Welcome, everybody. Thank you for joining us for this session titled Emerging Issues in Addiction Consultation in the General Hospital Setting. My name is Joji Suzuki. I'll be chairing this session. Just for housekeeping issues, we're going to go through all four presentations sequentially, about 10 to 12 minutes or so each, and then feel free to submit any questions or comments you have through the chat function, and we'll address them all together at the very end. Just to keep things smooth, we would ask that you keep the audio muted. But if you feel comfortable, please keep your video on. We actually do like to see you. And certainly for the Q&A portion, we would hope that we can see you as well. I hope that everybody's enjoying the conference so far. And without any further ado, let's jump right in and starting with Dr. Bhatt. So I'm Jasra. I'm one of the addiction psychiatrists on the consult service here at Brigham and Women's Faulkner Hospital. I have no disclosures. And I'm going to be talking about implementation of addiction consult service in a general hospital and the various models. Let's start with the case. Let's meet Ms. X. Ms. X is a 26-year-old female with history of type 1 diabetes mellitus, opioid use disorder, alcohol use disorder, cocaine use disorder, and tobacco use disorder. She has history of recurrent MSSA, bacteremia, complicated by hip osteomyelitis, untreated hepatitis C, and now being admitted for treatment of right lower extremity cellulitis. This case was in August. And around this time, addiction consult liaison service here at Faulkner Hospital, which we call ARCS, had been established. Previously to this admission, she had been admitted in June for DKA, in May for cellulitis, and then again in Feb for cellulitis and in Jan for DKA. During this admission, addiction consult was involved. However, we were not consulted on day one. We evaluated the patient, and a microdosing of a suboxone was done, and she was linked to Bridge Clinic. Total length of stay for this admission was around nine days. After discharge, she connected with the Bridge Clinic and continued with suboxone. In November, she was again hospitalized for cellulitis. She relapsed around the end of October because her insurance changed, and she couldn't buy suboxone. She presented to emergency room and requested suboxone microinduction again. And this time around, addiction consult liaison service was involved right from day one. And the length of stay for this admission was for three days, and she followed with Bridge Clinic again. So the take-home point from this case is that we were able to reduce the length of stay from nine days to three days, and also from a harm reduction point of view, this was a win. She continued to take suboxone regularly from August until the end of October. So what is addiction consult service? Can we have the poll, please? So addiction consult service is basically, okay. So it seems that in many hospitals, it's staffed by psychiatry. Okay, let's talk more about this. So addiction consult service is basically an intervention. It is a consult service, but basically it's an intervention to engage hospitalized patients with substance use disorder with care and meet their goals for substance use disorder treatment. Now, there are different kinds of models, and some addiction consult services are just based on physicians, whereas others are interprofessional and have providers from different services and specialties. For example, advanced practitioners, nurses, social workers, recovery coaches, pharmacists. What does an ACS do? It basically assesses and addresses the needs of people who have any kind of substance use disorder and are hospitalized in the hospital. ACS basically does a comprehensive assessment, withdrawal management, medication management, harm reduction interventions, for example, Narcan kits, Narcan trainings, efforts to support patient engagement and linkage to care across different settings, provide staff education, patient advocacy, and also create an implementation of hospital guidelines and protocols regarding various SUD, for example, methadone policies, suboxone microinduction policies, pain management in patients with OUD. Why is ACS needed? Because we are in an opioid epidemic, because it's a public health problem. As we are all aware, the latest CDC stats came out, and it showed that there was about a 28.5% increase in drug overdose deaths in the United States from the past one year. Increase in opioid-related overdose leads to an increased demand on acute care delivery system. How does that happen? By increasing the number of hospital readmissions and increasing the length of stays. This also shows that there is suboptimal or inappropriate care delivery. Hospitalized patients who inject drugs may leave the hospital before even completing the recommended medical therapy if the withdrawal signs and symptoms are untreated. Also, despite the fact that medications for opioid use disorder is evidence-based and has shown superior outcomes in preventing mortality and decreasing opioid use, it is not frequently offered to patients with OUD who are hospitalized. However, if patients are provided with the option of MOUD, most of the patients would, about three-quarters of the patients, would accept to start MOUD. Hence, addiction consult service is a need. It's the need of the hour. How do we pitch this idea? We basically have to justify that it's the need using all the three, using this business template. This business template, I find it very useful. This is taken from the paper by Priest and McCarty. We basically justify that it's a need by stating that it's a public health problem and undertreated substance use disorder leads to increased utilization of the hospital resources. It poses a drain not only on the public health but also on the hospital's revenue. A case can be made that patients with undertreated substance use disorder tend to utilize more hospital resources. With ACS service, this negative impact on the finances can be decreased by decreasing the readmission penalties and decreasing the length of the stay. Thinking about a cost-savings model versus a revenue-generating model. In order to set up an ACS service, things that were needed would be like, you would have to identify the gaps in the treatment, identify the problem, understand your institution, understand the area, and identify your champions and the stakeholders, who are the people who are your allies, who will support you. For example, here at Faulkner Hospital, we have robust addiction services. We have an inpatient detox. We have outpatient dual diagnosis clinic. We have partial hospitalization program. However, we were lacking an addiction consult liaison service. There was a gap, and that was the basis of pitching the idea. Another way to make an argument is successful running or establishment of ACS at another institution. In our case, Main Drigham campus has a robust and successful addiction consult liaison service, which we used as an example. The different barriers. The barriers that we feel or see are mostly like stigma and discrimination. There is resistance from internal and external stakeholders, lack of community-based treatment programs, and restrictive or misinterpreted OAT policies. The most of the number one barrier is financing barriers. What model is the best model? The short answer is, it depends. There's no specific answer. It's a dynamic process, and it's ever-evolving. It depends upon your institution, what resources you have. It can be proactive. It can be collaborative. It can be purely addiction psychiatry. It can be purely addiction medicine. The idea of one-size-fits-all does not belong here. It's about patient care and improving the outcomes. Regarding our addiction consult service, it's here at Faulkner Hospital. Like I say, know the institution. Faulkner is a non-profit community teaching hospital. It's a 162 bedded hospital. We have robust medicine and surgical specialties. These are the inpatient admissions that we have. We have robust medicine and psych residency programs. Like I said, complete spectrum of addiction services. Initially, I was just working with consult liaison psychiatry service, but later we evolved. Like I said, it's a dynamic process and collaborated with addiction medicine providers in internal medicine. On January 11th, we started addiction consult liaison service, and we call it ARCS. Our service is embedded in CL psychiatry, and we are supported by psychiatry residents and CL fellows. It's a unique model because it's a collaboration between hospitalists and psychiatry. For order system, we have an EPIC order system, and the primary team's page, our psych CL pager, and the fellow then assigns the case. Overnight coverage is provided again by psych residency, and weekend coverage and holiday coverage is provided by ARCS or the hospitalist team. We work in shifts. The shifts are usually from 8 to 12 and 1 to 5 p.m. Our team, currently our team includes one addiction psychiatrist, an addiction medicine specialist. Usually, there's like one during each shift, one MD. For social work, we usually use the help of psych CL social worker or the floor social worker. In emergency room, we have psychiatry interns, which is like really, really helpful. We also have visiting fellows from different organizations rotating with us, pain medicine fellows, internal medicine residents help us, and we have advanced practitioners and medical students. The most