The opioid crisis is a uniquely American challenge. Many factors catalyzed this national nightmare and others continue to fuel it. This presentation delves into some of the major contributors, offer suggestions for reducing this deadly public health problem, and describe challenges for implementation.   The United States stumbled into a series of imprudent decisions can be instructive: it is feasible to “reverse-engineer” past mistakes; it is  important to compile a  “lessons learned” list, a cautionary tale for future drug crises. The initial stimulus, overprescribing of pain-killers, is being gradually reversed, albeit now requiring thoughtful actions to prevent unintended consequences. Responses cannot remain stagnant and locked into fixed solutions, as emerging trends continue to challenge old premises. Illicit fentanyl and heroin now are the two leading contributors to overdose deaths, alone or combined with psychostimulant drugs such as cocaine and methamphetamine.  Prevention strategies based on reducing supply of fentanyl/heroin/cocaine/methamphetamine are clearly different from those involving prescription opioids. Universal principles of treatment, alternatives for pain management, evidence-based treatment involving medications, rescue, and long-term recovery support can be applied to those with an opioid use disorder regardless of chemical class of opioids. Nonetheless, challenges to implementation abound, from resistance to change, stigma, scalability and effective transitions of care.

Learning Objectives:

1. Understand why the opioid crisis is a uniquely American challenge

2. Learn at least 4 factors (of  > 32 factors) that fueled the opioid crisis

3. Lessons learned that can be applied to emerging drug threats

4. Learn 12 principles of treatment and weaknesses in current system

As one of the few evidence-based treatments shown to decrease mortality, buprenorphine use has grown in the United States and abroad.  Buprenorphine is a first line option for opioid use disorder shown to reduce cravings and withdrawal symptoms leading to increased treatment retention, reduced risk for infectious complications and overdoses. For prescribers who obtain DATA waiver training in the United States, this medication can be started in a variety of clinical practices from general practice, specialty practice, or emergency rooms.  Due to buprenorphine's partial agonist, partial antagonist effects at the opioid receptor, early administration following opioid use can be complicated with potential risks for precipitated withdrawal.  To minimize the risk, several induction strategies from in-office, home induction, and slow and fast microdosing strategies have been used.  This session delves into the many approaches to induction techniques and how to select the best method for an individual patient.

Learning Objectives:

1. Compare traditional and home induction methods

2. Describe alternative microdosing  induction strategies

3. Identify appropriate patient populations for each method.

Substance use disorder (SUD) remains a highly stigmatized medical condition in the US.  One of the most effective methods of treatment for SUD, specifically for opioid use disorder and alcohol use disorder, is medication assisted treatment (MAT).  However, MAT as a treatment pathway is itself stigmatized, both with the public and within the recovery community.  Due to this stigmatized perspective, individuals who could benefit from participating in MAT can be dissuaded from initiation or encouraged by non-medical personnel to modify their treatment regimen.  Social support remains a critical component in the treatment of SUD. However, those within the recovery community who would traditionally lend support for those with SUD in their recovery process may moderate their support for those within an MAT pathway.  This session will discuss the stigma that those with SUD face, and it will focus on the stigmatized perspective toward MAT as a treatment pathway.  The presenter will discuss preliminary results from a recent study that examines perspectives from the SUD recovery community toward MAT, exploring how this stigma may interrupt or moderate social support for those who greatly need this component in their recovery. The session finishes with recommendations for addressing stigma toward MAT.

Learning Objectives:

1. Articulate the components of stigma

2. Understand the three types of stigma

3. Acknowledge how stigma can impact social support

4. Recognize and address stigma toward medication assisted treatment

The opioid crisis erupted from a tragic convergence of factors from the private and public sectors. Changing sensibilities on opioid use and abuse, perspectives on addiction and recovery, better chemistry and more diligent regulation offers some avenues forward.

Learning Objectives:

1. Brief history of opioids

2. The impact of opioid addiction not just on users but on families, communities, and society

Breathing emergencies secondary to opioid use are the leading cause of death in Americans under the age of fifty.  Sadly, many of those who suffer from substance use disorder face a high level of stigma which negatively impacts both access to and quality of care.  Healthcare providers are primed to provide education to both patients and the public on the disease state model of substance use disorder.  This education can lead to a culture change wherein substance use disorder is viewed, as it should be, as a disease rather than a choice.  Furthermore, several misconceptions exist around the treatment of substance use disorder.  Discussing the evidence around substance use disorder treatment with patients can help reduce the negative perceptions surrounding this topic.  This presentation will review the disease state model of substance use disorder and discuss the evidence around common myths surrounding substance use disorder.

Learning Objectives:

1. Discuss the disease state model of substance use disorder

2. Discuss the evidence surrounding common misconceptions regarding substance use disorder

Urine drug testing has become an essential part of the management of patients with chronic pain.  Testing provides objective information regarding drug compliance, diversion, and abuse to medications and to recreational drugs.  Determining pharmacogenomics variants is also useful to determine individuals who are outliers from the expected urine drug concentrations, e.g., fast metabolizers having less drug and slow metabolizers having more drug present.  Unfortunately, these tests are infrequently ordered.  Knowledge of pharmacology and pharmacokinetics is important in interpreting laboratory results in order to provide physicians with the besting information to make optimal therapeutic decisions.  Cases are presented to illustrate the variety of pain management medications that are available and how genetic variances affect the efficacy of the drugs and avoid toxicity. Patients on analgesic drugs for chronic pain have access to testing results and should learn what the results indicate. An educated patient is one that is more compliant with his/her medications.

Learning Objectives:

1. Recite the important pain management medications in use today and the important routes of metabolism

2. Determine compliance to pain management test results based in prescriptions

3. Undertand how to interpret pharmacogenomics variances in the genes that encode cytochrome P450 with relevance to pain medications