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Trends in Addiction Medicine and in Synthetic Drug Use Michel A Sucher MD FASAM Medical Director Community Bridges, Inc. Stephanie Siete Director of Community Education Community Bridges, Inc. Slide 2 Disclosures Greenberg & Sucher, PC President and shareholder Community Bridges, Inc. Medical Director Community Medical Services Medical Director Medical Staff Membership Scottsdale Healthcare, Banner Behavioral Health Hospital, Mission Hospital Pharmaceutical Companies-NONE Other Treatment Providers-NONE Slide 3 Agenda Addiction Medicine 101 The PHP Model Medication Assisted Treatment-controversies and challenges Tools to Assist in evaluation and treatment Community Bridges, Inc. The Prescription Drug Epidemic-Problem and Solutions The New Era of Synthetic Drugs Slide 4 Addiction Medicine 101 Addiction Defined-Addiction is a primary, chronic disease of brain circuitry. Addiction is characterized by inability to consistently abstain from drugs of abuse, impairment in behavioral control, craving, diminished recognition of significant problems with ones behaviors and interpersonal relationships. Slide 5 Addiction Medicine 101 Addiction is a chronic medical illness Similar to diabetes, asthma and hypertension Progression to Addiction Social or As prescribed use-no issues or consequences Abuse-use begins to cause problems in life Addiction-life interferes with using (loss of control) Slide 6 Addiction Treatment 101 Treatment Works Substance dependence treatment is effective Levels of Treatment Medical Detoxification-inpatient and outpatient Opioids, Benzodiazepines Other Outpatient Residential/Inpatient/Extended residential Medication Assisted Treatment Slide 7 The PHP Model Physician Health Programs have the most objective data on treatment of substance use disorders Backed by objective data Drug test results Face to face relapse prevention therapy groups Regular case management interviews and reports Worksite monitoring No self treatment/medication Slide 8 The PHP Model Actually this is disease management of substance dependence BMJ 11/08 904 physicians, 16 states, 7.2 year follow up, all specialties Most programs are fully abstinent based No alcohol, opiates, benzos, other drugs (unless medically required and Rxd by knowledgeable physicians No self medication Slide 9 The PHP Model Extraordinary Success Rates BMJ Outcomes 78% no positive drug tests Of remaining 22%, 2/3 had only 1 positive drug test Only 6-7% had long term consequences such as license loss, death, suicide, etc. Arizona State Board of Dental Examiners 92% success rate in most recent 5 year study 79% success rate in prior 10 years (before addition of relapse prevention groups, mandatory inpatient treatment and strict compliance measurement Slide 10 Medication Assisted Treatment Opiate Dependence Methadone (agonist) Buprenorphine (Suboxone, Subutex, etc) (agonist/antagonist) Naltrexone (antagonist) Alcohol Dependence Antabuse Naltrexone (oral and injectible) Acamprosate Other Slide 11 Opiate Dependence Issues Legitimate medical use-physical dependence Pain management Substance dependence Illegitimate/illegal drug use-physical dependence and addiction Abuse Addiction Pseudo addiction Slide 12 Treatment of Opiate Dependence Medical Detoxification Inpatient Outpatient Maintenance Treatment Methadone Buprenorphine Opiate Antagonist Treatment-Naltrexone Abstinence Treatment Slide 13 Controversies in Opiate Addiction Treatment Maintenance vs Abstinence Medical Disease Model Good news-Its a disease Bad news-Its a disease, in the US we treat diseases with medications (eg hypertension, diabetes, etc.) Abstinence much more rarely offered or attempted Often young heroin or Rx opiate addicts placed directly into medication assisted treatment without any opportunity to try abstinence or antagonist treatment Slide 14 Treatment for Alcohol Dependence Medical Detoxification Medication Assisted Treatment-still rarely used Includes antabuse, naltrexone, acamprosate Levels of Treatment Alcoholics Anonymous Intensive Outpatient Treatment Inpatient/residential treatment More treatment is better Slide 15 Challenges in Addiction Treatment Medical marijuana (18 states plus DC) Legal marijuana (WA, CO currently) Synthetic drugs (spice, bath salts, etc.) New synthetic drugs Slide 16 Drug Testing A lab test for a medical condition to determine if the disease is in remission The most objective measure of abstinence Should