We'll, from Vancouver, we'll be talking about public policy and opioid psychopharmacology. I have no disclosures. The educational objectives of this session is that you'll understand the difference between legalization, decriminalization, and depenalization. You'll be able to critically assess the rationale and outcomes of decriminalization initiatives. You'll compare decriminalization initiatives around the globe, and you'll become familiar with harm reduction models. That really is the objectives for the whole workshop, but each, I think each presenter does not have objectives anymore. I think this was the objectives for everybody, but I'm not sure. Anyway, so the goal is is that each speaker is gonna speak for 12 to 13 minutes. Dr. Bunt is gonna have a little, he gets an extra minute or two because he has a poll that he's going to take afterwards, and then we want to open it up for a debate. The audience will be asked to share timed comments about the potential beneficial and detrimental aspects of decriminalization, mandated or coerced treatment, and harm reduction initiatives. I say each comment will be timed and limited to two minutes. I hope I can adhere to that. And an attempt will be made to alternate comments between beneficial and detrimental aspects. But of course, it's never that binary. Okay, I just have a few slides. Much of this is going to be repeated by the other speakers, but I wanted to put just definitions up in this kind of list way so that when it comes up throughout the other talks, you'll have seen it and you can refer back to this in the slides. Your slides are in the info portion of your app. Felony, typically defined as a crime punishable by a term of imprisonment of one year or more. Misdemeanor, often defined as offenses punishable only by fines or by short terms of imprisonment up to a year. Legalization, drug possession and use are legal. Regulations control production, distribution, sale, and supply. There are no penalties if regulations are complied with. Decriminalization, removing criminal penalties. The action remains illegal, but the legal system would not prosecute. The penalties can range from no penalties to a civil fine. Defelonization, drug possession penalties have been reduced from a felony to a misdemeanor. Depenalization, reducing but not eliminating criminal penalties. And then finally, quasi-legalization, which is the Dutch model where it's not legal, but there's no penalization. Three legal concepts to bear in mind. Harm reduction. This will be gone over quite a bit, especially in Dr. Matthews' presentation. Harm reduction aims to prevent overdose and infectious disease transmission and offer low barrier options for accessing healthcare services like syringe service programs, supervised consumption facility, safe supply, which he'll talk about. Diversion. These are de facto initiatives or de jure legislation that direct people away from criminal sanctions and toward services. This would be something like drug courts, which was mentioned this morning in the forensic symposium. De jure diversion is also considered legal coercion. That is, you can either serve time or you can do treatment. When there's decriminalization, you don't have this option. Mandated treatment, which Dr. Bunt will talk about in Florida, like the Marchman Act in Florida. Legal coercion is a form of legal coercion. There's mandatory assessment of up to 60 days inpatient for SUD. There's involuntary treatment, and then there's involuntary or assisted outpatient treatment like Kendra's Law in New York, but that is not a law for SUD, just for mental health issues. That's it. Oh, then quickly, the European experience. Also, this will be gone over by Dr. Bunt. The Netherlands never legalized cannabis, but developed a longstanding policy of non-penalization or the coffee shop system. In Portugal in 2001, there was decriminalization of low-level possession and consumption of all illicit drugs and reclassified these activities as administrative violations. But alongside with decriminalization, there was an increase in treatment. Dr. Bunt will talk about this more. When funding decreased for the treatment, the decriminalization didn't work as well. And as the Director General of Drug Policy said, if you decriminalize and do nothing else, things will get worse. In Canada, we'll hear about that from our two Canadian speakers, in British Columbia had a three-year exemption for decriminalization that began in January 23. Public drug use is illegal. People are not allowed to possess in public places, but you can possess small amounts of some illicit drugs for personal use. And then there's a certain amount of use that they're allowed to possess. However, Canada, or British Columbia, unlike a lot of other places, has a lot of oversight involved insofar as they want to research what impact this is going to have on their population. Will there be, to inform changes in law enforcement practices, pathways to services and treatment, they're using, I believe, maybe Dr. Matthew will tell us otherwise, using this as an experiment of sorts to learn how to better do this. The U.S. experience, we'll be talking about Oregon, which decriminalized from 2020 to 2024. They recriminalized in the setting of rising overdose deaths, and it was felt that the need for recriminalization was attributed to a failure to fund new treatments. Seattle, also from 2021 to 2023, or actually till September of 2023, made possession of drugs, made the, no state, there was no state law making the possession of drugs a crime. So that was an experiment that perhaps Dr. Buntin will speak more about. The U.S. experience, there's the Kensington area of Philadelphia, which is just sort of de facto an open air market, and the administration just said it's just too hard to clean it up, so they just sort of let it happen. There was no law involved. And that is all I'm going to say. I want to mention that in the back table, there's the ISAM brochures, the Hamburg Conference. Oh, okay, yes, yes. So the International Society of Addiction Medicine is an international organization of addiction medicine physicians, and they have an annual conference. The one in, the next one is May in Hamburg, and there are brochures. The deadline for submitting has just been extended from today to the end of the month. And public policy is a big topic of interest in the international addiction medicine community. So pick those up. And here is the former president of the International Society of Addiction Medicine. Do we have the clicker? Okay, thank you. So welcome, everybody, and in the interest of time, I'm gonna kind of race through some of these slides and the material. Now, one of our priorities is to get input from our colleagues in addiction medicine, and we value your opinions. And we believe that you have the qualifications, addiction psychiatrists, well-trained, to influence public policy best in relation to public policy about addiction treatment and co-occurring behavioral health disorders. So your opinions are very important to us. And time permitting, we're gonna have a survey of the audience and see where we all stand. Let me say that a lot of these issues are controversial amongst our colleagues. And I've had many discussions and debates, and that's why we felt this was very constructive. And I think we can learn from each other. And we do learn from each other. Our opinions and knowledge evolves as we discuss and debate these issues that are so critically important in terms of public policy and treatment. So in the interest of time, some of the issues are to be informed about harm reduction, decriminalization, and also points of views of the colleagues. We're gonna be looking in a comparative way of the Portugal model, Oregon, Kensington, New York, Florida, Philippines, and Malaysia for specific reasons. Now, APA says we should decriminalize addictions. We all, I hope, can agree we should decriminalize addictions. Where we're gonna disagree is how we define decriminalization. That's where the controversy comes up. And I'll be going through that. Now, decriminalization and legalization and depenalization overlap. But with decriminalization, what some of us define as recriminalization, others define as still decriminalization, not recriminalization. And what some of us define as quasi-legalization, others of us define as decriminalization. And that's where the controversy is. There are several types of treatment. There is the mandatory, legally mandated treatment. We have many forms of that from different courts, as we had mentioned. And then we have coerced treatment, where the individual is pressured into treatment. And then we have compulsory treatment, which is really even not treatment. It's like more boot camp experience. And a lot of the compulsory treatment centers are in Asia and very controversial. This is an example of coerced treatment. I urge you to look at the film. It's an ESPN documentary. Unguarded, Chris Herron, tremendous basketball player, world-class, got into addiction, and then he ended up in our treatment center in Samaritan Daytop Village. And he was really pushed and coerced into staying in treatment. He left the facility three times, got back. Both his counselor and his wife said, you get one last chance. You gotta decide, either your family or go back out and use. And so, get a hold of that film if you can. Now, is addiction a disease? We