Before I announce our very last symposium for this meeting, I have one big announcement. I'd like to congratulate the winners of the Tom Pender's Pursuit Foundation Award, Dr. Soyun Jo and Dr. Narmarta Walia. I think Dr. Jo is with us, so congratulations. And then the other announcement is to remind you all about the community event that's going to be happening right after the event was created for all of us to share our expertise with the community while we're here in Florida. So if you're available, please meet us in the Royal Palm 1 and 3 for the event after this next symposium. Now it is my pleasure to welcome the last symposium for this annual meeting. It is called Addressing Emerging Drugs, Emerging Drug Threats of Fentanyl Adulterated and Association with Xylazine via Harm Reduction and Clinical Innovation. It is chaired by Dr. Adam Gordon. Dr. Adam Gordon is a professor of medicine and psychiatry at the University of Utah. He's the section chief of addiction medicine at the VA Salt Lake City Healthcare System. He's a board certified addiction medicine and internal medicine and a fellow of the American College of Physicians and a distinguished fellow of the American Society of Addiction Medicine. Thank you. Hello, everybody. Thank you all for being here at this last symposium of a very nice AAAP conference and we really, really appreciate you all being here on a very sleepy Sunday morning. We're going to try to make this workshop or symposium very interactive just to make sure that we all keep awake as we go along. I want to first just introduce our distinguished panelists for this symposium. The symposium is about emerging threats with regards to the drug supply, particularly with regards to xylazine, but more importantly how a large healthcare system has really, the VA has really tried hard to mitigate any risk associated with these emerging drug supplier adulterates. We have Grant Baldwin who is the director of the Division of Overdose Prevention at the CDC Injury Center. He leads the Division of Monitoring Trends in Emerging Drug Supply. He also identifies and scaling up the prevention activities associated with emerging drugs and the drug crisis as well as supporting drug community coalitions. He is affiliated professor with Emory University. We have Joseph Liberto who is the VA National Mental Health Director of Substance Abuse Disorders at the Office of Mental Health within the Department of Veterans Affairs. He is a past president of our organization, AAAP, and he also is affiliated professor at the University of Maryland. And finally we have Elizabeth Oliva who is a coordinator of the VA National Opioid Overdose Education and Naloxone Distribution, or OAND, at the Office of Mental Health at the Department of Veterans Affairs. She is an investigator at the VA Center for Innovation and Implementation in Northern California and senior evaluator at the VA Program Evaluation and Resource Center, or PERC. So with that, we're going to get moving, going forward. With regards to disclosures, Dr. Liberto, all of us have no relevant financial relationships to ineligible companies to disclose. Presenters are all full-time within the Department of Veterans Affairs as well as the CDC in prevention, and it's important to realize that the findings and presentations and conclusions of this presentation are those of the authors and do not necessarily reflect the official position of the Department of Veterans Affairs or the CDC. At the conclusion of this session, our goal is to have, number one, describe biological trends in fentanyl and xylosine in the United States, its clinical considerations for addressing fentanyl and xylosine in clinical practice, and critical and clinical research gaps. To discuss the elements of harm reduction, the importance of incorporating harm reduction in clinical practice, and resources to support harm reduction, particularly in a large healthcare system. And then finally, describe innovative and effective SUD prevention, harm reduction, and treatment within and outside of SUD specialty care clinical environment. We're going to try to have a lot of interaction throughout this presentation of the symposium. We first will have Dr. Baldwin, who will be talking about the epilogical trends associated with emerging drug threats in the United States. We'll then move into Dr. Liberto, who is going to talk about the VA's responses to the emerging threats. We'll have about five minutes of a little bit of audience participation and questions for both those two presentations, and then Dr. Oliva will describe VA harm reduction efforts. Again, another five minutes of Q&A, and then I'll be the wrap-up presenter and talk a little bit about how, in this large VA healthcare system, we are able to confront medical harms such as xylosine within non-specialty care environments. And then hopefully at the end, we'll have about 10 minutes for a good Q&A. So with that, I'm going to give it to Grant Baldwin to talk about the epilogical trends of xylosine. Good morning. Thank you so much for sticking around for this conversation that we're about to have. I'm going to do a couple of things. I'm going to give you what we know is the latest data on the drug overdose crisis, include data that was released just earlier this week by CDC, but then take a sort of a longer view of how we got to this moment. I'll also unpack for you what we believe to be the drivers of the recent decrease in overdose deaths that you'll hear about. Then I'm going to shift to talk about what we, CDC, are doing at the population level to help curb the overdose crisis. Well I had updated this slide. I will give you updated data from what's here. Earlier this week, we released data through June of 2024. This is provisional data. So I'm going to be comparing the 12 months ending in June 2024 to the 12 months ending in June of 2023 and the predicted number of overdose deaths. So in earlier this week, in June of 2024, there were 96,801 predicted overdose deaths. This is the second month in a row that we are now below that 100,000 threshold. This represents a 14.5% decrease in that 12-month period. So something that I think we're all buoyed about given how long we've been working at this crisis. Synthetic opioids, excluding methadone, again, fentanyl, continue to be the primary driver, but we've seen an 18.6% decrease in the 12 months ending in June 2024 and a 9.3% decrease in overdose deaths involving psychostimulants with abuse potential, again, largely methamphetamines. A 10.9% decrease involving deaths associated with cocaine and dramatically a 34.1% decrease in heroin-related deaths and a 16.9% decrease in prescription opioids. Again, this graph or this map has actually gotten better. So the update, which you can pull up online with the National Center for Health Statistics provisional data, now a total of 45 states have seen a decrease in their predicted overdose deaths between the 12 months ending in June 23 and the 12 months ending in June of 2024. The largest predicted decreases were observed in North Carolina, Ohio, Virginia, South Carolina, and Pennsylvania. North Carolina saw a fully 30% decrease in that time period. But as you can see, when we have a conversation about overdoses in our country, there is some heterogeneity, although we've seen a dramatic decrease across the large swath of the eastern United States, there are some states in the west that continue to see increases, and you can see those in Alaska, Nevada, Oregon, and Washington, with Alaska having the largest increase at 38.7%. So again, this is a larger view. Anytime I give a presentation about overdose deaths in our country, I think it's important to sort of contextualize how we got to this moment and compare in 2000 when we had just over 17,000 overdose deaths to the over 100,000 that we had in 2023. Again, the bars represent counts. The line here represents the percentage, in this case, of overdose deaths that involved an opioid. You can see on this graph the waves of the opioid epidemic, beginning with prescription opioids in the late 1990s, this is the gray bars on the graph. Heroin increasing in around 2010, that's the green bar. And then the huge skyrocketing of deaths associated with fentanyl beginning around 2023, the light blue bar. And the yellow and then red bars are methamphetamines and cocaine. Drug overdose deaths have increased six and a half fold during this period. Prescription opioid overdose deaths have begun to decrease since 2020. Heroin deaths have begun decreasing in 2018, but again, although we've seen a decrease in what I just told you about in 23, there are synthetic opioids excluding methadone. Those deaths have increased 93 fold since 2000. And again, the graph here says that psychostimulant deaths and cocaine deaths are still increasing. That's actually not true, as you just heard from me. They are beginning to come down now. Again, bars are counts. Lines are percentages corresponding respectively to the two y-axes. This is a representation of the just specifically opioid-involved overdose deaths in the last 23 years. You see that nearly 800,000 of our fellow Americans lost their lives to an opioid overdose in this time period. But you see that the percentage of deaths involving prescription opioid peaked at 69%. Again, that's the gray bar, or the gray line, excuse me, and have dropped since then to just 16% in 2023. Heroin deaths peaked at 39% in 2015 and have dropped to just 5%. And really the story about overdose deaths in our country, just about every question you ask, the answer probably has something to do with fentanyl. You can see that the percentage of deaths involving synthetic opioids excluding methadone continues to rise and is currently at 93%. This is a much more expansive view of the information I provided earlier, looking at state-level death rate changes over time. As you know, Appalachia has been particularly hard hit. West Virginia had the highest rates when you compare 22 and 23. But six states saw a 15% decrease. You see those listed here, Nebraska, North Carolina, Arkansas, North Dakota, Maine, and Indiana. And five states had over a 15% increase, although you see those changes that I just talked about. Again, for context, in 1999, the overall U.S. drug overdose death rate was 6.1 per 100,000, and now it's 31.5 per 100,000. You heard in the presentation earlier this morning the dramatic heterogeneity across race, ethnicity in our country, and this graph sort of tells that story in detail. This is drug overdose death rates by race and ethnicity over the last five years. You can see all races represented on the far left in the purple. They have increased 46%. Non-Hispanic whites have increased 26%. For the first time beginning in 2020, non-Hispanic blacks surpassed non-Hispanic whites, the death rate, during this period of the drug crisis in our country. But you can see, as you heard during the first presentation this morning, the huge disparities that exist for AIAN populations, and you can see just from 2019, the death rate has increased 115%. You see similar increase in non-Hispanic native Hawaiian and other Pacific Islanders, as well as increases in Hispanics. So what's happening with fentanyl in our country? This is data from DEA about drug overdose seizures. I think seizure data is great to be a kind of a leading indicator about what's going to happen in our country, and a record amount of fentanyl continues to be seized here in the United States. So in 23, there were over 13,000 kilograms of fentanyl powder seized. That was double what we seized in 2021. And counterfeit pills continue, which, as you know, mimic the appearance of commonly prescribed drugs, continues to be a major problem, and I'll show data in a second to unpack that a little bit further. I think disturbingly, and I suspect maybe you've heard this, that now seven out of ten counterfeit pills collected in the country contain that potentially lethal dose of more than two milligrams of fentanyl, and that's up from just four in ten. So if you think about young people and even adults taking pills, your risk of potentially taking a lethal dose has increased dramatically. You can see the average purity of fentanyl is about 2.4 milligrams. Again, that's the average, with some samples containing as many as nine milligrams. So I like this graph because it sort of tells a story, not just of how we got to now, but why fentanyl is so dangerous. When you think, and you as addiction psychiatrists know this better than I, that people who are at risk of developing a use disorder and potentially dying from that use disorder, historically that increased across the continuum of use, from no use to initiation experimentation, so you get to the far right side of this graph where you can see you have a DSM-diagnosable use disorder. But in an era of fentanyl, as we all know, given its potency and lethality, your risk goes up at every level across this continuum, and that's borne out by, as you know, the increases in deaths that we've seen among youth and young adults, although that is beginning to decline in recent years. So we worry a lot at CDC about telling the story of the drug crisis, and one of the things that we've done, and I'll talk a little bit more about our Overdose Dated Action Program in a few minutes, is stood up some new surveillance system. This one has been around for eight or so years, and this is called the State Unintentional Drug Overdose Reporting System, or SUDRS. If you Google that in Dashboard, you can pull up some of these