 I am JoLinda LeClaire, Director of Drug Prevention Policy for Vermont. I oversee the Governor's Opioid Coordination Council, which Governor Phil Scott established by Executive Order in January 2017. Since then, the Council has focused on its mission to improve Vermont's response to our opioid challenges through prevention, treatment, recovery, and enforcement. This crisis touches everyone in our state. Many Vermonters have family members and loved ones who have become addicted after receiving opioid prescriptions for pain. Others were exposed to opioids and other drugs through friends, dealers, and traffickers. Regardless of how they were exposed, we know we have among us many who now have the chronic isolating and too often deadly disease of addiction. We are making progress. Treatment is available across the state through Vermont's nationally known hub and spoke system of treatment. Recovery centers in our communities are providing effective wraparound support to help people achieve long term recovery. Many communities are building prevention coalitions to provide our children and families the tools they need to be resilient in the face of life's challenges and traumas. Vermont law enforcement has steadily worked to increase community safety and to decrease the supply of illegal drugs. They also work hard to support prevention strategies that will reduce the demand for opioids. There is more we can do and must do to turn the curve on Vermont's opioid challenges. Drug prevention education is a top priority for schools and communities. Increasing intervention opportunities in emergency rooms and other places will help more people enter treatment and recovery. Individuals and families in recovery need support to obtain jobs and rebuild their lives and support for harm reduction through safe and appropriate use and disposal of drugs and syringes will increase safety in homes and communities. Something we all can do to take every opportunity to raise awareness and reduce stigma by talking about addiction. To highlight the science of addiction as well as the cultural, social and economic challenges associated with addiction the producers and hosts of Vermont Cable Access and the Opioid Coordination Council have created an eight-part series entitled Understanding Vermont's Opioid Crisis Working Together to Create a More Resilient Community. The second in this series is about treatment. In this segment host Ed Baker interviews Vermont experts in treating opioid use disorder. They will discuss options for treatment and Vermont's nationally recognized hub and spoke system available in all regions of our state and resulting in positive outcomes for a growing number of individuals and families. Supporting, evaluating and improving treatment is a priority strategy for Vermont's Opioid Coordination Council. Hi everybody and welcome to our show Understanding Vermont's Opioid Crisis Working Together to Build a Resilient Community. Thank you Jolinda for your introduction. As Jolinda had mentioned the focus of our show today is treatment and to help us to understand both the art and the science of treatment we have three distinguished guests Deborah Hopkins, Dr. Chris Lacones and Dr. John Brooklyn. Thank you so much for being on the show. Thanks for having us. Thank you. I thought we would start out the show by having you introduce yourselves and let people know what your roles are today relative to opioid use disorder. Well my role is I'm the Operations Director for Central Vermont Substance Abuse Services and we provide outpatient services to folks that have addiction issues, primarily folks with opiate issues. In addition to that we have a partnership with Baymark which runs one of the hubs in the region and we provide staffing for that program and we also provide spoke services. And I'm Dr. Chris Lacones I work at Gifford Health Care in Randolph in Berlin Vermont. I'm a psychiatrist by training and board certified in addiction medicine and I've been working with folks with opioid use disorders now since 2003 and in our clinic which has comprehensive care with counseling and medication support we provide both suboxone and vivitral treatment. Thank you. Hi I'm John Brooklyn. I'm board certified in addiction medicine and family medicine and I've been practicing in the Burlington area since 92. I've been involved with research on buprenorphine at UVM since that time. I also am a staff physician at the Community Health Center of Burlington and I run two of the hubs in the state one in Burlington run by the Howard Center and one in St. Albans run by Baymark. And I provide full range of addiction services for alcohol, opiates, other substances and primarily focus on buprenorphine and methadone in my practice. Thank you. Thank you Deborah. Thank you Dr. Lacones and Dr. Brooklyn for your introductions. But thank you. Thank you more for your dedication. You know your track record dealing with this most grave situation that we face in Vermont today. I want to recognize your work. I thought that we would start the program by beginning at the beginning. A working definition for the viewing audience on on what is this brain addiction that we call opioid use disorder? What is it? Well, why is it so powerful? Why are so many people dying from it in our state? I'll just I'll throw that out to the to the panel. John? Well, it's an interesting question because for a lot of people who've never taken opiates, it's hard to imagine the grip that they can oftentimes have on people who take them. We know that for a lot of people who seek treatment, they either started on medication for pain, they maybe have started with a prescription. And for whatever reason, they were psychologically vulnerable to taking more than they should have it. It took away the pain but also took away some of the psychic pain. We also know there are people who start with other substances and they migrate to to opiates. But whatever way you end up because of the fact that we have receptors in our brain and our spinal cord and our gut for opiates, once people start taking them for a period of time, they can become physically dependent, meaning that when they stop taking them, they feel ill. When they feel ill, it's a variety of symptoms that can occur. And so for many people when they come seeking treatment, they've tried many times to get off on their own. They may have gone to rehabilitation program or done abstinence based program and not been successful. And so because of the current epidemic, we have with some of the more potent opiates like fentanyl and carfentanyl which are very, very deadly in small amounts because people have been using heroin for over 100 years and having