important point, getting the word out, marketing. So, change takes time, and there's a lot of, there's always resistance that would be faced, we'll all face. So, marketing, showing your face, getting the word out, emails, knowing the different departments. For our service, it was collaboration with ID that was really, really helpful, with emergency department that was really, really helpful, advanced practitioners with social workers. These are your allies. Attending different rounds, making flyers and posters. For example, this is our flyer, and we have been posting it like in practically all the departments. So, the data so far. So, the number of consoles, as you can see, this is our number of consoles from January until October. We get about like 26 to 28, it's there per month, about like two consoles a day. Around June, like consoles, you know, you can see there's a dip there. This is, I think so, mostly because of the fact that the residents changed around that time. Most of our consoles are for management of alcohol withdrawal and benzodiazepine withdrawal, and we see a lot of like stimulant intoxication here as well. Most of the consoles come, again, from medicine floors and ED, and the usual consoles are like pain management in opioid use disorder patients, alcohol withdrawal management, we use a lot of phenobarb capers, which you're going to like hear about, suboxone microinduction, detox, MOUD, AUD, and management of meth intoxication. So, recent like, you know, data from the hospital that we got was like, as you can see, the hospital-wide readmission rate for all kinds of diagnosis have decreased into 2021 in comparison to 2019 with the, after the initiation or the initiation or the starting of this ACS. You can see that there is also a decline in readmission rates for substance use disorder. So, basically, you know, this is what was the pitch. The second part, self-directed discharge also decreased. Now, you can see the hospital-wide discharges, self-directed discharges for all the diagnosis have been climbing and going up, whereas for substance use disorder, they are coming down, which is again a win. So, in short, and just to wrap it up, from my journey so far, the things that I've learned, that collaboration is really, really important, clear communication and rules, having a structure and transparency is really, really important, being flexible, understand money, understand who the stakeholders are, where the finances are coming from, billing, these are things that usually we are not taught, but it's an important part of the job, curiosity, ask questions, seek out help and ask for resources, mentorship, I couldn't have done it without my mentors, support of my team over here, understand who your allies are, educate and have patience, because change takes time, collect data, because that is your, that is information, that is what you can use to change or grow and spread the word, you will have to market, thank you. Great, thank you, Dr. Bhatt, let's move on to Dr. Hathaway, who will be talking about buprenorphine-related issues. So, hi everyone, my name is David Hathaway, I'm an addiction psychiatrist, I live in Boston and I practice at Brigham and Women's Hospital. Today, I'm going to be talking about initiating buprenorphine in hospitalized patients with a particular focus on perioperative management and buprenorphine. Oh, and by the way, from yesterday's session, we're not calling it microdosing, right, we're calling it low-dose initiation. So, I wanted to start with a poll on buprenorphine and preoperative safety considerations. So, at the hospital you are most closely affiliated with, what is the most common method for treating opioid withdrawal? Clonidine or other symptomatic treatments, methadone, buprenorphine or buprenorphine naloxone, full agonist opioids like morphine or oxycodone, benzodiazepines or other sedatives, no treatments are typically offered for opioid withdrawal, not applicable or unknown. You can go ahead and answer the second one too, it's okay. So, the second question asks also about cows and how commonly at your hospital nursing uses cows to manage opioid withdrawal. So, never, rarely, occasionally, often, always, or I don't work in a hospital, or unknown. So, we're going to get two for one here. All right, very interesting. Okay, so clonidine has been used in about a quarter of the cases, buprenorphine is not quite 50%, but it's close to half, and the methadone is actually less common than clonidine. Nobody's using benzo, that's good. Full agonist opioids are being used in some cases. Not everybody's practicing in the U.S. either, right? So, no treatments, that's concerning, right? Six percent. And this is impressive. So, it looks like in quite a few places, nursing is using cows, which is encouraging to see. So, it looks like if we add that often, occasionally, and always, that's a substantial number of hospitals. Move on. So, why should you care about perioperative care? Well, it's in your future. You don't have to open a fortune cookie, you can just look at your age. For each age, decade of life, you're estimated to have about one procedure, and about two-thirds of those procedures will be in an OR. So, whether you or your patients, surgeries are coming your way, and it's best to ensure that we're getting optimal care and pain management, especially for patients that have opioid use disorder. I want to start by talking about a case I saw when I was a fellow and working with Choji, actually. Walk into the room, and it's a patient that just had a hip operation, and he told me that he had stopped his buprenorphine a few weeks before because he had been told to do so by his provider. And as a result, a few days later, he had begun experiencing cravings, and by a week out, he just couldn't put up with any more, and he had started using again. After the operation, his hip operation, he experienced really severe pain, which he just couldn't really get to a place where he felt comfortable, and he said he was going to leave the hospital against medical advice, or in a patient-directed manner. I wanted to offer him buprenorphine, but at that time, we didn't really have any options in terms of starting people who had had recent fentanyl exposures and severe pain that required round-the-clock opioids, and so I kind of had to let him go. But I always wondered, was there something else I could have done that would have helped this gentleman? It made me wonder, was it time to rethink our approach to perioperative management of buprenorphine? At that time in the hospital, we would see a lot of cases where buprenorphine would be discontinued prior to surgery, and it didn't always seem that it was restarted after surgery either. So I'm going to ask a question about this. So patients on maintenance buprenorphine may be asked to discontinue buprenorphine prior to a surgical procedure. Do you feel this is generally a safe practice? So the poll should come up in a second, but I'll read the answers while we're waiting. Yes, it's safe to discontinue two months out before an operation. Oh, here we go. Yes, it's safe to discontinue two weeks out before an operation. Yes, it's safe to discontinue two days before an operation. Unsure. No, it's possibly not safe. No, it's probably not safe. And no, it's certainly not safe because I recall a case where a patient who returned to apticus substance use in the setting of buprenorphine being held before an operation. Looks like we're getting a double poll. So you can just answer the first one, I think. Wait for the results here. That's incredible. Isn't that incredible, Joji? 45% of people have seen a case of someone going back to use. It's incredible. Well, just so you know, there's no case reports in the literature that I'm aware of of that. So people can write me and send me their cases. We can write up a big case series. So the thrust of this today, we're gonna look at three main strategies briefly. Avoiding needless, which I've found to be kind of, I think the antidote to some of these issues that I encountered with that patient. I like to put it in the framework of a stoplight. So avoiding stopping buprenorphine unnecessarily before operations, not missing opportunities to continue buprenorphine if someone stopped it briefly when they first came into the hospital, and also utilizing low-dose initiation of buprenorphine to get people back on track. So let's start with the first one. So people are very familiar, I think, with the opioid epidemic, and particularly with the rise of fentanyl and all that. You may be less familiar, though, with the need for surgeries in this particular population, the OUD population. And you can see it kind of paralleled in many ways in terms of the acceleration, nearly doubling from 2011 to 2015 in the number of hip or knee operations. So there's been a lot of concerns about this, and people have said, well, maybe we should hold opioids or try to get people off of opioids. And I think by extension, that has kind of spilled over to the buprenorphine literature or buprenorphine guidelines as well, where people will think, oh, we should hold buprenorphine prior to surgeries to get better outcomes. However, one thing that kind of contradicted this was data coming out of the maternal field medicine field, where women seem to be doing better if they were continued throughout their pregnancy and throughout even labor on opioids, I'm sorry, on methadone or buprenorphine. And it seemed like buprenorphine, even though it was a