Rio Bravo qWeek

Rio Bravo Family Medicine Residency Program
  • 5.0 (11)
  • MEDICINE
  • UPDATED SEMIMONTHLY

qWeek is the official podcast of the Rio Bravo Family Medicine Residency Program. Residents and faculty routinely present key topics and relevant discussions, coupled with medical jokes and Spanish medical terminology.

  1. 2D AGO

    Episode 210: Heat Stroke Basics

    Episode 210: Heat Stroke Basics Written by Jacob Dunn, MS4, American University of the Caribbean. Edits and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.   Definition: Heat stroke represents the most severe form of heat-related illness, characterized by a core body temperature exceeding 40°C (104°F) accompanied by central nervous system (CNS) dysfunction.  Arreaza: Key element is the body temperature and altered mental status.  Jacob: This life-threatening condition arises from the body's failure to dissipate heat effectively, often in the context of excessive environmental heat load or strenuous physical activity.  Arreaza: You mentioned, it is a spectrum. What is the difference between heat exhaustion and heat stroke?  Jacob: Unlike milder heat illnesses such as heat exhaustion, heat stroke involves multisystem organ dysfunction driven by direct thermal injury, systemic inflammation, and cytokine release. You can think of it as the body's thermostat breaking under extreme stress — leading to rapid, cascading failures if not addressed immediately.  Arreaza: Tell us what you found out about the pathophysiology of heat stroke? Jacob: Pathophysiology:  Under normal conditions, the body keeps its core temperature tightly controlled through sweating, vasodilation of skin blood vessels, and behavioral responses like seeking shade or drinking water. But in extreme heat or prolonged exertion, those mechanisms get overwhelmed. Once core temperature rises above about 40°C (104°F), the hypothalamus—the brain’s thermostat—can’t keep up. The body shifts from controlled thermoregulation to uncontrolled, passive heating. Heat stroke isn’t just someone getting too hot—it’s a full-blown failure of the body’s heat-regulating system.  Arreaza: So, it’s interesting. the cell functions get affected at this point, several dangerous processes start happening at the same time. Jacob: Yes:  Cellular Heat Injury High temperatures disrupt proteins, enzymes, and cell membranes. Mitochondria start to fail, ATP production drops, and cells become leaky. This leads to direct tissue injury in vital organs like the brain, liver, kidneys, and heart.Arreaza: Yikes. Cytokines play a big role in the pathophysiology of heat stroke too.  Jacob:  Systemic Inflammatory Response Heat damages the gut barrier, allowing endotoxins to enter the bloodstream. This triggers a massive cytokine release—similar to sepsis. The result is widespread inflammation, endothelial injury, and microvascular collapse.Arreaza: What other systems are affected? Coagulation Abnormalities Endothelial damage activates the clotting cascade. Patients may develop a DIC-like picture: microthrombi forming in some areas while clotting factors get consumed in others. This contributes to organ dysfunction and bleeding.Circulatory Collapse As the body shunts blood to the skin for cooling, perfusion to vital organs drops. Combine that with dehydration from sweating and fluid loss, and you get hypotension, decreased cardiac output, and worsening ischemia.Arreaza: And one of the key features is neurologic dysfunction. Jacob:  Neurologic Dysfunction The brain is extremely sensitive to heat. Encephalopathy, confusion, seizures, and coma occur because neurons malfunction at high temperatures. This is why altered mental status is the hallmark of true heat stroke.Arreaza: Cell injury, inflammation, coagulopathy, circulatory collapse and neurologic dysfunction.  Jacob: Ultimately, heat stroke is a multisystem catastrophic event—a combination of thermal injury, inflammatory storm, coagulopathy, and circulatory collapse. Without rapid cooling and aggressive supportive care, these processes spiral into irreversible organ failure. Background and Types: Arreaza: Heat stroke is part of a spectrum of heat-related disorders—it is a true medical emergency. Mortality rate reaches 30%, even with optimal treatment. This mortality correlates directly with the duration of core hyperthermia. I’m reminded of the first time I heard about heat stroke in a baby who was left inside a car in the summer 2005.  Jacob: There are two primary types:  -nonexertional (classic) heat stroke, which develops insidiously over days and predominantly affects vulnerable populations like children, the elderly, and those with chronic illnesses during heat waves;  -exertional heat stroke, which strikes rapidly in young, otherwise healthy individuals, often during intense exercise in hot, humid conditions.  