graphics. Why is SUDRS so important? It pulls data from three specific data sets, death certificates, medical examiner, and coroner reports, and post-mortem toxicology on all drug overdose deaths in most states and deaths in 75% or more of deaths in states that have a large number of deaths. And by the way, that post-mortem toxicology looks at over 1,400 chemicals. So on every drug overdose death, we capture data on over 615 variables, so we have a really comprehensive picture about the decedents in our country. So you can see here the percent of the distribution of overdose deaths by opioid and stipulant involvement. You can see that fully a quarter of overdose deaths among SUDRS decedents involved just illicitly manufactured fentanyl, and 21% involved IMF and cocaine, and 13% involved IMF and methamphetamines. I'll unpack this note in a few minutes a little bit further. You know that smoking, the route of administration among overdose decedents, smoking is now the primary route of administration that has surpassed injection, which has historically been the highest. Finally for us, and again, this is through all of 2024, you see that 64% of overdose decedents had at least one potentially missed opportunity, which sort of tells us as public health practitioners, or you as addiction psychiatrists, what can we be doing differently? Where are the gaps? Where are the missed opportunities? So you can see that fully three quarters of people had a history of drug use. And just a small sample, less than 7% were prescribed medications for opioid use disorder, and a significant portion, almost three quarters again, the death occurred in a decedent's home. And we've talked over the course of this conference about the importance of treating co-occurring health conditions. You can see here that a quarter of all decedents had a diagnosed mental health condition at the time of their death. So let's talk about some emerging drug trends. Xylosine that Adam mentioned is critically important. As you know, this is on the street, typically referred to as Trank. It's increasingly found both in the U.S. drug supply and in overdose deaths. It was declared an emerging drug threat by the White House Office of National Drug Control Policy in April of 2023. And it's been found, again, using that drug seizure marker as a leading indicator that I talked about a few minutes ago it's been found in all 50 states, D.C. and Puerto Rico. It's most frequently found in a powder form, but it's also found in about 5% of fentanyl-associated pressed pills. I think one of the things that's striking about xylosine is in that second to last bullet, which is in a sample of eight from eight SSPs in Maryland between 21 and 22, xylosine was found in almost 80% of drug samples, and I'll reinforce that in the next slide. But importantly, almost nine out of 10, 86% of users had no idea that xylosine was in that supply. So again, it's an adulterant that users don't typically know that they have. And in Philadelphia, it's found in 31% of fentanyl or heroin-involved overdose deaths. So this is from a Morbidity and Mortality Weekly Report that we released in June of last year that looked at xylosine co-involvement in IMF deaths from January of 2019 to June of 2022, shows that that proportion increased 276% from just 2.9%, and January of 19 to almost 11% in June of 2022. And as you heard throughout my talk, there's a tremendous amount of state variability and heterogeneity, you can see that co-involvement of IMF and xylosine was highest in the Northeast, Mid-Atlantic, and Midwest, with almost 30%, 27.7% of IMF-related deaths in Maryland also co-involving xylosine. More recently, we've also been worried about and attending to metatomidine, which is also an alpha-2 agonist, much like xylosine, increasingly appearing in the drug supply. Most notably for us, we were called to do an epi-aid in the city of Chicago in May after an increase of metatomidine-associated deaths. You know, we're still in the process of unpacking those data, we'll be releasing an MMWR, it's in clearance now, but you can see the history of metatomidine outbreaks over time, increasingly showing up in cities like Philadelphia, Chicago, Toronto, and elsewhere. This is also a preview of something we'll be releasing in December, which, as you know, carfentanil is a fentanyl analog that's 100 times more potent than fentanyl. It was problematic in our drug supply initially in 2016 and 2017, but frankly has largely disappeared in recent years. You know, it's reemerging, and I'll tell you a little bit more about that, and you can read more when the MMWR comes out in early December. So in 2020, in these 32 jurisdictions of SUTRS data, there were 277 deaths with carfentanil detected. This decreased to just 28 deaths in 2021, and just seven deaths in 2022. But again, from preliminary data, which we'll be publishing out, as I said, in December, there are over 150 carfentanil-associated detections and deaths, and that's increasing. I think worrisome for us, this is not regionally isolated, so this is occurring across the country, as you can see on the graph, and I think the picture, which I suspect you've seen before, juxtaposing what a potentially lethal dose of heroin, fentanyl, and carfentanil looks like, just a real small amount of carfentanil can kill you. I talked about counterfeit pills. This is an MMWR from September of last year where we looked specifically at the increasing percentage of overdose deaths that involved counterfeit pills. You can see that the percentage of deaths has doubled from July and September of 2019, from 2% to December, October to December of 2021 at 4.7%. But again, notice the regional variation. Fully, almost 15% of deaths in the western United States involve counterfeit pills. Again, that signals to us what we need to be doing as public health practitioners differently in different parts of our country. So here is the additional data that I promised to show you about changes in route of administration among overdose decedents. So the percentage of deaths that involved evidence of injection, again, this is SUDOR's data again, decreased almost 30% from 22.7 to 16.1%, and the percentage of deaths involving smoking, again, this is the light blue line here on this graph, increased 73.7% from 13.3 to 23.1%. Again, it's the most documented route of use in overall U.S. drug overdose deaths, and nearly 80% of overdose deaths with evidence of smoking had no evidence of injection. One of the things that we heard also in the last session that I think was pretty telling is this is a story that we tell ourselves often but continues to worry all of us, that is basically the percentage of Americans who are in need of medications for opioid use disorder and the percentage that actually get them is still relatively small. This is data that we released in June of this year looking at NSDUH data, so in 22, about 4% of the U.S. population, the U.S. adults were in need of OUD treatment, only 25% received that standard of care medications for opioid use disorder, methadone, buprenorphine, or naltrexone, and you can see the variability. I think one of the things, if you looked at some of these graphs, it's the second bold that I wanted to highlight here. Most adults who needed OUD treatment either did not perceive the need, that's 43%, or received treatment without medications for opioid use disorder, that's 30%, so again, three out of four people who were in need did not receive it. So I promised to show this to tell you the story of what we think is driving the recent decrease in overdose deaths. These are 10 hypotheses that we need to test out to determine what has actually caused this decrease. We think that it's not obviously one of these things, but some combination. The extent to which we can establish the attributable fraction for each is still also an open question. So let me just run through them for you. So wider naloxone availability and distribution, obviously it's available over-the-counter. We've made big pushes to make naloxone saturation widely available. I have an expression of making sure that naloxone is within arm's reach of need, and that means that people who use drugs or family members or caregivers and friends of people who use drugs have naloxone widely available. While I just disparaged where we are with access to medications for opioid use disorder, we actually have made an increase. I think some of the telehealth flexibilities have been very good to that end. The improved overdose surveillance to target prevention and response activities, we worry a lot about where is the problem, what do we need to do, and how do we target our interventions. Increased engagement in harm reduction services, so drug checking, fentanyl and xylosine test strips, syringe service programs, et cetera. I mean, if you asked around the room, or excuse me, in the general US population, what fentanyl was even five years ago, I don't think you'd have a lot of people who knew that. And I think public awareness about fentanyl has continued to increase. I think importantly, it's also important to recognize that now fentanyl's everywhere. So we've seen fentanyl-associated deaths start in the east and midwest and slowly migrate to the western United States. And now, so you see a saturation of fentanyl-associated deaths. An adulteration of fentanyl with drugs like xylosine, decreasing the amount of fentanyl present. I didn't talk about the necrotic skin lesions that are associated with xylosine use. But those adulterants like xylosine we think is also a potential driver. Changes in drug use behavior. I talked already about the shift to smoking. Greater efforts to interdict the drug supply, including on precursor chemicals. And then lastly, let me just highlight that pandemic-related disruptions in trusted drug supply as well as harm reduction treatment and recovery support services have substantially improved. And then finally, let me just go over briefly, that's what I wanted to, oh. Oops. Now I wanted to talk a little bit about what we're doing at CDC. This, and I think this is about to change obviously with the upcoming changes in administration, but this is the current HHS overdose prevention strategy. You can see the guiding principles listed in the center of the slide. What's really important to highlight here is that harm reduction is one of the four key strategies and it has never been so prominently featured by HHS or CDC and that's important for all of us to recognize and celebrate. And something that frankly, I as a leader at CDC and a leader in the field in public health don't wanna lose ground in the next, as we go through the next four years. So what are we doing, oops, sorry. What are we doing within my division of overdose prevention? Let me just highlight a few things. We have a vision of people thriving in connected and resilient communities without overdose. We have three overarching goals. They include reducing opioid and stimulant-involved overdose deaths right now. We have an urgency of the moment given the number of deaths that are occurring. Addressing those emerging, identifying and addressing those emerging drug threats, some of which I've highlighted for you. I didn't talk about ketamine in the Q&A. I'm happy to answer a couple of questions about ketamine if you'd like. And then to prevent youth substance use initiation and use. I mentioned our Overdose Data to Action Program. This is our signature program. 49 states, DC, 39 big city or county health departments and the territory of Puerto Rico all receive a fairly significant amount of money, up to $300 million total every year for five years. So it's a $1.5 billion program to do as the program, the title of the program implies, to drive action where it's needed most. I do wanna highlight for you on this slide, we have an intentional focus on health equity and really for the first time are really encouraging our states and jurisdictions to use persons with lived or living experience to help guide what they're doing to make sure their interventions are meeting those who need it most. My time is running out a little bit. Let me just show you here, this is the footprint of the program. The only state that's not being funded right now is North Dakota and it's not funded because they didn't apply. Let me highlight a few of the prevention interventions. We have a requirement for clinical and health system engagement. That includes things like implementing the CDC opioid prescribing guidelines for pain that were updated in 2022, among other things in leveraging prescription drug monitoring programs. We also have a focus on biosurveillance. How can you use residual samples from peoples who are showing up to an emergency department with a non-fatal overdose, how can you use that to test that for the drugs that are on board to inform, again, local public health practitioners. Happy to talk more about OD2A state. This is OD2A local. Again, the footprint's the same. Let me highlight here, though, that also new in this version of OD2A is a very intentional focus on linkage and retention in care. We are also doing linkage and retention in care surveillance for the first time to understand those patient trajectories and where are the gaps and opportunities. This is our overdose response strategy. It's one of, besides OD2A, ORS is one of our other signature investments. This is where we pair, and now every high-intensity drug trafficking area in our country, a public health analyst and a drug intelligence officer to do the four