be widely used in the treatment of addiction (like checking blood sugars and blood pressure) Extremely accurate when done properly You wont find a drug you dont test for Slide 17 Drug Testing Urine-most common Hair/Nails-long look back period Blood-good for alcohol and therapeutic drug levels Breath-alcohol Oral Fluids-increasing use Can test for virtually anything except N2O Slide 18 CSPMP Arizona State Board of Pharmacy Any prescriber can enroll Looks at all controlled Rx prescriptions since 2008 Takes less than a minute once enrolled Gives Rx details re: prescribers and pharmacies Should be done on every patient, every visit Slide 19 Research in Addiction Medicine Brain and Neurotransmitter Research New Medications Vaccines Process Addiction Research Sex, Gambling, Food, High Risk Behaviors, etc. Outcome studies Slide 20 Rx Medications-The Problem Pain is 5 th Vital Sign Discipline more likely for under prescribing than over prescribing We have essentially become providers of narcotics on demand Pain management guidelines from the FSMB and AMB-good but often not followed We trust our patients but do not verify their histories-drug testing and CSPMP checks are NOT used nearly often enough Slide 21 Rx Medications-The Problem Hydrocodone most commonly prescribed Rx medication in the USA Accidental overdose deaths exceed MVA deaths every year since 2009 Much addiction, overdoses, deaths the result of treatment for legitimate medical conditions Opioids, Benzodiazepines, Sedative- Hypnotics now more common than illegal drugs as entry/gateway drug in teens; Most obtained from parents or friends parents medicine cabinets Slide 22 Alcohol Cigarettes Marijuana Prevalent Drugs of Abuse: Source: Monitoring the Future Survey, Institute for Social Research, University of Michigan, 1999. * Prescription Drugs Slide 23 Rx Drug Use An Epidemic Prescription drug abuse is the nation's fastest-growing drug problem White House Office on National Drug Policy 1.3 million emergency room visits in 2010, a 115% increase since 2004 Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008 Slide 24 Accidental Rx Overdoses Slide 25 o Every day 2,700 teens try a prescription drug to get high for the first time. Partnership for Drug Free America, 2010 Drug overdose death rates in the United States have more than tripled since 1990 and have never been higher. In 2008, more than 36,000 people died from drug overdoses, and most of these deaths were caused by prescription drugs. The Rx Nation Slide 26 Teen Prescription Drug Abuse According to the New PATS Data (2008-2012) Teen Prescription Drug Abuse According to the New PATS Data (2008-2012) One in four teens (24 percent) reports having misused or abused a prescription drug at least once in their lifetime 18 percent in 2008 24 percent in 2012 Translates to about 5 million teens. This is a 33 percent increase over a five-year period Of those kids who said they abused Rx medications, one in five (20 percent) has done so before age 14 More than a quarter of teens (27 percent) mistakenly believe that misusing and abusing prescription drugs is safer than using street drugs Slide 27 Parental Lax attitude about Teen Rx Use According to the New PATS Data (2008-2012) One in six parents (16 percent) believes that using prescription drugs to get high is safer than using street drugs More than half of teens (56 percent) indicate that its easy to get prescription drugs from their parents medicine cabinet. About half of parents (49 percent) say anyone can access their medicine cabinet. One in five parents (20 percent) report that they have given their teen a prescription drug that was not prescribed for them. Survey also found that 17 percent of parents do not throw away expired medications, and 14 percent of parents say they themselves have misused or abuse prescription drugs within the past year. Slide 28 Over-prescription of Rx drugs In Arizona, 476 million pills were prescribed in 2011. Pain Relievers accounted for over 50% of these scripts Nearly three out of four prescription drug overdoses are caused by prescription painkillers. Opiate overdoses (once almost always due to heroin use), are now increasingly due to abuse of prescription painkillers In AZ, 1,176 Rx deaths were attributed to drug overdoses in 2010 Slide 29 Slide 30 Arizona drug-related DUIs rising Prescription painkillers and synthetic drugs such as spice are common culprits Alberto Gutier, director of the Governors Office of Highway