Arreaza: In our community, farm workers are especially at risk of heat stroke, but any person living in the Central Valley is basically at risk. Jacob: Risk factors amplify vulnerability across both types, including dehydration, cardiovascular disease, medications that impair sweating (e.g., anticholinergics), and acclimatization deficits. Notably, anhidrosis (lack of sweating) is common but not required for diagnosis. Hot, dry skin can signal the shift from heat exhaustion to stroke.  Arreaza: What other conditions look like heat stroke? Differential Diagnosis: Jacob: Presenting with altered mental status and hyperthermia, heat stroke demands a broad differential to avoid missing mimics.  -Environmental: heat exhaustion, syncope, or cramps.  -Infectious etiologies like sepsis or meningitis must be ruled out.  -Endocrine emergencies such as thyroid storm, pheochromocytoma, or diabetic ketoacidosis (DKA) can overlap.  -Neurologic insults include cerebrovascular accident (CVA), hypothalamic lesions (bleeding or infarct), or status epilepticus.  -Toxicologic culprits are plentiful—sympathomimetic or anticholinergic toxidromes, salicylate poisoning, serotonin syndrome, malignant hyperthermia, neuroleptic malignant syndrome (NMS), or even alcohol/benzodiazepine withdrawal.  When it comes to differentials, it is always best to cast a wide net and think about what we could be missing if this is not heat stroke.  Arreaza: Let’s say we have a patient with hyperthermia and we have to assess him in the ER. What should we do to diagnose it? Jacob: Workup: Diagnosis is primarily clinical, hinging on documented hyperthermia (>40°C) plus CNS changes (e.g., confusion, delirium, seizures, coma) in a hot environment.  Arreaza: No single lab confirms it, but targeted testing allows us to detect complications and rule out alternative diagnosis.  Jacob:  -Start with ECG to assess for dysrhythmias or ischemic changes (sinus tachycardia is classic; ST depressions or T-wave inversions may hint at myocardial strain).  -Labs include complete blood count (CBC), comprehensive metabolic panel (electrolytes, renal function, liver enzymes), glucose, arterial blood gas, lactate (elevated in shock), coagulation studies (for disseminated intravascular coagulation, or DIC), creatine kinase (CK) and myoglobin (for rhabdomyolysis), and urinalysis. Toxicology screen if history suggests.  Arreaza: I can imagine doing all this while trying to cool down the patient. What about imaging? -Imaging: chest X-ray for pulmonary issues, non-contrast head CT if neurologic concerns suggest edema or bleed (consider lumbar puncture if infection suspected).  It is important to note that continuous core temperature monitoring—via rectal, esophageal, or bladder probe—is essential, not just peripheral skin checks.  Arreaza: Treatment Management: Time is tissue here—initiate cooling en route, if possible, as delays skyrocket morbidity. ABCs first: secure airway (intubate if needed, favoring rocuronium over succinylcholine to avoid hyperkalemia risk), support breathing, and stabilize circulation.  -Remove the patient from the heat source, strip clothing, and launch aggressive cooling to target 38-39°C (102-102°F) before halting to prevent rebound hypothermia.  -For exertional cases, ice-water immersion reigns supreme—it's the fastest method, with immersion in cold water resulting in near-100% survival if started within 30 minutes.  -Nonexertional benefits from evaporative cooling: mist with tepid water (15-25°C) plus fans for convective airflow.  -Adjuncts include ice packs to neck, axillae, and groin;  -room-temperature IV fluids (avoid cold initially to prevent shivering);  -refractory cases, invasive options like peritoneal lavage, endovascular cooling catheters, or even ECMO.  -Fluid resuscitation with lactated Ringer's or normal saline (250-500 mL boluses) protects kidneys and counters rhabdomyolysis—aim for urine output of 2-3 mL/kg/hour.  Arreaza: What about medications? Jacob: Benzodiazepines (e.g., lorazepam) control agitation, seizures, or shivering; propofol or fentanyl if intubated. Avoid antipyretics like acetaminophen. For intubation, etomidate or ketamine as induction agents. Hypotension often resolves with cooling and fluids; if not, use dopamine or dobutamine over norepinephrine to avoid vasoconstriction.  Jacob: What IV fluid is recommended/best for patients with heat stroke? Both lactated Ringer’s solution and normal saline are recommended as initial IV fluids for rehydration, but balanced crystalloids such as LR are increasingly favored due to their lower risk of hyperchloremic metabolic acidosis and AKI. However, direct evidence comparing the two specifically in the setting of heat stroke is limited.  Arreaza: Are cold IV fluids better/preferred over room temperature fluids? Cold IV fluids are recommended as an adjunctive therapy to help lower core temperature in heat stroke, but they should not delay or replace primary cooling methods such as cold-water immersion. Cold IV fluids can decrease core tempera

