Opioid Misuse Prevention

Foreign. I'd like to welcome everybody to today's presentation on opioid misuse prevention. We are winding down our series for Recovery Month 2020. I am your host, Dr. Donnelly Snipes. In this presentation, we're going to identify the types of prevention. If you haven't been through those before, Learn the steps in prevention, understand why people use opioids. We can't prevent it unless we understand why they're doing it. Explore the connection between pain and mood disorders and hence partially the reason people, some people, partially explaining the reason some people use opioids. And identify five prevention strategies. Your prevention types. Primary prevention means keep people from developing a problem in the first place, which means keeping them from misusing opioids in the first place. Secondary is preventing the problem from getting worse if they start to develop a tolerance or dependence on opioids, preventing it from, from escalating. And then tertiary prevention says, okay, the person's substance misuse has progressed, they've got a problem with opioid misuse, but let's prevent them from getting other problems, including hiv, homelessness, stroke. There are a lot of things that can occur as the result of opioid misuse, especially your heroin and your other injectables. If you want to think about it that way. We're not going to go through a lot of pharmacology today, but it is important to recognize that opioid misuse has. Well, all addictions have far reaching impacts on the person. Physically, affectively, cognitively, interpersonally, environmentally. You know, it just, it affects every area of their life. When we're trying to develop a prevention program, the first thing that we need to do, and this isn't on the slide, the first thing that we need to do is do an assessment of our area. What are the needs in our area? What are the issues in our area? We're going to talk a lot about meta concepts and interventions later. But the needs and the problems in one area, such as rural Tennessee or Appalachia, are going to be different than some of the problems that are prevalent in a place like New York or Miami or even Nashville. It's going to be important to do an assessment. And if you go to SAMSA's website, the Substance Abuse and Mental Health Services Administration's website, they do have a section on prevention programs and they can walk you through doing that needs assessment. So that's the first step, is to figure out what the issues are. The next step is to raise awareness of an issue if it is, for example, homelessness or Chronic pain. You know, you want to raise the awareness of the issue and how it's connected to opioid misuse. We want to help people understand, for example, that opioid misuse doesn't happen just because of pain issues. Opioid misuse happens for a lot of reasons. So we want to help people connect the dots and see what the underlying issues are that are triggering or promoting this problem. The next step is to change what people know, believe and think about the behavior. We want to change what they believe, for example, about opioids. For the longest time we thought opioids were super safe. You know, think about 15, 20 years ago when you would have surgery, they would send you home with a big old bottle of opioids. Now they send you home with maybe six. We've developed much more knowledge about what opioids do and this is true for anything. It's not just opioid prevention. These, these steps are true for any type of prevention activity, whether you're talking about diabetes or high blood pressure or dementia. If you, you know, raise awareness and then educate people about the issue in order to help them make better health conscious choices. Teach the skills needed to perform the behavior. If people are using because of chronic pain, well, maybe they don't know any other alternatives besides opioids to treat pain. You know, a lot of people, their knee jerk reaction whenever they're in pain is to pop a pill. And it may be important to teach them skills to deal with, you know, non, non cancer related pain. Cancer related pain is something completely different. But what we're talking about here is, you know, what can this person do? Build a person's confidence in his or her ability to perform the behavior in a particular situation. Build their confidence to, to use that skill when in, when they're in pain. Maybe it's guided meditation, maybe it's massage, maybe it's heat or ice pack. Help them develop confidence that this other technique will work. Now I'm getting a bit ahead of myself, but I'll give you a hint here. A lot of people use opioids to address mood issues. So skills you might need to teach them or going through this, raise the awareness of the connection between depression and anxiety and opioids. How do opioids help people feel better? Change what people know, believe and think about opioid use and then teach the skills needed to address depression and anxiety other than self medicating with opioids. Build people's confidence in their ability to use those skills to address their anxiety or their depression. And then provide support for sustaining this new behavior. These new skills are very, very weak at first and it's important to help people understand that they're not going to be perfect at it at first and they're going to need support until they really, you know, become extremely proficient in using things like dbt, act, psychological flexibility, guided imagery, whatever tool or tools that you're talking about, understand the reasons people use. Now, acute pain management is one of