partial agonist, didn't seem inferior to buprenorphine. So this was encouraging. And based on this data, we began to consider continuing buprenorphine perioperatively. We also did a study on our own data, and this is data courtesy of Joji, who looked at 32 patients, and they were divided into two groups. So 17 continued their buprenorphine in the perioperative period, and 15 stopped it. And these groups, by the way, were similar. There was no difference in their mental health or substance use, age, gender. Those were all no significant differences. Pain was much better controlled in people who continued. Cravings were much less in people who continued the buprenorphine. People who were not continued ended up getting more opioid scripts to go home with. And it wasn't statistically significant due to small numbers, but it was twice as many patients ended up having resuming use post-operatively. So very concerning. So this data combined with other data really suggested that as a system, we should begin continuing buprenorphine in the perioperative period. And we came up with a set of guidelines where if buprenorphine was low dose, it would be continued throughout the perioperative period. And if it was gonna be a higher dose, then it would be more of a patient preference or potentially the dose might be decreased to four milligrams BID on the day of the surgery. So let's move on to not missing opportunities to continue buprenorphine. So I have a poll here. I think we already did this poll. So we know that quite a few nurses are using cows. And I'll just say, I mean, the reason I ask about that is I think nursing is the key. And because you think about it, if we're trying to do this all ourselves, assessing cows on the floors, it can become very difficult. And also if you have a nurse who's doing the same assessments throughout the day, it can really enhance the reliability of those measures. And I think also help us buy in. But starting suboxone can be quite complex. And we were trying to find ways to really make this more turnkey. I have a three-year-old son and I knew I could play Candyland with him even at the end of the day, even if I was really tired. So I said, well, I'll turn it into a Candyland diagram. Did they receive their buprenorphine? Were they supposed to get bup? Had they received bup in the last 48 hours? And based on that, it would tell you what type of thing you were supposed to do. But people looked at this and they said, David, that's too much. Let's try something else. And so we did. We ended up getting to a set of guidelines where if buprenorphine had been taken within the last 72 hours, it can be continued through the perioperative. It could be not restarted, but continued. And the rationale for this was the half-life of buprenorphine is actually quite long, at least 37 hours. And if people have accumulated, especially through repeated doses, it can be much longer than that. Here's just a case series we're putting together looking at patients that have been started on buprenorphine after delays of hiatuses of up to three days. And it seems like people did pretty well, actually, even with a three-day lapse. So finally, we're gonna look at our buprenorphine low-dose initiation protocol. So people are familiar with the concept of, in a traditional initiation, you'll titrate down, and then when people are in withdrawal, bring them back up and rescue them with buprenorphine. And I like to illustrate to this when I'm talking to trainees and to patients even, by talking about an elevator. I think the classic example is going, if you're on the 100th floor, in terms of opioid receptor stimulation, barely breathing, and somebody gives you Narcan, it's almost like you're in a large building, and you're in an elevator in a large building at the top floor, and the elevator cord cuts loose, and you go crashing down to the ground floor. Very unpleasant experience. Kind of similar as buprenorphine, which I think we typically envision as being at around the 40th floor, so to say, or 40% activation. And so with using the CAO score, we can kind of get the, I think it's more of the delta or the acceleration, actually, than the actual absolute position, get a sense of where someone is and what buprenorphine will do to them. And the idea with microdosing or low-dose initiation being that it's not so much that you don't change from point A to point B, it's more that it's a smooth ride. As you recall, when you go in an elevator, you don't feel like a sudden jerk, unless it's one of those really old elevators. You barely notice you're on an elevator. So we designed a protocol, based on others after a literature review, that kind of walks us through two different types of initiation methods. One more suited for patients that have been on high-dose methadone maintenance treatment, and one shorter one, simpler, that can be done quickly. I want to just highlight some cases that are relevant here, just as we finish up. So we've been able to do this now in a patient that was pregnant, and that preferred to use TD, transdermal buprenorphine, over sublingual buprenorphine. We have a, I have a colleague next door who does a lot of ICU work, and he's begun using the buprenorphine patch as part of his, and treated some patients in the ICU with some good success. This would not have been possible before because of concerns about precipitated withdrawal, for many of the patients he treats. And then I think the case I'm most interested in is of a gentleman in his fifties who had opiate abuse disorder, and we actually went from transdermal bup to sublingual to an LAI sublocate in a period of four days successfully. So that's all I got for today. You can take questions. Great, thank you, Dr. Hathaway. And let's move right on to Dr. Veracallone. Okay, so hello, everybody. So again, my name is Joe G. Suzuki. I'm an addiction psychiatrist at Brigham and Women's Hospital. I've worked with these wonderful folks that you're hearing from. And I'm gonna be talking about some of the data we've been collecting around the inclusion of peer recovery coaches to try to improve outcomes for the patients who are hospitalized for medical complications of their substance use. But let's first start with this poll question. So if you can launch a poll, does the hospital system you're most closely affiliated with offer recovery coaches to patients with substance use disorder? And whether it's an inpatient, outpatient, I don't really, that's not the issue. Whether you include recovery coaches as part of your clinical programs is what I'm interested to know. 50-50, interesting. So this is a really an emerging intervention that we're offering to patients. And yeah, I think that's wonderful to hear. Let's see. So here's the case. Mr. B is a 45-year-old male with a history of PTSD and opioid disorder, admitted for a painful abscess. As Dr. Botts sort of mentioned, this is a common presentation for individuals who inject drugs. The abscess is strained and the pain is now well controlled. When the involvement of clinicians from the addiction consult service, Mr. B is amenable to starting sublingual buprenorphine but he's never been in any formal treatment before. Patient's given information about a local treatment program and has an appointment three weeks after discharge. And buprenorphine is initiated and provided with prescription that lasts until the intake appointment. So overall, this is a relatively good outcome. As Dr. Bott mentioned, historically, these types of issues were not addressed during the hospitalization. But today, I think there's a clear recognition that hospitalized patients with substance use disorder can benefit from this intervention called addiction consult service. Facilitation around the initiation of medication for OUD is a critical one. Managing pain better, as Dr. Hathaway sort of alluded to. Managing withdrawal, again, as Dr. Hathaway mentioned. Any kind of counseling, motivational work, increasing engagement with the staff, facilitating linkage to care. Again, Dr. Bott mentioned that. And then of course, peer support. I think so increasing number of hospital systems are employing peer support, but specifically for hospitalized patients. And so all these interventions I just listed here, we think are good things to offer our patients. And there's a clear growing evidence based around the initiation of medication treatment in the hospital and improving outcomes like improving linkage of care, reducing patient-directed discharges, reducing readmissions. And for those who are receiving long-term antibiotics, actually, any use of medication treatment will increase the likelihood of completing antibiotic treatment for the infections. So all in all, this is very good. The problem is, so this is all the good part. You know, the consult service, the withdrawal management protocols, the microdosing or low-dose buprenorphine, perioperative management, all these things for consultation services have really improved outcomes for patients while they're in the hospital. I think the part that we've begun to recognize and see there's a need for improvement is after they leave the hospital. This, you know, treatment after they leave. And so linkage is actually part of the issue. So this is actually a combination of the different consult services that have published their results of looking at post-hospitalization linkage to care after initiation of buprenorphine or after engagement with the addiction consult service. There's MGH, Boston Medical