overdoses. So from that respect, it's not necessarily a new problem. We're really focused more on getting people onto medication to really protect them from overdosing. And so the value of buprenorphine and methadone and in some cases naltrexone and blocking that receptor in the brain so that if people take too much, they don't overdose is even more important maybe than it was even 20 years ago. And I think to that point, we have a very robust system in the state for supporting that. But the belief is really that for most people who become dependent on opiates, replacing it with another opiate that's safer is many times a better option. So there are receptors in the brain receptors in the spinal column receptors in other parts of the body that grow dependent on opioid. And if the opioid is diminished or discontinued, the person can actually go into withdrawal and seek and seek the drug. Would you like to add a little bit about addiction itself? Well, yeah, I think in addition to the physical withdrawal symptoms that people have, you know, in order to try to feel better, they often get engaged in behaviors which, you know, are illegal or dangerous. So often their lives fall apart on account of the pursuit of the substance. So really, the medication can restabilize the neurobiology of the brain so that people can then focus on rebuilding their lives, making good counseling groups, get legal situations worked out, do things like, you know, perhaps regain custody of children who have been lost because they've been neglected. So that that's really kind of the other side of the addiction story. All right, thank you. Deborah, do you want to add something? Well, one of the other things that we're dealing with a lot is that the opiate epidemic is huge. However, there's a lot of other kinds of addictions that go along. So oftentimes we see folks who are struggling, they may have started with pain pills, but may have been drinking as well. So it really is, we really try to look at addiction as a whole as an overall life issue. The opiate addiction, the opiate situation actually has medication that can assist which other kinds of addictions don't have as much alcohol does and some other. But when we look at things like even marijuana and the research is being looked at now around the addiction level of that. We need to look at the whole person when it comes to an addiction. And that's why I think it's really important. And I think the state of Montstown are really good job at looking at that balance. I would agree with you. And that'll be part of the program today is to take a look at the state's response to both opioids and other other substances too. Let's get into the treatment proper pot, meaning medication assisted treatment and the hub and spoke model hub and spoke model of health care delivery to people with opioid use disorder is certainly a very popular becoming more and more popular national nationally. And I understand Dr. Brooklyn that you are one of the main chief architects of that model. I'd like you to explain that to the general public because I don't think everyone really has heard of it or knows about it. Sure. If you think about any medical problem that you might have and you go to see your doctor and you may develop some complexity to it that your doc's not completely comfortable or taken care of they will refer you to a specialist. So if you have a cancer diagnosis or a lung problem or a liver problem, you see a specialist and no one thinks twice about that. And when we begin to think about opiate use, we look at as a chronic disorder. We know that the outcomes for people who receive treatment are very, very good. And so when we think about treatment, a lot of treatment has traditionally occurred in an opiate treatment program like a methadone program. So when most people think about treatment around the country, they say, Oh, you're a heroin user, you need to be on methadone. If you're going to be on medication, because of the research we had in Vermont, a lot of docs were familiar with buprenorphine as an option. And so when buprenorphine became available known as suboxone in 2003, the state of Vermont put a lot of effort into getting docs trained because you need to take a special training to be able to prescribe it. You can prescribe it in the office, you can give a person a prescription, they go to the pharmacy and they fill it and they take it. But like anything else, sometimes people get into difficulty, they use other substances, they struggle with their mental health or there's questions about whether they're fully taking it. And in the past, what would happen is many physicians would decide, I can't really take care of you anymore because of what you're doing that behavior got in the way. And they would discharge the person from treatment. Well, we know that when you discharge someone from treatment, the outcome is worse because they may return to using heroin with potential overdose. So it became apparent that there was no connecting methadone programs with doctors who were prescribing buprenorphine. And the concept of linking the two, even though it may seem novel is not unique because we do it in every other aspect of medicine. And proposing the idea that the methadone clinics start to prescribe buprenorphine so that if a patient's at a doctor's office and becomes unstable, they can be referred to the hub as we're calling them for a more intensive level of service where they would be getting regular counseling, have regular witness urine screening if possible, regular daily dosing with buprenorphine, maybe they switched to methadone. It helps people stabilize. And so you are really gathering a safety net under folks to prevent them from losing their treatment. And subsequently they come into treatment, they become stable and hopefully we'll go back to their doctor at some point to receive treatment. The other thing that happens is a lot of people who don't have a prescriber of buprenorphine will come to a hub and be started on it. In fact, in 2004, the first induction center started at Central Vermont where people would come in, would get started on buprenorphine and sent to their physician's office. So that was actually one of the earliest of the induction models. All the hubs will do that. So there's a bi-directional flow of people so that we have that many more people in treatment and sustained in treatment. In addition, all the hubs provide certain amount of medical home service. So we provide a certain amount of care management. We do some basic screening for blood pressure and weight and smoking and depression so that we're, again, taking part in trying to help people get better health care. All the