sample, and then to also describe their experience and kind of thoughts on patient drug overdose deaths. And then we used Chi-square and Fisher exact test to explore associations between high stress after patient drug overdose death and the impact on clinical practice and the helpfulness of processes. So in total, 12,000 people received an email to participate. A thousand people opened the survey link, and then 523 completed the survey. In terms of who completed the survey, it was largely physicians, 47% of the sample, followed by counselors, nurse practitioners, and nurses. Among the physicians and the nurse practitioners, 75% were wavered to prescribe buprenorphine. And then among the physicians, 41% had additional formal training in addiction and were either ABPN or ABM certified. In terms of other demographics of the sample, it was largely white, largely female. The average age was 52 years with a standard deviation of 12 years. And this was largely people that had been in practice for a period of time. And so on average, respondents had been in practice for 16 years. When we looked at preparedness for overdose death, one of the first questions we asked was whether or not respondents had received any training in postvention. And postvention are interventions that are conducted after suicide to support the bereaved. And so only 24% of respondents had had this type of training that could be helpful in potentially preparing them for a drug overdose death in their practice. And we looked at three different categories of preparedness. We looked at how well they're prepared to cope with a drug overdose death, how prepared they felt to support a colleague, and how prepared they were to talk to the family members of an individual who died of a drug overdose death. And you can see below there these are kind of the three different categories in the x-axis. The blue bars represent people who felt not at all prepared. The orange bars represent people who felt somewhat fairly well prepared. And then the gray bars represented people who felt very or extremely well prepared. And you can see that kind of overall that people felt somewhat fairly well prepared themselves to cope with an overdose death, prepared to support their colleagues, and then somewhat fairly well prepared to talk to family members. I think it is notable that there's a higher percentage of people who felt not at all prepared to talk with family members relative to, you know, those who felt not at all prepared to cope with a drug overdose death or prepared to support a colleague. And then next we looked at providers experience with patient drug overdose deaths. How often is this happening in people's clinical practice? And 55% of respondents reported that they have had a patient drug overdose death in their practice. And we looked at different types of processes that have been looked at in the kind of provider experience after completed suicide literature and kind of looked at things that are often commonly done or described in that literature, including consulting with colleagues, having a critical incident debriefing session, and then also interacting with the patient's family. And so across this sample, the blue bars represent kind of this is something that people never did after a patient drug overdose death. This is something, the orange bars are processes that they did less than 25% of the time. And then the gray bars represent something that they did the majority of the time, so greater than 75% of the time. And you can see that, you know, 48% of the sample kind of after most patient drug overdose deaths did consult with a colleague. But then when we look at kind of how frequent critical incident debriefing sessions were kind of how often people are talking with patients' families, these things were happening less often, kind of less commonly happening after patient drug overdose deaths in these respondents' practices. And so only, you know, 24% of people had a critical incident debriefing session after the majority of the patient drug overdose deaths in their practice. And then only 20% of people interacted with the patient's family after a patient drug overdose death in their practice. When we looked at different types of individuals or processes that have been kind of described or looked at, and again, in this literature on providers' experiences after a completed suicide, and looked at this for people's experiences on kind of for themselves with coping with a recent patient drug overdose death, you know, these are different kind of categories. And then you see in the colors, the orange are helpful or very helpful, and then the blue and the purple are unhelpful, and then gray is neutral. And you can see that kind of the most commonly identified type of individual or processes that was kind of helpful in terms of coping with a recent patient drug overdose death were colleagues. And then I think it's notable given that not many people are meeting commonly with a patient's family, that people also identified that meeting with a patient's family was helpful or very helpful as kind of one of the things that was, I think, kind of highlighted in the way as a process that was helpful in helping them cope with a patient drug overdose death. And then most people did not think it was helpful or felt neutral about consulting with a malpractice carrier after a patient drug overdose death. And then we also looked at, you know, kind of people's stress, level of stress after a patient drug overdose death. And this has been something that's, this impact of event scale is something that's been used, again, in this, the literature on providers' experience after a completed suicide. And the impact of event scale measures symptoms of trauma or traumatic stress. And at a certain cutoff level, if you have above that cutoff level, there's concern potentially for post-traumatic stress disorder. And so, among people who had a patient drug overdose death in the past year, there were 141 respondents. 