those. When you have dental surgery, when you have any kind of surgery, a lot of times they send you home with a certain amount of opioids. When you're in the hospital, they're often giving you opioids intravenously or sometimes orally. So in the medical community they still do you use opioids. Opioids have a place in certain circumstances. I'm not saying that they are all bad. You know, right now, to the best of my knowledge, I'm not an anesthesiologist obviously, but to the best of my knowledge, we, we don't have anything that quite does the job of certain opioids, especially for acute pain. So there may be a, a time and a place for this chronic pain management. Now, there are a lot of people, and I wish I would have gotten that statistic for this presentation, but there is a significant portion of the population, if I remember from my one of my pain videos, it more than 30% of the population, I believe, experiences chronic pain. And chronic pain is defined as any pain that lasts for more than three months. Autoimmune issues trigger inflammation, that inflammation triggers pain in a lot of people think Crohn's disease or irritable bowel syndrome or fibromyalgia. There are a lot of things that are pain oriented and chronic in our society. Now we're going to talk later about what contributes to some of those things. What contributes to chronic pain? Acute pain, you know, that's going to be accidents, that's going to be surgeries, maybe even waking up, you know, with a stiff neck or something. You know, acute pain is identifiable and it ends relatively quickly. But chronic pain, there are a lot of triggers for chronic pain. Anxiety and depression are two other reasons that people use opioids. I have worked with dozens of people who have flat out said that the reason they use opioids is because it makes them feel relaxed, it makes them feel their uber selves. It takes that anxiety and out of the equation so they feel better, they're not always stressed out. We've also seen that there's a strong connection between opioids and depression remission, we've seen that there's a connection between depression and inflammation. Well, if we address some of this inflammation and we help people start feeling better and take away some of their pain, a lot of times their depression recedes. Some of that is due to calming down, tamping down, if you will, the HPA axis. So the body is not secreting the inflammatory cytokines, etc. And withdrawal. Let's face it, people unfortunately can get developed tolerance to opioids really quickly and you know, within a matter of days they've, they've seen that the body starts to develop a tolerance. That, that doesn't mean that they are, you know, irreparably addicted, but the body does quit or slow down its production of endogenous opioids very quickly. When you're taking external, you know, injectable or oral opioids, what does that mean? That means when you quit taking those synthetic opioids or you know, over the counter, not over the counter, but not endogenous opioids, that the body does needs time to get the clue and start making those endogenous opioids again, which generally are not as powerful as what you're taking in in a pill or in an injection. What you're taking in a pill or in an injection is between 30 and 400 times more potent than your own endogenous opioids. Those endogenous opioids are kind of like your pain tolerance. And when your body's really not producing them much then, and, and you're not taking opioids from an external source, then you're going to feel a lot more aches and pains. And you know, that's often referred to as refractory pain. It takes a little while after somebody stops taking their opioids to, for their body to, to start managing their pain a little bit better on its own. And this can be, if they're prescribed a long course of opioids and they take it as prescribed. But if they're on it for a long period of time, the body still adapts. Obviously if they're abusing opioids, you're going to see the same refractory pain. Anxiety activates the HPA axis, your threat response system. This increases inflammation, which makes sense. Your bot HPA axis prepares you to fight or flee. And immediately when this happens, the cortisol secreted, norepinephrine secreted, dopamine secreted, you are prepared to take on whatever that threat is, ideally as when the threat is passed The HPA axis kind of winds down and then it secretes the inflammatory cytokines throughout your system. The goal of those things is to go to wherever in the body was injured from this fight and that you allegedly had and repair it. Unfortunately, when people are chronically anxious or in chronic pain, those inflammatory cytokines are just kind of always going through the body. So there is increased inflammation, increased levels of cytokines, and they can measure that with a blood test. Increased levels of cytokines in the body. When people have chronic anxiety, chronic stress, chronic depression, chronic pain, it's important to recognize that because those inflammatory cytokines, that inflammation can also trigger autoimmune issues and is associated with increases in depression. Interestingly, and I'm not a fan, this is my personal opinion, obviously there is some literature behind it, because ketamine clinics are popping up all over the place right now, which is, again, I'm not a fan, but it is what it is. Ketamine is a really powerful anesthetic. It's basically, we always used to call it a horse tranquilizer and it's what vets use in the field to literally tranquilize horses for surgery. It is a powerful anesthetic that's used in pain relief, but