    23 min

  2. 12/12/2025

    Episode 209: Do not Do

    Episode 209: Do not Do Stephanie Granat (medical student) explains three screenings that are USPSTF Grade D (Do not do): Prostate cancer, genital herpes, and pancreatic cancer. Dr. Arreaza shares some insight about testing patients with lower urinary tract symptoms and genital lesions.  Written by Stephanie Granat, MSIV, Ross University School of Medicine. Edits and comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice.

    22 min

  3. 12/05/2025

    Episode 208: Cough Basics (Pidjin English)

    Episode 208: Cough Basics (Pidjin English) Written by Ebenezer Dadzie You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Episode 201: Cough – Revised Version (Host + 1 Resident; Resident speaks Nigerian Pidgin, Host speaks regular English) [Play intro music, start loud, then lower volume under speech, fade out later] HOST 1: [Introduction] Today we're tackling one of the most common complaints in clinic: the cough. Joining me is one of our amazing residents. Doctor, please introduce yourself. RESIDENT: Na Dr. Resident from Rio Bravo. I dey here to gist about cough wey dey disturb plenty patients for area. Segment 1 – Cough Basics HOST 2: Let’s start simple. When a coughing patient walks into the exam room, what is the first step? RESIDENT: First tin na history. You gats ask whether na dry cough or cough wey dey bring sputum, whether e just start or don tey. Whether person get exposure, dust, new medicine—history dey open many doors pass Google. HOST 1: Exactly. And as we know, acute coughs are usually viral, but chronic coughs lasting more than eight weeks can point to asthma, GERD, ACE inhibitor side effects, or more. Segment 2 – Valley Fever HOST 2: And since we’re here in Kern County, we have to mention Valley Fever. We see thousands of cases every year, many of them presenting with cough. RESIDENT: True. Valley Fever fit look like pneumonia, bronchitis, or even TB. Patient go come with cough, tiredness, sometimes rash. If person dey work for outside or dey around dusty area, you suppose reason am. Segment 3 – Workup and Treatment HOST 1: So let’s talk evaluation. When you have a cough here in California’s Central Valley, what is your approach? RESIDENT: Start from basic: chest X-ray, CBC, ask good history. If e no improve, add Valley Fever blood test. If cough get phlegm, you fit send sputum. If weight dey drop or sweats dey night, you reason TB or cancer. Treatment depend on severity. Mild one fit resolve, but if no be small, na antifungals—like fluconazole—and you go monitor liver enzymes well. Segment 4 – Humor Break HOST 2: Alright—quick humor break. Got any memorable cough stories? RESIDENT: One man tell me say “doctor, my neighbor ghost na cause my cough.” We check-am finish, na allergy. Ghost no dey push fungus, sha! [Both laugh] Segment 5 – Takeaways HOST 1: Before we wrap up, give listeners top key points on cough. RESIDENT: One—ask better history. Cough dey tell story. Two—if person dey Bakersfield, reason Valley Fever, e fit sneak. Three—no dey give antibiotics anyhow. Virus and fungus no go respond like bacteria. Trivia Time HOST 2: Trivia question: In adults who don’t smoke and aren’t on ACE inhibitors, what is the most common cause of chronic cough? A) Asthma B) GERD C) Chronic bronchitis D) Postnasal drip (Upper airway cough syndrome) RESIDENT: I go choose D—postnasal drip. Na e dey cause that tickle wey no dey go. HOST 1: And that’s correct—postnasal drip is the number one cause of chronic cough. Nicely done! You win bragging rights and a cough drop. HOST 2: Thank you for joining us today on Rio Bravo QWeek. To all our listeners—stay curious, keep learning, and if someone sounds like a barking seal in the waiting room, you know it might be more than a cold. HOST & RESIDENT (together): ¡Hasta luego! [Music fades in, rises, then fades out after 10 seconds] References: Irwin, R. S., & Baumann, M. H. (2018). Chronic cough due to upper airway cough syndrome (UACS): ACCP evidence-based clinical practice guidelines. Chest, 129(1_suppl), 63S–71S. https://doi.org/10.1378/chest.129.1_suppl.63S (Guideline on postnasal drip/upper airway cough syndrome as a leading cause of chronic cough)Dicpinigaitis, P. V. (2022). Evaluation and management of chronic cough. New England Journal of Medicine, 386(16), 1532–1541. https://doi.org/10.1056/NEJMra2115321 (Comprehensive review on causes, diagnostic strategies, and treatment of chronic cough)Centers for Disease Control and Prevention. (2023). Coccidioidomycosis (Valley fever) statistics. U.S. Department of Health and Human Services. https://www.cdc.gov/fungal/diseases/coccidioidomycosis/statistics.html (Official CDC data and epidemiology of Valley Fever in the U.S., including high incidence in Kern County)California Department of Public Health. (2022). Coccidioidomycosis in California Provisional Monthly Report. https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Coccidioidomycosis.aspx (State-level surveillance data showing high incidence rates in Bakersfield and Kern County)Prasad, K. T., & LoSavio, P. S. (2023). Approach to the adult with chronic cough. In UpToDate (L. M. Leung, Ed.). Retrieved June 20, 2025, from https://www.uptodate.com (Evidence-based resource for differential diagnosis and workup of cough in primary care)Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