things that you see listed on the slide. Importantly, share data. So what is law enforcement seeing? To support one another to implement evidence-based interventions at that intersection, so things like post-overdose outreach, naloxone leave behind, quick response teams, et cetera. Then ultimately to design the novel strategies at that intersection and disseminate and scale them up. You know, I am in the process of reading Malcolm Gladwell's Revenge of the Tipping Point. And one of the things that he talks about in that book is really focusing in on local problems in very local ways. And we invest at CDC in overdose fatality reviews because that's exactly what OFR is intended to do, really understand what's happening in localities across sectors, where are the gaps and opportunities that can be addressed. I suspect everyone in this room has familiarity with OFRs. We do have a tremendous amount of energy because they can identify very specific and granular gaps. So my last substantive slide is this one. We've been working with ASAM on an addiction medicine toolkit to inform now that with the elimination of the X-Waiver, how can primary care clinicians do more and do more of their part to support people, connecting people to definitive care, to treat their use disorders. So we work with ASAM on this. It's really robust and case study driven, which I know you all appreciate. Then finally, just in closing, let me mention, we work with the National Governors Association on this roadmap. Again, we at CDC are working at the population level. This sort of unpacks for you where there are some potential opportunities at scale. So independent of what we fund at CDC or what SAMHSA funds, what's being funded by opioid settlement dollars, we think there's a great pathway through under the leadership of our governors or mayors to help drive action in communities. I spend a lot of time on a baseball field. I have a 13-year-old rising ninth grader, and it's increasing. To me now, this has changed because he's more mature, but when he was a little bit younger, as I suspect if you had a young boy or girl who played baseball or softball, you know that they can catastrophize when things don't go their way. So when my son Aaron would be pitching, I had to remind him periodically that the most important pitch is the next one. So we're very focused. I'd encourage all of us to be focused on what's next for us in our fight with the overdose crisis. So that's my part. Let me turn it over to Joe first, or you had Joe talking and then me answering questions. Why don't we go ahead and open up for discussion? Okay, great. If there's any couple of questions, anybody has questions... Hi. Jeremy Williff, Yale University, University of Alberta, Edmonton. Two questions. One is, in public health and the CDC, we continue to call it harm reduction. And I'm just wondering if there's an opportunity to just call it tertiary prevention. Yeah, so that's a great question. We are, to put more meat on the bone, we are harm reduction for whatever reason has a specific valence, that we are concerned, especially with the politics of the moment, that may actually impede our ability to do the important harm reduction work. So we are, in fact, thinking about changes in framing and terminology. We're also thinking the same as we think about words like health equity, to reframe it in other ways that, again, won't, you know, the work needs to happen. The evidence is there. We need to make sure we label it in a way that allows us to continue to do it. Yeah, the politics are complicated. And I'm just, I have this pet theory that maybe medicalizing it and just calling it medical treatment and calling it what it is can sidestep some of that. Yeah, I think one of the things that's important for us when we talk about, you know, meeting people where they are, supporting people who are using drugs to keep them healthy and well, but always keeping an eye towards maybe not now, maybe not a year from now, maybe not five years from now, but at some point getting them connected into services. So I think it's going to be important to tell that part of the story as a federal government to make sure that we're, you know, supporting people where they're at, not trying to push them to do something they don't want to do, but also being attentive that eventually we really do hope that we can link people into definitive care. One more quick question. I hope this question is not offensive. Once upon a time back in the 20s or 30s, we had a medicine. We called it Hero. That was heroin. When it came, we prescribed. Later on, methadone came and we did prescriptions. In your toxicology of the death, do you check for buprenorphine, simply because it's a partial agonist, still agonist? I don't have data for me to know if this is being mixed with other agonists. Is that going to be disastrous or not? Yeah, so we do have information in suitors on buprenorphine co-involvement. And one of the things we published out a paper on was that the telehealth flexibilities that were put in place and the increased buprescribing that occurred did not increase, did not lead to an increase in buprenorphine-involved overdose death. So the short answer is yes, we do have those data. Thank you, Grant. And we'll have a really extended Q&A period at the end of the symposium. Thank you. Dr. Liberto. So I'm really just going to take a few minutes to sort of set the stage for what Dr. Oliva and Dr. Gordon are going to be talking about in terms of how VA has approached treatment and harm reduction approaches for fentanyl and xylosine. And it really kind of stems in the backdrop of the overdose epidemic. And much like the nation, certainly veterans are dying primarily of opioid-related overdoses, fentanyl kind of leading the charge, and stimulant-related overdoses. And probably within veterans, probably cocaine a little bit more than you might see in the general population, but cocaine and methamphetamine certainly leading the way there. And this is the last vetted data that VA has published, in 2022, and looks at the years 2010 to 2019. And while the age-adjusted drug overdose mortality rates for women veterans versus women non-veterans was about the same, there was a fairly significant difference regarding male veterans and male non-veterans. And so if you look at those two kind of solid lines in the middle of this graph, you'll see that actually, if you're a male veteran in the United States, you had a lower risk of overdose mortality than if you were a male non-veteran. So in fact, in some ways, veterans fared better in terms of overdoses. But in terms of veterans who are in VHA care, being treated in our VA medical centers and community-based outpatient clinics, the real important piece for us is that dashed line at the top and the somewhat dotted line at the bottom, which basically shows that male veterans in VHA care have much higher rates of overdose mortality than those who are veterans who don't access VA care. And the main feeling that this represents is that VA treats a more vulnerable population. It treats a population with a lot more medical comorbidity, a lot more mental health comorbidity, having a lot of social determinants of health that put them at higher risk for overdose. So that's sort of the backdrop and the importance of providing care in an effort to help reduce overdose fatalities among veterans in VHA care. The other thing I just want to note is that when we look at data for veterans who have died of stimulant-related overdoses, we find that almost 50% of those patients also have an opioid in their system at time of death, one out of every two cocaine-related deaths, one out of every three methamphetamine-related deaths. So it has important implications for our harm reduction strategies in that, as you'll hear from Dr. Olivo, we're not only focusing on naloxone distribution to those with opioid use disorder, but also for those who have stimulant use disorders. And then, of course, the VA is always very focused on reducing veteran suicides. And it's clear that substance use disorder plays a significant role in the context as a risk factor for suicide. And in fact, I think we think of suicide a lot in the context of depression. But in data that VA looks at, basically you're seeing that substance use disorders, particularly opioid use disorder, sedative use disorder, and stimulant use disorder, have almost two to three times the rate of depression associated with suicide. In fact, one in four suicide decedents had a substance use disorder diagnosis. So VA is very focused on trying to treat substance use disorder as hopefully a modifiable kind of risk factor for helping to also kind of reduce depression, reduce suicide. We have really, over the last four years, tried to kind of embrace the National Drug Control Strategy. And Grant kind of talked a little bit about this. Our main focus has been on expanding evidence-based treatments, particularly medications for opioid use disorder. And although we're not gonna talk about it as much today, and you heard more about it earlier during the conference, contingency management and cognitive behavioral therapies for stimulant use disorder. Advancing racial equity in our approach to drug policy. And we have some initiatives that we're doing in that area, not really so much the focus of this talk today, but certainly can talk about that. And enhancing evidence-based harm reduction efforts that you'll hear a lot about from Dr. Oliva. I mean, the VA is the largest integrated healthcare system in the United States. And VA has the ability to move patients across a continuum of care, ranging from inpatient care where we may be doing things like alcohol detoxifications, or treating comorbidity. We have a very large domiciliary substance use disorder program that's the VA equivalent of residential treatment programs, in which a lot of SUD care happens, and linkages made from those residential programs to our general outpatient clinics. We have 33 opioid treatment programs, and every VA medical center needs to have a specialty substance use disorder clinic. We also work very closely with our general mental health programs, our behavioral health interdisciplinary programs, our primary care mental health integration programs. And VA does universal screening for alcohol use disorder, as well as provides, depends on support from mutual self-help groups such as NA and AA. I think one of the things I will want to say here though is that when you look at veterans who are treated for substance use disorder in VA, the majority are not treated in an SUD specialty care setting. They're treated in general mental health, they're treated in primary care settings, they're treated in pain management settings. So really our focus over the last few years has been not so much to look at only specialty care as where we want to put our resources and treatment, but trying to build resources and capacity across the larger continuum outside of substance use disorder care, even outside of mental health. And you'll be hearing more about that from Dr. Gordon. We really kind of at our base have tried to message strongly that the care within VA should be guided by the clinical practice guideline that VA puts out. This was last published in September of 2021. As you can see there, we focus on MOUD as a main treatment for opioid use disorder, and again, CBT and contingency management in particular for stimulants as I noted earlier. But it's also kind of looking at that in the context of really providing shared decision making with veterans and trying to also address their co-occurring needs, whether they be mental health or medical, and addressing their underlying psychosocial problems. And in fact, some of the resources we have put into VA in the last few years have been focused on employment and trying to provide supported employment opportunities for veterans who are in early recovery. Mentioned before, and I think Grant also mentioned, you know, that really the National Drug Control Strategy over the last several years has focused on not only treatment, but also harm reduction activities, including naloxone, drug test strips, and syringe service programs, and Dr. Olivo will be kind of updating you a bit on where we're at with that within VA. And I think just to say in the end, we've tried to approach SUD care within the VA in the context of harm reduction principles in healthcare that were put forward by Hawk and Culture. And a focus on humanism, you know, basically respect and dignity of patients, and really where there are no moral judgments, because moral judgments don't usually produce positive health outcomes, and we try to send that message very clearly on regular community of practice calls that we have with the field on a monthly or bimonthly basis. Pragmatism, that abstinence is neither prioritized or assumed to be the goal of the patient, particularly in the context of harm reduction type initiatives. Certainly I think individualism and autonomy sort of speak for themselves. Incrementalism, any positive change is really a step toward recovery. And finally, accountability without termination. We really are trying to strongly send the message that patients shouldn't be discontinued from treatment if they don't achieve certain goals, that we need to keep them engaged and continue to work with them, and that's certainly been a focus of our efforts. So with that, I'm gonna turn things over to Elizabeth. Elizabeth oversees our naloxone distribution programs and has a big