Center, OHSU, and we have data from our institution as well. Overall, it's about 50% of individuals who are discharged actually make it to their first appointment or successful linkage, some better than others. But when you look at six months out, the outcomes are pretty dismal. And when Boston Medical Center did their randomized trial of buprenorphine initiation in the hospital, at six months, it was less than 10% of those who were initiated on buprenorphine remained in treatment. And this contrasts with what we see in the typical outpatient outcomes, where at six months, you know, we think that we're doing a generally decent enough job if half the patients still remain in treatment. I think we can do better than that. But this is a typical sort of outcome you would encounter in an outpatient buprenorphine program, for example. Interestingly, the seminal Yale randomized trial of initiating buprenorphine in the emergency room had a very remarkable outcome where they had a very high linkage rate, close to 80%. And then at six months, even though they didn't differ from the other control group arm, they still had a very high treatment retention in six months. And the two key things, you know, from this, from these data, actually, I glean is the fact that the two highest linkage rates that we see are from the Boston Medical Center randomized trial and the Yale randomized trial. Both of them actually referred patients to their own program. And that was actually the birth of the BRTS clinic. So I'll say more about that later. So the linkage is poor. And then the first six months treatment retention is actually poor for these patients. And if you look at even longer out, and this is a study we did with individuals hospitalized for endocarditis. And those, some were offered some accepted buprenorphine, some accepted methadone, some declined altogether. But what we were able to see is that within two to three years, close to 40% had yet another episode of endocarditis. This is not a recurrence of the old infection, but a repeat new episode. So high rates of repeat infections despite initiating buprenorphine or, you know, methadone. And then some chemo actually did a much, much more rigorous study looking at every single hospitalization in Massachusetts for endocarditis or osteomyelitis between 2011 and 2015, using this chapter 55 data set, pretty fascinating methodology there. But they were able to look at every single hospitalization for these infections from injection drug use during those four years. And they were able to actually compare those who were initially on MOUD or not, and looked at variety of outcomes, repeat infections and mortality. What they were able to discover is that, you know, at 12 months, whether these individuals initiated medication treatment or not, mortality was no different, approaching 10%. So this is a patient population that, while they may be amenable to treatment initiation in the hospital, you know, once they leave the hospital, things change dramatically and they have particularly poor outcomes. So one of the things that we became interested in sort of thinking about, how do we improve this, you know, transitions of care? It turns out there's a lot of literature and data and studies to examine, how do we improve this transitions from the hospital setting to the community? And as you see on the left side, there's a lot of things that are listed there, the things that we think improve this transitions. But some of the key elements that we thought were important from this list are things like monitoring and managing symptoms, education to promote self-management, and enlisting social and community supports. So one of the questions that we had was, could a recovery coach, a peer recovery coach, specifically assigned to work with the hospitalized patients in the hospital and then into the community? So not just while they're in the hospital, but also facilitate the linkage into the community for let's say up to six months, would that actually work? It turns out there are a variety of studies that have looked at this, not for substance use disorder patients specifically, but this is a particular model called the mission model where they paired a care manager and a recovery peer recovery coach to work with dually diagnosed veterans. And they're able to show that the transition from an inpatient psych unit to the community setting was improved by having the team work with these patients during this transition phase. So peer support. As we all know, peer support is a critical element of addiction treatment that we offer today. If we're able to offer it, we try to offer medications, some kind of counseling and mental health support, and then finally creating this recovery-oriented environment, which often includes peers. And peers can come in a variety of flavors. We're gonna be talking more about recovery coaching specifically, but being a member of a Tulsa meeting, that alone exposes you to peers. Having a sponsor or even just attending group therapy, there are peers in that kind of a setting. So peer support has always been a big part of addiction treatment, but having formally trained recovery coaches is actually relatively new. And so who are these recovery coaches? These are individuals with lived experience of having sustained recovery. Now, in reality, we do encounter recovery coaches who don't have a personal experience. They may be a parent or a sibling of somebody who's overdosed, for example. So there are individuals who may not be in personal recovery themselves, but the vast majority are. And they obtain training to be certified coaches. And this varies from state to state. In Massachusetts, we have about a one-week-long training event that they offer, 40 hours, and then they need to receive supervision, et cetera. But there's some initial formal training that they receive. And these individuals provide non-clinical assistance and mentorship. And I think the key thing that these individuals do is actually individuals who can support all pathways to recovery. This means medication treatment or not, interested in abstinence or not, interested in going to a structured clinical program or not. Recovery coaches are able to engage with patients really wherever they may be and however they may want to achieve their own idea of recovery. And also peers actually is part of the main core principle of trauma-informed care. So I think inclusion of peers, I think, is a good evolution in addiction care today. And so people sort of talk about the four different domains in which recovery coaches help, emotional, informational, instrumental, and affiliational. And I just think that these sort of align with the elements of interventions that may support transitions of care. And so we really thought that the recovery coach could actually facilitate the transition. But what's the evidence based on recovery coaching general for substance use sort of treatment? It's still emerging. This is a really nice systematic review done recently, identified 24 reports total, seven randomized trials. Others were either quasi-experimental or observational studies. Overall, very heterogeneous. Depending on who you look at, who you ask, what role they're playing, it's extremely heterogeneous. So from one hospital to another, the roles could be very, very different and often poorly defined and not necessarily manualized. And this is one of the, I think, weaknesses of the existing data is that oftentimes it's unclear exactly if there's any sort of attention paid to fidelity of the intervention itself. But overall, the evidence suggests that the effects are probably positive, but likely to be small or moderate in magnitude. So again, because of the limitations around the data, it's hard to say anything too conclusive about it, but the data is emerging. So let's see, the case continues. Mr. B's offered to have a peer recovery coach move them while still in the hospital. He's enthusiastic and accepted the offer. And doc, I really appreciate it. In hospitals, I feel like I'm being judged for things that I do. I want to have that same feeling with a recovery coach. And this is a quote that I heard from a particular patient. So the study that we just completed, it's called the ISOP Study Initiating Sud Treatment for Hospice OUD Patients, randomized prospective trial of the Brigham inpatient patients with OUD who are newly starting medication treatment. And the intervention is a manualized recovery coach intervention adapted from the mission model that I alluded to earlier. And the control group is treatment as usual. And as you probably all know who practice in the hospital setting, treatment as usual is see you later. Good luck with your discharge. You know, the consult service in the hospital has a very clear demarcation of, you know, what we provide in the hospital. And once they leave the hospital, we generally don't. And the primary outcome of interest was treatment retention at six months after discharge with a variety of secondary outcomes, including things like time to discontinuation treatment or brief addiction monitor. If you went to the workshop on Dr. Markovits around the monitoring of symptoms and measurement-based care, BAM actually is quite a useful tool, both in clinical settings and research. And this was one of our secondary outcomes. This is what the intervention generally looked like. There's in-hospital components as well as sort of a gradually tapering intensity of contact, you know, once you