Safety By Jim Walsh The Republic | azcentral.com Tue Jan 15, 2013 10:55 AM Slide 31 o OxyContin most recognized and abused form o Prescribed to relieve pain o Twice as strong as morphine o Time released (8-12 hours) o Pills crushed and snorted or cooked down and injected to break down time release component o Strong, heroin-like, euphoric effects o Expensive o Dollars to milligrams: 10, 20, 40, 80, 120 (ex) o Other variations: Percocet and Percodan Oxycodone Slide 32 In 1980s = 3.6% pure 1990 = 18% pure 1998 = 41% pure Today = 60-90% ??? No longer have to inject heroin to feel the effect. Purity so high effects felt by snorting or smoking 1996-1998 19 young people die of heroin overdoses in Plano, Texas Purity levels ranged up to 75% Heroin Purity Slide 33 Rx Drug Take Back Day 742,497 pounds of Rx drugs were collected from almost 6,000 sites around the country on April 27. More than 2.8 million pounds of prescription medications have been removed from circulation during the 6 national take-back days the DEA has sponsored. www.DEA.gov Slide 34 Whats happening? Methamphetamine Heroin Marijuana Bath Salts Krokodil Spice Change a few molecules Slide 35 Unknown: chemicals, effects, outcomes Chemicals not drugs What chemicals? What does a ban mean? How long does it last? Who enforces these legal efforts? Who has authority? Community collaboration needed East Valley Synthetic Drugs Task Force Slide 36 Desomorphine Krokodil Desomorphine o Dirty cousin to morphine o Roughly same effect as heroin but at least three times cheaper and extremely easy to make o Active component is codeine, a widely sold over-the-counter painkiller (non toxic on its own). Mixed w gasoline, paint thinner, hydrochloric acid, iodine and red phosphorous o In 2010, between a few hundred thousand and a million people, according to various official estimates, were injecting the resulting substance into their veins in Russia and now Germany o The "rotting" explains the drug's nickname. At the injection site, which can be anywhere from the feet to the forehead, the addict's skin becomes greenish and scaly, like a crocodile's. Blood vessels burst and the surrounding tissue dies o Gangrene and amputations are a common result, while porous bone tissue, especially in the lower jaw, often starts to dissipate, eaten up by the drug's acidity Slide 37 Krokodil Drug - Desomorphine Slide 38 Ofc. L.Gill ASUPolice Slide 39 End Results For Users Initially the injection site turns a yellow/green and the surrounding flesh begins to grow lesions Lesions break open into gaping wounds. These areas are then highly susceptible to gangrene Continued use the flesh begins to eat away, sometimes to the bone Vital organs of the users body began to decay and fail Longest know life span of an addict is 2-3yrs One year is the typical length Ofc. L.Gill ASUPolice Slide 40 Kratom Opiate-like leaf from Southeast Asia Chewed as a leaf or in a tea Legal and unregulated in US Street names: Thang, Kakuam, Thom, Ketum, Biak Small doses acts as energy boost Is in the coffee family Larger doses creates mellow, sedating effect Acting on opiate receptors Slide 41 Kratom Kratom Use on the Rise appealing to bath salt crowd Kratom On the Rise POSTED: 05:00 PM MST Mar 07, 2013 Kratom Sales Its not that bad KING 5 News Posted on January 15, 2013 at 12:13 AM Slide 42 Kratom Overdoses Hallucinations Delusions Listlessness Tremors Aggression Constipation Nausea Slide 43 More Kratom info Similar heroin withdrawal effects Effects occur within 5-10 minutes. Lasting 2-5 hours Added to DEA drugs and chemicals of concern list In 2005, only 2 incidents nationwide in 2011, Banner Good Samaritan Poison Control in Phoenix saw 6 cases Untraceable in drug tests Slide 44 2C-I or Smiles First surfaced in 2003 European club scene Closely related to 2C-E Limited research 2 deaths in 2012 (ND and MN) Slide 45 2C-I or Smiles MDMA and LSD combo more potent Speedy charge, intense hallucinations Liquid, powder or pill form common Can be mixed in food/drinks Effects can occur within 40 minutes, last 2-3 hours Schedule 1 substance possession and distribution illegal Untraceable in drug tests Slide 46 Benzo Fury Stimulant and hallucinogenic effects The drug is a synthetic, laboratory- designed substance Similar effects to amphetamine and cocaine Slide 47 25I-NBOMe 25-I or N Bomb New synthetic version of LSD Use with a blotter and/or put it on your tongue Powerful hallucinations Deaths in Louisiana, California and