hand in a lot of our harm reduction efforts. Thank you. Okay, I'm gonna go through a lot of slides. They are in the app, and you'll see my email. I'm happy to take emails and answer questions. But I just want the kind of three key takeaways is that harm reduction does allow you to reach and engage a large segment of individuals who use drugs and who are not yet ready for treatment. When we started in the VA with naloxone over a decade ago, what was interesting and what I loved is that there were nurses who said, hey, you know, there's this patient. I have just not been able to convince him to come for treatment, but he keeps coming back to me for naloxone, and I keep having that opportunity to offer him treatment. So I do feel like it's a pretty, you know, it's one of the tools we now have in our clinical armamentarium that will allow us to reach more people. Whether or not you have the capacity is a different story, but it will actually, I think, bring in some people that you may not have been able to engage in the past. So VHA is leveraging efforts with MOUD, the original OG harm reduction, which Dr. Gordon will be talking about, and also naloxone to integrate drug test strips and syringe services programs. So I will talk about how we're using our efforts in naloxone over the past decade to really help inform our efforts around the other harm reduction initiatives. And also just wanna note, this website's amazing, guys. So I have it on here. We have a plethora of publicly available resources to support harm reduction, and I don't know how many clinical pharmacists are in the house. I don't know if there's anybody here, maybe not. But if you guys, they are amazing, and so these are all made by our academic detailing group, which are all clinical pharmacists, and so they've been very amazing in supporting these efforts. So again, leveraging that clinical pharmacy staff too is super helpful in your work, I imagine. So again, this is what our academic detailing service campaign looks like internally. It's gonna look different externally, but I have, you probably can't see it very clearly, but there are so many different campaigns they have that are relevant to you as addiction psychiatrists. So a lot of the topics that were mentioned earlier today are addressed in these. So again, on the right-hand side is what you'll see. And again, for each of these topics highlighted, you can get some really helpful patient and provider resources. Really great for trainees as well. So VHA harm reduction. So again, as Dr. Liberto mentioned, the National Drug Control Strategy came out in 2022, which was the first to really talk about this and include it. And we have successfully implemented our efforts and are using it to inform SSPs and drug test strips. So just as a kind of broad overview, our Rapid Naloxone Initiative started in 2018, had three elements, although we've been doing OAND since 2014. So in that decade, we've gotten naloxone to over 600,000 VHA patients. That's again, almost 1.5 million prescriptions given out with over 5,700 reversals. We did start with VA police naloxone and almost all of our VA police officers are caring very close to at every facility. And we also have a select AED cabinet naloxone effort, which again has naloxone in over 1,200 cabinets. And again, you can see the reversals from that. So this was awarded the John M. Eisenberg National Level Innovation in Patient Safety and Quality Award, which is one of the highest honors from the Joint Commission and National Quality Forum. Our work has also been featured in that National Drug Control Strategy as a way to reduce fatal overdose through data-driven efforts to get naloxone to where it's most urgently needed. So you'll see how we do that in future slides, but basically we were noted as the experience of our program should inform this area. And so we did publish our work in 2017 and talk about how we established our program and some of the major innovations. You guys, everyone's doing this now, so it's probably not as helpful, but back when we published, it was definitely a lot newer. For those researchers, we were also featured as an exemplar in the VA Quality Enhancement Research Initiative, Roadmap for Implementation and Quality Improvement. And this actually just demonstrates the theory-based approach to mapping barriers to implementation strategies. So you can see at every single level, the veteran, the clinical team, the hospital, and the health system generally, what we've done. And I'll give you some examples, but this is really helpful as just thinking through what you might be able to do to increase. And again, applying these to broad harm reduction, not just naloxone, but these are all different levels you should be looking at and thinking about. So again, we received this great honor for the work that's been done in our system, tons of papers and podcasts and blogs about what we've done. I did still just do it. I'm not sure how many of you know Eliza Willer, but I really loved Dr. Shorter's comment about, you know, we need to get out of our silos and talk to other people in the community because we are standing on the shoulders of giants in VA. When I first started looking into this, or when we first started looking into this over a decade ago, I reached out to community partners who are really leading, this came out of the community, naloxone did, as did all these other harm reduction efforts. So we just do it is actually what Eliza said to me when we first met in 2012 about, you know, how we can do this. So again, that's an ode to her. But again, thinking through how you can partner with your communities, because this is a community issue, is really important. So as part of our efforts around AED cabinet naloxone, we actually asked the joint commission some questions about, again, we were taking gold status practice that was occurring in Boston, and we then had to, it was selected in our diffusion of excellence program, and I was kind of brought in to help with scaling nationally. And so during that, we had to, again, take a facility level approach and then think through how we can get it across the system. And so we did meet with the joint commission, and they actually, after that, put out an FAQ on how to stop reversal agents in nontraditional areas. So again, if you guys end up being involved in that, there are some, this is a really helpful FAQ, just talking about what's needed from a joint commission perspective. Our efforts in this space have also been included in the safety station program guidelines in federal facilities that just came out. So just so folks are aware, as quick background, in 2009, I think, was the last federal safety station, it wasn't called safety, it was more like AEDs. That was the last guideline that came out. And so that was updated in 2023 in December. And so our toolkit is again, this went out to all the heads of federal agencies to talk about how to integrate naloxone into safety stations, AED cabinets and such. So this is naloxone hemorrhagic kits and AEDs are typically what's talked about, those three components. But again, that's our toolkit, which is publicly available. One of the things that I'm probably most proud of is the fact that in 2016, so this came out a little bit later, this codified what happened in 2016. But for those of you who are aware of the Comprehensive Addiction and Recovery Act of 2016, CARA legislation, we eliminated co-payments for naloxone and education on naloxone forevermore. So no veteran will ever have to pay for that, which is awesome. So that again, was codified in 2021, but did come out in 2016. And I think some of the things we've also learned, and I think that's helpful for this audience is that I'm not sure how many of you are familiar with the compassionate overdose response efforts, but we do highlight, because there are different naloxone formulations out there, right? And some of them are pretty high dose and can precipitate withdrawal. So we do recommend using shared decision-making at the very bottom in determining if a higher dose or potency opioid antagonist device should be prescribed. And so just so you're aware, so these are recommendations for use that our pharmacy benefits management puts out nationally. And so again, these are helpful in guiding clinical guidance for these efforts. But again, just really highlighting if you are working with patients, using shared decision-making is, because again, I know there's some theories about why we have a number of patients who do not want naloxone after they have an opioid or stimulant overdose. And I know when I've spoken with my community partners, they have some theories that it may be because of their experiences with precipitated withdrawal, with awful experiences. So anyways, putting that out there in case that's helpful. And then we do have a memo to increase naloxone distribution to veterans at high risk. So Dr. Baldwin mentioned some of the groups that they're focused on. And so within VA, we have a focus on patients diagnosed with opioid use disorder, stimulant use disorder, and those who have a previous opioid or stimulant overdose, as well as patients who are identified as very high-risk patients prescribed opioids by VA's stratification tool for opioid risk mitigation. So we do have a predictive model that identifies very high-risk patients who are prescribed opioids. So remember, Dr. Baldwin kind of showed you that the evolution of the different ways of the overdose crisis. And we've always had a huge interest in making sure our providers are identifying patients who are, again, are high-risk or prescribed opioids. So that's, again, these are four groups that we focus on. And I'll show you how we try to drive and identify patients to make it easy for providers to reach out to those patients. So this is how we do it. So we have an O&D dashboard that, again, those four groups you can see on the top, I think I'm trying to think on your guys' left-hand side. So on the top left-hand side, it shows you the veterans at high risk. So those are the four groups we focus on. And every facility has an ability to identify how many patients in each of those groups they've been able to get naloxone to, and also those actionable patients. And as Dr. Baldwin mentioned as well, we are also interested in health equity. So we have another way of looking at patients who need naloxone from a health equity perspective as well, which is pretty awesome. So these are all, again, I get huge kudos to our academic detailing group, because, again, this is really a lot of these products are based out of their work. This is what our O&D campaign looks like. For those of you not in VA, I do highlight, anything highlighted just for your awareness, our staff can order for free to stock in their clinics. So that's a pretty awesome thing. I didn't realize how helpful that was until, O&D materials are the number one campaign materials given out by academic detailing pretty much every year. So we do, again, have a lot of great resources for our staff and patients. And let's see here. So this is just an example of what the clinician guide looks like. So again, this is probably not as big of an issue. I think more people are familiar with it, but again, you remember, we do have new people coming on. And generally speaking, people have not necessarily been trained as much as O&D prior. So we do have ways of summarizing kind of what O&D is, as well as how to have that conversation. I think this is a big one, which you'll see. We do a lot to help people feel more comfortable with having conversations about this. And this is the patient guide. So you saw the clinician guide. This is how we target our messaging to patients. I have in the red box the watch out. This is kind of, you know, when we talk about O&D within VA, we have kind of three prongs, opioid overdose, and the opioid overdose education piece. So I always say, you know, you have O, E, and N, D. And the O, E part really focuses on how to prevent an overdose, as well as recognize and respond. And I think that was even more important, I think, earlier on when it was prescription opioids, because a lot of times, I think, if you remember, it was patients, you know, looking like they were nodding out or just tired, and then they would actually be overdosing right next to people. So that recognition was a lot more of an issue. I think now these days, now that it's kind of transitioned more to illicit, it's pretty obvious to most folks. So it's not quite as big of a focus, but I think the prevention piece is kind of really where we need to shore it up, because whenever I've been in recent kind of education, it seems like people, staff, think that the education's about the naloxone. There's a reason naloxone's over the counter, right? It's easy to use. So really, I think focusing efforts on how patients can prevent an overdose, because A, risk perception's terrible. They don't necessarily think they're at risk, but they also don't know what puts them at risk. And I think that's where we, as educators, can really help our patients understand what is putting them at risk, what's happening in the drug supply and such. So a lot of, I think, opportunity in that space. So again, the first two pages are all prevention, and the next two are recognition and response. And then Dr. Baldwin mentioned the rise in carfentanil. This made me feel better, Dr. Baldwin, about making sure we have, because this has been a fentanyl and carfentanil brochure we've had for a while, so it's