121 of them completed this particular scale. And 18% of them had very elevated impact of event scale scores. And when we explored this relationship between high stress and kind of your actions, you know, when we compared providers with low stress to those with high stress after a patient drug overdose death, those with high stress after a patient drug overdose death were more likely to refer patients to higher level of care, were more likely to focus on overdose and suicide risk factors, were more likely to use peer consultation. And then there was no difference in record keeping a relationship with colleagues. And so, I was pleased to see that there wasn't a difference in relationship with colleagues, knowing that that's an important source of support for people after a patient drug overdose death. But was, you know, do you think that it's worth exploring or trying to understand more in future research, this finding that people with high stress after a patient drug overdose death were more likely to refer a patient to higher level of care, just given that people that are struggling, who we work with sometimes aren't quite ready to go to a higher level of care. And if we're really pushing them to go to a higher level of care, they may not come back to see us and may be less likely to engage in care. So, in summary, many providers do not feel well prepared to cope with a patient overdose death or to support a colleague after an overdose death, which I think, you know, is something we need to be thinking about as we're thinking about trainings and trainings that should be developed. And then patient drug overdose deaths are common people's practices and colleagues are an important source of support. And then a patient drug overdose death can change clinical decision-making for providers who are experiencing high levels of stress related to an overdose death. So, with that, I do want to thank my collaborators on this work and, again, acknowledge and thank the provider clinical support system for their funding support of this project. Thank you. Thank you, Dr. Yu. Okay. So, hi, everybody. My name is Brian Furline. I am the Director of the Psychiatric Emergency Room at VA Connecticut, and I'm presenting this on behalf of me and Lorena Mitchell, who is our social worker at VA Connecticut in the Psychiatric Emergency Room, who admittedly did a lot of this work. So, the Psychiatric Emergency Room. I will tell you a little bit about what we do. We are a 24-7 locked, dedicated, psychiatric-only emergency room, which is next door to our medical emergency room. We're very novel for VA hospitals. Most VA hospitals, in fact, virtually no VA hospitals other than us, have a separated, locked, psychiatric-only emergency room. Most have sort of an embedded psychiatric part of the medical emergency room. We have a 14-bed capacity. Of course, we run 24-7. We have the ability to hold patients for, you know, several days if needed. So, it's not – it's sort of a hybrid between an emergency room and a psychiatric OBS unit, and it's staffed by approximately 30 attending-level psychiatrists at some point throughout the month. There's, you know, some full-time people during the day and several key people that work after hours, but there are approximately 30 total MDs who work in the psych ER at some point. The patient population that we serve primarily have substance use disorders. Many are homeless. Many live in congregate settings, such as homeless shelters or treatment settings of other types. The thought behind this study, which I'll talk about in a second, was that people who live in these congregate environments, people with an alcohol use disorder, people with mental health conditions, are known to have an increased risk of contracting COVID-19. So, we wanted to look at vaccine administration among this particular group of psychiatric emergency room patients. Also, this group is known – there have been – you can see the reference there – at least one prior study that showed that there is some vaccine hesitancy specifically among a group of patients with mental health and substance use disorders. So, keep in mind, this is – this was very early on in the COVID-19 vaccine administration process. This was in February of this year. Now, the vaccines have become a bit more ubiquitous and very easy to obtain, especially in the community. VA Connecticut was one of the first sites to obtain the initial doses of the vaccine earlier this year, and the psych ER, because it is an emergency room, was dedicated to be one of the initial sites within the hospital to have vaccine access. So, this – at the time that we did this study, we were in a very select few groups of people that had access to the vaccine and were able to administer it to patients fairly freely. What we did was, during one of the first months that the vaccine was available, we took all patients that came in. We asked them about their interest in the vaccine, and I'll show you all the numbers in a second. If they were interested, we explained how they were able to get the vaccine