leave the hospital. there's a whole manual guidebook that the patients themselves use. One of the key things is actually a personal relapse prevention plan that the recovery coach actually facilitates in having the patient fill out. And here are the basic outcomes, 27 total that were randomized and generally pretty serious comorbidities. Obviously everybody had OUD, but about half with alcohol, majority with cocaine, a significant number of those with depression and anxiety or PTSD. So this is a pretty sick population. So in terms of the primary outcome, unfortunately six months outcome was no different, 40% retention. So we do think that the overall retention and treatment was maybe better than average in what we saw in other studies. Part of the issue for us was that when we launched the study that's when we launched our bridge clinic. I had no control over the timing of the study and the launching of a bridge clinic. I wasn't certainly gonna fight that. And there's a high linkage rate in both groups. I think it's an indication that this is not entirely due to the peer coach, but the fact that we actually launched a bridge clinic that allowed for close to 90% linkage rate in those in the intervention group and exceeding 70% in the control group. So these rates exceed even those that we saw in the Yale study that Dr. D'Onofrio and the BMC said that Dr. Lipschitz said. So that probably partly accounted for the fact that it may have diluted the intervention, but still when we look at the time to discontinuation, we do see that there is a slight delay in discontinuation of treatment. So perhaps overall the recovery coach intervention may delay the recovery. And this is reflected in the fact that at least in the first month after discharge, we were able to see that the recovery coach intervention had a dramatic impact on substance use. There's an overall reduction after hospitalization, but in the early months, early sort of weeks after hospitalization, we definitely saw an impact. Overall reduction in risk factors, slightly better for the intervention. The higher numbers is actually better and also protective factors, overall improvement across the board. Another poll, so does the hospital system you're mostly closely affiliated with have a bridge clinic? Next. Oh, wow, 50-50. So we have an audience with very innovative programs and implementing awesome things. That's really amazing that half the folks actually endorse having it. That's really remarkable. So again, linkage to care after hospitalization, probably the biggest impact, unfortunately, recovery coach probably has an impact, but the impact may be small. But really the important thing might be the availability of a rapid transition to a program within your own system. Geographically co-located, low barrier, low threshold, treatment on demand, and that's exactly what we had available to our patients. In the heart of our hospital, staffed by psychiatry and medicine, we have therapy, we have recovery coach, we have embraced a harm reduction approach, and then hopefully at some point transition to longer term treatment. But also allowing even walk-ins. And so I think the combination of having some kind of peer support in the hospital, but also allowing for a rapid access to treatment following discharge, I think are key elements in improving outcomes after hospitalization. So addiction consult service is important for improving hospital outcomes, but I think we need additional services to make sure that the improvement that we see is sustained over a longer period of time. Thank you. And then let's see if Dr. Vercolone's slides are working. So hi, I'm Lisa Vercolone. I am a hospitalist who's boarded in addiction medicine, and I work on the AHRQ's consult service at Faulkner with Dr. Bott. And I wanted to spend a little bit of time today talking about phenobarbital and alcohol withdrawal syndrome. So I think it would probably be most appropriate to do the poll now. So at the hospital in which you are most closely affiliated is phenobarbital used to manage alcohol withdrawal? No, never. Yes, rarely. Yes, occasionally. Yes, often. Yes, very often. Yes, always. I'm not affiliated or unknown. Oh, okay. So it's like across the board. So there, no, never. It was about a third of people have never, or their institution has never used phenobarbital and alcohol withdrawal. 20% rarely, 26% occasionally, but only 3% often and 10% very often. So, and always. Okay, so maybe about 20% of people are using phenobarbital on a pretty regular basis. So most of my experience with phenobarbital, I work, so in Faulkner, we have an eight bed level four treatment unit for medically supervised withdrawal. And that is where I've been a lot of my experience using phenobarbital. Next slide. So I'm just gonna briefly go over a case. A 35 year old woman, no significant past medical history. She was brought in by her husband after he witnessed her having a seizure after she was attempting to cut back her alcohol intake. So she tells you, she tells us that she's a middle school math teacher and she describes herself as a social drinker prior to COVID. But once school went to all remote learning, she noted that her drinking had picked up and then further increased during the vacation, the summer months from school vacation. And she admitted that she had been trying to cut back in preparation for starting school in September. And this was her first time ever seeking treatment. Next slide. So the first thing you wanna get a handle on is how much is she actually drinking? And one thing I like to do is ask these two questions. I find that I get sometimes a more clear answer. One is how often do you go to the liquor store? And then two, or nowadays you also have to ask how often could you get it delivered to your home? And then the second question is, what do you buy when you go? And when asking her this question, I found that she drank, she was drinking 1.75 liters of whiskey every two days and that equated to 19 drinks a day. So very heavy alcohol intake. Next slide. So when I saw her, she was feeling a little nauseated. Her vital signs didn't look terrible. She was a mildly tachycardic. Her blood pressure looks okay. She was a little tremulous and diaphoretic and overall had a CUS4 of eight. Her lab showed that she had a BAL of 350. Her rest of her uterx was negative. She had some hypokalemia and some mild to moderate transaminitis. Next slide. So I wanna review some of the key points. And although we've only had a couple of slides, I think that there's enough information there for us to assess the risk of alcohol withdrawal here. So drinking 19 drinks per day obviously is very concerning, a red flag. Number of admissions for management of alcohol withdrawal. She hadn't had any, this was her first. So she hadn't had a history of complicated withdrawal, but remember she did have a seizure and that is what prompted this admission. But really the most concerning thing for me was the fact that she was, she had a CUS4 of eight in the setting of having a BAL of 350. So this is someone that I become very concerned about right away. Next slide. And so what is the next best step? And this is not on the poll. I just want you to think about this. Should we place her in a CUA driven symptom triggered protocol or do we favor using a fixed dose protocol, either benzodiazepine regimen or phenobarbital regimen? And next slide. So I think that most of us would agree in someone like this, who's already had a seizure, we would probably favor using a fixed dose regimen and whether or not we go with benzodiazepines or phenobarbital, I think either one of those could be a correct answer. But before we make a decision in this case, let's review a few things about phenobarbital in alcohol withdrawal syndrome. Next slide. So we tend to consider using phenobarbital, one, when there's been a complicated withdrawal history. Two, if someone's already showing signs of delirium or encephalopathy. Three, actively withdrawing despite having elevated BAL or actively in DTs or severe withdrawal. A benzodiazepine non-responder would be another person and someone who is at risk for paradoxical disinhibition from benzodiazepines. Next slide. So I wanted to just briefly talk about phenobarbital's mechanism of action. And so the two most important neurotransmitter systems in alcohol withdrawal syndrome are GABA and glutamate. And I think most of us know that benzodiazepines, they act on the GABA receptors and they increase the frequency of the channel opening. It's important to know that this requires the presence of GABA because we know in people who are drinking excessively, their GABA is depleted. Now, barbiturates on the other hand, they increase the duration of channel opening, but they do not require the presence of GABA. Now, the other important neurotransmitter system is the glutamate receptors. And benzodiazepines really have no effect on this receptor system, but barbiturates do. And so phenobarbital will inhibit the glutamate receptors. So I think that overall, this lends to phenobarbital being mechanistically superior to benzodiazepines. Next slide. A couple of key points about phenobarbital pharmacokinetics. One, the fast onset of action coupled with the fast peak effect. So this is a wonderful aspect of phenobarbital. Within five minutes, and definitely by the 15, 20-minute mark of an IV administration, you can assess your patient and you are seeing the max effect of that dose that you gave. And the reason that is