seeming like we should probably still keep emphasizing that. So you guys can take out your phones if you like, but this is, again, is a really nice brochure made by our academic detailing folks on fentanyl and carfentanil. And I think what's nice about this is, on the back, it does have what you can do. So it increases awareness, but also says, here are some options for things for you to think about offering patients. And so, like I said, again, we do a lot of example scripts, because we do know for staff who haven't necessarily been trained, probably not this audience, but generally speaking, if you do have trainees or fellows or folks coming in, we do have population health outreach scripts for naloxone. Those are internal links, but I did embed it. I don't know if you guys have access to that. So again, feel free to contact me, and I'm happy to share the Word docs and such. But one of the other things we do to really help with standardizing and scaling is we do have a national progress note that is called Overdose Education and Naloxone. And this does, again, support standardized OAND, and we streamline the note with key health factors, which for those of you who are not aware what that means, that means that we are able, like each of these buttons is tagged, such that our corporate data warehouse is like where we store all the data. We can actually pull and find out how many people had each of these sorts of check boxes clicked. So in this, I just wanna kinda highlight that one of the things that's really difficult from an implementation perspective is just making sure, I just went through a ton of resources. How does a provider even know where to go, and you guys have so much on your plate. So we do embed as a hyperlink these resources and these links to just make it easier for them to identify. From a Naloxone implementation perspective, because it's widely available externally, we do have a way, and what I have clicked there is has current Naloxone, because again, we are tracking very closely who has Naloxone in the past year, but we do have a way of identifying if they actually have current Naloxone, like it's not expired, because we do know a lot of them have long shelf lives. We're able to capture that, and then again, credit people and help with reducing burden on them for reaching out for people who actually do have it. They just, it's current, it's just the prescription's expired. So we also have, again, we're doing a lot to increase awareness and try to get more patients to get Naloxone. So we do have letter-based approaches that people have created to, again, increase awareness and offer Naloxone, secure messaging approaches. And one of the things that I've really been focused on and thinking about, and I thought when Dr. Baughman showed that slide about how many people who had died actually had, or I think there was one where he was talking about how many people have declined treatment or didn't think that they were, didn't need the OUD treatment. This is kind of in a similar vein. We, remember I said everything we have is quote-unquote health factored. We actually, I had my project coordinator, Justina Wu, code the reasons for declining Naloxone among the 11,000 patients with OUD who had declined it. And interestingly, a third, it's green because they actually had it, people just weren't coding appropriately, but 40% didn't want it, feel it was needed or cited being in treatment as a reason for declining. And the being in treatment particularly was concerning because a lot of what this rose out of was people in VA at least, the first places that adopted were residential programs and it was because people were basically going and overdosing right after being discharged or coming back from PATH. So the idea that being in treatment is why they don't need it was kind of concerning. So I'm gonna be focusing a lot more on this upcoming year on really trying to get people to think about that prevention piece and think about how we can talk to patients about that. Because again, being in treatment, these are just examples, you can see some of the quotes in here about why for each of those domains I mentioned, some examples of patient responses. And so I think, kind of what can we do about this? So Dr. Dom DeFilippis, who is Dr. Liberto's second in command, his deputy director is an expert in MI. So he helped pull together a sample dialogue of how you can potentially approach this topic with folks. So again, this is a really nice approach as well that people can think about, particularly if you think a patient might be declining naloxone or harm reduction generally. I show this because whenever I present to VA staff, I say, we are never at a loss for having resources, so many, I've already mentioned a ton, but I put my name at the top and I make it very clear to them, there's a lot of stuff out there, I don't want you wasting your valuable clinical time searching for stuff because I can find it in a second. So just contact me. So again, we do have a ton of technical assistance and I think, again, having a champion who is available and supportive and can get providers across the country what they need. As long as I'm not presenting, I usually try to respond there, my number one priority because they're the ones on the ground getting the work done. So now I'm transitioning, how is that informing our work in SSPs? So just, again, if you think about it, I don't think I made it as crystal clear for you, but when we work on this, we think about it at multiple levels. So the first thing you see here in terms of the resources we have is the evidence. What is the evidence for this intervention? Next we have policy, so we do have a memo that supports SSPs and VA. We've created national SSP kits that help standardize, again, what is being given out. And we have a national note template, so again, similar to OAND, we made a national note. Similar to OAND, we made an SSP dashboard, patient and provider education, and again, have lots of technical assistance. And one of the things that's really awesome about the SSP sort of approach, though, is we do have a partnership with a research group, the Center for Health Equity Research and Promotion at Pittsburgh, who does amazing work, so we're really excited to have an external kind of evaluation team looking at how we're doing. And so again, just kind of a quick overview, what does this look like? So here's, we have a systematic review of the effectiveness of syringe services programs, so that is publicly available. Again, these are what our national SSP kits look like. We did consult with NASDAT and other community partners to get a sense of what are the kits that we should have. So we do have three types of kits, or three types of syringes, and then basically small and large, so 20 versus 100. So again, three syringe types and two quantity sizes. And so we also work with pharmacy to get this in the national drug file, that's huge. So that makes it really easy, and we also centrally funded it. So, and there's no copays in general for supplies, so it's fine in terms of like the burden on the patient, but we did have this centrally funded, which again, can be super helpful. What does our patient ed look like? So again, this is publicly available, safer injection practices for people who inject drugs, so this kind of goes over the key issues. We have a provider guide, similar again, how harm reduction and SSPs for safer drug use and infection prevention, a VA clinician's guide, great infographics, great background information to again, help with getting buy-in in terms of adoption and such. And this is what our national SSP note looks like. So again, I'll kind of focus, the one thing I do wanna highlight here is, given that this topic of this session is about emerging drug trends, we do have xylosine, I'm not sure you can probably barely see it, but on the left-hand side, xylosine is one of the ways, it's being routinely collected in terms of substances being used. So that's gonna be, I think, super helpful for us from an evaluation perspective. And we do have, you probably could barely see it, but there's this whole view, relevant patient information button, and that gives a host of information to the provider at the point of care about the last time naloxone was prescribed, last prep, last vaccinations, last STI tests and such. So really helpful information. I know we're blessed in VA to have this, but again, you could probably, depending on if you have an EHR, there are ways I think of leveraging your EHR to do something similar. And so what does it look like in terms of what's pulled in? We do have education topics, so state-for-use strategies, again, that SSP handout that I mentioned, infectious disease prevention, overdose education naloxone, and then resources to support substance use goals. So you can see here, again, we hyperlink at the point of care in the note template all of these resources to, again, make it easy for providers to have it at their hands when they're talking to patients or in a session. We have orders for additional harm reduction supplies, so condoms, fentanyl test strips, naloxone, additional sharps containers. So with this, we'll be able to better track what's being given out, and if there's anything we're getting a lot of others on, for instance, we can then think about, you know, do we need to make that more standard? So this also ends with additional orders, labs, and referrals. So again, just pretty much all that stuff that was in the view patient information is in here, and then we also have, again, referrals to a host of different places. And so what does the SSP dashboard, and this is, again, a dashboard that's available at every facility. It has a snapshot of clinical information for people with possible recent or active injection drug use. What's super cool about this is that it uses natural language snippets, so we do use, we pull some NLP into this so that at the top, you can see in the top right-hand side, if there are any note mentions of, you know, that might suggest injection drug use, it's pulled in so a provider can easily identify if a patient, and think through where, you know, and it has the date of the note and such, and the context, so people can kind of identify if harm reduction might be appropriate. And what's nice, again, is it has a host of harm reduction interventions listed that, again, can be helpful in what's been given and what could be considered. And like I said, really excited that Dr. Sherry Rogal from the VA of Pittsburgh is, that her evaluation team is helping. This is remarkable, folks. So they partnered with the HIV Hepatitis and Related Conditions National Program to identify effective implementation strategies for hep C treatment implementation, and like that graph is remarkable. I know that Dr. David Ross is super excited. I think he says he wants this on his headstone, like how much they've been able to really move on hep C treatment. And so again, they do these, what they call getting to implementation sorts of toolkits to help places. So again, they've worked also with HHRC on HIV prep, as well as improving cirrhosis care. So they were excited and thrilled that they're partnering with us to look at SSP implementation and how we can get low performing sites and more people on board. So as of August, 2024, we have 40 facilities in 25 states with SSPs. So just know that like not, SSPs are not allowable everywhere. So we do have 33 active and seven operationally ready SSP programs. So I'm gonna shift gears slightly to talk about again, the title of this session, which is emerging drugs. So we have done a lot in xylosine. So I think I'm not gonna give a whole bunch of background because this was mentioned by Dr. Baldwin briefly, but fentanyl adultery with xylosine was designated an emerging drug threat in April, 2023. So this required actually a host of things. Once something is designated as an emerging drug threat, I'm pretty sure this might've been one of the first times this was actually designated. It does require a response plan. And so the goal of that response plan is termination of fentanyl combined with xylosine as an emerging threat. And there are six pillars of action that are involved with that. And also with the goal, which is really interesting kind of participating in this is that they do have to say, we know what exactly that means. So it's a 15% reduction in xylosine positive drug poisoning deaths in at least three or four census regions. So again, there are six pillars of action that were developed as part of this response plan and VA was designated in three of those. So I'll kind of show you, we were invited to present to the FDA last year. And again, one of the domains testing, we have mandated already that fentanyl be included as part of VA's basic panel. We're gonna integrate point of care testing, when they become available. We've also been in consultation with our Office of General Counsel related to drug test strips. And we've also consulted with the National Institute of Standards and Technology, NIST, to again, with regards to testing and evaluation of fentanyl and xylosine test strips. Because as we note here, the major barrier to implementation from a national perspective is that we don't really have any sort of agency that evaluates or oversees performance on those drug tests. So if you're thinking like of writing a contract, it's really hard if there's really no standards out there. So in this next area that VA is involved with and named, evidence-based