or not. If they were not interested, we asked why. And some were interested who were not able to obtain the vaccine. But this all occurred very early on in the month of February 2021. I believe it may have gone a little bit into March, but it was approximately one month early in the vaccine administration campaign. So, during that month of the study period, we had 117 total eligible encounters. That means 117 patients who presented to the emergency room during the day, during the week, because that's when the social worker and the staff were there who could administer the vaccine at that time. Of those 117 eligible encounters, seven of them were unable to be consented for reasons such as they were too psychotic or actively intoxicated or confused or delirious. So, we didn't talk to them about the vaccine because they weren't able to consent. So, we had 110 qualifying presentations of people who could potentially receive the vaccine. Of those 110, 14 were duplicate presentations, the same patient who presented multiple times. So, we consolidated those, and we had a total of 71 people who declined the vaccine, including the duplicates, and 39 who were interested in obtaining the vaccine, including the duplicates, for that total of 110. So, if someone came in more than once, we would ask them more than once. If they accepted the vaccine initially, we wouldn't ask them subsequently, but if they declined initially, we would ask them subsequently if they were interested in other times. So, of the 39 people who were, and you can see more were not interested, they were interested. Of the 39 people who are interested, 23 received their initial dose of the two-dose sequence, received their initial dose in the psychiatric emergency room, and 16 who were interested did not. Of the 23 who received the first dose, 21 also received the second dose. Our social worker, Lorena, who was involved with this study, made it a point to follow up with all patients who received the first dose to make sure that they also received the second dose since they would no longer be in the emergency room three weeks later. Two of them were lost to follow-up, but 21 did successfully receive the second dose. Of the 39 who were interested, 16 did not receive the vaccine. And the reasons why were, you can see the numbers below, 13 were unable to receive it due to the ER setting. So the vaccine was available typically later in the day for administrative reasons. And many of our patients had to be discharged or transferred out of the emergency room before the vaccine dose was allocated by pharmacy. So even though some were interested, we were unable to administer that for administrative reasons. And then for three veterans, the vaccine was contraindicated. Two had a recent tetanus shot, and one had a COVID-19 infection within the two weeks. 71 of the original 110 declined the vaccine. So of those who declined the vaccine, we asked them, what was the main reason that you were not interested in receiving the vaccine? Six of these veterans were declining everything. You know, I'm not interested in anything. They were in the ER, but they were not interested in our help, which isn't terribly uncommon for some of our patients. 15 of them had just a general mistrust and general concerns about the vaccine and the vaccine side effects. So just sort of a general mistrust. 19 had a strong mistrust specifically of the vaccine, and were not interested in hearing any more information about the vaccine. 17 were potentially interested, but they were really focused on why they were in the emergency room. Often it was for alcohol withdrawal, or for heroin use, or for depression. And while the vaccine sounded appealing, they weren't interested today because they were more interested in what they were there for. Nine declined for psych ER setting-related reasons. So again, sort of administrative reasons why they were not interested in the vaccine. And then five were just not concerned about COVID. I'm not really interested in COVID. I don't really think it's a big deal, and I'm not that interested. So we had a small victory. And again, now the vaccine is very ubiquitous. But at the time, we were able to vaccinate with a first dose of the vaccine in an emergency room setting, 23 of the 110 total visits, really of the 96 unique visits, we were able to dose 21, 23 with the first, and 21 with the subsequent. So 21 had the full sequence of the two doses of the vaccine, which was initiated in the psych ER. But we had some challenges, and the challenges were that these administrative challenges were primarily that the six-dose vials, so the vials of the COVID vaccine came in doses of six. And if there was one patient in the psych ER who was interested in taking the vaccine, the pharmacy was not willing to waste the other five doses, and there was a very sensitive time limit as to when they could be administered. So there was, again, these administrative reasons that I'd be happy to answer more questions about if anybody's interested. But that was the main challenge that we experienced. Also the length of stay was short. Many patients just might have been interested but prioritized why they were there. Some were just acutely intoxicated or lacked capacity to sign, and others had just vaccine hesitancy in general. They were just not interested in the COVID vaccine. So with that, I will end it, and I will turn it back over, and I'm happy to answer questions at the end. Thank you, Dr. Brian Ferling. So I'm going to proceed to Dr. Arun Prasad