    14 min

  4. 11/28/2025

    Episode 207: Understanding Hypertension and Diabetes (Pidjin English)

    Episode 207: Understanding Hypertension and Diabetes (Pidjin English) Written by Michael Ozoemena, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Hypertension Segment 1: What Is Hypertension? HOST: Let’s start with the basics. Blood pressure is the force of blood pushing against the walls of your arteries. Think of it like water running through a garden hose—if the pressure stays too high for too long, that hose starts to wear out. Hypertension, or high blood pressure, means this pressure is consistently elevated. It is measured using two numbers: Systolic: the pressure when the heart beatsDiastolic: the pressure when the heart relaxesNormally reading is around 120/80 mmHg. Hypertension is defined by the American College of Cardiology/American Heart Association (ACC/AHA) as 130/80 mmHg or higher. The American Academy of Family Physicians (AAFP) defines hypertension as persistent elevation of systolic and/or diastolic blood pressure, with the diagnostic threshold for office-based measurement set at 140/90 mm Hg or higher. Segment 2: Why Should We Care? HOST: Hypertension is known as “the silent killer” because most people have no symptoms. Even without symptoms, it steadily increases the risk of: Heart attackStrokeKidney diseaseThink of high blood pressure as a constant stress test on your blood vessels. The longer it goes uncontrolled, the higher the chance of complications. Segment 3: What Causes High Blood Pressure? HOST: Hypertension usually doesn’t have a single cause. It often results from a combination of genetic factors, lifestyle, and underlying medical conditions. Modifiable Factors High-salt diet and low potassium intakePhysical inactivityTobacco useExcessive alcohol intakeOverweight or obesityChronic stressPoor sleep or sleep apneaNon-Modifiable Factors Family history of hypertensionBlack race (higher prevalence and severity)Age over 65Hypertension may also be secondary to other conditions, such as kidney disease, thyroid disorders, adrenal conditions, or medications like NSAIDs or steroids. Segment 4: How Is It Diagnosed? HOST: Diagnosis requires multiple elevated blood pressure readings taken on different occasions. This includes office readings, home blood pressure monitoring, or ambulatory blood pressure monitoring. If you haven’t had your blood pressure checked recently, this is your reminder. It’s simple—and it could save your life. Segment 5: Treatment and Management HOST: Lifestyle changes are often the first line of treatment: Reduce salt intakeEat more fruits, vegetables, and whole grainsAim for 150 minutes of moderate exercise per weekManage stressMaintain a healthy weightGet enough sleepLimit alcoholQuit smokingIf these steps aren’t enough, medications may be necessary. These include: Diuretics, ACE inhibitors, ARBs, Calcium channel blockers, Beta-blockers Your healthcare provider will choose the best medication based on your health profile. Segment 6: What You Can Do Today HOST: Here are three simple, actionable steps you can take right now: Check your blood pressure—at a clinic, pharmacy, or at home.Pay attention to your salt intake—much of it is hidden in processed foods.Move more—even a 20-minute daily walk can help reduce blood pressure over time.Small steps can lead to big, lasting improvements. Summary Hypertension may be silent but understanding it gives you power. Early action can add healthy years to your life. Take charge of your blood pressure today. Diabetes 1. Wetin Diabetes Be and Wetin E Go Do to Person Body? Q: Wetin diabetes mean? A: Diabetes na sickness wey make sugar (glucose) for person blood too high. E happen because the body no fit produce insulin well, or the insulin wey e get no dey work as e suppose. Q: Wetin go happen if diabetes no dey treated well? A: If diabetes no dey treated well, e fit damage the blood vessels, nerves, kidneys, eyes, and even the heart. 2. Wetin Cause Diabetes and Why Black People Suffer Pass? Q: Wetin cause diabetes? A: E no be one thing wey cause diabetes. E dey happen because of mix of gene, lifestyle, environment, and society factors. Q: Why Black/African Americans get diabetes more? A: Black people for America get diabetes more because of long-standing inequality, stress, low access to healthcare, and the kind environment wey many of them dey live in. These things dey make Black people more at risk. 3. Diabetes Rates for America and Black People? Q: How many people get diabetes for America? A: For America today, over 38 million people get diabetes, and the number dey rise every year. Q: Why Black people dey suffer diabetes more than White people? A: About 12% of Black adults get diabetes, compared to just 7% for White adults. Black people also dey get the sickness earlier and e dey more severe. 4. Signs and Symptoms of Diabetes? Q: Wetin be the early signs of diabetes? A: The early signs no too strong, but when e show, e fit include: Too much urine (polyuria)Thirst (polydipsia)Hunger, tiredness, and blurred visionWounds no dey heal fastTingling for hand or legSometimes weight loss5. How Doctor Go Diagnose Diabetes? Q: How doctor fit confirm say person get diabetes? A: Doctor go do some lab tests to confirm: Fasting Plasma Glucose (FPG): 126 mg/dL (7.0 mmol/L) or higherHbA1c: 6.5% or higher2-hour Oral Glucose Tolerance Test (OGTT): 200 mg/dL (11.1 mmol/L) or higher after person drink glucose.Random Blood Glucose: 200 mg/dL (11.1 mmol/L) or higher plus classic symptoms like too much urination, thirst, or weight loss.Q: Wetin happen if HbA1c test no match the person? A: If HbA1c result no match person symptoms, doctor fit repeat test or try other tests like FPG or OGTT. 6. Wetin Screening and Early Diagnosis Fit Do? Q: Why screening for diabetes dey important? A: Screening dey important because early detection fit prevent serious complications from diabetes. Q: How often person go do diabetes test? A: Adults wey get overweight or obesity, between 35–70 years, suppose do diabetes screening every three years. But because Black adults get higher risk, doctors dey start screening earlier and more often. 7. How Person Fit Manage Diabetes? Q: Wetin be the best way to manage diabetes? A: The two main ways to manage diabetes be: Lifestyle changes: Eat better food (vegetables, fruits, whole grain, beans, fish, chicken) and exercise regularly.Medicine: If person sugar still high, doctor fit give drugs like metformin, SGLT-2 inhibitors, or GLP-1 receptor agonists.Q: Wetin be SGLT-2 inhibitors and GLP-1 drugs? A: SGLT-2 inhibitors dey help with kidney and heart problems, while GLP-1 drugs dey help with weight loss and prevent stroke. Q: Wetin be first-line treatment for diabetes? A: First-line treatment for diabetes be metformin, unless person no fit tolerate am. Q: How much exercise a person suppose do? A: Person suppose do at least 150 minutes of moderate exercise per week. This fit include things like brisk walking, swimming, or cycling. E also good to add muscle-strength training two or three times weekly to help control sugar. Q: When insulin therapy go be needed? A: Insulin therapy go be needed if person A1c is higher than 10%, or if person dey hospitalized and their glucose dey above the 140-180 range. This go help bring the blood sugar down quickly. 8. Wetin Be the Complications of Diabetes? Q: Wetin fit happen if diabetes no dey well-managed? A: Complications fit include kidney disease, blindness, nerve damage, leg ulcers, heart attack, stroke, and emotional issues like depression. Q: Why Black adults get more complications? A: Black people get higher risk of these complications because of inequality, stress, and poor access to healthcare. 9. Wetin Dey Affect Access to Diabetes Treatment? Q: Wetin make Black people struggle to get treatment for diabetes? A: Many Black people no dey get new effective treatments like GLP-1 and SGLT-2 inhibitors because of price, insurance issues, and lack of access. COVID-19 also worsen things. Q: Wetin government and doctors fit do? A: Policymakers dey work on improving access to drugs, better community programs, and screening for social issues wey fit affect diabetes care. 10. Conclusion Q: Wetin be the solution to reduce diabetes impact? A: The solution go need medical treatment, early screening, lifestyle support, and policy changes. With proper treatment and community support, e possible to reduce the impact of diabetes, especially for Black communities. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References:  Whelton PK, Carey RM. Overview of hypertension in adults. UpToDate. 2024.Carey RM, Moran AE. Evaluation of hypertension. UpToDate. 2024.Mann SJ, Forman JP. Lifestyle modification in the management of hypertension. UpToDate. 2024.Giles TD, Weber MA. Initial pharmacologic therapy of hypertension. UpToDate. 2024.American Heart Association. Understanding Blood Pressure Readings. Accessed 2025.American Heart Association. AHA Dietary and Lifestyle Recommendations. Accessed 2025.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