prevention, harm reduction, and treatment implementation and capacity building, again, we're using our work in naloxone to help with informing these efforts. We've already, I'll show you what some of the patient and provider education we've developed. We're also disseminating emerging practices related to addressing xylosine exposure. And we do have a communications plan as well to increase awareness of xylosine among both providers and patients. And so we are also looking at distribution pathways. Again, seeing if, you know, if or when there's any sort of standard that's developed, we can definitely help with making sure we procure and distribute via pharmacy and logistics. We also are, again, as I showed you, trying to track, figure out ways of tracking xylosine exposure and such. And I'm gonna show you some super cool work that's being done in how we're trying to use natural language processing to identify xylosine exposure. And again, I already showed you how we're collecting it in our clinical notes. One of the things we also had looked into, I have to double check where things are with that, was just improved coding of injection drug use. There is no ICD-10 code to track injection drug use. And so it was discussed at the September 2023 ICD-10-CM committee meeting. But again, that's one of the big gaps in terms of identification of patients who could benefit. So in terms of basic and applied research, this is a third area. ORD, our Office of Research and Development, development is a major funder of research, and they committed to supporting the goals of that response plan via its pain and opioid use actively managed portfolio. So they pulled in, this is a special consideration for studies that are looking at these different areas at the very bottom, very exciting. And again, the sort of patient and provider education, Dr. Gordon is gonna really be focusing on provider education. But just in terms of, I think this is just more just so you guys know that we do have some helpful xylosine patient guides and what people need to know and how to reduce harm. There's lots on how to reduce risk of harm as well as I think the big kind of, one of the big things, right, is what should I do if somebody has overdosed or is not responding, call 911 and use naloxone. And then also I think recovery position. And we're doing a lot in terms of educating on making sure, at least in terms of differentiating like non-responsiveness versus issues with respiration types of things to help with differentiating response. So xylosine, again, Dr. Gordon will be talking more about this, but there's a great provider guide that we have that was recently updated. And this is kind of the kind of summary slide. There's actually a lot out there about xylosine. I know it's a newer thing. But internally we have, this is what we have shared with our internal folks. We are working on NLP to again identify folks who may need some care. And so again, there's lots of great resources out there. Okay, so I'm not sure how many NLP folks are in the audience, but I was really excited to hear from the team and get this update for folks. So preliminary NLP annotation guidelines. So again, this is very preliminary, but I wanted to at least show you what we've been doing is we have an NLP that's looking at identifying suspected exposure, which is evidence that whether a patient has been exposed to xylosine or not. And so it looks for a positive assertion that it shows that there was xylosine exposure as well as a negative assertion, which is the absence of xylosine exposure. And then we have a whole host of things that are in other, which is xylosines mentioned in the note, but it's not in relation to exposure. So this is talking about education on xylosine risk, xylosine test strips, harm reduction. So there's, or someone else being exposed other than the patient. And so this is what the preliminary xylosine classification pipeline results look like. So of the notes that were examined, and you can see the dates here is from September, 2022 to 2024, there's a lot of notes that were scoured. And this is kind of what the counts look like. So about equal numbers of other and suspected positive exposure, and then some negative, suspected negative. So not as much of people saying that people don't have it, which makes sense, because you guys don't usually put in your notes when people don't have something, but usually when they do, and this just gives you an idea of the different types of notes that these came up in, in case it's helpful. And this is a preliminary Power BI interactive map showing suspected xylosine based on our LLM models. And so you can see, as would be expected, a lot of it is occurring on the East Coast, and you can kind of see those heat maps related to that. Okay, guys, that was, I'm now gonna shift gears to post-overdose care. So as, one of the things we're really trying to do in this, cause again, I think it's related, the reason I pulled this in, cause this is like, could be a whole talk on itself, is the fact that when we think about emerging threats, the thing about it is post-overdose care, we know is a huge, huge clinical touch point. And we know that the data out of Massachusetts, one in six people who die of an overdose had a non-fatal overdose. This data was also, I saw, I think I was doing the calculations while Dr. Baldwin was presenting, I think it's one in eight in the suitor's data. But again, I think that this is a huge opportunity for us as clinicians to really shift care and get people care that they need. So in VA, we have what's called the Suicide Behavior and Overdose Report. And this is, again, a national note template that does facilitate and streamline the process of overdose reporting across the VA, and helps make it more visible, and also facilitates real-time tracking. The thing that's really key to this, I think, is this Overdose Review Team. Every report, you have to click who should review this Suicide Behavior and Overdose Report. So we have an Overdose Review Team, and these have been stood up across our system, and for, I'm not sure if anyone in here is part of those at the VA, but really appreciate your efforts. We have a memo, you can see here, again, policy, a memo that went out to require all overdose events be reported through these national standardized notes. And also note that clinical staff must adhere to the overdose reporting and response in the VHA directive for SUD that Dr. Liberto's in charge of. And so if you scroll to the very end of that directive, which is available externally online, you'll see a whole section on what we're trying to do to improve post-overdose care. And I think the big thing, again, on the right-hand side that I'll probably emphasize is we do have a database risk review must be completed, and I'll show you some data about how that might be going and how we think this is actually, we have preliminary data that this is actually making a difference. But at minimum, the team must include representation from the VA Medical Facility SUD Program or a mental health provider who can facilitate rapid engagement in SUD care. And so the pieces that I think are, that we were added as well are C and D, which I think, again, given that we know that that period post-overdose is a very critical period, we do also require at least four mental health or SUD outreach efforts or clinical contacts within 30 days of discharge for patients hospitalized for an overdose, as well as those who are discharged from the ED or urgent care center. So again, really trying to bolster our overdose reporting and response. And I just like to highlight it's more than just documentation, because I talked a lot about these notes. And I think the reason why people use these notes, because again, it's really meant to be helpful to the clinicians. The thing about this is that if this, this is a whole section that if you don't, you can see, it's probably hard to read, but this section to be completed by the patient's treatment provider. Once that's clicked, if it's not clicked, it triggers a cover sheet. So you'll see in the renal record that there was an overdose event. So it makes it very clear and visible that there was an overdose event. But in terms of this section to be completed by the patient's treatment provider, most folks, I mean, you guys are all specialists, but outside of your areas, most people probably haven't been instructed on how to reduce risk of overdose, right? And so this goes through a number of the risk factors for overdose and what they can do. And the big thing to kind of take away is again, we have lots of resources and these are all hyperlinks. These are hyperlinks to main resources that can support clinicians at the point of care. And again, addressing these areas of risk. So you guys, substance use, there's a ton of things we have there for substance use, for mental health conditions. We have like VA mobile apps, benzodiazepine risk discussion, slowly stopping benzos. Pain's a huge issue. So we have a lot of pain resources. And honestly, the thing I'm probably most proud of is incorporating social determinants of health. So many providers may not know about all the amazing resources available for patients around homelessness. We have a national call center, justice involvement, family and social stressors, financial concerns. So there's a lot of resources available. So again, this helps with standardizing that across our system and also getting referrals. So again, we incorporate Naloxone and we have really excited. I like to always bolster the amazing work by these teams. So there was a paper that went out on the implementation and evaluation of these overdose review teams in one of the sites. And you can kind of see how many of those folks recommended, how many of those recommendations were actually implemented. Because again, this is an external team that is making recommendations and we're hoping that that actually does make an impact. So these are studies looking at that. And as promised, the potential impacts of SBOR completion and risk reviews, left hand side, a preliminary evaluation found that receipt of a case review within 30 days of an SBOR reported overdose was associated with a significant 38% reduction in risk of subsequent overdose. This is very similar. The reason we require this is because we have other data on our STORM, our high risk patients prescribed opioids that showed a 22% reduction in mortality based on STORM being case reviewed and having that STORM designation. So we are identifying that this does seem to be making a difference because we don't want to keep requiring something that isn't making a difference of our staff. We know it's a lot of time. And then on the right hand side, this is one that I like to end with. So in the study, my post-overdose care study, this I think just stuck with me. This is one of the veterans who had an opioid or stimulant overdose who said, again, we're looking, we're interviewing these patients to see how can we improve post-overdose care. And he said, most of the time, we don't know what's out there for us. We don't know what we qualify for. The only way we hear about it is through other veterans. So there's just so much we can do to help increase awareness about what is available. So thank you. That was a lot. But again, my email's there in case you guys have any questions. But yeah, I'm gonna hand it over to Dr. Gordon. Thanks so much. Wow, that was a whirlwind. I'm gonna end for the next 10 minutes. We decided to just go through the next 10 minutes and just continue the presentations and then we'll open up for discussions after that. We'll have 20 minutes of discussion. My presentation really is to describe a little bit about the trends we've seen in the VA with regards to movement of addiction care within non-specialty care settings. So SUD clinics traditionally have been where we have seen a bulk of SUD care in the VA for many, many, many years. But over the last eight years, we've really seen a push and a movement toward non-specialty care, primary care, mental health, and pain. And there are two reasons why I'm presenting this today. Number one, first, it's a harm reduction strategy in and of itself. If you move from programmatic care to more of an individualistic, face-to-face, primary care, mental health, or pain clinics, or non-specialty care clinics, it tends to be a little bit more harm reduction. Think of a primary care provider or even a mental health provider who's dealing with hypertension or depression. Oftentimes, you're working with that patient in order to reduce the risk associated with either hypertension or depression. And you use risk mitigation strategies in order to improve the healthcare. So that movement has been really to push more of a harm reduction approach to SUD care in the VA. Secondly, as you move into more medical care and getting out of SUD specialty care, you're getting a little bit more opportunities to address emerging threats. Xylosine is often a medical condition. You're seeing it in medical care, you're going into inpatient hospitalization, you're treating with wounds. And as you're engaging people in addiction care that are in non-specialty care settings, this is an opportunity to address threats like xylosine. Before I begin, how many of you in the room have actually addressed a patient with xylosine exposure with wound care? Anybody? One, I see a couple. Okay, so secondly, I have another audience participation. We don't have this slide in our presentation. How many, Dr. Baldwin mentioned a little bit about the percentage of people receiving medication treatment for OUD. I'm gonna ask you, in the VA, of the people who have an opiate use disorder as a diagnosis, what percentage of people are on medication treatment? So the percentage of people that are on medication treatment, whether it be methadone, buprenorphine, or naltrexone, versus the denominator of people who have an opiate use disorder diagnosis in the last year. Throw out, what percentage do you think the VA is doing right now? 8%? 