for his next presentation. Hi, everyone. My name is Dr. Arun Prasad. I'm a psychiatry resident at Bronx Care Health Systems, ICANN School of Medicine in New York. My presentation today is about long-term opiate prescription and LTOP, a retrospective chart with special emphasis on the duration of, basically, the pandemic on how things have affected the MMTP program in prescribing habits of methadone. So first of all, I don't have any... Doctors do not have any disclosure conflicts of interest to report. And the study was conducted, basically, within our own health system, Bronx Care Health System, and it was done at the MMTP program that's situated right next to our psychiatry hospital. So the methadone prescription is governed by Part 8 of Title 42 of the CFR. The COVID pandemic led to relaxation of rules as it applies to take-home prescriptions. Usually, what we do is we give a prescription. A patient usually has to come in every day to get his methadone. And as trust is built, reliability is built, the patient can start taking two daily, three daily, four daily. It goes to become weekly, becomes two weekly, and then becomes usually monthly. That's the pattern in which methadone is being prescribed. If the patient is found to be unreliable, has a history of using during taking opiates, or has been found to be selling his dosage or diverting it, his dosage frequency is reduced down. So, for example, in Ohio, for example, the blanket take-home prescriptions were allowed for patients with COVID and patients with significant medical comorbidities. So we're basically discussing changes in our practice at our own OTP here at Bronx Care and discovered certain common characteristics and patterns in prescribing practices for methadone. So the methods that we use are, with the anecdotal information available, a team was made to review chart information. It was basically a retrospective study based on patients enrolled in the MMTP study. A total of 144 charts were reviewed, and the data collected included the race, gender, age, current dosage of methadone, time in the OTP when the patient was enrolled in the first place, and the UTOX results, and comorbid drug use during the pandemic. So we also looked at medical comorbidities, the relapse, and COVID infection rates. So when we did the study, the results that we collected were, so according to race in our MMTP program, out of the random, we basically collected data from the beginning of the pandemic in New York, which was around February, March 2020, and it was for a period of one year, up to March, up to present, I think September or October is the duration of the study. So we had around 68 Hispanic nations, 20 African American, and unknown race, which was mostly race not reported, or mixed races were the unknown race. It was more of a male population, 106, and more of an elderly population, about 60 years of age was the majority, although closely followed by 50 to 59-year-olds. So looking at the frequency of comorbidities and changes, so there was basically an increase in comorbid drug history. The frequency basically was 106 out of the population had a comorbid drug history, although 38 didn't. The comorbid psych history was present in a lot of them around 76. So on following up on UTOX after decreasing the frequency of them coming in to collect opioids, it was found out that the majority of patients had a negative UTOX, around 78 versus 66. So it didn't really change drug usage. It was pretty much effective. Methadone was pretty much effective in controlling their drug cravings and drug usage. Comorbid medical history, majority of them had comorbid medical history, which they were actively following with their primary care doctor, mostly via telemedicine methods. And also drug prescribing was increased, giving them six-month supply of medication compared to the regulatory three-month or four-month period. So out of the population, there were only four cases of patients who actually contracted COVID during this period, which could have been significantly higher if they were coming in person with respect to what was going on in our medical flows during this six- to eight-month period of the peak of COVID in New York. So change in frequency. So in those patients who needed a dose change, a majority of them needed no change, while a significant amount of them also had a decrease in opioid methadone prescription needs. And the factor for this is basically because their drug use was reduced, and they just basically needed less amount of methadone, and they requested to go down on methadone during the period of the pandemic. So looking at the regression results of our study, none of them were actually statistically significant in the first phase of the study. The dose change, it showed... I mean, most of them, as I already mentioned, it was like a decrease in the dosage, but it wasn't statistically significant. And basically, it's very preliminary data at this point, because it was just a very short period of the study. It was like six to eight months with an N of 140, which we have to further explore. So coming to the discussion, the COVID-19 pandemic has affected substance use treatment across the spectrum of substance use disorders. Patients were fearful of attending OTPs daily due to risk of contracting infections. So most of them stayed home, and even in the MMTP, it was basically sometimes phone sessions to check on how they're doing. In some other programs, which I've personally experienced, like Long Island Jewish in New York, they've