all agree that it's a disease. But what kind of a disease we disagree about. And here again, even with our colleagues in addiction medicine in ASAM, there are two different views of the type of disease addiction is. And we'll get into that. Harm reduction. We can all agree that harm reduction is really good, and we utilize harm reduction in every good treatment program. And it correlates very well with the treatment. Where there's controversy is whether harm reduction advocacy involves opposing any kind of mandated or coerced treatment. Some of those on the extreme of harm reduction regard any kind of mandatory or coerced treatment inappropriate, and that the individual should have the freedom to determine and decide treatment. Now, in terms of the debate we're gonna have, Thomas Paine, he who dares not offend cannot be honest. So, we're gonna offend each other in this debate. Patrick Kennedy, a real strong advocate and the Foundation for Drug Policy Solutions, meet them where they're at, but don't keep them where they're at. And Igor Kutsanok, a Ukrainian-American, talks about both emphasizing a public health and a public safety approach, that one only leads to either relapse or noncompliance. High attrition rates with public health, high recidivism with the safety. Combining treatment, supervision from a legal mandate, and treatment led to more success in outcomes with this study. And this is the International Association for Alternatives to Incarceration. And this is an organization you can access on the web, and you will find a lot of information about a continuum of treatment in the justice system that they advocate for. Community-based outpatient treatment, short-term, long-term residential, and aftercare. And that treatment needs to be effective, integrated with mental health, affordable, safe, healthy, and pleasant. Those characteristics are often lacking in treatment programs, and that's why many of them fail. This, again, is Architect of Portugal and the Portugal system, which was a model throughout the world. And they really established themselves as a leader in drug policy. Now, as Carol pointed out, there is, oh, this is Carl Fischer, Eric Fischer. He has spent a lot of time in Portugal, and he has this book, The Urge, which you should try to get a hold of. And it's an outstanding expert and speaker in our field. Portugal has an annual, or a biennial conference, and Dr. Weiss and Dr. Tensa spoke this year in Lisbon, and might be able to tell you more about it. It clearly improved overdose and treatment access over the years, but in time, because it was not properly funded, as it was laid out in the plan, the access to treatment diminished, and so now it's less effective in relation to alternatives to incarceration. Now, the Portugal model does emphasize alternatives to incarceration. They believe in giving the individual a choice between either going into treatment or they might have legal sanctions. This is opposed by some of the harm reduction advocates who are on the extreme. Now, in Portugal, there are some signs of evidence of public use of drugs, but the crime is not too bad right now. How it's gonna evolve without good access to treatment is not known at this point, but in certain public areas, you can see evidence of public use of drugs and addiction. So it's controversial right now as to how successful it is, but some of the scholars point out that the architect himself, Guileo, said that it is not a silver bullet if you decriminalize and do nothing else, things will get worse. Now we turn to the Oregon model, measure 110. Is everybody familiar with measure 110? This is a model that was voted by the public in Oregon decisively, 58% to 42%. Funded outreach services and decriminalized, but also had law enforcement severely restricted. It was deemed a failure by most and was reversed recently. Why? There's a lot of controversy about why. As you can see, some of the decriminalization advocates said that the treatment was not effective quickly, that the police were not trained, and that the pandemic and fentanyl were factors and unaffordable housing. So those were the advocates of decriminalization with law enforcement given the order to have hands off. The Oregon measure was studied. This is some research data that you can access but there are several viewpoints that it's a misunderstanding or insufficient measures or restrictions of law enforcement. Now Kotech reversed this and she's being criticized. Now here we turn to Kensington and Philadelphia. And here again, on the streets of Philadelphia, you can see in this documentary, really an abysmal situation. The mayor of Philadelphia now has reversed it also. And the harm reduction advocates say, you're recriminalizing it. But the treatment advocates say, you're not recriminalizing it, you're just giving them alternatives to incarceration. And it ties into the Zurich Needle Park experiment, which goes back into the 90s. City of Zombies was in the 90s. And here, even in the San Francisco Chronicle, are we repeating that in some areas where law enforcement is restricted. In California, only around 10% had access to treatment on the streets of California. I mentioned Philippines and Manila. This is not harm reduction. This is not decriminalization. Hard-nosed police. And you had treatment centers, but they were not funded publicly. So people didn't have access. In Malaysia, you had the death penalty. And a lot of controversy about that. You had the compulsory camps, like work camps, not treatment. In New York, we have, again, various stages where individuals can get referred to treatment. Here's the Samaritan Day tough. We have veterans courts and young mothers courts, treatment programs for civil court. In New York, there's a history. Rockefeller implemented the Rockefeller laws. The problem was the treatment was terrible. It was like a mandated, long-term work camp. And this is the experience that people had, either one of their prison or treatment. You take your pick, but they were both bad. Or here, oh man, the coffee is cold. In hell, you'd think one thing you could get is a hot cup of coffee. Well, they didn't get that. And some of the treatment programs, you can't. You can't get a cup of hot coffee. Standards, UNODC and our state department are working on it. Finally now, the Markman Act in Florida mandates outpatient treatment or residential by families. You have to take it to civil court. Advantages and disadvantages, controversial. But again, we can have a debate about that, whether that's a good thing for those up to 60 days. And usually in a good treatment center, families can advocate for a court to mandate people into treatment. And finally now, with Vancouver, they also changed their policy, in fact. And the mayor, Kim, said today's changes will make public drug use effectively illegal and provide the police with the authority. But while the public safety is a primary concern, we still invest in mental health and treatment. So that's decriminalization in their view, which some people argue is recriminalization. And here again, the Vancouver police chief. It is not compassionate to allow people who pose a serious and immediate danger to themselves and others, something that psychiatrists can relate to. So here are the references. And time permitting at the end, you can actually get your cell phones up. You can either join on the web by going to poev.com, and then you have to do Gbunt334, or you can text to 22333. The username password required is Gbunt334. Okay, that concludes my presentation. Yes, you can do it now. You should be able to connect. Should be able to connect. Pardon? The poll is locked, yes. And it will be unlocked at the end when our other speakers, but you can stay on. You can stay on. For the educational objectives, I'm hoping at the end you guys will be able to understand the different definitions of harm reduction, critically examine the evidence supporting safe supply, and understand the outcomes from safe supply. So really importantly, the views and opinions expressed in this presentation are those of myself and should not be attributed to any organization. So one of the first things I want to do is define terms. So when we talk about safe supply, what do we mean by this? So safe supply is not injectable opioid agonist therapy, which is a program that we have in Vancouver. It is not drug checking services. It is not safe consumption sites. It's not naloxone. It's not opioid agonist therapy. So for the purposes of this talk, safe supply is prescribed pharmaceutical grade drugs that are consumed by the patient for intoxication in an unsupervised manner. So this was the program that was implemented in Vancouver in March 2020. So I want to get some things out of the way first. So I work with Dr. Azar, and one thing that we want to make firm is that we are not against people receiving opioids. So Pooja is going to get into some details about this, but we're publishing papers about giving IV fentanyl to folks to control their withdrawal and cravings, especially when they're in hospital. So we're not against people receiving opioids at all. We're also not against harm reduction, but I think the definition of harm reduction can be problematic. So the standard definition, according to the International Harm Reduction Association, is that harm reduction refers to policies and programs and practices that aim to reduce the harms