25%, anybody else? What? Five, zero? Well, the five, zero person won. So we're approaching about 50% of people who are receiving medication treatment in the VA who have a history of an opiate use disorder within the last year. And that's a really remarkable thing. And part of the reason why I'm talking today is we're gonna show you how we've improved that access in these non-specialty care settings and driving it forward. Now, Dr. Drexler is in the room, so I'm gonna shout out to her that in 2018, there was a big push in order to think about how to address addiction care within non-specialty care settings. And the approach was to provide a step-care approach. Step zero is more of community care, AA, NA, self-help groups, et cetera. Level one care is really where patients often are seen, the VA, or healthcare providers. That being primary care, mental health, maybe pain clinics, maybe the emergency room, maybe inpatient hospitalization, hospitalists. And then step one, step two is SUD specialty care. So it's a very similar approach to that you would have with someone with complicated diabetes or even hypertension, for that matter. If you're in a primary care approach and you're working really hard to address that patient's hypertension and you can't get it down, you're gonna do, maybe you send it to specialty care. You may send it to a cardiologist or you may send it to an endocrinologist. It's an endocrinological problem. And you step that person up to level two care, and then if they get taken care of and they get addressed, then you can step it down to level one again. In a continuity care clinic, if you do recognize that addiction is a chronic medical condition, then longitudinal care is the best approach in order to address that on a long-term basis. In 2018, the VA adopted the Step Care for Opioid Use Disorder Trainer Initiative. This is funded by the VA central office as well as a query, which is a research shop to improve implementation of evidence-based practice in the VA. And this scout initiative was basically to improve medication treatment of OUD within the confines of these non-specialty care settings, primary care, mental health, and pain clinics. There's been a lot of work on the scout. We've actually just finished, we're actually finishing phase three, moving into phase four. But in the first phase two, we incorporated the scout initiative within 72 clinics across the country. This is in over 50 facilities across the country as of in 2022. And the whole point was to engage clinical care within primary care, mental health, and pain clinics to address medication treatment for opioid use disorder. Phase one and phase two has been a resounding success. The top graph here shows the number of buprenorphine prescriptions received by patients in these non-specialty care clinics, not the facility, but the clinics itself. And you've seen, even during COVID, we continue to have a rise in the percentage, or the number of people receiving buprenorphine care, particularly within these non-specialty care settings. And then if you see on the bottom, this is phase two, so the second wave. Again, a dramatic increase in the number of patients and providers, threefold, both in patients and providers actually either receiving or giving buprenorphine care within these non-specialty care settings. And we actually looked at some comparison clinics of clinics that were not engaged in the scout initiative through an external facilitation process and showed that the scout initiative really has driven in these special clinics much more than the non-scout clinics in order to improve access to medication treatment. This is the hot off the press. We've actually done a little bit more work in terms of facility variations. So we went into these facilities, and the VA has about 150 facilities across the country. We engaged in about 40 or 50 of them. And we compared the facility rates of medication treatment of scout facilities versus non-scout facilities. So not just the clinics themselves, but the facility, the culture of the whole facility. And we found that actually within the facilities themselves, if we were engaged with them, we actually improved access to medication treatment much more than the non-engaged facilities that were out there in the country. And then this is what I'm really most proud of. And I'm just gonna concentrate on the left side of the screen. This is where we're looking at buprenorphine prescriptions by the type of clinics where you're actually receiving it within the VA. In 2017, we recognized that about only 15% of SUD, buprenorphine care was actually provided outside of SUD specialty clinics. So about 15%. As of 2022, and I will tell you in 2023, we're about 50%, but about 40% in last year, in last year, 40% of all buprenorphine prescriptions were actually outside of specialty care, which is very impressive. The fact that we're normalizing this care within a longitudinal clinics, and you're improving the access of that care over time. And we've shown a lot of, you may say, well, how are you doing it? Well, we're actually, it's not a provider problem. You know, in many respects, models of care of how you address addiction care can actually be a team-based approach. Many insurers across the country are actually using a collaborative care stop code now, or insurance model, where you can provide this care by nurses, or provide it by clinical pharmacy specialists, or even social workers that are engaged in large healthcare systems that can do the bulk of the care. It doesn't have to be just the prescribers that's actually doing it. And we've done a lot of work in this area. I just wanted to make sure that you had this slide, that if you're interested in these collaborative care models, there's a lot of literature out there from the SCOUT initiative that can relate how we're addressing this type of care in non-specialty care settings. So with regards to the harm reduction approach in the VA, we've really had a great opportunity to provide through these new, novel, non-specialty care settings, low threshold care, or low barrier care, where there's not a lot of protocols, there's not a lot of programmatic care, and potentially a little bit more patient-centric, and provide the medication-first approach for patients. Second, as Dr. Oliva had mentioned, we've started to see SSPs actually not only in specialty care, but now in non-specialty care settings, and there's several SCOUT initiative clinics that are actually doing SSP within a primary care model, which would be unheard of in the VA as of 10 to 15 years ago. As Dr. Oliva mentioned, we have a huge OEND approach, OEND approach, we have about 10 to 20% of all buprenorphine care that's telehealth, and the key thing about all this movement is that you have an opportunity to address comorbidities associated with that care, particularly wounds associated with xylosine. So I wanna talk in the next couple slides, I expected that many more people here would have had a little bit more expertise within xylosine wound care, but xylosine is a very nasty medication to deal with, both on an acute intoxication episode, but also in withdrawal. And I wanna give four main points here that we need to address when we're dealing with how to address xylosine within the confines of the current epidemic that we're facing. Number one, first-line treatment obviously is to prevent the overdose. Now with xylosine, as you know, you may not, you actually may think, oh, I gave someone naloxone in the field and they're still sleepy, they're still not waking up. Well, it may be that xylosine intoxication that's causing that problem, it's not the fentanyl, it's not the carfentanil that's dealing with it. And we've seen many anecdotal reports where people are constantly giving naloxone, saying wake up, wake up, wake up, and they're not waking up. What they're really dealing with is a xylosine intoxication at that point. So you have to be aware of that, because of the proliferation of xylosine that you may have some problems with overdose prevention. Once this does occur, when someone does have xylosine intoxication, oftentimes much more than you do with a normal fentanyl overdose. So you're gonna have to deal, airway support, you may have to intubate the patient. You may have to provide really acute care very quickly, not only in the field, but also in the hospital. With regards to withdrawal, it can actually be very complicated. I saw some hands in here, people who have actually seen someone with xylosine. Have you dealt with opiate withdrawal? Has anybody dealt with xylosine withdrawal? Is it easy to deal with? Okay, everybody shake their heads no. Perfect, so it's not the easiest thing to deal with, because there's a lot of different things that you're considering. Number one, you're having to deal with the opioid withdrawal, right? And so you're giving people buprenorphine, or you're giving people adjunctive medications to deal with that withdrawal. And that may not necessarily deal with the xylosine withdrawal. Xylosine withdrawal can be very toxic for people. As many of you know, you'll have a lot of agitation, irritability, people are seeing things sometimes. It's very complicated, and it can be very individualistic. One xylosine withdrawal is totally different from someone else's xylosine withdrawal. The issue is that you really need to be very careful in supportive care, and often you're dealing with people within the hospital in this situation. You can provide primary treatment. We suggest right off the bat that you provide buprenorphine care for withdrawal management, or to initiate someone, rather than withdrawal, and initiate people on buprenorphine who are on fentanyl and are coming into the hospital. But you're also gonna have to deal with that withdrawal of the xylosine. So oftentimes you're providing alpha-2 adrenergic agents, such as clonidine, in order to prevent any of that alpha-2 antagonism, or agonism, that's now gonna be unsupported. So we provide clonidine, and we titrate to effect. Oftentimes you're providing a lot of benzodiazepines as well, just to reduce the agitation and irritability. With regards to tissue injury, it can be very nasty. Many xylosine lecturers often show these nasty slides of wounds, and it's pretty gross. It's really disgusting. I've seen many of them, actually, in the inpatient side, even in the outpatient side in the field. And they can be very nonspecific. Some of them can be very, like a little bit of irritation slash ulceration on the arm or leg. Sometimes it's actually necrotic all the way to the bone. It can be very deleterious. One of the things that we've actually found, though, is that often surgeons get really nervous about this. So they oftentimes just start to be debriding the wounds very forcefully, sometimes amputation to save people. And we've actually recognized that that's probably not the best approach for this patient population. It's actually much better, if you can, to try to have a limb-saving therapy, providing some wound care, moist wound care, minimal debridement is probably the best way to go. And then finally, remember that as people go into xylosine withdrawal and or they're engaged in wound care within the inpatient setting, often you really wanna see about transitioning that patient to outpatient care or SUD programmatic care, and that's really important. With that, Dr. Leva did mention that we have a nice brochure about what providers need to know about xylosine. We could be spending two or three hours with all the different complications, and the evidence really isn't that good right now about how to best approach patients with xylosine and concomitant opioid issues. This next four slides, I just wanted to make sure that you have it available to you in your PowerPoint or your PDF so you can look at it. It's a really good synopsis of kind of what you need to know as a clinician, but more importantly, how to deal with it both in the withdrawal period, but also with regards to the wound care that actually occurs. Very similar to what I just mentioned with the four points earlier, you're making sure that that's an opportunity to engage people in SUD care over time. With all that, I wanted to make sure that we have about 15 minutes left for discussion and questions, so I'm gonna open it up for the audience. Please feel free to come up to the mic. If you do do a question, it would be really helpful for us to just say your name as well as what your affiliation is or where you come from. We want to get to know you as best as possible and we'll open it up for all the panelists to answer. Thank you all very much. So why don't we go to the left side. Dr. Hagel. Hi, Holly Hagel. I'm from the University of Missouri-Kansas City and I'm the PI for the SAMHSA-funded Prevention Technology Transfer Center and also on the leadership team for the AAAP, who's the prime of the Opioid Response Network. This isn't really a question. It's more of a comment for Dr. Baldwin to maybe elaborate