had a system in which insurance would pay for a truck to go and deliver methadone to patients who needed more frequent dosing. And sometimes they would also have a physician go along with them just to have a quick checkup of the patient. Not a detailed examination, but just a quick checkup to see how the patient is doing before prescribing the medication. Relaxation of rules for methadone take-home prescriptions have had a positive effect, including compliance, prediction of risk of relapse, and reduction in the risk of infection with COVID. Some patients are also noted to have a dose increase due to the pandemic. This preliminary data may give evidence for an indication for a larger multicenter study to develop protocols for future instances when patients may be stratified into groups who would benefit from take-home medications. So in conclusion, methadone take-home prescriptions have been beneficial. A careful assessment of risk versus benefits, and overdose risks and patient safety related to take-home prescriptions and daily clinic attendance need to be protocolized. Phase two of our study is to conduct a survey among our patient population to assess patient perception about take-home medication. This is going to be done in the form of pamphlets, distributed paper, for opinion on how it's impacted their experience with the MMTP program. Yeah, that was the end of the presentation. Thanks so much, guys. Hi, everybody. My name is Ilana. I'm a fourth-year medical student at the University of Hawaii at Manoa and a researcher at Hawaii Strategic Neuroscience, also in Honolulu. And I'm going to be discussing my research entitled Systematic Review of Recruitment Bias in U.S. Addiction and Substance Use Phase 2 and 3 Randomized Clinical Trials of Adults, 2008 to 2019. I have no disclosures. So some of the educational objectives of this project were to strive for equitable demographic representation in clinical trials related to addiction medicine as well as substance use disorders, to improve treatment of diseases impacting heterogeneous populations, and to promote health care equity in medicine. So as a bit of an introduction, as we, I'm sure, all know, historically clinical trials have lacked verification of gender, but also racial and ethnic minorities. And various governmental organizations, NIH, the WHO, and the FDA have all passed initiatives that were aimed at improving this issue, both in reporting and in representation, because a lot of the time clinical trials might include minorities, but they might not report the kind of demographics of those minorities. However, over time, this inclusion of diverse patient groups has unfortunately remained low. And the importance of inclusion, particularly in the field of addiction medicine, is really important because these disparities are particularly prevalent in addiction medicine. So that was kind of the introduction to this project, and these were some of the issues that we were considering as we were progressing through it. So this is our method slide. It's a little bit cluttered, but basically we started out with a huge number of trials, not only within the field of addiction medicine, but this was kind of a part of a larger project. So we had over 5,000 trials from four databases that we used to identify these trials. We looked at a period of time from 2008 to 2019, and that was because in 2007, we saw expansions in demographics reporting requirements for clinical trials. So in 2007, they had to report demographics more strictly, and there were kind of more penalties for them not doing so. We had two independent reviewers reviewing every trial, and we were specifically looking at adults. So trials that only included people over the age of 18. We wanted to look at people that were kind of actually affected by the condition, so we were interested in Phase II and III trials specifically. Location only within the U.S. A lot of clinical trials that are multi-centered will have locations internationally, but we only wanted to look at the United States because we were interested in U.S. demographics. Randomized and completed trials, and then results of trials that were posted on or before this particular date. They had to be pretty much wrapped up by the time we were looking at them. We didn't want to look at trials with children or, as I mentioned, trials with international locations, and this left us with 245 trials that were specifically related to substance use disorders. All of these were identified, as I mentioned, by the two independent reviewers, and we were using the ICD-10 code system to kind of break these trials down. So all of these were within the spectrum of addiction. At this point, we had over 42,000 participants over the span of all of these trials over the years, and we identified meta-analyses to obtain summary proportions and 95% confidence intervals of gender, ethnicity, and racial groups within all of those trials. We looked at the gender breakdown as a binary. Obviously, gender is not a binary, but for the purposes of trial reporting, most trials do not, as we discovered, report gender minors. So male versus female for simplicity. Ethnicity, meaning Hispanic versus non-Hispanic. And then we looked at these specific racial subgroups because these were the ones that were the most commonly reported. So American Indian, Alaska Native, Asian, Native Hawaiian, Pacific Islander, Black, White, and multiracial. And then these summary proportions were identified and compared to their corresponding U.S. census