    40 min

  5. 11/21/2025

    Episode 206: Street Medicine and Harm Reduction

    Episode 206: Street Medicine and Harm Reduction.  Mohammed Wase (medical student) and Dr. Singh describe what it is like to provide health care on the streets. They share their personal experiences working in a street medicine team. They describe the practice of harm reduction and emphasize the importance of respecting autonomy and being adaptable in street medicine.  Written by Mohamed Wase, MSIV, American University of the Caribbean. Editing by Hector Arreaza, MD. Hosted by Harnek Singh, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Introduction  Dr. Singh: Welcome to another episode of our podcast, my name is Dr. Harnek Singh, faculty in the Rio Bravo Family Medicine Residency Program. Today we have prepared a great episode about street medicine, a field that has grown a lot during the last decade and continues to grow now. We are joined by a guest who is passionate about this topic. Wase, please introduce yourself. Wase: Hello everyone, my name is Mohammed, many know me as Wasé, I am a 4th year medical student from the American University of the Caribbean. Today we’re diving into a topic that sits at the intersection of medicine, compassion, and public health — Street Medicine and Harm Reduction. We’re going to step outside with this episode, literally, away from the clinic and hospital, to explore more about what care looks like in the streets.  Historic background: How did street medicine start? Wase: The roots of Street Medicine in the United States go back to Dr. Jim Withers in Pittsburgh in the 1990s, who literally began by dressing as a homeless person and providing care on the streets to build trust. His efforts have shaped street medicine to what it is today. It combines primary care, mental health, and social support.  Dr. Singh: For family physicians, this model aligns perfectly with our holistic approach. We don’t just treat diseases; we treat people in context — their environment, their challenges, their stories. What is the main population seen by a street medicine team? Wase: This patient population includes those struggling with homelessness, housing insecurity, food insecurity, substance use disorders; with patients being preoccupied on where they will sleep that night or when their next meal comes, they do not have the luxury of prioritizing their health. Street Medicine is a powerful outreach program to bring care to them in order to provide equitable care within our community.  Dr. Singh: How is street medicine different than caring for patients in the clinic? Wase: Working on the street means we have to think differently about what healthcare looks like — and that’s whereharm reductioncomes in. What is Harm Reduction? Wase: Harm reduction is a public health philosophy that focuses on reducing the negative consequences of high-risk behaviors, rather than demanding complete abstinence. Dr. Singh: Preventive care is the backbone of family medicine. For example, we keep up with the USPSTF guidelines and make sure our patients are up to date with their screenings. But what does that look like in the street medicine setting?  Wase: In practice, that might mean: -needle exchange program: Offering clean syringes to prevent HIV transmission and removing used needles -distributing naloxone to prevent overdose deaths -offering fentanyl test-strips to prevent use of substances that are unknowingly laced with fentanyl Dr. Singh: Also: -providing condoms to prevent sexually transmitted infections -providing wound care to prevent further spread of infection Wase: Yes, the idea is: people are going to engage in risky behaviors whether or not we approve of it, so let’s meet them with compassion, tools, and trust instead of judgment. Harm reduction also applies beyond substance use; think about safer sex education, or even diabetic foot care among people who can’t refrigerate insulin or change shoes daily. It’s all about meeting people where they areandkeeping them alive and engaged in care.  Planning in Street Medicine:  Wase: It takes careful disposition planning and aftercare for this population. Instead of the traditional outpatient setting where we can place referrals and expect our patients to follow through with them. On street medicine, for follow up visits it requires arranging transportation, finding a pharmacy close in proximity, educating and counseling on medication adherence and how to make it, and making sure they have some sort of shelter to get by.  Dr. Singh: Let’s describe a typical street med encounter. Wase: A typical Street Medicine encounter might look like this: a small team — usually a physician, nurse, social worker, and sometimes a peer advocate — goes out with backpacks of supplies. They might start with wound care, blood pressure checks, or even medication refills. But what’s just as important is the relationship-building. Sometimes, the first visit isn’t about medicine at all — it’s about showing up consistently. Over time, that trust opens the door for conversations about addiction treatment, mental health, and preventive care. For example, in some California Street Medicine programs, teams are treating chronic conditions like hypertension, diabetes, and hepatitis C, right where patients live with the same evidence-based care we’d give in a clinic. One of my favorite quotes from Street Medicine teams is: “We’re not bringing people to healthcare; we’re bringing healthcare to people.” Challenges in Street Medicine: Wase: The populations that you will encounter include many people who will often downplay their own health concerns and prior diagnoses. Unfortunately, this is usually from countless months or years of feeling neglected by our healthcare system. Some may even express distrust in our healthcare system and healthcare providers. Patient will, at times, be apprehensive to receive care or trust you enough to tell their story.  Dr. Singh: Interviewing patients is a critical aspect of providing equitable care on the streets. It is always important to offer support and medical care, even if the patient denies it, always reassure that your street medicine clinic will be around every week and ready for them when they would like to seek care.  Wase: Respecting patient autonomy is an utmost concern as well. Another element of interviewing to consider is to invite new ideas and information; instead of lecturing patients about taking medications on time or telling them they need to stop doing drugs—simply asking a patient “would you like to know more about how we can help you stop using opioids?” respects their choice but can also spark new ideas for them to consider.  Singh: Adaptability is another key component to exceling patient care in street medicine. Like, performing physical exams on park benches or in the back of a minivan. Always doing good with our care but also respecting their autonomy is crucial in building a trust that these patients once lost with our system.  Wase: Each patient has their own timeline, but we as providers should always assure them that our door is always open for them when they are ready to seek care.  Conclusion. Wase: So, to wrap up — Street Medicine and harm reduction remind us that healthcare isn’t just about hospitals and clinics. It’s about relationships, trust, and dignity. Every patient deserves care, no matter where they sleep at night. If you’re a resident or student listening, I encourage you to seek out these experiences — volunteer with Street Medicine teams, learn from harm reduction workers, and let it shape how you practice medicine. Thank you for listening to this episode of the Rio Bravo qWeek podcast. I’m Mohammed — and I hope this conversation inspires you to meet patients where they are and walk with them on their journey to health. Dr. Singh: If you liked this episode, share it with a friend or a colleague. This is Dr. Singh, signing off. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Doohan, N.C. “Street Medicine: Creating a ‘Classroom Without Walls’ for People Experiencing Homelessness.” PMC – National Library of Medicine, 2019.Hawk, M., et al. “Harm Reduction Principles for Healthcare Settings.” Harm Reduction Journal, vol. 14, no. 1, 2017.Withers, J.S. “Bringing Health Professions Education to Patients on the Streets.” Journal of Ethics, AMA, vol. 23, no. 11, Nov. 2021.“Our Story.” Street Medicine Institute, 2025, www.streetmedicine.org/our-story.“Principles of Harm Reduction.” National Harm Reduction Coalition, 2024, https://harmreduction.org/about-us/principles-of-harm-reduction/.Salisbury-Afshar, Elizabeth, Bryan Gale, and Sarah Mossburg. “Harm Reduction Strategies to Improve Safety for People Who Use Substances.” PSNet, Agency for Healthcare Research & Quality, 30 Oct. 2024.Douglass, A.R. “Exploring the Harm Reduction Paradigm: The Role of Boards in Drug Policy and Practice.” PMC – National Library of Medicine, 2024.Theme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