has shown significant promise in the treatment of acute suicidality. They've done a lot of studies and they've shown that with a ketamine nasal spray or an injection or an IV drip of ketamine, that acute suicidality and treatment resistant major depressive disorder does show significant improvement in a fair number of people. I'll just leave that at that. I mean, that's going to be between somebody and their doctor. The point I want to make is that if you've got, got somebody with depression, we know that one of these drugs, you know, ketamine, actually does directly impact their mood and in short order. So let's think about what are people doing when they're injecting heroin, when they're taking, you know, OxyContin or fentanyl, you know, sometimes they may be addressing their own mood issues. So it's important that we recognize that even if somebody doesn't have pain, which they're going to have some pain if they're addicted to opioids. But if you're preventing it, if we're talking about early stage prevention, we need to be aware that if they experiment with opioids and they find that, hey, this makes me feel pretty good, then they are at a much greater risk of self medication. I will tell you for Me, and I'm one of those people, I take one Benadryl and I'm out like a light. You know, I'm, I'm a lightweight when it comes to a lot of medications for some reason. But there are certain types of opioids that I've taken in the past after a surgery or whatever that I can tell you. That certain type of opioid, I can see where people could get addicted to it because I felt, felt really good. You know, I didn't feel like I had a care in the world. I was like, I kind of like this feeling. I can see how people would get addicted to this and other types of opioids I've taken. I didn't have that same reaction. So it's also important to recognize that if somebody's prescribed opioid X after a surgery and it has no effect on them, and then they have another surgery and they're prescribed opioid Y, it may have a different effect. So they may be more prone to misuse with opioid Y if it, you know, produces that anti anxiety effect and, you know, that's rewarding enough for them to try to engage in drug seeking behavior. Just kind of an interesting side note. What do we do? Well, pain, anxiety and depression are three of the main reasons that people use opioids. They don't wake up and say, hey, I want to get addicted. They wake up and they say, I need this dysphoria. Either physical pain or emotional pain. I need this to stop or at least, you know, be mitigated a little bit. What we can do, we can help people reduce inflammation. When that HPA axis is activated, inflammation's going up. When we've got an injury, when we've got something wrong, inflammation goes up. There are a lot of things that can contribute to increased inflammation. What do we know? We know that anxiety and depression are associated with increased inflammation. So we can teach emotion regulation skills, skills so people can start learning techniques to regulate their HPA axis. That begins with mindfulness, being aware of how they feel, noting, you know, when I get angry, these are my physical symptoms. When I start getting angry, these are my physical symptoms. When I start feeling depressed, these are my cognitive, my thought symptoms. When I start getting angry or anxious or depressed. Encouraging people to identify their early warning signs, if you will, of dysphoria is going to be really important. Emphasizing with people that emotions are natural, emotions are normal. And I always go through this because too often we talk about eliminating depression or eliminating anxiety. Well, we don't Want to eliminate it completely. Those are natural emotions. People are going to get angry occasionally. It's what they do with it. So learning that mindfulness, becoming aware of what it feels like for them when they're starting to get angry, learning how to notice that and accept it without judgment and say, okay, I'm angry now. What can I do to improve the next moment is going to be really important. Helping them recognize that anger and anxiety, those are two emotions that are designed to protect us. So they're not going to go away completely. We have certain parts of our brain that are wired just for, you know, identifying threat. So those things aren't going to go away. But we don't have to nurture them. It's when we nurture them and hold on to them chronically that we increase the cortisol, we increase our everything, all of our excitatory neurotransmitters and our inflammation. Helping people develop those skills, anti inflammatories have shown some promise in actually helping people improve their mood. Now, I don't know about you, but when I'm not in pain, I tend to be in a better mood. You know, pharmacokinetics aside, I tend to be in a better mood when I'm not in pain. But they do have shown in, in studies that anti inflammatories, even if somebody is not noticing their pain, if they've just kind of got this generalized systemic inflamma, high levels of inflammatory cytokines, when they're given anti inflammatories, it does help with their mood. Am I saying go out and start taking anti inflammatories every day? Heck no. They have side effects. It's something to talk about with your doctor. You know, it's not something to take lightly, but it is interesting to note that the connection, the strong almost one to one connection between inflammation and dysphoric moods now improve nutrition. This is something that everybody can do. Reduction of highly processed foods. When we eat highly processed foods and