proportions. So these were some of the, I think, quite interesting results that we found. So red identifies underrepresented, and green identifies overrepresented. And this is in comparison to, as I mentioned, the 2010 census proportions we were comparing each summary proportion to. So as you can see, females to Hispanics, Asians, and White participants were, on the whole underrepresented in trials related to substance use disorders, while American Indian, Alaska Native, Native Hawaiian, Pacific Islanders, Black and multiracial participants were overrepresented. As you can see, none of these were, as we say statistically, like the null, meaning comparable to the disproportion, meaning they were basically all misrepresented in some way, whether it's underrepresented or overrepresented. And as a note, there were no transgender or gender minority participants at all reported across the 245 addiction and substance use trials, which we thought was kind of unfortunate, but maybe not so surprising. Another interesting finding was that many trials did not report race or ethnicity at all. For ethnicity, 64% did not report, and then for race, it was a little bit better, but still 44% did not report. So that in itself is kind of an interesting finding. So in conclusion, these results highlight disparities in substance use clinical trial recruitment. As I mentioned, over half of trials do not report ethnicity, and there were no transgender or gender minority participants reported. They may have participated, but it was not reported by the trial, so we don't have that data. So either they're not participating or they're not reporting the trial. Either way, not great. Our results suggest that women, Hispanics, Asians, and white groups are underrepresented, while American Indians, NHPI, black and multiracial groups are overrepresented. And overall addiction and substance use trials unfortunately may not reflect the demographics of populations thought to be served. These are my references. And thank you so much for paying attention to this presentation. Thanks to Hawaii Pacific Neuroscience and the Brain Research Innovation and Translation Lab for supporting this project, and for all of you for attending this presentation. Mahalo. All right, thank you so much, Elena. I'm going to proceed to Mr. Westernbrook for his final presentation. Oh, wait a minute. Sorry. Can you guys see my presentation? Yeah? Okay, awesome. Okay, really good presentations so far. I think I'm the last one. I'll be presenting on an international consensus on treatment of high-risk substance use and increased risk of overdose among youth. So my name is Jean Westerbrook, and my co-presenters are Dr. Martha Ignacewski, Dr. Nikki Matthew, and Dr. Pouya Assar. And we're located in Vancouver. I'm in Germany for the moment, but this research was done in Vancouver. And the presenters have no relevant disclosures. So drug overdose deaths in the US have topped 100,000 annually. And what is especially alarming is the significant increase in overdose deaths among young people. And this is a serious challenge. For youth with high-risk substance use, only a small number of them receive any intervention at all. And those that do receive an intervention receive behavioral interventions and family-based approaches in combination with absence-based treatments. So in a cohort study done by Dr. Olinsky and her colleagues, less than one-third of youth who had experienced an overdose received any addiction treatment at all within the 30 days following the overdose, and less than 2% received any pharmacotherapy. And so these kinds of results are very shocking, especially given that the preferred treatment for adults is opiate agonist treatment, and that studies and national resources broadly support the use of medications such as buprenorphine, methadone, and naltrexone for opioid use disorder among youth. So in the face of unprecedented mortality, there's an evident necessity to better address the mental health and substance use needs of adolescents and young adults. And there's a saying that goes something like, understand the past, you can shape the future. And so if we look back at the early 90s in Switzerland, Plastwitz Park in Zurich was the epicenter of the open drug scene at the time. And the Swiss successful response to these open drug scenes was a shift from a repressive attitude against drug-using youth to an active policy of supportive measures to prevent health and social deterioration. And the key to that paradigm shift in Swiss drug policy was the mapping out of scientific consensus and controversies to then facilitate improvement in the standard of care provided to those with high-risk substance use. And so with that, we aim to design a Adelphi study, and the two main objectives of this study were to first source best practices from an international panel of experts, and then to establish consensus for the screening, treatment, and management of high-risk substance use in adolescents and early adults. And so this exercise is not to be perceived as an attempt to establish treatment guidelines, but rather as a concerted effort by an international community of practice to achieve clarity and agree on certain standard practices to secure a healthy future for youth. And for the purposes of this study, high-risk substance use was defined as any use of substances with a high risk of adverse outcomes, and this includes misuse of prescription drugs, use of illicit drugs, and use of injection drugs. And the term youth was defined as