    21 min

  6. 10/31/2025

    Episode 205: Atopic Dermatitis

    Episode 205: Atopic Dermatitis Kara Willbanks (medical student) explains the definition, pathophysiology, and treatment of eczema. Dr. Arreaza adds some input about bleach baths and topical steroids.  Written by Kara Willbanks, MSIV, American University of the Caribbean. Comments and edits by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. October is the Eczema Awareness Month! What Is Atopic Dermatitis?  Atopic dermatitis, a form of eczema, is a chronic, relapsing inflammatory skin disorder that often begins in childhood but can affect people of all ages.  Other eczematous dermatoses include seborrheic dermatitis, contact dermatitis, juvenile plantar dermatosis, and stasis dermatitis.  Atopic dermatitis is one of the most common skin conditions in the developed world, typically affecting up to 20% of children and 5-10% of adults. Patients usually present with severe pruritus (itchiness) and dry, inflamed patches of skin. Common sites include the face and extensor surfaces in infants, and flexural areas — like the elbows and knees — in older children and adults.  Atopic dermatitis is often associated with other allergic conditions like asthma and allergic rhinitis — what we call the “atopic triad.” These conditions should also be considered when diagnosing someone with atopic dermatitis.  Pathophysiology Atopic dermatitis is believed to occur due to a combination of genetic, immune, and environmental factors. A major component is a defective skin barrier, often linked to mutations in the filaggrin gene. This allows irritants, allergens, and microbes to penetrate the skin more easily, triggering inflammation. Differential Diagnosis Atopic dermatitis can sometimes mimic other skin conditions, so it’s important to keep a differential in mind:  -Contact dermatitis – triggered by allergens or irritants; often limited to the area of exposure but also tends to be very itchy.  -Seborrheic dermatitis – greasy scales, typically on the scalp, eyebrows, and nasolabial folds  -Psoriasis – well-demarcated plaques with silvery scales; sometimes found in similar areas of the body as eczema.  -Tinea (fungal infections) – ring-shaped lesions with active, scaly borders -Important to note that treatment of tinea with topical steroids can make the rash much worse.  -Scabies – intense itching, especially at night, with burrows between fingers.  Ruling out these conditions helps guide the right treatment and prevent chronic mismanagement. As a recap our main differential diagnosis: contact dermatitis, seborrheic dermatitis, psoriasis, tinea, and scabies. The treatment cornerstone: Moisturizers  The most important daily treatment for atopic dermatitis is regular moisturizing. Moisturizers repair the skin barrier, reduce water loss, and protect against irritants. They should be applied at least twice daily, ideally right after bathing while the skin is still damp (within 3 minutes is most ideal). Use greasy ointments or thick creams rather than lotions — think products with ceramides or glycerin (hydrates and protects skin).  It is best to choose ointments or creams without additives, perfumes or fragrances. Greasier ointments are the preferred vessel; however, patient compliance may be less as they may be unpleasant to some. Bleach Baths  For patients with frequent skin infections or severe eczema, dilute bleach baths can be a game-changer. How to do it? Use ¼ to ½ cup of household bleach in a full standard bathtub of water (about 40 gallons) and soak for 10 minutes, twice a week. This helps reduce bacterial colonization — particularly Staphylococcus aureus — which commonly worsens eczema.  After the bath, pat the skin dry and immediately apply a moisturizer (within 3 minutes).  Bleach baths are endorsed by the American Academy of Pediatrics and the American Academy of Dermatology as an adjunctive treatment for atopic dermatitis, especially in patients with moderate to severe disease and frequent bacterial infections, but the evidence for their efficacy is mixed, and further well-designed studies are needed. Medical Treatments -Topical corticosteroids: When moisturizers alone aren’t enough, we move to anti-inflammatory therapy. Topical corticosteroids are the first-line treatment for flares. Some studies suggest that a short burst of a high-potency topical corticosteroid to rapidly control active disease, followed by a quick taper in potency, is most effective, whereas others use the lowest-potency agent thought to be needed and adjust upward only if this fails. Common steroids used are hydrocortisone (low potency), triamcinolone (medium potency), or betamethasone (high potency).  -High-potency steroids should never be applied to sensitive skin like the face. With short-term use of lower-potency steroids, there is a low likelihood of skin atrophy but use for more than 6 months is linked with greater levels of skin thinning  -Wet wrap therapy: Wet wrap therapy improves absorption of topic steroid. Apply a topical steroid, then layer a wet dressing and then a dry dressing over the top of that. This can be beneficial in providing  both relief of symptoms and prevention of itching. In pediatric patients it is called “daddy’s socks therapy” because large socks may be used to cover the arms of kids. -Topical calcineurin inhibitors — like tacrolimus — are great alternatives for sensitive areas or for maintenance once inflammation is under control. They may burn upon application which can scare patients away from their use. -PO antihistamines can help with itching, especially at night, but they don’t treat inflammation itself. -Systemic therapies, like dupilumab (Dupixent®), an IL-4 receptor antagonist, are reserved for moderate to severe cases unresponsive to topical therapy. This is a great time to refer to your local dermatologist for management! Many of the newer treatments are highly effective but can require more frequent monitoring. Recent Research  One recent study is the 2024 Cochrane network meta-analysis comparing effectiveness of topical anti-inflammatory treatments for eczema that was recently published in the AFP Journal in July of 2025. Here are the highlights: -Over 291 RCTs with ~45,846 participants were included.  -The analysis ranked potent topical corticosteroids, JAK inhibitors (for example ruxolitinib (Opzelura® 1.5 %), and tacrolimus 0.1 % among the most effective for reducing signs and symptoms of eczema.  -In contrast, PDE-4 inhibitors [like crisaborole (Eucrisa®) 2 %] were among the least effective in this comparison.  -Regarding side effects: tacrolimus and crisaborole were more likely to cause burning or stinging at the application site; corticosteroids were less likely in the short term to cause local irritation. -Long-term outcomes regarding effectiveness or safety of treatments for eczema were not addressed by the review because they are rarely reported.” -Another insight from this study is considering cost when initiating treatment. Most topical steroids are significantly more cost effective than JAK inhibitors or calcineurin inhibitors so it may be best to start with a cheaper solution in an uninsured patient considering their relative effectiveness.  Additional Tips & Lifestyle  -Keep baths and showers short and in lukewarm water. -Avoid harsh soaps and detergents — use gentle, fragrance-free cleansers. -Wear soft cotton clothing instead of wool or synthetics. -Identify and avoid triggers — common ones include stress, sweating, allergens, and certain foods (especially in kids). -Ice packs can help reduce itching and relieve any burning sensation. -Keep fingernails short, especially in children, help cause less trauma to the skin from repeated itching.  Living with eczema  Many celebrities like Kerry Washington, Jessica Simpson, Kelly Rowland, Brad Pitt and Kristen Bell have spoken out about their lives with eczema. They have shared personal stories about how they were diagnosed, what treatment works for them, and the general impact it has had on their lives and mental health. I feel like it can be so important for celebrities to speak out about their lives with certain conditions because it helps to normalize the condition, raise awareness of the struggles, and encourages more open dialogue. It is important to remember that for patients living with eczema, the persistent itch-scratch cycle can be very distressing, causing patients to struggle with their sleep and day-to-day activities. Anxiety and depression are common in patients with eczema so as physicians it is vital to monitor for signs of distress. Support groups can be incredibly helpful for patients [National Eczema Association] If you are interested in providing additional information to your patients or getting this for yourself, you can find more resources on altogethereczema.org or nationaleczema.org.  Key Takeaways  Atopic dermatitis is chronic but manageable. Moisturizers are the foundation of treatment. Topical steroids and calcineurin inhibitors control inflammation. Bleach baths help reduce bacterial load and flare severity. Always rule out other skin conditions to ensure appropriate management. Atopic dermatitis can be managed by the primary care physician but in certain cases (cases refractory to standard topical treatment, recurrent infections, etc.), a referral to dermatology can be especially helpful. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or vi