associated with the use of psychoactive drugs in people unable or unwilling to stop. And I think the word aim is the problematic aspect of it. I think what Pooja and I would support would be policies and procedures that have been proven to reduce harm, because there's a difference between the intention and something actually reducing harm. And I think this is something that's occurred in British Columbia. So what is the context that all of this has been taking place in Vancouver? So this is in 2020, and this is when Safe Supply came out. These were the comparative overdose death rates. And so the U.S. was the highest at 277 per 100,000 people. So at that time, British Columbia, the province that we're in, which is the equivalent of a state, had 344 deaths per 100,000. So this is a massive increase. In fact, on planet Earth, the only place that had a higher opioid overdose death rate was the Appalachian region in the United States. That's it. So this is higher than Oregon, higher than California, higher than Portland. So we had a massive overdose death rate there. So this was a slide I actually made in November 2020 talking about Safe Supply. And the assumption is that patients would use an opioid prescribed, such as hydromorphone, instead of fentanyl. They would substitute one for the other. And if that occurred, there would be harm reduction that would occur. So that was the first assumption. But there's other possible outcomes. So it might not decrease fentanyl use, and then the hydromorphone is used in addition to the fentanyl. And if that's the case, it's unlikely that harm reduction is going to occur. Or that patients may sell their Safe Supply to get more fentanyl. We didn't know if any of this was occurring at that time. And then Safe Supply might be diverted, creating more addiction in the population. So folks using fentanyl might not use the Safe Supply hydromorphone. And then finally, patients may use Safe Supply in harmful ways, causing more harm. So they might be diverting it and injecting it and getting infections and whatnot. So any evaluation of the program would need to consider all of these possible outcomes. So I'm going to go through the evidence, and I'm going to go through it in a temporal manner. So this is what was released at the time in British Columbia when we were looking at Safe Supply. So this was a poster presentation by Heather Pallas. And they looked at 2,780 people, and they looked at them over the course of five months. And what they found was that the overdose death rate was 0.4%. Now this was seen as, this is something that's very effective. But what if we drill down into these numbers? So of those folks, only half of them were using opioids. About a quarter of them were prescribed stimulants. Another fifth of them were given drugs for withdrawal management from alcohol, which I'm not sure if we can really call that Safe Supply. And then 12% were prescribed benzodiazepines in Safe Supply. So I'm an addiction psychiatrist, but I'm also a forensic psychiatrist. And one of the things that they try to drill into us in forensic psychiatry training is, what are the base rates? And one of the issues with that poster presentation was it wasn't compared to anything. So what if we looked at the base rates? I'm not going to go through it. You guys can have my slides afterwards and check the math and whatnot. But the base rate of overdose deaths was 0.2%. So 0.4 is actually much higher, but they were using that to backstop Safe Supply. The other thing is that 0.4% was only over five months. It wasn't over the course of a year. So it's likely a larger number. And then they didn't tell you what percentage of those folks were prescribed opioid agonist therapy, a proven treatment that can reduce mortality in folks with opioid use disorder. And as I said before, there were no comparison groups, and there were no objective measures. So in 2022, they gathered an evidence summary for Safe Supply. And I'm going to focus on this one part. And what they found was that Safe Supply reduced death and or overdose. So both drug-related deaths and deaths from any cause among people receiving Safe Supply were rare, and they had fewer overdoses. And so you can see the list of publications that support this statement. So I want to drill down into this. So the first part, both drug-related deaths and deaths from any cause among people receiving prescribed Safe Supply were rare. So if you looked at the Young paper that they referenced, there was no comparison group. And we saw what happened before when you don't have a comparison group. And in the Gomes, Kohler, and McCormack paper in 2022, there were no statistically significant difference in overdose death rate or all-cause mortality between Safe Supply and control groups. But this was a paper that they referenced to support the above statement. Then the other issue, the second part of the statement was that people receiving prescribed Safe Supply had fewer overdoses. What was that based on? So this was the list of references that they used. And they used a lot of qualitative data based on interviews. So these were semi-structured interviews. So I'm not saying that qualitative data or research is unimportant. I think that it can give you insight into the human experience of things. But it's not the same as objective outcomes. So talking to folks who use drugs and saying that less people, them self-reporting that less people are dying is not the same as looking at census data and seeing if less people are dying. One of the first ones that came out that they used to support Safe Supply was the Selfridge paper. And there was a chart review. And what they showed was there was a reduction in fentanyl use, but that was based on self-report. For about half the patients, they had urine drug screens. And when they looked at the urine drug screens of folks, what they found was that about the same amount were using fentanyl and hydromorphone at the same time. So when you looked at the actual objective measure and not the patient self-report, it actually came to the opposite conclusion. So then they had an evidence update. This was summer 2023. And again, it was more semi-structured interviews based on patient self-report that they were using to backstop this measure. And then the Lew paper itself said, the emergency shelter introduced safer opioid supply in combination with a safer use space for substance use, access to opioid agonist therapy, harm reduction supply distribution, and improved opioid toxicity response capacity, rendering it difficult to isolate the relative impact of each measure. So in that one where they showed that there was a decrease, there was a bunch of things that they were doing. And they couldn't isolate what the actual benefit of Safe Supply was. So fast forward to January 2024. So this was a paper published in the British Medical Journal. And this is some of the first objective data that they have regarding Safe Supply. And what they said in their results was that risk mitigation prescribing, so this is what they called safer supply, opioid dispossessions of one day or more were associated with reduced all-cause mortality and overdose-related mortality. In the subsequent week, so the effect was for one week, dispossessions associated with reduced all-cause mortality also occurred. But they didn't find a reduced mortality for stimulant prescribing. So for opioid prescribing, they found decrease in all-cause mortality and a decrease in overdose. But what if we drill down into this? So if you look on the chart on the left, when they controlled for folks who were getting opioid agonist therapy, what they found was that the effect was not significant. So if someone said that they had a cure for cancer, and then they controlled for standard treatment like chemotherapy, and then they didn't find a benefit, that's essentially what happened in this paper. This was another paper. This came out one week after the last paper, and this was also in January 2024. What they found was that there was an increased prescribing of opioids in British Columbia at the time, and they compared it to other provinces, Saskatchewan and Manitoba, and what they found was that there were increases in opioid-related hospitalizations in British Columbia. So it's hard to say what that's actually from because there's confounding factors such as the COVID pandemic and things at that time, but it's something to consider. And then this was based on coroner data, and they looked at the percentage of children who died from overdose, and in 2017, 2018, 2019, 0% of youth who died from overdose had hydromorphone in their system. In 2020, the year safe supply came out, it was 5.6%, and then in 2021, the second year, it was 8.3%, and then in 2022, it was 22.2% of youth who died from overdose that year. So what happened to overdoses in British Columbia writ large? In 2020, the year safe supply came out, so this was from the previous charters, 344 per 100,000, and in 2023, this increased to 440. So there was an overall increase. We don't know what this is from, there's a lot of confounding factors, but it doesn't Okay, so I'm going to sort of switch gears a little bit and talk about public policy, but how that relates to how we treat the patient in front of us, particularly through pharmacology. I think the point that I'm going to try to make is how policy has to evolve with our clinical needs and the