hubs have this status where they're known as medical homes or have medical home certification as a specialty clinic. So the reason it's gaining traction nationally is that there's no other state that's coordinated this level of interaction between physicians and specialty care and de-stigmatizing it so that you can go to your doctor's office, sit in the waiting room, get treated for opiate use disorder with the moms and the grandmoms and everybody else is going for regular medical care and nobody's the wiser that you're there for that kind of treatment. So we have more people per capita on methadone and buprenorphine than anywhere else in the United States and part of that is because of this model and the state has really put a tremendous amount of effort into continuing to support it. I'm not going to get into the different medications. I think Chris could probably do that, but we do offer all three and then we also offer a lot of services that Deb could talk about. Great. Thank you. Thank you for comprehensive analysis of what is truly an important innovation in health care. Would you like to expand a little bit on that induction program and how that functions at CVSAS, Center for Bronze Episcopal Services? Well, I think what Dr. Brickman was talking about was when we were one of the first clinics to actually do it in the outpatient setting, which helped lay the groundwork for understanding the need for hubs and spokes. At this point, we actually don't do induction because the hub and spoke model has really taken that up. It can be in the beginning, it was only being done in hubs and now there are certain specialty clinics, such as Dr. Lacones's, that can handle doing that kind of induction. That allows us as a counseling program to get into what we really know the best and that is working with the augment of services that individuals need as they go down that path. Once that safety net is created, then we're able to do more for them. But I know that Chris is doing a lot with induction and particularly with some of the newer medications that have been very useful for us. Yeah, so it seems that over time what has occurred is like a very effective integration of different levels of care for different populations at different points in their pathways to recovery. Congratulations and thank you so much for that. Dr. Lacones, you want to talk a little bit about that? Yeah, I'd like to add that one of the really nice things about the hub and spoke models that we have something called the MAT team, Medication Assisted Treatment Team. So providers who are providing Suboxone in the spoke, so out in primary care offices and specialty offices, have the services provided by the state of a nurse and a counselor who will help make sure that the level of care that the patients are receiving with their Suboxone meets health home standards, just as a medical home would be in the hub. And that team can also help to make transitions between hubs and spokes back and forth, depending on the stability level of a patient and what their needs might be. So it's really kind of like the grease and the glue. I think it was brilliant that the state put that in place. Very, very nice indeed. And I'd like to add to that. It also is allowing people who are progressing in their treatment to actually live their lives as they choose to. So if they want to move from one region to another, they have that additional assistance, which is a reality of a person's path. Often when we want them to change where they live or who they live with, we have an automatic system that will help them set those circumstance up so that they don't fail. It seems to me that over time we've learned to respond to the power and the lethality of this particular addiction, opioid use disorder. And I think, John, you hit on it exactly that breaking through stigma and treating this as any other chronic disease has enabled us to build systems that really respond to the nature of the disease, the disease in offering people avenues to health. We don't give up. I can remember when people with opioid use disorder were blamed for relapsing. Oh, they don't want to get better. It's their fault. I'm going to terminate treatment because you're not getting better. This doesn't happen anymore because we understand the power of the disease. What about the nature of medication? Can I ask you, Dr. Lacanus, about that? Let's take Buprenorphine. What is the nature of the medication? How does it work in the brain to help the person with opioid use disorder find health? So what Buprenorphine does is it stimulates opiate receptors the same way that heroin or fentanyl or something like that might. But it only partially stimulates opiate receptors. And the key important part of that is that means that there's less of a risk of an overdose or respiratory depression if someone were to overtake it. And unlike things like heroin and fentanyl, which are in and out of your system very quickly, Buprenorphine has a very long what we call half-life. So it's metabolized slowly. So when people take the medication, it stabilizes the level of opioids in their system instead of kind of being a roller coaster ride that you might have with heroin. So that allows people to feel normal. They don't feel higher euphoric and they're not in withdrawals. They can go about repairing their lives. So in some senses, the dose would prevent a person from entering into withdrawal. But it would also be at a level where the person would not be experiencing opioid intoxication. Correct. And then the person would be free to follow whatever their path in life is. Have children, work, be creative like anybody else. Right, yeah, not being engaged in behaviors that put their freedom and their health at risk. Yeah, I think the general public sometimes looks at those behaviors and it's irrational and it's hard to understand. But if you see those behaviors as a symptom of the disease, it becomes much more understandable. Yes. What about nautrexone? Would one of you like to begin to talk about that a little bit? It's another MA chain. Sure. Well, nautrexone, unlike buprenorphine, binds to the opiate receptors and blocks them so that any incoming opiates don't have access to the receptor. It binds very strongly. So what it does is, you know, if a person is administered nautrexone and they take an opiate on top of it, they don't feel anything. The problem is if you give it in pill form, we know that medication adherence for all medications, not just the medicines we prescribe but even for antihypertensis, it's not very good. So they actually have a time release injection called Vivitrol, which can provide a steady nautrexone level for a person over the