North Dakota 25I is an analog, or derivative of 2CI 25I-NBOMe in Utah Slide 48 N-bomb drug stirs fear in Phoenix area By JJ Hensley The Republic | azcentral.com Fri May 3, 2013 10:24 PM A drug marketed as an alternative to LSD or mescaline could be among the most powerful and potentially deadly of the synthetic drugs that have inundated the market in recent years, police and physicians believe. A 19-year-old from the West Valley was in a medically induced coma for four days after taking the drug, a synthetic hallucinogen known as n-bomb, and would have died if he had not received treatment when he did, according to a physician. Scottsdale police are investigating whether the deaths this year of two 18-year-olds are linked to the drug. Slide 49 25i-NBOMe The first case in Scottsdale involved an 18-year-old Saguaro High School student who died in late January after taking what he assumed was LSD. Scottsdale police are also investigating the death of an 18-year-old Arizona State University student who authorities believe died after taking the drug last weekend. In the January case, Noah Carrasco lost consciousness shortly after taking the dose, administered through nose drops. An onlooker thought Carrasco simply needed to get some fresh air and sleep it off, said Carrascos mother, Susan Wadsworth. A friend drove Carrasco around for a while but later became more concerned and took Carrasco to the hospital about 1:40 a.m. on Jan. 25. Hed been dead already at least for a couple of hours, Wadsworth said. They didnt know that thats what they were taking. My son was not a reckless person. He decided to try what he thought was acid, and obviously I didnt know this at the time. But he would never have tried something he knew was that dangerous. Sold as Smiles Treated with Milk in one case cocaine and meth in the other Slide 50 Who is Molly? Slide 51 Molly is Molecule MDMA Slide 52 Synthetic Cannabinoids and Substituted Cathinones Slide 53 "Spice" or "K2" Synthetic Cannabinoids "Spice" or "K2" o Often referred to as: "Spice," Genie" Blaze and "Zohai" o K2 contains synthetic chemicals that act on the cannabinoid receptors in the brain o Sold in headshops or on internet as incense or potpourri for $5 - $60 per gram o Rolled up in joints or inhaled from pipes o Undetectable in many drug tests o February 2011 AZ bans Spice (10 chemicals) o March 2011 Federal ban of substance (5 chemicals) o July 2012 Federal ban of 20 more chemicals (25) o January 2013 31 Federally banned chemicals o April 3, 2013 ALL chemicals illegal in AZ Slide 54 HB 2167 (2011) JWH-018 JWH-073 JWH-019 JWH-398 JWH-200 JWH-250 JWH-015 HU-201 CP 47,497 and its C8 homologue Previously banned cannabinoids in Arizona Slide 55 JWH 1995 - Professor John W. Huffman at Clemson University received a federal research grant to study marijuana effects of marijuana on the brain. JWH was told he needed to create substitute chemicals to study the secret chemical substitutes were ripped off and now are frequently abused. Slide 56 HB 2327 Key provision: Expands the state's definition of dangerous drugs to include chemical configurations that typically compose synthetic cannabinoids and bath salts All chemical compounds illegal Illegal in sales, possession, manufacturing and transferring Class 4 felony up to two and a half years of incarceration CBS News - HB 2327 Slide 57 Where does it come from now? Southeast Asia Purchased chemicals Research Chemicals Personal production Internet Sales How to Slide 58 Prevalence-2010 Ofc. L.Gill ASUPolice Slide 59 Prevalence-2012 Slide 60 Ingenuity of Designer Chemists JWH-018AM-2201 Change one strand of the molecule and you have a new, legal substance. This makes the exponential growth of these drugs a reality. Ofc. L.Gill ASUPolice IllegalLegal Slide 61 Possible Health Risks Hallucinations, delusions, severe agitation, elevated heart rate and blood pressure, vomiting, tremors, and seizures In the most severe cases users have blacked out for several hours, had feelings of cardiac arrest, and/or recorded feelings of psychosis Some of symptoms such as increased agitation, elevated blood pressure, and heart rates severely increase in Spice Marijuana label is mislabeling! Spice is NOT pot Slide 62 Thalidomide OTC tranquilizer released in the late 1950s Marketed in 46 countries as sleep aid, alleviating nausea given with complete safety to pregnant women and nursing mothers without any adverse effect on mother and child. During 4 years it