    24 min

  7. 10/10/2025

    Episode 204: Adult Pneumococcal Vaccines in 2025

    Episode 204: Adult Pneumococcal Vaccines in 2025.  Luz Perez (MSIV) presents all the available pneumococcal vaccines for adults. Dr. Arreaza guides the discussion about what to do with adults who have previously received pneumococcal vaccines.  Written by Luz Perez, MSIV, Ross University School of Medicine. Comments by Hector Arreaza, MD. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Today we’re answering a clinic classic: Which pneumococcal vaccine should my adult patient get—and when? This is an update of episode 90. Why pneumococcal vaccines matter? Pneumococcal vaccines prevent infections caused by the bacteria Streptococcus pneumonia. These bacteria can cause serious infections like pneumonia, meningitis, and bacteremia. In 2017, the CDC reports that there were more than 31,000 cases of pneumococcal infections and 3,500 deaths from invasive pneumococcal disease.  Children are vaccinated in early childhood, before age 5, with PCV15 or PCV 20, at the age of 2, 4, 6 months and a last dose around 12-15 months.  Why do we vaccinate adults? Adults are vaccinated because they’re at higher risk of getting pneumococcal disease or of having worse outcomes if they do. Vaccines are important because they protect these at-risk patients and reduce the spread of infections among communities.  What are the available vaccines? PCV vs PPSV. There are two pneumococcal vaccines used in practice: a polysaccharide vaccine (PPSV) and a conjugate vaccine (PCV). Both protect by targeting capsular polysaccharides from pneumococcal serotypes most often responsible for invasive disease. In simple terms, these vaccines target a part of the bacteria “coating” and create antibodies or proteins that protect the body when the strep enters the body.  PPSV (polysaccharide): PPSV is made from purified pieces of the pneumococcal capsule or coating. The current vaccine PPSV23 (Pneumovax®) covers 23 serotypes (or strains) that were the leading cause of pneumococcal infections in the 1980s.  PCV (conjugate): Pneumococcal conjugate vaccines (PCVs) take capsular polysaccharides from the bacterium and chemically link them to a carrier protein, which changes and strengthens the immune response. Current PCVs come in four versions:  PCV13 (Prevnar 13) PCV15 (Vaxneuvance) PCV20 (Prevnar 20) PCV21 (Capvaxive)  The number indicates the amount of pneumococcal capsule types covered by each vaccine. PCV21 was designed around adult disease patterns and covers many serotypes currently driving invasive disease in adults. However, it does not include serotype 4, but this serotype is covered by the PCV20 and PCV15. Who should be vaccinated?  In 2024, the United States Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) updated their recommendations on Pneumococcal vaccinations for adults. Their recommendations are:  Everyone 50 years or olderAdults age 19–49 with risks: chronic lung/liver disease, heart failure, diabetes; CSF leak or cochlear implant; immunocompromised states (e.g., HIV, hematologic malignancy, CKD/nephrotic syndrome); functional/anatomic asplenia.Patients with history of prior invasive pneumococcal disease: still vaccinate. What vaccine should be given for adults that have never received the Pneumococcal vaccine? For eligible adults with no prior pneumococcal vaccines, there are three choices: PCV21 oncePCV20 oncePCV15 now, followed by PPSV23 later, usually 1 year; 8 weeks if immunocompromised, CSF leak, or cochlear implant.PCV 20 or PCV21 seem more convenient. Once and done.  If available, PCV21 is a great one-and-done pick for most adults because it’s tailored to current adult serotypes.Serotype 4 caveat: If your patient is at higher risk for serotype 4 disease—think Navajo Nation, or folks in the Western US/Canada with substance use disorders or experiencing homelessness—choose PCV20 (or PCV15 followed by PPSV23 if PCV20 isn’t available).What if the patient already received a Pneumococcal vaccine in the past? Plan depends on which vaccine they received and when. PPSV23 only: give PCV21 ≥1 year later (or PCV20 if serotype-4 risk or PCV21 unavailable).PCV10 or PCV13 only: give PCV21 (or PCV20 if PCV21 unavailable) ≥1 year later. If a PCV is not available, discuss PPSV23 now vs waiting until PCV is available.If patient receives PPSV23 now will need to return ≥1 year later to receive a PCV vaccine, and no more vaccines are needed after that. Is it safe to administer the Pneumococcal vaccine with other vaccines? Coadministration is fine with other non-pneumococcal vaccines, as long as we use different syringes and sites. Data support same-day administration of PPSV23 + influenza, and PCV20 with influenza or mRNA COVID-19 vaccines.Some patients are hesitant to receive vaccines, Are there side effects and contraindications to the vaccine? Local reactions are most common: pain/tenderness; swelling/induration (~20%); redness (~15%). Some people “baby” the arm for a couple of days. These typically resolve in 3–4 days; NSAIDs and warm compresses help. Systemic symptoms: fatigue, headache, myalgias/arthralgias, chills; fever ≥38°C is uncommon (Contraindications: history of severe allergy (e.g., anaphylaxis) to a pneumococcal vaccine or components.  Bottom line: If a patient is 50+, or younger with specific risks, they likely need one conjugate dose—PCV21 or PCV20—and they’re done. Use PCV15 followed by PPSV23 when needed, and remember the serotype 4 caveat. Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Musher DM, Rodriguez-Barradas MC. [Pneumococcal Vaccination in adults. UpToDate Inc. Literature review current through September 2025. Topic last updated January 13, 2025. https://www.uptodate.com/contents/pneumococcal-vaccination-in-adultsCenters for Disease Control and Prevention. (2025, May 29). Pneumococcal conjugate vaccine (interim) VIS: What you need to know. U.S. Department of Health and Human Services. Retrieved [access date], from https://www.cdc.gov/vaccines/hcp/current-vis/pneumococcal-conjugate.html?CDC_AAref_Val=https://www.cdc.gov/vaccines/hcp/vis/vis-statements/pcv.htmlTheme song, Works All The Time by Dominik Schwarzer, YouTube ID: CUBDNERZU8HXUHBS, purchased from https://www.premiumbeat.com/.