course of 28 days. But the caveat with nautrexone is it's difficult to get patients to accept it because you need to be free of all opiate. So if somebody's using heroin on the street and they need to be free for about 7 to 10 days on average before they can receive the pill or the injection or they'll be thrown into withdrawal when their opiates get kicked off their receptors. So, you know, I was a clinician for a long time, so I understand what's going on in the brain a little bit. And it seems that, you know, you hear about like impulsive behavior. I'm sure you've all spoken with clients or patients who didn't want to self-administer a drug with all their, you know, might. But something happened in the environment, some emotion happened, or some crisis happened, and impulsively they fell back into the old behavior of drug taking when they were trying not to. It seems that something like nautrexone would provide that person with the time to reconsider, with the time maybe to reach out for some support rather than acting impulsively. Is that true? One thing that is true. We're smiling because, yes and no, I mean, it depends, it depends on the circumstances. We know that if you decide not to renew your nautrexone shot, you're suddenly not protected anymore. But nautrexone has also been used for other disorders. I mean, there's some evidence that it works for gambling addiction. There's some evidence it works for overeating. There's some evidence that may help with methamphetamine use. So it can sometimes help with cutting behavior, impulsive behavior. So there are some circumstances, and again, it's still an emerging field in many ways, what the applications are. And for that matter, you could be on methadone or buprenorphine and still act impulsively. It's not so much whether the medication is going to protect you. It's what is missing in your toolbox that you don't have to help you during that impulsive period. And the nature of this disorder is impulsivity. And so we often are struggling with how do we help people? And we know that people are going to reuse. They're going to use even on medication. They're going to perhaps drink or drug. And the question is, don't necessarily get mad at an individual, but help them the next time that they have that same. And you know that as being a counselor. And I'm sure I could speak to that's a struggle for many, many people is, what do I do when I get stressed out? I don't have any other tools. But Ed has a point, though, I think you're referring to something in the literature, too, where interestingly enough and for reasons that we don't understand, when naltrexone is injecting the time-release form over the course of months, opioid cravings do significantly decrease. And that's some part of the neurobiology of new opioid receptors that we don't understand. But that seems to be independent of people simply refraining. There's something about the naltrexone that's decreasing craving. So you know, perhaps you're going to have a point. Well, I have to speak to Dr. Brooklyn's point that a person who is receiving naltrexone, that there would be a deterrent toward self administering an opioid because the opioid would have no effect. So there's that moment then that kind of ties into the idea of having a toolbox. What do I do now with that moment? Have I learned that maybe to call a sponsor to make an extra appointment with my counselor and have that little bit of extra time to maybe move toward some additional help. The other piece when we speak of time that we need to keep in mind is that if you are heroin addict, it's a very costly adventure. And many people spend a lot of their time just trying to get the money together and accessing the drug. So there is the piece of where the medication can help. But during that time when a choice can be made, that's also a time to look at other choices in life. You're right. A person needs to have a toolbox. And that's where treatment comes in. That's where people do planning. What am I going to do at those times? Who am I going to hang out with? Where do I live? Which is a big challenge in our region because people were not as mobile as in some other states. And so for a person who is in downtown Barrie trying to find another affordable living place while they're struggling with these decisions, they face quite a bit. So oftentimes we have to look at relapse prevention plans or if someone's relapsed, how do we process that and communicate that to the medicating positions so that we can look at whether someone needs adjustment or whether we can make a change in their personal situation. I mean, that's a good description of the vulnerability of addiction and also the vulnerability of early recovery. Do you have them at Central Vermont Substance Review Services? Do you have intensive outpatient programs? Yes, we do. We actually run one during the day and we're picking up another one where we run it during the evening. It's nine hours a week, three, three hour blocks. And this is designed for the person who, by using assessments and tools, determining that that person needs an opportunity to structure their life in blocks of time during the week without use and discussing the challenges that they face on a regular basis. It can be a little intimidating at first, but it's also a very powerful opportunity for people. So sometimes with Matt or Nautrexone or Vivitrol, whatever the medication assisted treatment would be, there's a high input of other types of psychosocial therapies. Absolutely. Particularly with people who are in the hub in Central Vermont we're really lucky because we work so closely with the hub that a lot of those people come and also get their intensive outpatient therapy at the same time and we can work in concert with them. And I think this is really crucial because it helps make that bridge to not only the medication assisted part of their service, but also how do they look at their life? What's the structure of their life? And what do they need to do to make changes to help continue on the successful path? Yeah. I think it really underlines the all-encompassing nature of opioid use disorder. In many cases, the amounts of support that people need. I think Dr. Wilkin had said in the beginning, people respond well to treatment. People respond well to adequate treatment. If we can give them what they need, eventually they are very likely to get better. I had two additional questions like two sides of the same coin. So is there treatment for opioid use disorder without medication? And then is sometimes medication alone the treatment for opioid use disorder? So let's begin with the first question. Is there treatment for opioid use disorder