important is because this prevents dose stacking. The other feature of phenobarbital is that it's got this incredibly long half-life of about 80 hours, and this allows for a up to two-week slow auto taper, and it prevents those rebound symptoms. It also has a very wide therapeutic index, and this is pulled from data in its use for seizure disorder. But we know that if we give a 10 milligram per kilogram load of phenobarbital, we hit about 15 micrograms per ml. So we're getting nowhere near toxicity, which is 65 micrograms. Phenobarbital is very predictable unless we add benzodiazepines. And then benzodiazepines and phenobarbital become synergistic because they are focusing on, or acting upon, two separate areas of the GABA receptor. Next slide. So at Faulkner and at Brigham and Women's Hospital, we have been using a protocol, a phenobarbital monotherapy protocol that has been derived from a protocol that was created by Mass General. However, I will add that the Mass General protocol was derived from the IVAS protocol, which was published in 1991. And the IVAS protocol published in 1991 was actually derived from a protocol that had been used for decades. So this protocol has actually been used for many, many decades. So just briefly, MGH has recently published their protocol. You can see it in these papers. But what they have found is the first paper, they looked at patients with alcohol use disorder, alcohol withdrawal syndrome, and they compared patients being treated with benzodiazepines versus patients being treated with phenobarbital monotherapy. And they found that phenobarbital was an effective and well-tolerated alternative to benzodiazepines. Next slide. The second paper, they looked at a different patient population. They looked at the acute surgical trauma patients and also comparing benzodiazepines to phenobarbital monotherapy. And they found in this setting that phenobarbital had superior outcomes to benzodiazepine and decreased alcohol withdrawal delirium and uncomplicated alcohol withdrawal syndrome. And the authors stated that they thought that phenobarbital may be safer and potentially more effective. Next slide. So in using the MGH protocol, it's two steps before you use the algorithm. First step is to assess the risk of alcohol withdrawal. And you're basically looking at whether or not the patient is at medium or high risk. And this is the criteria that the authors used. Next slide. Step two is looking at the risk of complications. And the two things we're looking at is the risk of sedation and the risk of respiratory compromise. And this is the author's criteria. Next slide. And here's our algorithm. So once you determine the risk of alcohol withdrawal and then the risk of complications, it will guide you to arrange dose. Next slide. So the loading dose is anywhere between 16 to 15 milligrams per kilogram. And that's based on ideal body weight. You can give that over 30 minutes as a continuous infusion, or you can fractionate it into three doses. Once you get the loading dose, then we transition the following day to a four-day tapering oral regimen. Next slide. So in our patient, we have a patient who is at high risk for alcohol withdrawal, low risk for sedation, low risk for respiratory compromise. So she started on a 12 milligram per kilogram loading dose. Next slide. And that gives her about 780 milligram dose. We divide it into three doses over the course of six hours. But what is our goal that we're looking at? Next slide. We're really looking at our RAS score, and we really want RAS to be zero to negative one. Next slide. And that puts our patient at being alert and calm and just maybe slightly drowsy. Next slide. So we reassess our patient. The RAS is zero. We started on the oral regimen the following day. Next slide. What I think is the most important part of this discussion is this particular case. This gentleman, 51 years old, severe alcohol use disorder, drinking 35 drinks a day. His very complicated withdrawal history. We give him 15 milligrams per kilogram. So the top end of the range dose. Next slide. And you go back and see him, and he's still tachycardic, and he's still hypertensive, and he's tremulous, and he's diaphoretic, and his RAS is two. So what do you do? You've already given the highest dose that the protocol guides you to give. Next slide. So you can give more phenobarbital. You could put them on the CWO protocol with lorazepam, start the PO dose tomorrow because you've already given the max dose, or you could give another loading dose. Well, I think here, next slide, the best answer is to give an IM dose of phenobarbital, 130 milligrams. Next dose, or next slide. So basically what we do is we give anywhere between 65 to 100 milligrams every hour to achieve a RAS of zero to negative one, and sometimes even up to 260 milligrams. Next slide. And so in this patient, he required a couple additional doses, and that actually brought his total loading dose to 18.5 milligrams. And so for me, I think the most important take-home message is that phenobarbital, there are no phenobarbital failures. There's only the failure of giving an adequate dose. And us as consultants, it is very important that we're guiding our primary teams to continue to give enough phenobarbital to the point that a patient is comfortable. And I've had a handful of patients that have required over 20 milligrams per kilogram. So you just need to continue to be diligent and giving more and more. And once you reach a therapeutic level, the patient generally does well from that point on. Thank you. Next slide. Great. Despite the technical difficulties, you got through that. So thank you so much. So yeah, so we do have 20 minutes remaining. I think that's not so bad considering we had a lot to cover. So this is, the floor is open for any questions or comments that the audience may have. I was particularly surprised that many of you work in hospital systems that do utilize recovery coaches and have bridge clinics. And also many of you guys actually do have addiction consult service and also utilize phenobarb. So even though we call this the emerging issues in the consult setting, this may be becoming standard practice in many locations, which is really nice. David, do you have your hand up? Yeah, I'm just wondering if it's possible to turn on the chat. It looks like it's disabled, at least for me. I don't know. Well, yeah, it says, oh my goodness. Was the chat disabled this entire time? Okay, so that was not meant to be because the chat function was how we were going to be soliciting questions. So my apologies that somehow I didn't notice that. I don't even know how to disable the chat. So I'm not sure how that happened. Sorry. And again, if anybody's comfortable having your video on, we'd love to see you. But yeah, so let me pose a question to the speakers. Lisa, I know you mentioned that you're increasingly seeing higher doses required. As we talked about the initial rollout of the protocol, we were recommending dose ranges six to 12-ish mgs per kg. But it's interesting to hear that your experience has been that the higher ranges are often required. Yeah, and I think that there's a lot of data to support that 10 milligrams per kilogram dose is a safe dose. So I encourage people to start with that dose. If they don't have a lot of experience with phenobarbital, start with 10 milligrams per kilogram. You can always give more. And also, if you're concerned about using phenobarbital and don't have a lot of experience, you can always opt for that three divided doses option. And that will allow you to see how the patient's doing before they complete the entire loading dose. And that'll allow you to stop it at any point. But we initially were seeing low doses ordered, and we actually had a couple self-directed discharges for patients who had been underdosed and the primary team, given inexperience, wasn't sure what to do. So we really advocate for getting our patients comfortable within a few hours of admission. Yeah, and we have a couple of questions for you, Lisa. Question about use of dexmedetomidine in cases of severe withdrawal or in combination with phenobarb. Apparently, there are places that do that. And also a question about whether you utilize any anticonvulsants. You know, we do sometimes we'll add valproic acid. A lot of our patients are already on gabapentin. We always make a point to make sure that we continue that. If patients are not on gabapentin, we generally will talk to the patients about starting gabapentin. Usually we'll start with the 300, 300, 600 regimen. And then we'll continue that at the point of discharge. Concerning precedence, you know, I don't work in the ICU setting. We don't have the ability to use that on the floors. But I think that that cannot be, Presto-X cannot be used as monotherapy for alcohol withdrawal syndrome, and you would need to incorporate additional medication to manage alcohol withdrawal. And how often do you give those extra doses up to the third dose? You know, keep in mind that my experience is in a level four unit. And so the patients that we're seeing have very high tolerance and independence to alcohol. I would say about 50% of the time, patients are needing more, and that's with us starting at like 12 to 15 milligrams per kilogram. Yeah, I would say about 50-50. Can I just add to that question? Great job, by the way. So I meant not how often in the patient population, but rather like you finish a third dose, the patient's still having those symptoms, and so you