impact that policy has in terms of our ability to treat our patients. So disclosures, I have done some consulting with Endivir for extended release buprenorphine studies. I'm going to skip the, okay. So a little bit about fentanyl pharmacology. I think it's important because we're going to talk a lot about fentanyl, is that there's a reason why fentanyl is so dangerous. It's a hundred times more potent than morphine, meaning that it binds onto the receptor, it has high receptor affinity, it has high intrinsic activity once it binds to the receptor, but it's also very lipophilic, meaning that it penetrates the CNS very rapidly. For all of those reasons, it makes it a very dangerous substance to use. And these pictures I'm sure you've all seen in the past, they just depict lethal doses of heroin versus fentanyl and carfentanil. And just in terms of the impact that fentanyl has had on overdose numbers, it's clear that with the prevalence of fentanyl in the unregulated drug supply, overdoses have increased. I remember when I started my addiction medicine fellowship in 2012, 2013, I really wasn't expecting to lose a lot of patients. Overdoses happened with heroin, but they weren't particularly common. And then the overdose numbers just spiked and it became very clear in real time that this is related to fentanyl. And we saw this transition where people were using heroin, and then they were using heroin that they did not know was laced with fentanyl. And then they were using fentanyl because they could not obtain heroin. And now we have a cohort of patients who have never used heroin before, and they've started using fentanyl, and they're using fentanyl now. This is a statistic that kind of hits me pretty strongly, and this is out of British Columbia. It says that overdose deaths are the leading cause of death in British Columbia for persons aged 10 to 59. That's more than homicides, suicides, accidents, and natural disease combined. The youngest person that I've had who's died of an overdose was 13 years old, and the oldest was in their 70s. So now I want to go through management of our patients from withdrawal to maintenance therapy and how policy may impact that. So withdrawal management, the mainstay in hospital, in the acute setting, is treating withdrawal through opioids, full agonist versus partial agonist. So now in the United States, according to the FDA Title 21 code of the federal regulations, essentially the bottom line is that physicians are able to administer short-acting opioids to hospitalized patients when they're given as indicated to their medical condition, meaning that if a patient is admitted, they have pain as a result of their condition, the pain can be treated with opioids. From my understanding, what many of my American colleagues have told me is that they cannot be prescribed solely for the purpose of treating addiction and withdrawal, meaning that if a patient comes into hospital, let's say with sepsis, there's no indication for opioids, then short-acting opioids cannot be used to manage their withdrawal if they use fentanyl and they're going into opioid withdrawal. In Canada, it's much different. The bottom line is in Canada, short-acting opioids can be used as per the physician's judgment. They can be used for withdrawal management, they can obviously be used for pain. Similarly, in our guidelines, it's recommended to use short-acting opioids when we initiate people onto opioid agonist therapy to manage withdrawal. So why is it so important to manage withdrawal in hospital and out of hospital with full agonist opioids? We saw this trend in British Columbia, and I'm sure you guys have seen it in your hospitals as well, where back in the good old days when people used heroin, you could manage withdrawal with oral morphine. So they would come in, they would be in withdrawal, we would prescribe morphine oral solution, 10 to 20 milligrams, Q3H, PRN, and that was adequate. Very quickly, oral morphine was no longer adequate to manage withdrawal as tolerances started to go up in the age of fentanyl. So then we started using parenteral morphine, then hydromorphone. Hydromorphone was adequate most of the time, but we still have encountered a cohort of patients where IV hydromorphone is no longer adequate to meet their withdrawal and to keep them in hospital. So we developed a protocol to use IV fentanyl, and here you see a picture of one of our residents with a giant syringe of fentanyl pushing it into a patient. So we're not going to go into the details of this protocol, it's beyond the scope of this talk, but we essentially created a protocol based on the pharmacokinetics of intravenous fentanyl to use fentanyl for the management of withdrawal in patients who use opioids in hospitals. So this was a patient who was admitted with sepsis. There's no indication for opioids, but she had a very severe opioid use disorder. She used fentanyl. She left hospital multiple times to use, and if she did not receive lifesaving antibiotics, she would have passed. So then we tried hydromorphone, it was not adequate. We used fentanyl, and we were able to keep her in hospital for her to receive her antibiotics with IV fentanyl, and then we were able to rotate her to methadone in the end. Here's an example of the doses we're talking about. So here's a patient who's receiving 8,000 mics of IV push fentanyl every couple hours to keep her in hospital. I took a picture of the EMR just because people sometimes don't believe me. On May 22nd, when she lost IV access, she left hospital to use, she came back, she got IV access, and we were able to keep her in hospital to receive the treatment. This is important because it objectively demonstrates the opioid tolerances that we're dealing with in the age of fentanyl. So in a hospital setting where policy tells us that we can't use short-acting opioids for the management of withdrawal, that's going to limit how we're able to manage our patients. This patient would not be alive today if we were not able to manage her withdrawal. So now hydromorphone is an important tool as well for management of withdrawal, and this is something that we use routinely. The doses we use are, I suspect, higher than some people here are used to. So for example, we'll use routinely 16 to 32 milligrams POQ2H PRN, half of that sub-Q, 8 to 16 milligrams, and half of that IV every 30 minutes just for withdrawal management. But we are now also able to use IV hydromorphone as a form of maintenance therapy in our injectable opioid agonist therapy program, which I'll speak to in a second. And just out of interest, IV hydromorphone is a little bit different than fentanyl in this setting because the half-life is longer. So when we titrate hydromorphone, we do have to be aware of accumulation versus elimination. So we've done some PK modeling. We've come up with a protocol where we now have a nanogram that can guide our dosing objectively based on our patients' requirements. So it sort of takes the guesswork out of managing our patients. And the point of this slide really is to demonstrate that we have developed safe ways to use high doses of hydromorphone to manage our patients' withdrawal. Okay. I'm going through this pretty quickly, and I have about seven minutes left, but I do want to talk about maintenance therapy and how things may differ in the United States versus Canada. Now, there's overlap. We both have buprenorphine. We have extended-release buprenorphine, and we have methadone for treatment. In the United States, you guys have extended-release naltrexone, which we don't have in Canada. In Canada, we use slow-release oral morphine. We also have the IOT program, so Injectable Opioid Agonist Therapy Program, using dicetylmorphine or heroin and hydromorphone. And actually, not on this slide, we also have a fentanyl patch program as well. Now, these other programs would not have been possible in a setting like the United States where there's restriction in terms of what we can prescribe for what condition. So now, in terms of buprenorphine management and policy, it seems to be not much different from the U.S. to Canada in the sense that physicians in the U.S. do need DEA registration. That includes Schedule III medications. And buprenorphine can be prescribed in any setting, not just limited to OTPs. In Canada, there is no requirement for any additional training or any additional licensing, so any physician can prescribe buprenorphine in any setting, in hospital, primary care clinics, et cetera. And of course, take-home doses are permitted in both settings. Methadone is a little bit different. From what I understand, in the United States, methadone is much more restricted. So physicians need to have completed training and have DEA registration. And methadone can only be prescribed in licensed facilities designated for methadone. That's different in Canada. In Canada, now, in this slide, it indicates that physicians do have to complete training and there is like an online training and two days of preceptorship. But in practice, as per our college guidelines, we actually don't need any additional training. So if a physician has prescribed methadone, they're comfortable with it, there's nothing preventing them from prescribing. So primary care physicians can prescribe it, addiction medicine specialists can prescribe it, and also it can be prescribed in any setting. It can be prescribed in a primary care setting, it