that does not involve medication? Absolutely. If a person is adamant that they're not going to take a medication, they will come into services and really have only the piece of the therapy portion. However, oftentimes what we find is during that process, we can help them sort out why they're resistant to the medication. And if, in fact, it's because of biases they have and a lack of education or that they need to know they tried it without the medication. What's really important for any of us providing services to this population is, first off, they see respect when they come through the door. Because this is something that many of these folks do not get on a regular basis. And second, we hang with them. We stay tight with them when they have a relapse. And we try to be as frank and positive to them as we can about the changes that they need to make in their life. So oftentimes we will get people coming through the door saying, I'm coming to you, no medication. We have had people who have been sent over to the hub the next day because we were able to talk with them about it and educate them a little bit more to actually why it's OK. We often parallel not just the specialist but the diabetic because oftentimes that's a long struggle for people if they have diabetes. They often fall off the wagon and need to be helped back up. And so we'll work with them. We have had some people who have been able to do it successfully. We generally see that in the younger population who are newer to it or people who, you know, we get people who have only been really dabbling in it for like six months. We've been able to work with that or a quick titration after they get to that level and have been able to use it. So it's really, it's a path for everybody. It's very different. Thank you for that. And what about the other side of that coin? Is sometimes medication alone treatment? Well, that's a great question. I think, how do I, how do I say this? So there are people who have tried on their own many times to stop using and then decide they want to be on MAT. And they may have gone through many rounds of counseling and they may have gone to rehab a dozen times. And for whatever reason, they return to use. And so we take them and we put them on methadone or buprenorphine and suddenly the craving stops, the use stops. And they may have been working already. Maybe they've got their life sort of together but there was that brain piece that was missing. And for those folks, we put them on medication and instantly you see zoom. They're taken right off. And you say to them, you got to go to counseling. I was like, how am I going to go to counseling? I work 10 hours a day. I got four kids. I got to pay a mortgage. I don't have time for that. And what you see is that they in fact do quite fine. And they take the medication and they don't have a positive screen and they may have never walked in and into a counseling session after that. But I think it would be unusual to take someone who's never had any sort of therapy or help and put them on medication to expect that they're going to thrive. They may not be using but they may have a lot of issues that need help. And so to Chris's point earlier about the MAT team, for a lot of people who enter their doctor's office and get put on Suboxone, they have access to what we call case management services. So it may be that they need some help in tweaking a resume or dealing with some legal issues and perhaps dealing with some marital issues and they get some brief intervention. They do that work. They get past it and they continue to do well. So again, it's how do you individualize it? I had people who've been on MAT now for 15 years and I think for a few of them, they've never walked and talked to any counselor ever because the original intention of Bupenorf and in the office was that the physician was going to be sort of the quasi-counselor. And as a psychiatrist, you probably do a lot of this where you have the skill and the capability to counsel people and work with them. And you just have to have the capacity to refer for counseling. There's no requirement that you go. And I think it's that recognition that not everybody needs to see a counselor. Maybe at certain points they have issues. So I hopefully answered the question but probably in a long-winded way. No, no, no, for sure. And I think what I hear you saying, one of the things I hear you saying is that everybody's different and we have to individualize care and that's where sometimes the MAT team comes in to figure out who is this person and how can I best understand them so I can put together a mix of services that will meet their unique needs. Is that part of it? Mm-hmm, yeah. Yeah. However, let me just point out that probably, I would guess 80, 85% of individuals who have this disorder need therapy, need counseling, need some work. It's not like the vast majority don't. And so for there, thank goodness for the skilled clinicians we have in this state who help people off the ledge all the time. Absolutely. There are some people who are going to need to remain on the medication and definitely particularly those who have underlying pain disorders which may put them at risk to relapse if they taper. But they may have really gotten their life into what we would call perfect order. They're model citizens. You know, they can sit and stare at a counselor. They can look at each other but if nothing is coming out of that, it's not good for anyone. So, but they're exceptions. And especially with what we know today about pre-existing conditions, ACEs, adverse childhood experiences, post-traumatic stress, things of that nature. And then when you consider the wounds of addiction and what that does to a person psychologically and socially, it kind of begs the question of therapy. I would imagine 85, 90% of people would definitely need therapy besides medication or therapy in and unto itself. Well, you know, one of the things that you said, I think you said, we hang with them. We stay tight. I like that. I think we could talk a little bit about that. Like, you know, where people, you know, our field did abandon people in the past. We kind of punish them sometimes because of their symptomatology. What is the philosophy today? How do we see this today? How do we hang with them? How do we stay tight? Even when they continue to relapse sometimes. We have to remind ourselves that it's their path and not ours. It's not about outcomes for a clinic. It's not about what my version of success is. We have to stay with them in the moment that they're in and recognize that nobody is going to be as difficult to them on a relapse or doing something wrong as they're going to be