give an additional dose, and then are you doing it like as needed every three hours again? Or how quickly do you kind of give the next dose until you reassess rest and then decide you can stop? Yeah, optimally you want to re-evaluate every hour and redose every hour. You know, an hour can go by very quickly. So sometimes, you know, it's a little bit longer, but you can safely give an IM injection every 30 to 60 minutes without being concerned about dose stacking. But I do try to make a point to, I'm on the floor, I'm in the units, so I pop my head in every hour and continue just to order additional doses. And again, sometimes I'll go with a 260 milligram dose up front if the patient's really looking like they're going to need more. And then I just keep going because we are titrating to clinical effect. We're not looking at levels. There's really nothing else. We're just really focusing on RAS and getting the patient comfortable. And in my experience, what I have found is that when a patient falls asleep, they've had enough. And I don't mean like they're over-sedated. I mean, they peacefully are able to finally sleep, and then I know I've gotten the right dose, and then the following day we'll start the oral regimen. Let me see, there's another question about using benzodiazepine, Phenobarb for benzo withdrawal. Yeah, that's an interesting question. So there is, we've had a lot of, we've talked about this a lot recently, and there is a protocol out of John Hopkins that they've been using for decades that uses Phenobarbital for benzodiazepine dependence. And it's a four-day protocol, and it's all, I think that maybe the initial dose is IM, but the rest of it is PO. But it doesn't start with a large loading dose. It starts with like a 200 milligram dose, and then you follow that with 100 milligrams every four hours for a day, and then you continue to titrate down. In terms of using this particular protocol with a large loading dose, I have to admit, I have done it once, but there is not any really, there's really no literature out there to support the use of this Phenobarbital protocol with a large loading dose in benzodiazepine dependence. But there's no reason to believe that it wouldn't work because we know Phenobarbital is a good option for benzodiazepine dependence. I think one thing I get concerned about is if I feel like somebody is not completely invested in their abstinence, I worry that if they go back to using benzodiazepines immediately after being discharged, then that synergistic effect of benzodiazepines and Phenobarbital could be problematic. Thank you, Lisa. Question for Dr. Bhatt. How do your addiction consult services manage a boundary between a regular psychiatry consult service? This particular question comes from a person with an addiction consult service that is staffed by addiction medicine fellows, some of who are psychiatrists, some are not, most but not all attending supervision by psychiatrists. So Dr. Bhatt, do you want to address that? Yeah, sure. Thank you for the question. So basically, like I said, our service is embedded in psychiatry. So the consult, when the consult comes in, goes to the psych fellow, CL fellow, which basically reviews the case. Now, if the case has a pressing psychiatry issue, for example, if the case has a simultaneously concern for suicidal-like ideation, then the case is staffed by addiction psychiatrists. If not, and if a substance use disorder is the primary concern, then it'll go to whoever is on the shift at that point of time. If it's addiction medicine, then it goes to the addiction medicine. Now, suppose addiction medicine is on and there comes a case where, similar case where there's alcohol intoxication and the patient is also endorsing suicidal ideation. At that point of time, the case would be staffed by, or seen by CL psychiatry because suicidal ideation, suicidality takes precedence in that point of time. It becomes a priority. And later, depending upon addiction consult service would take over, whosoever is, and we will follow up the case. I hope that answers your question. Right, because I think there's another question about how do you triage between addiction psych and addiction medicine. And Dr. Bhatt, you're describing the situation where there's general CL psychiatry, addiction psychiatry, and addiction medicine all kind of working collaboratively together. It creates a complicated picture, but I think what you're describing is that the input comes to a single location and it becomes our responsibility to find a way to triage it. I think our model is also, that's exactly right. Our model is also unique in that we just don't see, we don't limit ourselves just to addiction. I'm the addiction psychiatrist on the service. I see addiction as well as consult liaison, like mainly from a psychiatric perspective as well, so that we treat patient as a whole rather than just a part of the patient. Yeah, and this probably could go to any of the panelists, but the question is, I'm currently a resident rotating on the consult service and have seen a handful of cases where a patient's presentation is concerning for delirium versus DT. Do you have any advice on how you'd approach this situation, how you might advise the primary team? Kind of a loaded question, but anybody want to take a shot at that? I can take a stab at it, because we see quite a bit of fetal barb at Brigham as well. And I think one thing that's been really helpful is I know early in my training, residency training, I would just kind of stop paying attention when fetal barb got put on board, like, you know, it's benzos, I'm thinking about it much and looking at it much more closely. But I kind of, as a fellow, decided that I can do to become much more acquainted with fetal barb. So I like went on and figured out the protocols and all that, and really been trying to work as a trainee. So they're intimately acquainted with everything and kind of to, I really like how Lisa mentioned that she's tracking over time, the MIGs per Kigs that have been cumulatively given over the course of the admission. Because to me, once you've reached about 15 MIGs per Kigs, it's not that I say you have to stop, but you have to think, is you have to start thinking, could this be something else going on? Could there be another source of the delirium? So yes, I mean, the protocols do allow you to keep going and give taper to do either do a taper or rescue doses or whatnot, but you really should be, I think, a lot more thorough once you get beyond that benchmark, so to say, and make sure there's no other contributing causes. And I'll just quickly comment that the question is sort of the delirium versus DTs. Although I think technically it's more about delirium versus alcohol withdrawal. If you're really concerned for DTs, it's a medical emergency and you really need to really load the person with whatever agent you're using. But this is a situation where there's diagnostic ambiguity. Sometimes you don't even know if the person's a heavy drinker when you see the patient on the consult service. So is this delirium due to some medical cause or is alcohol withdrawal a contributing factor? And I would say that this is the one situation where anticonvulsants can be a very helpful way to minimize the need for benzodiazepines because that's the crux of it, right? If somebody's delirious from medical cause, you don't want to load them with benzos. So this is a situation where I think anticonvulsants can play a really big role, especially when there's diagnostic ambiguity. And there's a question from Dr. Rodriguez. Is there a reason for using IM versus IV? I'm assuming you're referring to phenobarb. So I know at MGH, they do not allow IV phenobarbital on the general medicine floors. And that's different than at Brigham and Women's Hospital. So I think that the IM is because that is what's allowed on the general medicine floors. I have a question I want to pose for Dr. Hathaway. You know, you did a nice job of showing the peer operative management with bupe and our default approach now is to not discontinue. And I see that Dr. Acampora is on this session. So I'd love to hear his take on it too, but are there situations where you would actually recommend against continuation and actually recommend that the buprenorphine be discontinued? Well, I'll obviously defer to my mentor, Dr. Acampora, but I guess the one kind of slam dunk one for me is, is it's a patient on, and this is a little bit of a cheap shot, but a patient on Vivitrol, who's going to have like a spinal surgery. To me, that's what I get, I hear about in the hallways where anesthesia is like, oh man, I couldn't get anything, any pain control there. But I'm really curious to hear Greg's thoughts on this. Yeah, so the thing I know, Joji, when I first presented stuff early, I had come up with this thing, because in our institution, we go for this lower dose, or if you want to call it micro dosing. And I had proposed that we'd use eight milligrams of Suboxone a day. And Joji said, why not 12, why not 16? And, you know, it did, it made me scratch my head and think about it. I don't think the answers are an entirely, I still, I'm very interested in something that's called the receptor reserve, which has to do with the tissue levels in different parts of the body, in which in some areas, you get synergy. And I think for me, at least the way I'm trying to drive this thing, if anyone keeps thinking about synergy of buprenorphine and the full agonist opioid, instead of