was on market, doctors prescribed it as a nontoxic antidote to morning sickness and sleeplessnesssold to millions. Affected 100,000 pregnant women, causing over 90,000 miscarriages and thousands of deformities to the babies who survived Effects: deaf, blind, curved spines, born without arms or legs, shortened limbs, heart and brain damage Slide 63 Who is using synthetic drugs? Arizona Teens 1 in 10 AZ teens using synthetic drugs 8 th graders 6.9% 10 th graders 11.1% 12 th graders 13.9% This is first time capturing synthetic drug data on teens in AYS Arizona Youth Survey, 2012 http://www.kpho.com/story/20272748/survey-1-in-10-az-teens Slide 64 DAWN Report Synthetic Drugs December 4, 2012 (Drug Abuse Warning Network) In 2010: 11,406 ER visits for synthetic cannabinoids or 75% of patients were ages 12-29 years of age The majority (76%) did not receive follow up care after discharge from ER 59% of 12-29 year old patients only presented with spice no other substance found Slide 65 In 2011 According to the U.S. Drug Abuse Warning Network, some 28,000 emergency room visits in 2011 were caused by known synthetic cannabinoids, more than double the 2010 number. Slide 66 Sold As Code Words not tobacco Potpourri Herbal incense Glass cleaner Plant fertilizer Insect repellent Souvenir Bath salts Slide 67 What are Substituted Cathinones? Bath Salts Derivatives of cathinone, a psychoactive substance with stimulant properties occurring naturally in the khat plant effects are similar to amphetamines like ecstasy and cocaine Street names Abyssinian Tea, African Salad, Catha, Chat, Kat, Oat Powder and crystal form that crumbles easily White to light brown in color Sold in 50 mg to 500 mg packets/containers Labeled not for human consumption Sold for $5 to $75 Easily available online Law enforcement and open news sources, Officer Donald Reid, 2012 Slide 68 Bath Salts Bans At least 42 states have outlawed substituted cathinones Poison control centers around the country received 6,138 calls about bath salts in 2011, according to the American Association of Poison Control Centers, up from 304 in all of 2010American Association of Poison Control Centers 3 federally banned chemicals: mephedrone, methylone, methylenedioxypyrovalerone (MDPV) Slide 69 Effects High similar to cocaine, methamphetamine, MDMA (Ecstasy) or LSD Initial euphoria last 3-4 hours Psychosis, hallucinations, suicidal thoughts can last 3-4 days Unknown long term effects 3-4 months after last initial use Cited as imminent threat to public safety by DEA Law enforcement and open news sources, Officer Donald Reid, 2012 Slide 70 More Effects Sweating Agitation Hallucinations Tremors Coma Excited Delirium (bizarre and/or aggressive behavior, shouting, paranoia, panic, violence toward others, unexpected physical strength and hyperthermia) Death Harm to self Harm to others Hypertension Permanently alter brains chemistry Psychiatric conditions Slide 71 Signs and Symptoms Extreme paranoia Psychotic features (reporting seeing demons, monsters, foreign soldiers, aliens) Violent behavior Tachycardia (rapid heartbeat) Chest pain Confusion High blood pressure Sweating Hyper-alertness Slide 72 Signs and Symptoms Sleep depravation Agitation Extreme anxiety Hallucinations Teeth grinding Excessive water drinking Tremors Seizures Slide 73 Ivory Wave Cloud 9 Ocean Bliss Eight Ballz White Lightning Hurricane Charlie Charge Plus Scarface Red or White Dove White Water Rapid Amped Ladybug Attractant Snowman Glass Cleaner Bath Salts Common Names Slide 74 Synthetic Cathinones Bath Salts Flesh eating bacteria Slide 75 Bath Salts in the News PD: Man on bath salts runs naked through Tempe neighborhood ABC 15 July 18, 2012 PD: Man ingests bath salts, swims naked in Tempe Town Lake AZFamily July 24, 2012 Flesh-Eating Disease Blamed on Bath Salts Jan 13, 2012 6:19pm 'Bath Salts' Drug Suspected In Miami Face-Eating Attack May 30, 2012 Man high on bath salts thought he was being chased by electricity during burglary, police say Friday, March 25, 2011, 7:56 AM Updated: Friday, March 25, 2011, 10:56 AM Slide 76 Can you still purchase? http://bath-salts-direct.com/ http://spice-gold- direct.com/acatalog/stimulating-bath-salts- powder-blends.html http://spice-gold- direct.com/acatalog/stimulating-bath-salts- powder-blends.html Spice Gold Direct shared a link. Spice Gold Directlink Slide 77 Synthetics in the News ABC 20/20 Synthetic Drugs - 9 minutes Bath Salt Use - Good Morning America Synthetic Drugs - shorter version 2 minutes Slide 78 How do we respond? Community awareness Product recognition Symptom recognition Treatment Medical care Law Enforcement Respond and Protect Legislation Eliminate it Be Safe and do NOT attempt to reason with someone under the influence. Call for help. Slide 79 Resources http://www.tascaz.org/ Banner Good Samaritan Poison and Drug Information Center 24-hour phone: 1-800-222-1222 www.dea.gov Slide 80 www.communitybridgesaz.org www.partnerupaz.org www.health.org www.drugfreeaz.org http://www.timetotalk.org www.theantidrug.com www.jointogether.org Helpful Websites Slide 81 Where can you find more information? Call your local poison center at 1-800-222-1222. Poison centers are open 24 hours a day, seven days a week, every day of the year for poisoning emergencies and for informational calls, too. www.aapcc.org Slide 82 Prerequisites for Solutions Acknowledge the Problem Understand the risks of inappropriate prescribing Learn that the common belief that chronic use of controlled substances is safe and non impairing may not be true Get everyone (public, patients, insurers, prescribers, etc) out of denial Educate, Educate, Educate Slide 83 Possible Solutions Education for Providers Proper prescribing courses (possibly required CE) Proper procedure and rules re: dispensing Addiction Medicine 101 and realistic information about true risk of addiction to controlled substances Taking complete histories, obtaining prior medical records, use of CSPMP and similar programs Role of physicians and pharmacists and how they can work together to identify and prevent abuse Slide 84 Possible Solutions Education for Providers, contd Effects of controlled substances on cognition and performance Treatment options for patients who become addicted and how to access appropriate treatment options Monitoring/disease management Outcomes data Slide 85 Possible Solutions Who to Educate Educate physicians Educate patients Educate parents Educate teenagers and children Educate society Educate insurers Educate all stakeholders Like we are doing here today Slide 86 Possible Solutions Increased regulation Increased enforcement and discipline Holding patients, family members responsible in addition to the medical profession Expansion/enhancement/improved funding for CSPMP and similar providers of key information Better coordination of care between providers for every patient Slide 87 Essentials for Change Understanding addiction treatment options and efficacy Separate treatment models for the substance dependent individual vs the accidental addict with legitimate medical issues Prompt Identification of patients in crisis from misuse/abuse of prescription medications Insistence upon detoxification and treatment when indicated Slide 88 Community Bridges, Inc. Started as medical detoxification in Mesa, AZ for the indigent Now full service crisis and treatment agency for mental health and substance abuse 30 facilities statewide, all connected by EMR and Telemedicine Highly qualified staff of psychiatrists, addiction physicians, psychiatric and family nurse practitioners Level IV Stabilization and Recovery Unit (SRU) in Payson Slide 89 Where We Serve Maricopa County Central City Level I East Valley Level I ADMIN DRC/CASS OP Ctr for Excellence OP Center for Hope Level II Journey/OP Prevention Partnership Steele Commons OP Az Bridge to Recovery Payson Level IV Globe Level IV Clinical Ops Admin. Probation OP Drug Court OP Holbrook Level IV Winslow Level IV Phoenix Yuma Level III Benson Level II Benson Level IV WV Triage Level III Casa Grande Level IV Mesa Aspire OP for Women Supportive Housing Glendale OP East Valley Triage Level III Slide 90 Summary These are real issues Education is a key component Improved communication between providers and all involved professionals is essential (physicians, pharmacists, other) Prevention and early identification are critical Treatment is effective Use drug testing and CSPMP queries Slide 91 Thanks for your attention Questions? Greenberg & Sucher, PC Michel A Sucher MD FASAM PO 1420 Scottsdale, AZ 85252 877-457-3111; Cell 480-213-7674 Email: drsucher@greenbergandsucher.com www.greenbergandsucher.com www.posttreatmentsupervision.com Slide 92 Thanks for your attention Questions? Stephanie Siete ssiete@cbridges.com 602.377.4591 24/7 Access to Care 877.931.9142 www.CommunityBridgesAZ.org Slide 93 Community Bridges AZ News videos, articles, upcoming presentations www.CommunityBridgesAZ.org