themselves. And I think when I said one of the things we try to offer people is respect, that we glass over that if we are professionals and we have jobs, but if we look at people on the street, when you've looked at a homeless person and looks them in the eye and say hello, you can see a brightening. Our folks are expected to be put down on a regular basis. And so we start with yes sir, no sir, how are you today? We get to know them a little bit more as people which helps bring their dignity up. And so that when they do have a relapse, they'll still walk through the door and know them as a person and they just had a bad behavior. And I think that that is a philosophy throughout the state. I think we're seeing that that there's, because first off, it's a critical mass. Everybody knows somebody who's affected by this in this community. Now that it's become less stigmatizing to talk about it, I'll admit my son's baseball games became a family support time for me with at least three other parents who knew I worked in the field. You know what, that's the good work we can do now. And it isn't just with the people that we're serving. I think with the elevation the state has made in bringing up this issue and the stigmas around it and the preconceived notions that are false. I think it's really helped open it up to be the family, the community issue that in fact addiction is. Yeah, and there is certainly great reason for hope in that, for reducing the stigma, eliminating stigma. And you know, welcoming this particular population with compassion, like we would a person with any other disease. When you hear about the fire chief or the landscaper who had a stroke or has cancer, your immediate response is, oh my God, what can I do for them? So be it with substance use disorder also, that should be the wave of the future. Would you like to talk a little bit about that, about stigma and about what we need to do in that area? Well, I was just reflecting on a visit I had today with somebody in St. Albans. And we talked about her relationship with family and I think for a lot of families, they feel a bit of shame that for whatever reason, their daughter, son, mother, father is using and they look at it as a badge of shame in some way and it comes out in many different ways. Hard for people to go to family functions because they feel like they might not fit in or families excluding them because they're afraid they're gonna get, it's contagious on some level and they're going to get it. And I think it just, it's hard. I mean, even myself, I have certain biases we all do but I think at the end of the day, if we haven't walked it, we really don't know what it's like to have to be sick and feeling poorly and feeling like we need a substance and until that happens to us, we really wanna understand what each person has to walk with. And I think what I hear a lot from people is that they just don't want anybody to know they're on MAT, they don't want their employer to know, they don't want anybody to know and yet it's such a common thing. I mean, we've had that with mental health for decades but I still don't understand why there's like, oh, I'm a diabetic, I'm on insulin, no big deal but oh my gosh, I'm on buprenorphine, I don't wanna tell anybody, I'm on meth and I don't wanna tell anybody and I guess it's sometimes shame and self-guilt and just a lot of other things that are wrapped into it which gets in their own recovery because they don't have self-compassion. It's a hard thing to earn is your own self-compassion and to that point I think you just really have to help people get to that point where they realize that they've gotta take care of themselves and everybody else can have to figure out how to deal with them. People can internalize a stigma, I think Vivek Murthy, the outgoing surgeon general in the 2017 report, Facing Addiction in America, talks a lot about stigma and people's reluctance to seek help and with this particular disease, he who hesitates can literally be dead. I do believe that one of the reasons is the public's misperception of addiction being a choice that somehow people choose to live the life associated with addiction. It's somehow people choose to perpetuate the symptoms associated with addiction when we know now that it's anything but a choice. I heard you say, mm-hmm, what is the question? I think that there isn't just a perception that it's a choice but I also think for the general public in some circumstances it's a safety net because if you believe it's a choice of someone else, you actually believe you can stay away from it. And so we see that with families sometimes that, well, your brother didn't do it, why are you doing it? Because it's so scary and it's so overwhelming and it's so easy to die from this that I think that there's a certain portion of otherness that people need when it comes to this. And so we like to believe that we can control this. We'd all like to believe that if we were put on a pain medication we wouldn't be one of those people who immediately become addicted. And there are people who that happens to. We don't like to believe that. So I do think there's, as with anything, there's a certain investment in keeping a stigma there and resentment in the community, which is really unfortunate but again, I think with a lot of the work that's being done now with trying to embrace families and other people in the community with the efforts around using naloxone and distributing that to families and others who are at risk that I really think it's helping widening the door to understanding. Let's talk about that a little bit, about Narcan. Well, who would like to begin to speak a little bit about Narcan? I'm doing a number of trainings in central Vermont. I have to say I'm so excited with the Washington County region. It started actually when Chris and I worked together because he worked at the hub and it was two years ago when the police chief of Montpelier, chief Fakos, who's an amazing guy, reached out because he had thought we had a waiting list for services. And he asked, as somebody said, you're wrong, you need to talk to central Vermont Substitutes Services. And what we found out in a very short period of time was that the police, nor the fire department, were carrying Narcan. And Narcan, of course, is medication, which the docs can speak too much better than me, that reverses an overdose. And if you see it in action, it's pretty miraculous stuff. And there's also very little concern that you'll harm somebody using it. And so the state has put a major initiative out to try to make this available to anybody who might be at risk of overdose or have somebody in their life who's at risk for