battling them with strength, that's why I tend towards the minimized dose or keeping a lower dose of buprenorphine rather than just piling it in and then saying, geez, if they don't respond, we can just blast it with fentanyl, which is what I heard in one of our discussions with the internal medicine folks yesterday over Sublocaid, because they said, oh, we just give them the Sublocaid and figure the anesthesiologist can just blast away with fentanyl. But from an anesthetic anesthesiologist standpoint, it's not ideal. You're gonna get a certain subset of people that can end up driving into the ICU who you might not need to. So my own bias is to still continue some reduction. In the latest iteration, David did a beautiful job producing the protocol graph. Some other nuances need to be included. One of our people over at Newton Wellesley does a lot of regional, and so she brought up the point that with a regional anesthetic, you can really rely on the buprenorphine in higher doses more. So a lot of answers still have to come in. The thing I keep reiterating to folks, there's no hard fact. We're suggesting doses, but the answers are yet to come out. The one thing I wanted to ask Lisa and the team on the phenobarbital protocols. So those of us in bigger institutions go ahead and use these very high dose approaches. What I always worry about is for other listeners who are at hospitals that have lower degrees of either intensive care or nursing care sophistication. Have you had, what are your thoughts about that? Because we recommend phenobarbital. My only concern is in these sort of less adept hospitals is that it's at a risk. Yeah, I mean, again, I think it's a cultural change, right? Because I think most of us who haven't trained in the last five years are just historically kind of afraid of phenobarbital. We haven't really used it. And we think we haven't used it because it's dangerous. And so part of the process is just getting over that fear. But I think, again, I counsel people just to, or recommend that people just use that 10 milligram per kilogram dose. I don't think you can go wrong with that dose. I really don't think that there's anybody, I mean, there's just so much literature to support that dose. And we just have not seen people being over sedated at all with that dose. And so I think, you know, again, people should feel comfortable with that. And if they, and we are now in our unit giving IV over 30 minutes, and I'll be honest with you, the first couple of times I did it, I was at the bedside the entire time. But then I started to realize over time that people are not becoming over sedated. But again, you always have the ability to separate the dose out to three separate doses if you're really nervous about getting a large dose, and then you can halt it before the full dose is given. But generally, people will become more and more comfortable with it. I caution people on using the six milligram per kilogram dose because I, underdosing to me is more dangerous than overdosing a patient. So I think that we need to really be mindful of the fact that underdosing is a serious problem. Yeah, and the thing that really, you know, I'd be curious if somebody is looking into this and to clearly clarify is with the emergence of Phenobarb, there's a, it's a weight-based loading strategy, which is distinct from the symptom trigger SIWA-based strategy, right? That SIWA-based strategy had become the norm. And if there's a reason to escape that, you do some kind of fixed dose regimen, but it was never a loading strategy. And my understanding is that, you know, there are folks in the audience who may have practiced, you know, decades ago where that was sort of the norm. You know, that's what I hear from my mentors about there was a time when we did loading strategy for withdrawal management. You load until you start to see sedation, nystagmus or something like that, then you stop and you're done. And so for unclear reasons, we moved away from that kind of strategy. And it's funny that now we're going back to this, you know, old approach. And it could be that it's a loading weight-based strategy is part of the reason why the Phenobar protocols are so effective and people are gravitating towards it. I used to, I used to tell Shamir, I used to say you're practicing slow motion anesthesia in a way or slow motion sedation, but it is the milligram, kilogram thing that's critical here. That's absolutely correct. Okay. Any other final thoughts, questions for the panelists? Great talk. Let's see. How do you dose buprenorphine when inducing the patients using fentanyl? Some of my colleagues advocate macro dosing. Oh, so we get to the micro versus macro. Here we go. We touched upon that here, but that's an emerging issue as well, for sure. Anybody want to comment on macro dosing? Lisa did a whole case presentation on it, though. I did it once and I'll never do it again, but I have that luxury, I guess, as an inpatient provider. Yeah, so for those who may not be familiar, macro dosing is the opposite. Instead of starting with a low dose buprenorphine, macro dosing is just flooding the individual with high dose buprenorphine to overcome the perceived withdrawal. And this includes simply giving somebody sublocate, even if they're experiencing withdrawal. And so, yeah, but Lisa had an interesting case about failed macro dosing. Yeah, and really, again, with a sophisticated thing, if you look at these mechanisms, and again, with this receptor reserve thing, I just say Star Wars doesn't work. And if you do a more balanced technique, you also get what's called the synergy because buprenorphine is a potent analgesic in certain regions and at those lower dose range, and it works synergistically with fentanyl when you use it in a good balanced approach. That's my pitch. And there's a question from Dr. Collins about how do you feel about phenobarbital in the outpatient setting? Great question. I don't think it's being done, to my knowledge. We don't advocate for it. We don't discharge patients with a phenobarbital prescription to complete a taper. I don't think many people are comfortable with that. Jody, do you have any thoughts on that? Yeah, I'm pretty sure that it's not routinely done. Typically, gabapentin would be the preferred, or other anticonvulsants would be the preferred agent for mild to moderate risk withdrawal. I don't know if anybody in the audience is actually using phenobarb for ambulatory alcohol withdrawal management. We'd love to hear from you, but probably not. Can I just mention, though, with the long half-life, your outpatients who leave the hospital are still gonna have phenobarbital in them if they receive it in the hospital. So it is an important consideration. I think it comes up a lot. People ask about this. This patient also has opioid use disorder and they have a history of overdose. Should we avoid phenobarbital in those patients? I'm not aware of any study results yet to answer that question, but it's an interesting question. It is a very common question. Especially if it's gonna be there for weeks, right? You dose it, it's gonna be there for a couple weeks once you load. And so we sometimes avoid using it in patients who are on maintenance benzodiazepines, and we know they're gonna continue taking it. We won't use it in that patient population who have a prescriber and they're gonna continue taking benzodiazepines. Right, and far as I know, there's no data to support that phenobarbital alcohol withdrawal management leads to greater likelihood of readmissions or overdoses post-hospitalization. And I think the data that is available, I think that showed that a phenobarb had better outcomes overall than benzo management. But it's a great clinical question that I think comes up all the time is, is it really safe to give phenobarbital to these patients who we know are gonna potentially relapse after hospitalization or use other benzos or opioids? I'm not aware of any data to say that phenobarb actually leads to greater harm post-detox or post-hospitalization, which is reassuring. Because when I first started hearing about phenobarb being used for detox, the first thing I heard from people older than me was, how many people have died so far? Because if people are convinced that this leads to greater harm, but that's not what we're seeing, which is, again, reassuring. Right, so less likelihood of delirium. I think we've underestimated potentially the impact of really adequately addressing the NMDA or the glutamate side of this equation. We focus entirely on the GABA side and perhaps it's sort of refocusing on both sides. We're potentially thinking about combination therapies, right? There are other NMDA antagonists that we could utilize. Ketamine is emerging as potential for adjunct for alcohol withdrawal. People just came out looking at ketamine for opioid withdrawal in combination with buprenorphine. So potentially other agents could be utilized beyond just benzodiazepines. So I'm being informed by AAAP that we do have to wrap up. Thank you, everybody. It's been great to hear from you and see you. Thank you to all the panelists. I hope that everybody's enjoying the conference. And then hope you all have a good evening.

Addiction Consultation

General Hospital Setting

Buprenorphine Management

Low-Dose Initiation

Peer Recovery Coaches

Continuing Buprenorphine

Substance Use Disorder

Multidisciplinary Approach

Delirium Management

Alcohol Withdrawal Syndrome

Phenobarbital Use

Medically Supervised Withdrawal