    18 min

  8. 09/19/2025

    Episode 203: Microinduction and harm reduction in OUD

    Episode 203: Microinduction and harm reduction in OUD.  Nathan Bui and Sanjay Reddy describe how to manage opioid use disorder (OUD) by using microinduction and harm reduction, strategies that are reshaping the way we treat opioid use disorder.  Written by Sanjay Reddy, OMSIV and Nathan Bui, OMSIV. Western University of Health Sciences, College of Osteopathic Medicine of the Pacific. You are listening to Rio Bravo qWeek Podcast, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California, a UCLA-affiliated program sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. This podcast was created for educational purposes only. Visit your primary care provider for additional medical advice. Intro Welcome to episode 203 of Rio Bravo qWeek, your weekly dose of knowledge. Today, we’re tackling one of the biggest health challenges of our time: opioid use disorder, or OUD. Nearly every community in America has been touched by it: families, friends, even healthcare providers themselves.  For decades, treatment has been surrounded by barriers, painful withdrawals, stigma, and strict rules that often do more harm than good. Too many people who need help never make it past those walls. But here’s the hopeful part, new approaches are rewriting the story. They are less about rigid rules and more about meeting people where they are.  Two of the most promising strategies for treatment of OUD are buprenorphine microinduction and harm reduction. Let’s learn why these two connected strategies could change the future of addiction recovery.  Background information of treatment: The X-waiver (short for DATA 2000 waiver) was a special DEA requirement for prescribing buprenorphine for opioid use disorder. Doctors used to take extra training (8 hours) and apply for it. Then, they could prescribe buprenorphine to a very limited number of patients.  The X-waiverhelped regulate buprenorphine but also created barriers to access treatment to OUD. It was eliminated in January 2023 and now all clinicians with a standard DEA registration no longer need a waiver to prescribe buprenorphine for OUD.  Why buprenorphine? Buprenorphine is one of the safest and most effective medications for opioid use disorder. It has some key attributes that make it both therapeutic and extremely safe:  1) As a partial agonist at mu-opioid receptors, it binds and provides enough partial stimulation to prevent cravings and withdrawal symptoms without producing strong euphoria associated with full agonists.  2) Because it has a strong binding affinity compared to full agonists, it easily displaces other opioids that may be occupying the receptor.  3) As an antagonist at kappa-opioid receptors, it contributes to improved mood and reduced stress-induced cravings.  4) The “ceiling effect”: increasing the dosage past a certain point does not produce a stronger opioid effect. This ceiling effect reduces the risk of respiratory depression and overdose, making it a safer option than full agonists.  5) It also had mild analgesic effects, reducing pain.  6) Long duration of action: The strong binding affinity and slow dissociation from the mu-opioid receptor are responsible for buprenorphine's long half-life of 24–60 hours. This prolonged action allows for once-daily dosing in medication-assisted treatment for OUD.  Induction vs microinduction: The problem is, starting it—what’s called “induction”—can be really tough. Patients usually need to stop opioids and go through a period of withdrawal first.  Drugs like fentanyl, which can cause precipitated withdrawal —a sudden, severe crash may push people back to using opioids. Because buprenorphine binds so tightly to the mu-opioid receptor, it can displace other opioids, such as heroin or methadone. If buprenorphine is taken while a person still has other opioids in their system, it can trigger sudden and severe withdrawal symptoms. Opioid withdrawal sign sand symptoms: Opioid withdrawal symptoms are very uncomfortable; patients may even get aggressive during withdrawals. As a provider, once you meet one of these patients you never forget how uncomfortable and nasty they can be. The symptoms are lacrimation or rhinorrhea, piloerection "goose flesh," myalgia, diarrhea, nausea/vomiting, pupillary dilation, photophobia, insomnia, autonomic hyperactivity (tachypnea, hyperreflexia, tachycardia, sweating, hypertension, hyperthermia), and yawning.  Think about all the symptoms you run for COWS (Clinical Opiate Withdrawal Scale). It is estimated 85 % of opioid-using patients who inject drugs (PWID) reported opioid withdrawal. Fortunately, even though opioid withdrawal is very uncomfortable, it is not life-threatening (unlike alcohol or benzodiazepine withdrawal, which can be fatal). Many patients who start the journey treating opioid use disorder experience “bumps in the road” --they avoid treatment or drop out early.  What is Microinduction?  Microinduction is a fairly new strategy started in Switzerland around 2016. It is also known as the “Bernese method” (named after the city of Bern, Switzerland).  With this method, instead of stopping opioids cold turkey, patients start with tiny doses of buprenorphine—fractions of a milligram. These doses gradually increase over several days while the patient continues their regular opioid use. While they begin this titer, they can continue use of the full agonist they were previously using–methadone, fentanyl, or heroin, while the buprenorphine begins to take effect.  Once the buprenorphine builds up to a therapeutic level, the full agonist is stopped. This method uses buprenorphine’s unique pharmacology to stabilize the brain’s opioid system without triggering those really nasty withdrawal symptoms. Early studies and case reports suggest this is safe, tolerable, and effective method to do. Microinduction is changing the game, and it has been spreading quickly in North America.  Instead of forcing patients to stop opioids completely, the dose is slowly increased over the next three to seven days, while the patient keeps using their usual opioids.By the end of that week, the buprenorphine has built up to a therapeutic level and the full agonist is stopped. The difference is really dramatic. Instead of a painful crash into withdrawal, patients describe the process as a gentle step down, or a ramp instead of a cliff.  It’s a flexible method. It can be done in a hospital, a clinic, or even outpatient with good follow-up. Once a patient and doctor develop a strong relationship built on the principles of patient autonomy and patient-centered care, microinduction can be closely monitored on a monthly basis including televisits. Microinduction has been shown to help more patients stay in treatment.  The Role of Harm Reduction  Instead of demanding perfection, harm reduction focuses on best practices providers can implement to reduce risk and keep patients safe. Harm reduction can vary from providing naloxone to reverse overdoses, giving out clean syringes, or offering safer injection education.  It also means allowing patients to stay in treatment even if they keep using other substances, and tailoring care for groups like adolescents, parents, or people recently released from incarceration. Harm reduction says that instead of demanding perfection, let’s focus on progress. Instead of all-or-nothing, let’s devote resources to keeping people alive and safe.  As mentioned,an option is providing naloxone kits so overdoses can be reversed in the moment. Also, giving out clean syringes so the risk of HIV or hepatitis infection is reduced while injecting heroin. Another way to reduce harm is teaching safer injection practices so people can protect themselves until they’re ready for that next step in their treatment.  It also means keeping the doors open, even when patients slip. If someone is still using other substances, they still deserve care. And it means tailoring support for groups who oftentimes get left behind. For people like adolescents, parents balancing childcare, or people coming out of incarceration who are at the highest risk of overdose.  Harm reduction recognizes that recovery isn’t a straight line. It’s about meeting people where they are and walking with them forward.  Conclusion: Microinduction is itself a harm reduction strategy. It lowers barriers by removing the need for painful withdrawal.When paired with a harm reduction culture in clinics, patients are more likely to enter care, stay engaged, and build trust with doctors for continued care.  Managing opioid use disorder is one of the greatest health challenges of our time. But solutions like buprenorphine microinduction and harm reduction strategies are reshaping treatment—making it safer, more humane, and more accessible. If we embrace these approaches, we can turn barriers into bridges and help more people find recovery.  Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you. Send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!  _____________________ References: Bluthenthal, R. N., Simpson, K., Ceasar, R. C., Zhao, J., Wenger, L., & Kral, A. H. (2020). Opioid withdrawal symptoms, frequency, and pain characteristics as correlates of health risk among people who inject drugs. Drug and Alcohol Dependence, volume 211, 1 June 2020, 107932. https://doi.org/10.1016/j.drugalcdep.2020.107932.De Aquino, J. P., Parida, S., & Sofuoglu, M. (2021). The pharmacology of buprenorphine microinduction for opioid use disorder. Clinical Drug Investigation, 41 (5), 425–436. https://doi.org/10.1007/s40261-021-01032-7. Taylor, J. L., Johnson, S., Cruz, R., Gray, J. R., Schiff, D., & Bagley, S. M. (2021). Integrating harm reduction i

    13 min
See All (210)

5
out of 5
11 Ratings

About

qWeek is the official podcast of the Rio Bravo Family Medicine Residency Program. Residents and faculty routinely present key topics and relevant discussions, coupled with medical jokes and Spanish medical terminology.

Information

  • Creator
    Rio Bravo Family Medicine Residency Program
  • Years Active
    2020 - 2026
  • Episodes
    210
  • Rating
    Explicit
  • Copyright
    © 2020 Rio Bravo Family Medicine Residency Program
  • Show Website
    Rio Bravo qWeek

You Might Also Like