overdose. And the commissioner of the Department of Health has written a blanket prescription that anyone using their own insurance can go into a pharmacy and ask for it without having to go to a doctor to make this available, which has confronted a lot of family members to say, should we have this in home? Which brings the conversation into the house. But you might want to talk a little bit more about the mechanics of how it works. I just know how to make it happen. Sure, sure. Thank you. So Narcan naloxone would be the generic name of it, is a relative of naltrexone, the blocker we talked about before. But in the form that the state is distributing it, it actually is atomized into a mist that's put into a person's nose when somebody is overdose. So if somebody recognizes an overdose, they can use a simple kit to give the reversal agent. It's also important that you call 911 though at the same time because the half-life, that thing we talked about before, the amount of time it stays in your body is pretty short for Narcan naloxone. So heroin or fentanyl, there could be another, an opioid in the system that would regain occupancy at the mu receptors and cause the overdose to kind of come back. It's a return. So half an hour later, the person's right back in the dire straits they were in. And the state of Vermont has good Samaritan laws in place so that if you happen to be using heroin with somebody and you need to administer the Narcan to them, if you call the police to ask for help or an ambulance when the authorities get there, their role is not going to be to prosecute you for having paraphernalia or drugs or being high. Very, very important. Yeah, that's very important. I think the US Surgeon General maybe five or six weeks ago also endorsed the wide distribution and use of Narcan on a national level. So it's been accepted on every level. And I think it's difficult to trace how many lives are saved or how many doses are administered, but it seems to be pretty widely used in Vermont. Do you have any idea about how widely used it is? I don't have the specific numbers, but Vermont is doing a great job of trying to track that. Not only can someone go into a pharmacy and get it, there are a number of organizations throughout the state that actually have been trained and can distribute it. We're one, but there are a number. The state's Department of Health website has an entire listing and anybody can go in. They don't have to explain why they want it. What we are tracking is the dose, the actual number on the box that we give them. And if someone comes and asks for another one, we ask, where the last one go? We don't have anything that would indicate the patient who used it or the circumstance they can report an overdose, but we're trying to capture enough information so that we can actually track the medication that's gone out so that if the emergency room gets somebody and they said, well, I just use this, I got it from Center Vermont. Well, all they need to know is it came from Center Vermont Substance Abuse Services and then that links to the information that I put in a database that I distributed it. So we are trying to find a way to demonstrate throughout the state and the different counties how much is being distributed and how much we're hoping are saving lives. Yeah, yeah, really important innovation. Did you want to add something about Narcan? I think that what people forget is that Narcan, when it works, the reason people are overdosing is the opiates are stopping their breathing. So basically a person stops breathing. And if they've just used heroin, a single dose of Narcan should be effective. But what happens is that the person is now awake and in withdrawal. So they're at risk for using again. And when people are going to the emergency room, the hope now moving forward is that they get a dose of Narcan. Center Vermont, UVM are embarked upon a program to start someone on Suboxone in the emergency room so that they don't go back out and use heroin later in the day to feel better because now they're in withdrawal. And if the one thing a heroin user doesn't like is being in withdrawal. The second thing is because fentanyl is so powerful, sometimes it takes three, four, five, even six doses of Narcan to revive somebody. And so oftentimes the reason people have become deceased is because it wasn't enough Narcan. So we're commonly having people, especially the Howard Center's Safe Recovery, they track this. There are hundreds and hundreds of reversals, but they're seeing sometimes up to six doses needed. So when we have people coming into the hub, we ask everybody, do you have Narcan? And at the Chittenden hub, pretty much everybody says, yes, I have Narcan, which is astounding to me that people who are actively using, it's rare to find somebody that doesn't have Narcan. So I think to Deb and Chris's point, it's been widely distributed, but we still have the next step to go, which is, okay, now we need to get you into treatment and keep you from going back up and using later on that day. Oh, I can't even tell you how important I think that point is for the general public to really understand that, that people are not being given Narcan so they can continue to use, they're being given Narcan so they can continue to live while we provide them the needed services to help them to find health and begin to function again the way they really want to inside. They're good, good point. It's like doing CPR on somebody who just had a heart attack and saying, okay, you can go home now. Right. You're not providing any follow-up or whatsoever. You get admitted to the hospital, you get a cardiac cath, you get a whole lot of things happen. We're trying to replicate that. Good analogy. And that it very much is, it's a matter of life and death. Again, with the lethality of the fentanyls and the fentanyl analogs, literally one shot, people with heroin and opioid use disorder or self-administering drugs, sometimes four or five, six times a day. So with the supply being contaminated by lethal forms of opioids, it literally is a matter of life and death. Thank you. Thank you so much for the important work that you do. You know, I know that you're all probably brimming with vignettes. And I really want you to share some of your vignettes. You know, over the course of your career, you know, with protecting confidentiality, of course, but what have you seen happen in your offices? What have you seen happen in your practices with this particular particular population? Have you seen lives restored? I actually have a great one. I got a phone call from a parent about six months ago, trying to track down a clinician that worked back in the day when the