our blood sugar levels go up really fast, things that have a, a lot of simple carbohydrates, things that have a lot of refined sugars in them, that increases our blood sugar. When our blood sugars increase, that actually increases systemic inflammation. So that's one thing people can do, increase raw fruits and vegetables. You know, obviously some people can't handle raw fruits and vegetables because they've got gastric problems. But if you can, fruits and vegetables have phytochemicals in them that assist in fighting inflammation. So your colorful fruits and vegetables, the darker the color, the better it is for you. Why do I say raw? Because a lot of these chemicals, when they're exposed to heat, actually break down. Vitamin C breaks down a lot of your vitamins, B vitamins break down in the presence of heat. So when you can eat things raw, you're getting more of those nutrients. And if you need to cook them, cooking them only lightly, you know, don't cook broccoli until it's gray. You want to have it be a bright green. Vitamin D is repeatedly associated with not only seasonal effective disorder, but also inflammation. Vitamin D levels help reduce inflammation. Remember vitamin D we mainly get, or most effectively get from being out in the sun about 10 minutes a day. I'm not, you know, we're not talking about sunbathing, we're talking about walking to your car, to your office, to the grocery store. You know, just doing your daily activities generally gets you enough vitamin D. Vitamin C is associated with improving your immune system, reducing inflammation and helping to maintain cartilage. Why is cartilage important? Well, if you're older like I am, the cartilage starts to wear out and break down and that starts causing pain in joints. So vitamin D, Vitamin C is great as a primary prevention for things like different types of arthritis. Vitamin C can be found in your fruits and your vegetables. You know, it's, it's pretty ubiquitous. Vitamin E is found in nuts and seeds and as well as omega 3s, these are also both associated with reductions in inflammation. It's important to remember that our body absorbs things that come from natural sources much better than from pills. So if people can get their vitamins from eating a healthy diet, that's obviously preferable. Things like vitamin E. Vitamin E is fat soluble, so it actually builds up in the body and you can overdose on things like vitamins A, E, K. So I don't recommend that people just willy nilly start taking mega doses of any vitamin out there without consulting their doctor first. Omega 3s have a lot of research behind them for brain function. You know, DHA is one of the omegas. There's a lot of research behind omega 3s for cognitive functioning as well as for reducing inflammation. Omega sixes, which are more plentiful in the American diet, are associated with increases in inflammation. So you want to, you may not be able to completely reduce your omega sixes, and we need some of those anyway. But you want to have more omega threes and that's, you can consult with a nutritionist to, or your clients can consult with a nutritionist to identify what they might be able to include in their diet like chia seeds or walnuts in order to increase their, their, their omega 3s. The next strategy is to improve health literacy. Less than 20% of the American population is health literate. We are not very well educated on a lot of, you know, basic things like nutrition. I can't tell you how many adults I've talked to who haven't known which foods contain carbohydrates or the difference between proteins and carbohydrates, or what they need to do to exercise. So there are a lot of very basic things that would help people to know about. Our culture is also very inattentive. We haven't the attention span for the most part of a gnat at this point, I think. So keeping things down to small chunks, Instagram images, things that can be said in 140 characters or less seem to be where people are. They've nicely started to call that micro learning. Whatever. We want to get information out to people. Most people prefer, you know, their day to day learning to be in small little snippets. Okay, so that's fine. Social media, Instagram, tick tock, LinkedIn, Facebook, however, we can get it out to people pushing public service announcements, if you will, that in improve health literacy. Teaching it in schools is super important and it's easy if they want to to incorporate health literacy information into schools. When you're talking about nutrition, for example, there's a lot of fractions involved in measuring, you know, a half a cup or a cup or two cups. You know, you can do fractions and also talk about nutrition at the same time. Yes, it would take a little bit of work on the front end, but it can happen in reading. You know, people can read books that teach about coping skills and proper health and sleep hygiene and all those things. It's real easy to. Or it would be really easy for somebody to write a book geared towards elementary school children that teach some basic health literacy information. And then mainstream media back in the day, I don't know if they still do it because I don't watch regular TV anymore. But back in the day CBS used to have these public service announcements because we care that were promoted periodically. I remember one that was particularly poignant was a particular news anchor sharing his experience with clinical depression to try to destigmatize it. But mainstream media is in the perfect position to provide micro learning through public service announcements. And a lot of people watch the news and you