can be prescribed in a hospital setting. You don't need a designated facility to prescribe methadone. Now, clearly, there is a treatment gap, both in the United States and in Canada, when it comes to management of patients on opioid agonist therapy. And this gap is patients who have opioid use disorder versus those who receive treatment. And as of 2019, about 86.6% of people with OUD were not receiving opioid agonist therapy in the United States. Interestingly, that number isn't much different in Canada, where about 80% of people are not on OAT. Okay, I do want to talk a little bit about, again, this business of in the age of fentanyl and the ever-increasing opioid tolerances, what this translates to in terms of dosing of our patients. Because what I've found, that dosing also differs quite significantly from the United States to Canada. Objectively speaking, with regards to opioid tolerances, let's take that patient who I described earlier, who was on IV push fentanyl. She was using approximately 48,000 mics of IV fentanyl per 24 hours. And when it came time to discharge her, we talked to her about converting her to methadone. She was in agreement, so we kind of used this formula to convert her to methadone. We used a 20% decrease for incomplete cross-tolerance, and the dose we came up with was 380 milligrams of methadone. And that dose is huge for those of you who prescribe methadone. But this is essentially mathematically what was required, and this is what we did. We rotated her from IV fentanyl to methadone, and she ended up stabilizing at 390 milligrams. We essentially reduced the fentanyl by one-ninth a day, and we added methadone one-third every three days. Now, obviously, I'm not advocating that this should be standard care for all of our patients, but this is what was required for that patient in hospital to stabilize, and her fentanyl use went down from almost 50,000 mics per 24 hours to 4,000 mics per 24 hours. So this led us to create a study. So we're doing an RCT. In a community setting, using the same protocol where patients come in, they receive IV fentanyl as a dose-finding tool to essentially objectively quantify their opioid tolerance, and then we convert them to methadone. Now ICAP methadone starts on day one at 200 milligrams. So now in this study, we routinely have patients starting on 200 milligrams of methadone on day one as their starting dose. But we have an objective measure of their opioid tolerance using IV fentanyl. This is all done in an outpatient setting. We've not had any bad outcomes. And frankly, 200 milligrams, I capped it because it was so far outside of the norm as a starting dose of methadone, but it doesn't seem to be enough. I do, for the last few minutes I have, want to quickly touch on a couple of other programs we have. So the IOD program, Injectable Opioid Agonist Therapy, using dicetamorphine and hydromorphone, this is nothing new. It's happened in Europe for the past maybe 20 years. It's been in Canada for the past maybe 15 years. And studies show that both dicetamorphine, or heroin, and hydromorphone in treatment refractory patients can be more effective than methadone. Now I should stress that these studies were not done in a fentanyl-using population. And the doses that I'm about to describe were determined, again, in a non-fentanyl-using population. But these are the doses that we use when we start people on to hydromorphone, Injectable Opioid Agonist Therapy. So this is like a typical starting dose of a patient where they'll come in. This is all done in an outpatient setting, and I've actually done this in a clinic through telehealth where I would assess patients through telehealth. There was a nurse on the other side who would initiate the treatment. So first dose, 20 milligrams of IV push hydromorphone, followed by another 20 milligrams if it's not adequate 15 minutes later. Three hours later, they could return for their second dose. Three hours later for their third dose. So as you can see, we're using pretty high doses in an outpatient setting in patients with established tolerance who use fentanyl. And there's an alternate program, which is a twice-a-day dosing. So you start at 30 milligrams, then you go up by 30 milligrams. And essentially, you continue to titrate patients until you meet their opioid requirements, meaning there's a reduction in cravings and withdrawal, or until you reach your maximum dosing, which is about 200 milligrams per dose, or a total of 500 milligrams per day. Again, I want to stress that this was done in a non-fentanyl-using population. Patients are, in fact, much higher now. And the doses described here need to be higher to address opioid requirements of our fentanyl-using patients. And lastly, I just want to touch on the fentanyl patch program, which we have in British Columbia. This is using transdermal fentanyl patches as a maintenance therapy for opioid use disorder. And the titration is based on unknown tolerance versus known tolerance. So unknown tolerance, you start at 25 micrograms per hour, and you continue to titrate up at those increments. For known tolerance, you can be a little bit more aggressive. But ultimately, it's not uncommon to see patients reach over 1,000 micrograms per hour fentanyl patch transdermal doses as maintenance. Now, that seems like a lot. I mean, 1,000 mics of fentanyl. But when you, again, look at the doses that was required in hospital by a similar patient, and this patient is receiving 8,000 mics IV-push fentanyl, and that's not uncommon. In fact, that's sort of middle of the ground. I've had patients that require upwards of 20,000 mics of IV-push fentanyl to get out of withdrawal and become comfortable. So I'm going to end there. But in conclusion, I think it's important to consider public policy as it regulates how we prescribe our medications for opioid use disorder, and to ensure that it advances with the needs of our patients, because we're in such an evolving landscape with the prevalence of fentanyl in the unregulated drug supply. Thank you. While Dr. Bunt is going to have you all work on the poll, I'm going to ask the presenters to sit up front. And I'd like you to, before we have questions, sorry I didn't tell you this sooner, come up with a two-sentence soundbite to prepare us for our debate in terms of what is your recommendation or opinion regarding innovative or alternative approaches to how we are dealing with the opioid use crisis, whether it has to do with criminalization, decriminalization. We should have short-acting opioids. We should have safe supply. We shouldn't have safe supply. Safe supply is a good thing. It's not a good thing. If you could come up with a two-sentence soundbite, and Dr. Bunt as well, in terms of what your take-home message is. And then we'll do the poll. The soundbites. Questions? Can we display, Diego, the poll on the screen? So did everybody have success in connecting to the poll? Anybody having trouble connecting, or is everybody connected? It should be open now. Did you connect? Okay. Anybody? Yeah, Diego? Okay. Okay. So, everybody's connected? OK, so you can join either by going to PollEV on the web, on your browser. And then you have to put in, after a slash, gbunt, it's 334, I believe. And then you can also text to 2233 and 3. And then you put in that password. Everybody is connected now? Okay, you can go back to the screen, Diego. Everybody has that information? Okay. Walk over to, oh, here we go. So my take-home message is the precautionary principle applies to things where there is a systemic outcome that can cause a large downside. And what that means is that we should make sure things are safe before we implement them. And so my take-home message is for harm reduction policies, we should apply the precautionary principle where there could be systemic damage that has large downsides. I think mine might be an extension of Dr. Matthews in the sense that we do need evidence-based public policy that governs treatment. But I feel like we need to have an ability for public policy to evolve as the needs of our patients evolve, because I think having too restrictive of a public policy with regards to particularly pharmacological management of our patients, which is really due to the expertise of the physician managing the patient, if that's too restrictive, then I think we're going to be not serving our patients to the best of our capacity. So more studies guiding sort of objective opiate tolerances and coming up with guidelines with regards to pharmacological management that's less restrictive. Thank you. Oh, he's still working on it. I think from my brief introduction, it's a little different from yours, that decriminalization has an upside and a downside. The downside is that, speaking of contingency management, you lose a certain degree of leverage in terms of drug courts, for example. The upside of decriminalization is that if you have treatment programs in place, it serves a purpose. And it's a good purpose. Decreased cost going into incarceration and things of that nature. But as the Portugal drug czar said, without it being linked to treatment and funding for treatment, it doesn't serve a purpose. It doesn't make sense. That's my take-home message. Now let's see. Now let's take questions, and then we'll go into a debate, because there was so much. Yes. I have a question. If Canada has access to methadone through any physician, why is there still