use of methadone and suboxone was just beginning, really suboxone. And he was calling to try to find the counselor because his son, who he and his wife had come to grips with the fact that he would probably die from this, had just gotten married and had just been hired by a symphony orchestra in another state. And although it was five years later, he and his wife, when they woke up the next day, were in awe that he was alive and they credited directly to the work that was done. It took me a little detective work because I had to find the clinician who had retired down in Connecticut to make the connection happen. But those are the things that people forget that happen every day. And we do get phone calls that say, thank you, you saved my life. And that was just, I thought, a really good example. That's beautiful. And I think that Dr. Brooklyn had said that in the beginning, the right kinds of adequate care delivered in a mindful, respectful, dignified way has those kinds of results. It's not rare. I'm in recovery myself and my life is filled with recovering people. I see it all the time, the general public because of anonymity, stigma, whatever you wanna call it, privacy, does not get to see the fruits of your labor. Do you have a vignette that you'd like to share? Yeah, and it sort of underscores what I've learned over time is that patients always have something to teach you if you're willing to listen. I worked with a young woman starting about a year ago who was doing great in terms of her suboxone treatment. She wasn't using any opioids, going to her counseling and such, but was really struggling with using sedatives from the street. And my instinct was like, oh, danger, danger, a bad combination, high risk of overdose, I need to get her to the hub. And she was able to negotiate for, well, can we work on this together in this setting? Because it really works well and I can work with you. So we were able to really work on it. And I had to be sort of tough and see her a lot more often and create a program that had more structure instead of simply being frightened and moving her along to a higher level of care. And she's doing fantastic. And I was looking forward to actually talking about her recovery with other people in ways that they can enlist the help of providers. So. So she showed you that most vulnerable piece of herself and you responded to it. Yeah, absolutely. That's beautiful. Dr. Brooklyn? Well, I've been doing this since 1992, so it's a long haul. I think, so two things. One is that there are about 8,000 Vermonters right now on either methadone or buprenorphine. So when we think about as a state, the number of people who are not committing crimes, who are working, who are parenting, that's a lot of people. And to these folks right here, they deserve a lot of credit of what happened in Central Vermont because Central Vermont is really a great example of how a community can really make a difference. You know, I think about when I was in Berlin when it first started, we had 50 people and now I think there's about 500 individuals that go to the hub and I'm sure that some of them to this day are still there. But I was reminded just the other day, I met with somebody who was one of the very first people I started in 2003 and I said to him, so don't you ever get tired of taking buprenorphine under your tongue, sitting there for five minutes every single day. And he said to me, all I've got to do is remember that 25 years I spent chasing heroin every single day and I don't mind at all. Because if this is what it takes, I'm good. That's like, all right. Small investment in time. Everything is relative. That's priceless. We have a few minutes left before we close the show. And you know, you've been wonderful sharing your experiences and your strength and your hope with the viewing audience. I'd like to give each one of you a moment to really close the show with what you wanna tell the general public. Just a statement that you'd like to share with the public regarding opioid use disorder, treatment, whatever you'd like. Our response needs to be comprehensive. And I think Vermont is doing a really good job of filling in the gaps. It appears like it's a large investment of dollars up front, but when we look at the fact that we have a state that has an aging population, we wanna keep our citizens here and the cost of ill health for these people on the other end. I want people to realize that this is an investment in the future and our own citizens and it's worth it. I can't say that enough. We spend our days trying to figure out a way to become unemployed, to work ourselves out of our jobs. And I wish the state would help us by investing in these kind of projects. Thank you. So I'd like to say treatment is available. Pick up the phone, there are no waiting lists. At most, certainly at none of the hubs and most folks don't have a waiting list. Give treatment a try and we're really trying to work hard to make sure that there's no wrong door for a person to knock on. That every door is the right door. And if the first iteration of a treatment doesn't work out, then we'll find the best place for you. So simply pick up the phone and explore the treatment. Yeah, thank you. Thank you. I think what I would like to again go back to is that for a lot of people, this is a chronic problem that you're not gonna be cured by taking buprenorphine or methadone for three months, six months. I think we have to understand that we're in it for the long haul that there's, as Deb mentioned, there's a significant investment that we have to make in the healthcare system. I think also to the point is that we've got an awful lot of Vermonters who are solid back working, paying taxes, taking care of their families and that we really should be proud in Vermont for what we've done in terms of the resources we've put behind it. And kudos to our state government politicians who really feel like this is an investment. And then lastly, I think we also have to consider ourselves lucky that we haven't developed this disorder ourselves. As you said, a single pill may send people down the road that they didn't expect to be on. And so I think for a lot of people, it could happen to anybody and just a little more grace and understanding of the situation would go a long way. Thank you, thank you. And thank you so much for your participation today. I can't think of a better panel and I'm sure that the viewing audience has learned a great deal about treatment. We don't give up, we're Vermonters, we don't abandon Vermonters and we don't give up. And just again, thank you. Thank you for your dedication and your hard work over the years. Thanks for having us. Thank you.