being between the ages of 10 and 24, so encompassing both adolescents and young adults. So we had an international group of 31 experts that were participating in this Adelphi study, and so invitees were identified as distinguished clinicians and researchers in the field of youth substance use disorder who were able to provide insight from their in-depth, direct experience in working with adolescents. And so the panelists were from 10 different countries, as listed on the figure on the right, mostly from North America, Europe, New Zealand, and Australia and included a variety of medical experts, most of them being psychiatrists and pediatricians. And this is the general flow of the study. We had a first round of semi-structured questionnaire. So we sent a questionnaire to all of the panelists with the broad domains that we wanted to have answered and that we wanted them to give their input on. And from their responses, we created initial statements. Those initial statements were then sent to the panelists for a first round of rating, and they were asked to rate the statements from a scale of one to five, so whether they strongly disagreed all the way up to strongly agreeing with the statements. Any statement that reached 95% agreement among the panel was categorized as consensus, and any other statement which did not reach 95% consensus was then revised based on feedback provided by the panelists and sent back to the panelists for another round of rating. And this was done a total of three times. And we ended up with, at the end of the three rounds of rating, a sum of statements that had reached consensus and a sum of statements that had not yet reached consensus, so that were deemed controversial or of contention. And so the results of this consensus building process was a total of 60 international consensus statements that were developed for the prevention, treatment, and management of high-risk substance use and increased risk of overdose among youth. I obviously won't go over all 60 statements here in this short presentation, but I do want to go over the main takeaways from the consensus process and give insight as to what was deemed controversial among the international experts. The 60 statements were subdivided to five different domains, ranging from clinical risk, target populations, treatment goals, evidence-based interventions, and finally, treatment settings and expertise. So what were the main takeaways? This is only a few of them. I couldn't obviously present all 60 statements, but generally, the main takeaway was that experts recommended using the amalgamation of evidence-based medications for opioid dependence for youth. They also reinforced the fact that family is a major resource to have involved in a youth treatment process and should not be a barrier to youth receiving care. In the case of serious life-threatening events, there should be a youth-appropriate crisis response system so that every youth waking up in an emergency room, whether it be after a binge-drinking episode or after a non-fatal overdose, receive the best possible care immediately. And finally, the panelists want to express that if we want to reduce high-risk substance use, substance use disorder prevalence, and overdose among youth, we really need evidence-informed practices instead of personal beliefs and subjective preferences. In terms of areas of contention, one major one was regarding involuntary admission. And so although most experts did agree that involuntary admission could be considered as part of a comprehensive treatment approach in extremely complex and high-risk situations, most experts also drew attention to the potential significant consequences it could have on the trust and engagement of young patients. And so the worry is that youth who are hospitalized involuntarily report more distrust, including perceiving inpatient treatment to be more punitive than therapeutic. And so with that, the panel did not want to come to a consensus on an approach of this much weight and magnitude without first gathering more scientific evidence. And so as a conclusion for the general Delphi process, the take-home message is that we're failing to provide good care to youth. There's a dysfunctional treatment system and a lack of academic effort in this domain. And a consensus process is a necessary first step in addressing reform and systematic development. And so next steps must be a massive implementation of youth-specific solutions and an upscale of research efforts. And so without any change, we're sure to see a continuing rising of fatalities. Thank you. All right. Thank you so much to all the presenters, such an informative and wonderful presentation. We still have 15 minutes left. So I'm gonna read the Q&A and ask the presenters if they want to comment on that. The first one is directed to Dr. Yu. It's by Haley Pauls. Post-overdose. It says, fascinating that the colleague support was very helpful, yet not many felt very prepared to support another colleague after an event. Was there any assessment of what type of support is in place? For example, do we actually need to train everyone how to support each other or does simply having a dedicated space to share these issues help enough? So thank you for the question. As I typed into the chat, you know, I think it's a great question. We didn't assess in the survey what type of support people were providing to colleagues. When you look at the literature on provider experience after a completed suicide, it definitely suggests that it's helpful to