the same-size treatment gap? to prescribe, it's still limited. So intense incentivizing physicians to take on these patients I think is important and that's something that hasn't happened in Canada. So I suspect that that has a large factor in this. It's a very similar treatment gap. Yeah, I don't know, Nick, do you have a...? Yeah, I would, I would agree with Pouya. I think one of the big barriers is just because you can prescribe something, it doesn't mean that you've had any training or experience to do it. So a lot of folks, even though they could prescribe methadone, it's still, there's a training gap and an experience gap and it seems like one more thing for busy physicians to take on. So and then I guess stigma also plays a role too, like a lot of folks might not want to deal with this population. So I think those might be the three main barriers. Thank you so much. My name is Ricardo Restrepo. I work in Long Beach, California at the VA system with veterans. What a great presentation and what an incredible opportunity to see what other people are doing outside of the United States. Sometimes we look at ourselves, but we don't look outside and this is really helpful. My question is related with education in the medical arena and I'm curious in your experience in Canada, how was your education to achieve this point in your career? And I'm talking about, you talk about how the systems are different, but I wonder when you were a meth student, when you were a resident, and now that you are attendings and dealing with public health, how has been the path to achieve this point in Canada? It's interesting because, Nick, you did your residency training in the U.S. It would be interesting to hear from you in terms of the difference between the, and now you're an attending in Canada. Sure, yeah, I did my training in the States. I did an addiction fellowship in the States. What I find is that addiction education, at least in my fellowship, was very broad. It didn't just focus on opioids. What I think in Canada, it's very much focused on opioids and the opioid crisis. So I think the focus might be different, but I think in general, with general medical I think one of the things that's different, it's also different depending on where you are in Canada and even in the same city, for instance Vancouver, two big teaching hospitals. In our hospital the focus is on sort of training the trainers. So we have a consult service where it's a complex pain and addiction service where we treat patients with pain and addiction who are admitted to hospital. But we have worked really hard to empower all the physicians in the hospital to have some comfort when it comes to treating patients with addictions. So we have power plans and pre-printed orders etc etc and we've done a lot of education within the hospital. So now it's routinely the internal medicine service will, when a patient's admitted with sepsis and they have an opioid use disorder, they'll start them on methadone or they'll initiate low-dose buprenorphine inductions and then they'll consult us. Sometimes for the basic patients they don't even consult us. It's interesting because that's actually much different than a different hospital in the same setting where they have a model where the addiction consult service, they're the only ones who treat these patients and then becomes much more restrictive. So I think and I'm the fellowship director for our concurrent disorders fellowship program in our hospital and a lot of it is training our fellows but also training them to train other people to expand the capacity for treatment. Questions before we try to have a debate? I'm not very familiar with the safe supply program in Canada but I guess one question I had maybe for both of you is if you could turn back time with the knowledge that you had like how would you revamp the program to be safe? I think there is an understanding that safe supply might work for some folks but I think we should have went through with it like we do with everything else in medicine where you have a small pilot study and you have the research infrastructure in place so that you can look at all the upsides and downsides. So I mentioned things like you know an objective question is are people substituting their fentanyl doses, their illicit fentanyl doses for hydromorphone and these things could be done with urine drug screens. You could do this objectively. You could monitor the price of hydromorphone locally and see if there's a drop in price. So one thing that happened was before safe supply hydromorphone was $20 a pill and then after safe supply like that summer it dropped to $2 a pill. Then a year later it dropped to $1 a pill and then in some places you can get five pills for a dollar. So there's been a class-action lawsuit that's been implemented and then safe supply has been kind of pulled back kind of voluntarily by the physicians and now the street price has gone up to $2 a pill. So like these are all objective things that you can look at and then you can look at well what are the predictive factors of someone benefiting from safe supply. What instead happened was this was implemented throughout the province and there was no research infrastructure in place and they were only trying to look at the upsides. There was no focus on what some of the downsides might be or whether to be honest for two years our provincial health officer was saying that diversion wasn't taking place and then in Parliament the associate chief of police said there was a doubling of the illicit hydromorphone supply. So I mean but this is something that's explicitly not looked at in the evaluation of the program. So again look at all the upsides, look at all the downsides, look at who will benefit, find the predictive factors, find those folks out and then expand the program. So start with pilot studies first is what I would do. I think one other factor is in addition to trying to understand how it would benefit the patients that are prescribed safe supply I think it's important to try to understand how the prescribing of safe supply would benefit those that are advocating for this type of policy. So for instance our provincial health officer sort of the highest public figure in terms of public health he, Perry Kendall, he had a for-profit pharmaceutical company, Fairprice Pharma. What did it produce? Heroin and cocaine. How can you sell heroin and cocaine using a safe supply program? The head of our BCCDC, Mark Tindall, also had a for-profit company. What did he produce? Smart vending machines designed to do what? Dispense safe supply. Both of them were heavily advocating for safe supply program. So I think it's it's really important to also try to understand bias that goes into public policy and conflict of interest in that regard as well. Yeah, my name is Josh Walther. I'm down in Dallas, Texas working in the VA there. Thanks so much for you know y'all's talks and sharing your experience with how things are going out there. I had two questions. One was you know kind of an extension of what you're just talking about but you know here of course you know we just had a very controversial election and you know homelessness, drug use kind of factored in and like public perception of all that. You know with kind of you know the statistics you were sharing in British Columbia, I was wondering if you could just share a little bit about what the like public sentiment is around all that. If there's like pushes for you know pulling back of some of these policies. Things like that and kind of how those discussions are happening in the public sphere and also kind of separate from that you know with these kind of more diverse you know opioid agonists therapy options. What what place buprenorphine has in your practice and like for who it's good for not good for with people who have such high fentanyl tolerance. So I think there were a couple of questions that I'll try to impact them. So the first one was regarding public policy. So as Greg had presented they pulled back on decriminalization. So our one of the most sympathetic groups in society are nurses and so last year 2023 in January they decriminalized the public use of drugs and what ended up happening was the nurses union started releasing memos that they were receiving from higher-ups. So for instance if folks were using drugs in hospital to not disturb them. If they had blades less than four inches to not confiscate them. Things like that and so then a lot of reports started coming out into the media in in April early April of this year that nurses were being assaulted. They were being threatened with weapons and public sentiment really started to shift and then you started seeing videos come out of folks smoking crystal meth in a Tim Hortons. So Tim Hortons is like a Dunkin Donuts and so you know you'd see grandma's children and three guys smoking meth at a table and then the other thing is you'd see at public parks people leaving used fentanyl needles there where children play and and so I think that kind of stretched the limits of public compassion and and so then there was a poll and a conservative government which never had any influence in British Columbia started gaining ground and two days after the poll the premier reverse course on on decriminalization. So I don't think they really thought through decriminalization. So if someone's you know in a hospital room there could be