on. You mentioned the HIDAs have all of the public health staff on board and really they've been building this and it also goes to the comment that the gentleman made about tertiary prevention. Since 2017, and they now have certified prevention specialists in addition to the public health staff working on the HIDA teams and from our perspective, that means that they're looking at the whole continuum of care and that it really does bode well even with administration change and different terminology changes that we really maybe should go to the tertiary, the primary, secondary, tertiary on a population basis. Many of these certified prevention specialists that are on the HIDA teams have come through the PTTC networks, ethics training, just like any community coalition preventionist. So I see some optimistic forward momentum towards taking a more integrated public health approach. I didn't know if you wanted to elaborate it on. In 2017, I was at the Baltimore Washington HIDA and did their very first screening brief intervention referral to treatment. So it's not new and it's gone over several administrations and I just didn't know if you wanted to elaborate more. Yeah, thanks. Thanks for raising that. We couldn't, I couldn't agree with you more. One of the things that we've started to do at CDC is to leverage novel strategies. So if our state or local health departments, depending upon the, if the person, the person's lived or living experience prevents them from being hired, we've used alternate contractual mechanisms to make sure folks can both be on board and then importantly, we're working with SAMHSA right now to make sure they're compensated appropriately for their expertise and that's something that I think we've been very concerned about. You know, they are working professionals like all of us in this room, so giving them a target gift card is really not appropriate. I mean, they need to be paid for their expertise. Thank you. Let's go on to the right side. If you can, keep the question and commentary a little bit short so that we can get to all the questions and answers. Thanks. Logan Kinnamore, I'm a resident in Louisiana and planning to go into addiction psychiatry. This is kind of a counterpoint to the previous. Other than, well, one comment, I think changing the name harm reduction is going to be very difficult and cause rancor within the harm reduction community being that that term is by us, about us, nothing about us, without us and harm reduction started with people who use drugs. They were the original people providing syringes and I understand the need for semantic change potentially to make things more politic. So my question is besides name changing, what other bulwarks might there be within the CDC and within HHS to continue this work in light of political changes that might be coming? So for me, the short answer is that we have integrated harm reduction approaches in virtually every one of our large programmatic endeavors. And so it's core to what, so we would have to sort of disentangle the entirety of the infrastructure that exists for overdose data to action, the overdose response strategy, and even some programs like the drug-free communities that focus on youth and young adults. And we are now seeing, you know, those community coalitions support naloxone distribution across a wide variety of settings, including schools. I think Logan, your point's great. I would agree with you having, you know, the CDC was responsible in collaboration with SAMHSA to administer to support the National Harm Reduction TA Center. And we learned some really valuable lessons about how to work with community to make sure that that was structured and set up in a way that makes sense to be attentive to, frankly, the founding persons of the movement and make sure we did it right. So we've entirely pivoted that approach. We're using a hub-and-spoke model moving forward. And part of that was driven by community feedback to us that said, you didn't get it right. And you didn't get it right, and we're not, you know, we need to do better. And so we heard that, and we've pivoted. So I think it's, I'm trying to find the sort of sweet spot between, you know, recognizing harm reduction and celebrating the movement for what it is, but also be politically astute in the moment, because a worse outcome for me is that we don't do any of it. And so where, how do we do that? How do we be advocates for harm reduction and the founding of it, but also not potentially put ourselves at risk for not doing any of it? Yeah, thank you, and I think y'all are doing a good job of threading the needle so far. I just want to point out that the term harm reduction in the academic addiction world is becoming scrutinized a little bit. If you do give that a disease that we're dealing with, it's a chronic medical disease or mental health disease, do we call diabetes harm reduction, or do we just say disease improvement or quality improvement? And maybe that's, maybe to think of it a little bit differently as a positive approach rather than a reduction of harm is a better way of thinking of it long-term. Yeah. Or simply death prevention. Dave Conda, Phil Waco, Washington. Thank you for showing the energy, the skill, and the results in the federal agencies on saving people's lives. Much appreciated. I want to offer a modest contribution here. You may wind up carrying naloxone a long time before it's needed. Medications do not like to be kept in pockets at body temperature. You're not gonna get me and most other men in America to carry a purse. Therefore, I had a leather worker make me a belt loop, and that's how naloxone is on me whenever I am dressed for leaving the house. I would offer that as something to throw into your analysis. If you have a last mile problem where people who have naloxone don't have it when they need it, consider accessories that make it accessible all the time. Thank you. Dr. Leva, do you wanna? Thanks, that's super helpful. And we did look into giving examples, for instance, to VA police about, to make it easy for them to carry as well. So that's really good, and it's just giving me some ideas of what we can or should be doing to follow up and ask, because I do think that's part of the issue, right? We don't know when it hasn't been used per se, right? So I know some people are doing some QI studies. They have, people have fellows that are calling people to find out, you know, are they carrying it and such? So hopefully we'll have a bit more from some of the sites on, because that is a very important issue. So thanks for raising that. Our leather worker embossed this, naloxone saves lives, which is not as good a conversation starter as I expected, but it does start some good conversations. Thank you. Thanks. Thank you. Yeah, I'm Marcus Vicari. I'm a third year psychiatry resident at Beth Israel in Boston, also carrying naloxone and question related to naloxone. You know, I think there can actually be a little bit of a controversy around how much naloxone to give in terms of risking withdrawal, and especially in terms of xylosine, kind of mentioning that how some people can have xylosine on board, and so they might not necessarily respond to the naloxone. So I guess I'm wondering, in terms of in response to overdose, what is kind of the recommendation around how much naloxone to give if you suspect that part of their kind of non-responsiveness is related to xylosine? I'll go ahead and answer that. I think that's a great question, and it's something I alluded to in my presentation. There's a lot of debate, pharmaceutical debate, actually, about whether the naloxone doses are adequate with the amount of fentanyl that's on the street, and the carfentanil that's there, the potency. What generally is recommended if you're in the field, like EMS, is that you provide at least one naloxone administration of a normal standard dose. You may do a second one, but if someone isn't waking up, then that's probably much more than an opioid-related issue. So then you provide the supportive care. It could be providing airway support, et cetera, in the field for that patient, and just kind of be able to recognize it. Unfortunately, we don't have tests that automatically could do in the field that we could say, oh, this person has xylosine or not, but just be very prudent to know that you may have another substance on board other than the opioid that you're dealing with. Thank you. Thank you. Yeah, I think I'd just add to that, though I think that kind of from an educational perspective, it's are they breathing, right? If they're breathing, you don't need to keep giving them naloxone, and I think one of the most impactful presentations I've been to was early on when it was a nurse, street nurse, I think, out of Philadelphia was basically saying, if you think about it, just think about what it might feel like if you were basically immobilized, couldn't move, and people kept pumping you with something that was precipitating withdrawal. It's awful, it's awful. So basically, just thinking, I think the, I mean, I'm not sure if Adam agrees, but I think it's like, if they're breathing, which again, I know that there's some, you know, can layperson tell if someone's breathing, but usually, you know, if they're breathing, then it's unlikely, but again, it's always about calling emergency services right away regardless, just to make sure that they get some help. Yeah, just to point out that we've known about this substance for a long time. I mean, it's what's called Trank, that's the street name that's been on, it's out of Puerto Rico for the most part, kind of came there to Philadelphia recently, but there's been a lot of work in terms of how to deal with this type of substance, and you just have to be very prudent, knowing that you may not necessarily just have an opioid on board. Yeah, and if it's just helpful as well, if you look at the Compassionate Overdose Response, they have a paper that they put out, and these are, again, coming from community-based programs who are on the ground working with people who are actively using, who are saying, we don't need high-dose products. You know, just the standard ones are fine, so I would highly recommend that paper, it's really well-written. Aaron Stanley, I think, is, I can't remember who the first, yeah, yeah, yeah, is a first author, but it's a really good paper. There's a lot of controversy about the doses of naloxone. Let's not get into that, that's another symposium next year. Hi, Steve Wyatt from the Mountain Area Health Education Center in Asheville, North Carolina, and Dr. Baldwin, I was interested to see that North Carolina has had such a reduction in overdose deaths, it was pointed out as two states, and part of that that I see in North Carolina is Dr. Dasgupta's work at University of North Carolina, a colleague, that we're able to monitor what's on the street pretty easily. I mean, we've done a lot of work around that, but I just wonder if you have other comments about how North Carolina is in that position, and that I can take some information back to North Carolina, but also, you know, what are we doing that maybe is not being done in other states, just comments on that, I'd be interested in. Yeah, you know, I think Dr. Dasgupta's work is absolutely fabulous, both broadly in harm reduction and including the drug checking work. Part of what we're doing with Overdose Aided Action is to support more broad drug product and paraphernalia testing to understand what's on the street, and then ultimately educate back into the community. I think, Dr. Wyatt, you probably know better than I what is actually driving the decreases in North Carolina. It's just great to see, and the leadership of the state across the board has been fabulous. So, I've worked closely with Scott Preschel-Bell for many, many years. We went to school together, so we stay in close contact with one another, so it's great to see the leadership across the state coming together to make a big difference in North Carolina. So, would love to chat further, and maybe you can share with me what you think are on that list of top 10 that I said, suggested were drivers, maybe you have clarity on what is specifically beyond the harm reduction stuff that UNC and others are leading that is being done there by the harm reduction community. We have one minute left, so I think what I'd like to do is just, if you have any other questions, just come up to talk to us individually afterwards. I see the hook being pulled from the podium here. I just want to say thank you to our federal colleagues from the CDC and the VA for all the work that they're doing, and it's a great model of care, I think, to maybe emulate in other healthcare systems or in your individual practices, but more importantly, I want to say thank you. I mean, you all are on the front lines of all this stuff, and you're obviously passionate about your profession, you're at AAAP, and we hope that as a last, I guess a last symposium, we're excited that you stayed for the last symposium, and please save travels home as you go home to take care of your very vulnerable patient population. Thank you.

Veterans Affairs

opioid crisis

fentanyl

xylosine

overdose rates

harm reduction

naloxone distribution

substance use disorders

holistic care

syringe service programs

addiction treatment

veteran health

AAAP conference

xylazine

emerging drug trends

clinical innovations

Dr. Adam Gordon

Grant Baldwin

CDC

Dr. Joseph Liberto

VA

Elizabeth Oliva

naloxone

veterans