being willing to discuss the completed suicide and in particular to share your experience for the completed suicide. And it's important not to just kind of quickly and reflexively tell someone like, you did everything you can, like, you know, kind of in shut down a conversation about this topic. I think one important thing is that people often don't feel great about discussing adverse events in their practice. And so, you know, when someone says like, how are you doing? Can people say like, fine, they don't say like, my patient died. And so I think, you know, making sure that people know that it's important to be kind of telling your colleagues when something like this happens, or if you hear about this happening in a colleague's practice to, you know, to kind of let them know that you're willing and open to talk about this, but also not to put pressure on someone to talk about it because everyone deals with their grief and everyone's experience is different. So, but it'd be great to kind of continue to think about this particular topic and what types of support are helpful for providers after a drug overdose death. Thank you, Dr. Yu, for your comment. And the second question is for Ilana. It states, thanks for the very important presentation. You mentioned that under 18 years old were excluded, but were you able to find whether older adults, 65 plus, were over or underrepresented? Yeah, so I actually also, I got that privately and it was, I thought it was a really interesting question. We started out, when we started this project, we were including age as an identified variable, but it was so ununiformly reported across clinical trials. Many would report like 18 to 64, 65 and over, but then others would report bizarre ranges, like 18 to 25, 26 to 34, like it was not uniform. And so it was difficult to standardize, but I think that in and of itself is interesting because obviously it's very important to know if like elder people are being, or older people are being included or excluded from clinical trials. Historically, older people have been excluded from clinical trials. So the fact that that's not being reported in a standardized way, I think is kind of to their detriment. So an interesting area of kind of future research. Thank you so much. And finally, I just have one question. I wanted to ask Dr. Bryan regarding vaccine hesitancy. And there are a lot of other studies similar to yours that points that, you know, psychiatric patients have a lot more barrier and more severe the psychiatric illness, the more there's more hesitancy and more barrier to receive the vaccine. What could be the steps in the emergency setup that can help these patients to get the vaccine to overcome these hesitancy? Yeah, that's a good question. You know, when we did the study, we were, it was so early and I don't think people really were fully aware of the vaccine and what the side effects were. And a lot more has come out, a lot more people have taken the vaccine and things are a bit different. We continue to offer the vaccine to everybody who comes in, but because the VA had such a big push, we're finding that the majority of the veterans now who are coming through have been fully vaccinated. And a lot of the patients who were initially refusing the vaccine in the emergency room, for some of the reasons I mentioned, later on became fully vaccinated because the social worker continued to follow with the patients. I won't show that data here, but we saw that many of them became vaccinated later. At least in my experience with some of the veterans, there is a cohort that are just not gonna be interested. And I don't know how much of that is related to any of the mental health conditions they have or the substance use conditions they have, or just an overall philosophical belief they have of just not being interested in the vaccine. In the emergency room, there were definitely situations where the patient was interested in the vaccine and either not able to get it for administrative reasons or preferred to wait until they were more clinically stable, and which again, those patients did receive it at a later date. So I think compared to what I saw, and maybe even compared to some of the earlier studies of vaccine hesitancy, there may be some changes that more people are willing to take it, but I do think there is a core group of people that are not gonna be willing to take the vaccine, you know, if ever, just for their own philosophical reasons and their own personal beliefs. Thank you so much. Looks like we don't have any other questions, so I'm gonna proceed to our closing statement. Thank you to, special thank you to all the presenters for being here and giving such a wonderful presentation, and thank you everyone for joining in. This is going to be the last event of the AAAP annual meeting. And I would just want everyone to know that all sessions are being recorded and the recordings will be made available after the holidays. And we will be notifying you via email when they become available. And the CME evaluations will be sent via email at the end of the conference. You have to complete the evaluations by February 1st to claim your credits. To learn more about the CE credits for this event, please visit the CE Center in the virtual event lobby. Thank you everyone and have a very good day. Bye-bye.

AAAP annual conference

substance use

addiction

mental health

provider experience

overdose death

COVID-19 vaccine administration

psychiatric emergency patients

long-term opioid prescription