know, you have that segment, the one I look forward to is the one with the pets every week. But if you have a segment every day or every week, 30 seconds, two minutes, that provides a tip or tool for health literacy, it would go. It adds up. Over 365 days it adds up. And we can work with our local mainstream media, your local CBS affiliate, your local Fox News affiliate, your public television stations, your radio stations to get some of these things pushed out. Schools are a little bit harder, but social media we can do on our own and we can also work with mainstream media. So what are we teaching? What things are we promoting? Physically? We want to talk about vulnerability prevention, which comes under adequate sleep, proper nutrition, exercise and guess what? Breathing and pain management. Educating people about the multitude of non pharmacological interventions to help with pain. Affectively, we can give little snippets. I mean it's not hard to teach and a particular skill in cognitive behavioral therapy or like and help people learn it. Distress tolerance. You know, you could focus on one of the acronyms that Linehan created, the accepts or improves in a brief little public service announcement. There's no other better word I can think of for it right now. Cognitively we can teach and affectively we also want to teach people that it's important to add in the happy. It's important to develop what I call happiness habits. Cognitively we can teach psychological flexibility and cognitive behavioral skills. Environmentally, we can help people learn about the impact of things like low light and how that contributes to seasonal affective disorder or noise and how increased levels of noxious noise, whether it's road traffic or the railroad or whatever it is, actually increases people's stress levels and has been associated with significant increases in prescriptions for antidepressants. So we can start helping them learn how their environment contributes. It can trigger either happiness or it can trigger distress and interpersonal skills. Teaching about boundaries, assertiveness, attachment. You know what attachment is? You have to break it down a little bit if you're going to do it in micro, micro learning units. But it can be taught and it can be taught in, you know, three minutes or less. Just you have to have installments every day for a while to teach a big concept like that. Another prevention strategy is the development of opioid alternatives. There is a company called Pain Reform right now that I am super excited. They are working on, I believe they're in phase three clinical trials right now on an extended release local anesthetic. So it's an anesthetic that after surgery the doctor puts in this. I don't Know if it's a vial or packet or whatever, they put it into the wound before they suture the wound. And the extended release has taken it from a three hour window of activity where it only works for three hours to 72 hours. Now think about when you got your wisdom teeth out or when you had other surgeries. A lot of times the worst pain, the pain that you may or may not have needed opioids for was probably that first 72 hours. So this extended release local anesthetic keeps that area numb for the full 72 hours, hopefully eliminating the need for people to have take home doses of of opioids. Hopefully after that period they're able to address it with over the counter type medications. So I'm so excited and I can't wait for that to actually hit the market. But I digress. They've been testing it on herniate people who've had hernia operations. Most recently, CBD oil has been associated with a reduction in pain. It activates your endocannabinoid receptors which are in part associated with pain reduction and mood improvement. CBD oil does interact with most medications. So this is something that's really important for people to talk over with their doctor and not just add it to whatever else they're already taking. It's also not regulated like your prescription medications. So it's really important to fig find a reputable supplier of CBD oil, not just the CBD oil that you can pick up at the local, you know, corner store. Gabapentin is a medication that's a non opioid that has been shown to have a lot of promise with neuropathic pain. Pain associated with nerve damage, not so much with something like a broken arm, but with nerve damage. Muscle relaxants, those tend to be more helpful for people who have pain such as low back pain or muscular pain because they strained, sprained, tore, ruptured a muscle or a ligament. Muscle relaxants can be helpful for pain. Some people, there's been some research out, out there for people who've used muscle relaxants for things like chronic stress headaches. They don't seem to really do a lot for migraines, but that's an option that's out there. Can they be abused? Well, yeah, I think just about anything can be abused, but there are much lower abuse potential than opioids. Antiepileptics like Lamictal is another, are another class of medications that have shown some promise in pain management other than opioids. Acupuncture has a lot of research behind it for helping address pain, especially chronic pain and, and multiple different types of chronic pain. If you go to PubMed and you type in ACU, acupuncture and pain, you will come up with literally hundreds of articles. Chiropractics is also helpful, particularly for people who are experiencing pain in their, with headaches, pain in their neck, pain in their back. Chiropractics can be extremely helpful at trying to rebalance that musculoskeletal system. For people like me, I've