four people in a bed and you have your grandma with a broken hip and someone using crystal meth and someone using crystal meth you know blowing the smoke there a nurse would come in and say please stop using and the person would say no and then security would come and say please stop using and the person would say no and then they'd call the police and the police would say well this isn't a criminal issue and and so I think these are the kind of the elements that that really changed public opinion about that with safe supply that's kind of been relegated in that there's a class action lawsuit that's been coming out for folks who have been victims or face the downsides of safe supply and I think that's kind of decreased prescribing a safe supply to sort of a minimum but I'm not sure if it's ever gonna go away as long as it's it's legal so that was the the things regarding policy what were the other two questions yes so though the one class action lawsuit is so that there was a law firm that sued Purdue pharmaceuticals on behalf of the British Columbia government that same law firm is now suing the British Columbia government and the health authorities for safe supply and and so what they're gathering our patients who have been harmed by safe supply or you know there's children who've become addicted to opioids due to diverted safe so they're they're just gathering these folks and so I mean it always takes years to get through the courts but yeah I mean for me I feel like buprenorphine is one of mainstays of practice for myself so I work at a concurrent disorders hospital for people with severe mental illness and severe addictions the other place I work at is youth forensics so I do all of the prescribing for opioid agonist therapy in the province for youth and my mainstay of treatment is to try to get these kids on to supplicate because they often live peripatetic lifestyles where they're not gonna show up to a pharmacy there I mean so at least they have something on board where if they relapse it can possibly prevent overdose so that's what I'm hoping to do with a lot of the kids but buprenorphine is Puya's favorite molecule so I think two points to there's this narrative that buprenorphine is inadequate to manage patients who use fentanyl I think that's incorrect I've had many patients with very high opiate tolerances that as I've demonstrated who've done very well with buprenorphine I think we have to be a little bit sophisticated in terms of how we get people on to buprenorphine you know this expectation that people are going to go into withdrawal to prevent preceptor withdrawal you know I think that should no longer exist in fact I don't expect any level of withdrawal my patients who we put on to buprenorphine and we have low dose induction protocols within 24 hours we can get people on to supplicate without with zero withdrawal and yeah it's smooth it's autopilot so but if we're expecting somebody who uses upwards of 20,000 mics of fentanyl every two three hours to stop using have a period of abstinence going to withdrawal and then slowly titrate then I'm it's not going to be successful I don't think yeah so that's my point on buprenorphine was there another question around buprenorphine absolutely I do I do so again all of the studies for buprenorphine methadone we're done in non fentanyl using populations so yeah absolutely I do go above 32 starting dose is between 16 to 32 milligrams when we start patients and we do go above we just prescribe short acting PRNs for them to titrate themselves up we sometimes require short acting PRNs on top of the depot preparation extended release buprenorphine very rarely we've done double depots in our patients and this is something that we have to study and versus giving the injection every two to three weeks instead of every four weeks so those are different things that we're experimenting with as well yeah okay let's see we've had such a range of talks from speaking about cities in the US and in Europe that have decriminalized and then re criminalized on one end on another end we've talked about mandatory treatment in Florida Marchman Act and then we've also spoken about innovative and to some of us heretical concepts of how to handle opioid use disorder I know when I learned about injectable heroin as a as a public health policy in England when I was training we all thought that they were just dopes they just didn't understand the importance of long acting versus short acting so new models of how to treat if you all those of you who are have concerns about what's happening in the landscape as it pertains to cannabis which we didn't talk about or opioids please share your comments those of you who are happy and have positive things to say about what's happening in the landscape if you could share that is there anybody who would like to start I also think that some of the models that have already been looked at and evidently might have failed again are controversial and with the Oregon model in particular the the viewpoint that is very common is that it failed because not enough supportive services were provided quickly but then the other viewpoint is that the absence of legal restrictions and law enforcement the the law enforcement restrictions accounted for the problem that led to a lot of public use and distribution and when we say quasi legalization in in Portland and in Kensington there were actually a lot of dealers in the particular areas that were were kind of legalized in relation to the drug use so so there's that controversy now some of our colleagues believe in decriminalization meaning absence of law enforcement in those areas and others of us do not so we'll do this the old-fashioned way how many think you raise your hand how many think that the Oregon model failed yet you have two choices because there was a lack of support services housing treatment and how many think it was because law enforcement was hands-off and restricted those are two viewpoints so for those who believe that the failure was primarily due to the lack of support of services and treatment raise your hand in the Oregon model so we have okay we have quite a few and how many believe that it was because of the law enforcement restriction related to the failure of the Oregon model correct police are hands-off in these areas these areas okay there it is okay I don't know how you got that started but all right so we can we can You cannot expect a broken system to be installed, and then the broken system get defunded midway, and then expect good result. And then say, well, maybe that was not a good idea to begin with. The system is wrong. What part of the system? The system is— What part of the system is wrong? If you want to have it legalized, you try to decriminalize it. Because I want to, I can do. Yes, well access to treatment. Access to treatment, we all agree. But don't come to my child care. Okay, but the controversy is in these areas where you say you can go there and shoot up like in Kensington and certain areas in Portland and in Zurich, they had a lot of individuals shooting up, some overdosing, some involved in unsanitary conditions, drug dealing in those areas. So that's the controversy. Okay, so you you're trying you are of the opinion You're trying to cut the heads of drug dealers. You're providing drugs for these people. But why? Because an avenue to open a treatment. Okay. That's the case. But you believe then that law enforcement restriction should not be advocated by. The cop who is going to come and say I don't care because it's not legal, but the mother says, hey, look, I brought my granddaughter here to play this guy's shooting. I said, well, I cannot do anything. That's wrong. The law enforcement have to protect people, but also have to be a measure to get the addict in the right place to do the right thing. Okay. Others, others. We have three. We have. Ken, which model? The Portugal model. Portugal model. So the Portugal model was a model for the world. And I believe, I think most of us believe, it can work if access to treatment is available. However, the Portugal model does have law enforcement. That's opposed by the harm reduction extremists. They do not believe in any law enforcement in these areas. No police intervening. Now, that position has been changed in Oregon, you know, a liberal city by the mayor, in Philadelphia, and in Vancouver, where they have what is called recriminalized by the harm reduction advocates. But by the treatment advocates, it's not recriminalizing. It's still decriminalizing it. Like the Portugal model. That's a model. Why isn't it both? The combination, right? Yeah. Well, the combination. The combination is what is applied in the Portugal models, the combination of law enforcement plus alternatives to incarceration and access to treatment. It seems like, you know, I may be broadening the conversation here a little bit by this next comment, but it seems like our culture is, you know, we seem to be fairly divided as people in the Western Hemisphere these days. And it's either, everybody's like, well, it's either this way or this way. Well, in fact, life just isn't like that. I mean, for an example, people run red lights, no problem anymore in Connecticut. And I'm going like, even when there's a green light, I stop and look. So I think there has to be open access to treatment. I think it needs to be decriminalized. But there also has to be