got scoliosis. Chiropractics can, can be really helpful. They also have now inversion tables. You know those tables where you put your, put your feet in and you tilt backwards to take the pressure off your spine. Some people have reported that that really helps, especially if they've got low back pain. That's up to them to, you know, think about whether they want to try management of mood disorders and other substance use disorders. A lot of times opioid misuse does not occur by itself. It occurs with abuse of other substances, substances and, or with concurrent things like anxiety or depression. Ideally we would start screening for and addressing mood and addictive disorders in all people. So a universal screening at their annual physical. You know, children have to have annual physicals for sports and things. So they're going in theoretically as adults. We're supposed to go in for annual screenings, but it would be nice. And these screenings for mood and addictive disorders don't take long. There are a lot of brief screening instruments out there that the nurse can do or CNA or whoever it is that's, you know, taking your blood pressure and your temperature and everything else while you're waiting for the doctor. So it shouldn't be a huge imposition. We also want to improve access to mental health and substance use disorder treatment waiting lists. Oh my gosh, right now the waiting lists are incredible. I have a friend who's trying to get into treatment right now and there's a six week waiting list everywhere she calls. So it's important that we think about how we can improve access. Some of that may be opening up or increasing the number of virtual IOP programs that are out there getting creative about how we improve access, especially in the rural areas there, you know, if you're in Nashville, if you're in Miami, there are probably two dozen treatment centers. But if you get outside of that area, even 20, 30 miles, you may not have near the array of services available. So we need to figure out how to make that access available and available early. We don't want to wait. Ideally, don't want to wait until somebody is in crisis before they are able to access treatment. So we need to be creative. Putting prevention programs out there is really important. When I was in Florida, we used to do prevention programs in the schools and in community centers. Every year we had grants from SAMHSA to do that. SAMHSA is a great place. If you work for a nonprofit you can go. And they have grants every single year that fund various outreach and prevention programs. We also want to address macrosystem issues contributing to opioid misuse. And this is where I was talking about earlier that it's important to really assess your area. What's it, what is the big issue or issues in your area? In a lot of places it would. It's important or helpful to encourage conservative prescribing, which is, you know, after surgery, only prescribing a couple of pills or maybe not prescribing any at all and saying if you need them then call in now. Right now the expectation is that if you have any kind of procedure, you're going to get opioids. And we need to start reducing that expectation so people don't think that they are entitled to opioids all the time. So conservative prescribing would be a huge step in the right direction, accessibility and availability. We want to reduce both of those. Drug take back programs are helpful. You know, a lot of people, myself included, you know, my family over the years has had, you know, this injury. My son broke his nose, I, he had surgery. Whatever. We accumulate bottles of opioids and because we don't take them, you know, or if we do, it's like for the first day or something. So we end up with a lot of leftover pills. Drug takebacks are great for giving you an, a place where you can safely dispose of medicines that you haven't taken. Unfortunately it is, or it was, I don't know if it still is like right this minute, but it was, was the thing for youth, teens and tweens to go into their parents medicine cabinet and just get pills. Didn't matter what it was, just get pills and they would put them in a bowl and people would just randomly pick out pills and take them. Well, you can see where the problem starts to arise there. But there were also youth who discovered that their parents had opioids and they discovered opioids. We know that addictive substances are far more traumatic on the adolescent brain than they are on the adult brain because the adolescent brain is still very malleable, still forming. So that's one thing, but so parental parents do need to control if they're going to have medications in the house. You know, opioids, benzos, anything that could be potentially misused. I hate to say it, but it's anymore it really is important to keep those in a safe, you know, keep them locked away where curious youth can't access them. You know, if you're going to have them in the house, you know, treat it like you treat firearms. Keep them locked up so they can't be accessed by, by curious little people. And use injectables to reduce diversion. When we opened the opioid clinic in Florida many, many years ago, you know, that was a big issue was how are you going to prevent the methadone from getting diverted. And since then they've developed a lot of long acting injectables. They have a buprenorphine which it is a partial opioid agonist. You know, if you were in my medication assisted therapy class, you're aware of that. But buprenorphine for example, can be injected and it lasts for 30 days. So people aren't having take home doses that they could sell or divert in some way. So that is another issue that's really important because things like Suboxone and buprenorphine and obviously oxycodone and fentanyl and those sorts of things are worth a lot of money on the black market. So we want to be cognizant of those things and do whatever we can to reduce the diversion. We want to improve drug screening protocols. It makes me so irritable when I hear of a company that has a drug testing program and they tell somebody in there, they get, somebody gets a slip in their paycheck that says you need to go get drug tested in the next 72 hours or something. Or for some things even 24 hours is too long. There are so many ways that people can work around a drug test that it is much better, much more effective if they are called in, told that they're getting drug tested and drug tested on the spot. There are things, and this may be an education for some of you that you didn't want, but whatever. There are things, for example, for, for men it's called the wizinator and it is a false penis that they can strap on and it stores urine in it so they can store clean urine. It's going to be close to body temperature because it's been, you know, stored in the same place. And so when the person urinates in a one of those test cups the temperature scanner is not going to register that it's not their urine. And if somebody's not looking really closely during an observed drop, they are. They may not notice that it's actually not a real penis that the person is using to fill the cup with. I'm sure there are analogous things for women. I know that when I used to do observe drug testing there were lots of creative ways that women did similar things. So not to get too graphic, but we can't really make a dent in the problem until we start effectively monitoring for it. Because for a lot of people, if there's a chance that they're going to get caught, that's enough of a deterrent, they're not going to even start. But if they know that there are all these ways to beat the system, then they may be a little bit more loosey goosey. Drug free. Worst workplace policies really need to address that. I am a big fan of because of things like the Wizinator. I am a big fan of observed urine drops or blood tests. Those are more expensive sweat patches, more expensive, but really accurate. There are a lot of different ways that people can be tested. If you're not familiar, the sweat patch people put it on and it actually has shown to be pretty difficult to adulterate without voiding it completely. And you know, so if somebody voids their, their patch, you know, they were trying to cover, probably trying to cover something up, but somebody puts it on, they wear it for a week and then they take it off, they put it in a bag and send it off to the lab. And that gets basically 24 hour monitoring of what they're using or, or not using, which can be really effective in, in a lot of programs. I know a lot of drug courts are going to, using the stretch, going to using the sweat patches instead of random urine screening because it does give them that 24 hour, you know, coverage to improve drug screening. You know, not only workplaces, but also in high school and collegiate athletics. A lot of our youth are involved in extracurricular activities. If they have to be randomly drug screened, that may be a deterrent for them. Even if it's not a deterrent, if they test positive, a lot of times they probably haven't been using for that long. So we can start providing early intervention services before it starts getting to be a huge issue. Another thing that's been floated out there is to make public assistance benefits dependent on being drug free. I add to that, or actively participating in treatment. Somebody who's in treatment who's trying to do the next right thing needs to have a roof over their head and food in their bellies and the electricity on. They need to have those basic Maslow needs met from, from Maslow's hierarchy. So cutting off their public assistance is not going to help them get clean. It may send them further down the addiction rabbit hole. So I think it's really important that if somebody is actively participating in treatment that they are able to keep their benefits. That is my personal opinion. And enhancing community connectedness has been shown to really increase or reduce addiction across the board. And community connectedness means making sure that the community provides what people need in order to survive. So they're not moving every six months. So they develop relationships with one another, so they develop social support, which buffers against stress. So there are, you know, jobs that pay well enough that you can actually pay your bills and not be stressed all the time about money. There's a lot of things that go into community connectedness and making communities self sustaining. Nancy asks, have I heard much about eliminating hair tests because of discrimination for certain cultures that hold evidence longer in their hair? I have not heard that. However, I have heard that people are often in a lot of places, they are getting away from hair tests because they've shown to be somewhat unreliable. And I haven't really delved down to, through that too much because the hair tests are so expensive. Not a lot of places use them. But I can imagine that different people are going to retain drugs for longer. I know, for example, my, my stepmother, most people's hair grows a half an inch a month. And so when they do the hair test, they look at how long from the scalp to wherever this drug is, you know, how, how long has it been Assuming that their hair