guardrails about, yeah, you can't use crystal meth in front of my three-year-old granddaughter. I mean, we have to have some compromise about what's acceptable and what isn't in our culture. And that's a bigger discussion. I don't think you can legislate that with one law or one way or the other. But I think there has to be some discussion about that and some, you know, reasonable out, you know, way of attacking it. I don't know what the answer is. Yes, yes. But what about in the areas in Portland and Kensington where you had particular specific areas where public drug abuse was open, police were hands-off, and that position was reversed. Do you agree it should have been reversed, or do you agree that it should have been kept there with more support provided? You know, the Savage Sisters, you know, are the voluntary group that go out there. They opposed it. You know, they go out there and take care of everybody. It became a drug marketplace, Kensington. That is what is the viewpoint. That's the criticism. And so we have to be able to control that somewhat, too. You can't restrict the drugs. There have to be clinicians there and support people who can help people make real decisions. But if they're being blatantly destructive, then you have to do something legally with them. Yes. Yes. Okay. Hi. I'm Bill Janger, an addiction psychiatrist from Thomas Jefferson University in Philadelphia. I would say, you know, we've talked about access to treatment. There is tons of access to treatment in Philadelphia. Say that again. There is tons of access to treatment in Philadelphia. None of our methadone programs are even 50% occupied. The city keeps talking about mobile methadone vans in Kensington. The methadone programs in Kensington aren't full. It is very hard to get patients into treatment and then to retain them. And so a lot of it is not just the drugs. I mean, it's housing, food. And then kind of what you were – I forgot who one of you two were alluding to. You know, things kind of happen on a spectrum. There is a very strong kind of ultra-harm reduction group in Philly where not only do they want to try to make it safer, they want to normalize drug use and say this is kind of an alternative lifestyle and we should do everything we can to kind of normalize this and make it safe. And harm reduction has almost lost any meaning. It is basically just used to say, you know, do whatever. And then there are people who do want treatment, but for whatever reason, they are not able to make it. You know, they live – they are homeless. We have people who are kind of tuned up in our hospitals. They are put on a decent methadone dose and they are sent to our program and they never show up. You know, so it is not – it is not just access to treatment. Buprenorphine floods the streets of Philadelphia. I can't get anybody onto it. Everybody is afraid of it because they have all tried it themselves because so many people have just kind of indiscriminately prescribed it. It is really hard to get people onto it. We can get people onto it, but it takes a lot of work. So I guess what I am trying to say is it is – for some reason, our treatments are not good enough versus what the patients are getting out there. It is not worth it to them and I am not quite sure what it is, but we can't just say we need more treatment. We need more access to treatment. Right now in Philadelphia, we can't get enough people into treatment. That is not the issue and I think some of it, I don't want to completely blame it on this side versus that side, but there is some normalization of this where treatment is kind of now seen as part of the system, the bureaucracy, and I mean let's face it, a lot of people with lived experience who are kind of more on the harm reduction advocacy side, they may even tell people don't go to a methadone program. You know, we have had a lot of people. I think, I would say I see a lot of my colleagues actually tell patients not to do that. Don't go to treatment. Colleagues meaning addiction physicians? Addiction physicians, you know, they – You see, that is where that controversy does still exist and in fact, even in ASAM, a lot of the medical doctors, the primary care physicians in addiction medicine believe that coerced or mandated treatment is not appropriate and fair for the individual because they feel addiction is like diabetes, a medical disease, which the voluntary treatment is good, they say, but you wouldn't coerce or force or mandate a diabetic because their blood sugar is out of control into treatment. The psychiatrists often believe that the disease is more like a psychiatric disorder or psychosis where judgment is impaired, where they are a danger to themselves or others either in the short run or the long run. And so, that aspect of coercion or mandation is controversial among our colleagues and the harm reduction advocates, even in our organizations, AAAP and ASAM, often believe that it should only be voluntary. All I would say is you see those pictures in Kensington, if that was your diabetic family member, I don't think you would want them to just stay there in that condition. I think you would take some control over their lives and push them, maybe even coerce them into stronger treatment. So, I don't know what the ultimate answer is. I'm not saying lock them up. There there is kind of a movement of well, you know Very, very good point and interesting perspective from Philly and Kensington. Thank you very much. We're staying, and if you want to continue with comments, proceed. Yeah, one comment I had, and one thing that I think is often missed, even in Vancouver and in other jurisdictions that have tried to emulate the Portugal model, is that not, like, there's pillars. including getting employers to hire people. in order to encourage people to give graduates from these programs purpose and a reason to stay sober and to maintain their sobriety and achievement. And I think some of these things just completely get omitted and are completely unfunded in these approaches that have tried to emulate what Portugal did and you're never gonna have success unless you're trying to hit the start, the end, and the middle of the treatment process. And if you're only doing one thing, you're not gonna be successful. Very good point, because access to treatment, some people think there is access to treatment as our colleague from Philadelphia pointed out, but access to comprehensive treatment, including all of those aspects that you pointed out, are often absent or not funded appropriately. And that then creates the problem. You have law enforcement, but what happens The whole gamut, the whole gamut. So... I guess the novel aspect of the Portuguese model is that they actually were funding into like... Sorry. year. That was a great model until they cut back funding. They did and now they've started to fail again right? That's the key. So your point is well taken. If you apply some law enforcement but you have access to a full comprehensive treatment program which can be long term for some with all those social services that can work but then if you take away one or the other that's that's the root of the failure I think in these models. Before we hear our last exchange hot off the presses just want to let Dr. Azar know that he has won a free dinner at the catch of the pelican downstairs because he has referred the most people to this conference by far of anybody we were told of your many talents of your many talents Dr. Azar. I told Dr. Azar I'm a fan of his and now doubly so. Okay last comment. Hey I'm Nicole I'm a fellow Canadian as well Tons of factors. One being with the law giving out tickets to people that were just like traffic tickets and never actually implementing the laws where they were supposed to go and engage in treatment and then not following up with the fines. So that's a really big factor is that as well. I would say one thing we look at and talk about quite often, I think as addiction psychiatrists, we really have the specialty to be able to understand our patient as a whole versus where we look a lot with addiction medicine and harm reduction, we're able to kind of extend our arm and do some of these kind of wild treatments like we're looking at methadone and really just kind of meet the patient where they're at, but then utilize our skills to know that the treatment isn't a one size fits all model and to really help them to move forward using motivational interviewing and therapeutic techniques. And I think a lot of the studies sometimes lose that. It's like fitting people into a category where we're better able to use our skills and use different things for each person to move them forward. So I think that's been a huge factor as well. But thank you so much for your time. Yeah, very well put. I mean, I think one of the... We're very good at getting people. Go to your papers. Yes, I just wanted to comment that your voice can be very important in influencing public policy. You're knowledgeable, you understand the big picture, and that's why your opinions are so important in getting that kind of recommendation to the public policy makers, so thank you. Thank you, everybody. Thank you.

Vancouver workshop

public policy

opioid psychopharmacology

legalization

decriminalization

depenalization

harm reduction

Dr. Bunt

Portugal model

Safe Supply program

British Columbia

treatment access

opioid use disorder

public safety