grew a half an inch a month. My stepmother's hair may grow half an inch every six months. So if you're using that same calibration, you're going to be way off in assessing her hair, her hair growth level. So there are a lot of things that contribute to potential issues with hair testing. Harm reduction really looks at tertiary prevention. Remember, tertiary is preventing ancillary problems. The person may have an opioid misuse issue. Let's prevent them from developing, you know, bloodborne diseases. Let's prevent them from becoming homeless. So when we talk about tertiary prevention, we're talking about medication assisted therapy, which, remember, can be naloxone, which completely blocks the opioid receptors and puts somebody into detox. It can be buprenorphine, which only partially activates those opioid Receptors and remember that can be administered through a long acting injection so they don't have to come to the clinic every single day like they do for methadone. There are options out there for medication assisted therapy, needle exchange programs, and a lot of people really get upset about these. Excuse me. However, let's think about if you have people who are abusing injectable drugs, not only are they having issues because of that abuse, they also are probably developing other physical symptoms, other physical diseases, and maybe spreading them to other people. And then those people are, or anybody who gets sick is going to end up needing medical care. If they are sharing needles, they're probably not wealthy enough to be able to afford insurance. So it's probably going to be a drain on the health care system. You know, there's a lot of downstream effects of people who are sharing needles. So needle exchange programs have shown to be helpful at reducing a lot of the ancillary problem problems associated with injection drug misuse. Provider education and guidelines is also important. And I don't remember who it was when we were talking, doing the medication assisted therapy class, but it may have been one of you. And if it was, I, I'm sorry, I forget who it was. But pointed out that most of us when we were in grad school and most physicians when they're in all of their years of school, get very little education on co occurring issues. They get very little education on the need for collaborative, multidisciplinary approaches. So the question that she raised at that point was how can we increase this? How can we encourage professionals who are already in the field to okay, it was Nancy. So how can we encourage professionals in the field to get more education on the different strategies not only to address addiction but also the co occurring issues like mood disorders? Well, we can try to start changing curriculums in schools. That'll take a while. Another idea I had was to have insurance companies start requiring a multidisciplinary approach. And a lot of insurance companies require you to use the locus or some other screening or assessment instrument, if that screening or assessment instrument included, you know, complete biopsychosocial screening issues and referrals. You know, we might force people kind of in that direction of at least acknowledging the existence and hopefully increasing their curiosity about, about the area of integrated behavioral health. So there are some ways we might be able to, to smush it in there. Working with state boards to have them start requiring, just like they require, we have ethics training and they require, we have domestic violence training every year. Having them start requiring A certain number of hours of education on addiction and integrated behavioral health, you know, that could be another issue. But that would be something that has to be statutorily mandated, which means going before the board and trying to get them to alter alter the requirements. Opioids do have a place for acute pain management. I'm not saying they are all bad. They've also been associated with reductions in anxiety and depression. Dependence and tolerance on opioids develop quickly. And currently opioids are very easily diverted. Pills, tablets, sublinguals, you know, there's a variety of things out there and they can be easily diverted. So we need to think about ways to prevent that. Reducing prescribing by those long acting anesthetic things could be a huge help in reducing the number of opioid pills that are just freely out there. For example, prevention needs to focus on all of the reasons people abuse opioids, including stress and anxiety management, depression and pain. Not just think about it as something for pain. And it remember it doesn't always start. Opioid misuse does not always start as a result of pain. A lot of people have an injury or a surgery or something and they're prescribed the opioid and they get the type of opioid that does it for them and helps them feel their uber selves. To quote my client, and it may start from there. Other people may have just, you know, randomly stumbled across it or experimented with it and found that it helped. It was an effective method of, of self medication. So we do need to recognize that the path to opioid misuse differs for different people and the reason they use differs. Are there any questions? If this podcast helps you help your clients or yourself, please support us by purchasing your ceus@allce.com or getting your agency to support sponsor an episode. A direct link to the on demand CEUs for this podcast is@allce.com podcastceus that's allceus.com podcastceus to sponsor an episode of Counselor Toolbox and reach over 50,000 clinicians per week, go to allce.com sponsor thank you.