1. 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

2. Disclosures Greenberg & Sucher, PC Community Bridges, Inc.
President and shareholder
Community Bridges, Inc.
Medical Director
Community Medical Services
Medical Staff Membership
Scottsdale Healthcare, Banner Behavioral Health Hospital, Mission Hospital
Pharmaceutical Companies-NONE
Other Treatment Providers-NONE

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

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 one’s behaviors and interpersonal relationships.

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)

6. Addiction Treatment 101 Treatment Works Levels of Treatment
Substance dependence treatment is effective
Levels of Treatment
Medical Detoxification-inpatient and outpatient
Opioids, Benzodiazepines
Other
Outpatient
Residential/Inpatient/Extended residential
Medication Assisted Treatment

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

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 Rx’d by knowledgeable physicians
No self medication

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

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

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

12. Treatment of Opiate Dependence
Medical Detoxification
Inpatient
Outpatient
Maintenance Treatment
Methadone
Buprenorphine
Opiate Antagonist Treatment-Naltrexone
Abstinence Treatment

13. Controversies in Opiate Addiction Treatment
Maintenance vs Abstinence
Medical Disease Model
Good news-It’s a disease
Bad news-It’s 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

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

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

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 won’t find a drug you don’t test for”

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

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

19. Research in Addiction Medicine
Brain and Neurotransmitter Research
New Medications
Vaccines
Process Addiction Research
Sex, Gambling, Food, High Risk Behaviors, etc.
Outcome studies

20. Rx Medications-The Problem
Pain is “5th” 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

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

22. Prevalent Drugs of Abuse:
Alcohol
Cigarettes
Marijuana
* Prescription Drugs
Source: Monitoring the Future Survey, Institute for Social Research, University of Michigan, 1999.

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

24. Accidental Rx Overdoses

25. The Rx Nation
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.

26. 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

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 it’s easy to get prescription drugs from their parent’s 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.

28. Over-prescription of Rx drugs
In Arizona, 476 million pills were prescribed in 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

30. Arizona drug-related DUIs rising
“Prescription painkillers and synthetic drugs such as ‘spice’ are common culprits” Alberto Gutier, director of the Governor’s Office of Highway Safety
By Jim Walsh The Republic | azcentral.com Tue Jan 15, :55 AM

31. Oxycodone OxyContin most recognized and abused form
Prescribed to relieve pain
Twice as strong as morphine
Time released (8-12 hours)
Pills crushed and snorted or cooked down and injected to break down time release component
Strong, heroin-like, euphoric effects
Expensive
Dollars to milligrams: 10, 20, 40, 80, 120 (ex)
Other variations: Percocet and Percodan

32. Heroin Purity 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
– 19 young people die of heroin overdoses in Plano, Texas
Purity levels ranged up to 75%

33. Rx Drug – Take Back Day www.DEA.gov
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.

34. What’s happening? Change a few molecules
Methamphetamine Heroin Marijuana
“Bath Salts” “Krokodil” “Spice”
Change a few molecules

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

36. “Krokodil” Desomorphine
Dirty cousin to morphine
Roughly same effect as heroin but at least three times cheaper and extremely easy to make
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
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
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
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

37. Krokodil Drug - Desomorphine

38. Ofc. L.Gill ASUPolice

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 user’s 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

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

41. Kratom Kratom Use on the Rise Kratom Sales
“appealing to bath salt crowd”
Kratom On the Rise
POSTED: 05:00 PM MST Mar 07, 2013
Kratom Sales
“It’s not that bad”
KING 5 News
Posted on January 15, 2013 at 12:13 AM

42. Kratom Overdoses Hallucinations Delusions Listlessness Tremors
Aggression
Constipation
Nausea

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

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)

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

46. Benzo Fury Stimulant and hallucinogenic effects
The drug is a synthetic, laboratory- designed substance
Similar effects to amphetamine and cocaine

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

48. ‘N-bomb’ drug stirs fear in Phoenix area By JJ Hensley The Republic | azcentral.com Fri May 3, :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.

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 Carrasco’s 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.
“He’d been dead already at least for a couple of hours,” Wadsworth said. “They didn’t know that that’s what they were taking. My son was not a reckless person. He decided to try what he thought was acid, and obviously I didn’t 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

50. Who is Molly?

51. Molly is…
Molecule
MDMA

52. Synthetic Cannabinoids and Substituted Cathinones

53. Synthetic Cannabinoids "Spice" or "K2"
Often referred to as: "Spice," Genie" “Blaze” and "Zohai"
K2 contains synthetic chemicals that act on the cannabinoid receptors in the brain
Sold in headshops or on internet as incense or potpourri for $5 - $60 per gram
Rolled up in joints or inhaled from pipes
Undetectable in many drug tests
February 2011 – AZ bans Spice (10 chemicals)
March 2011 – Federal ban of substance (5 chemicals)
July 2012 – Federal ban of 20 more chemicals (25)
January 2013 – 31 Federally banned chemicals
April 3, 2013 – ALL chemicals illegal in AZ

54. Previously banned cannabinoids in Arizona
HB 2167 (2011)
JWH-250
JWH-015
HU-201
CP 47,497
and its C8 homologue
JWH-018
JWH-073
JWH-019
JWH-398
JWH-200
Previously banned cannabinoids in Arizona

55. JWH
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.

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

57. Where does it come from now?
Southeast Asia
Purchased chemicals
Research Chemicals
Personal production
Internet
Sales
“How to”

58. Prevalence-2010
Ofc. L.Gill ASUPolice

59. Prevalence-2012
Ofc. L.Gill ASUPolice

60. Ingenuity of Designer Chemists
Illegal
Legal
JWH-018
AM-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

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 61

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 sleeplessness—sold 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

63. Who is using synthetic drugs?
Arizona Teens
1 in 10 AZ teens using synthetic drugs
8th graders – 6.9%
10th graders – 11.1%
12th graders – 13.9%
This is first time capturing synthetic drug data on teens in AYS
Arizona Youth Survey, 2012

64. DAWN Report – Synthetic Drugs December 4, 2012 (Drug Abuse Warning Network)
11,406 ER visits for synthetic cannabinoids
¾ or 75% of patients were ages years of age
The majority (76%) did not receive follow up care after discharge from ER
59% of year old patients only presented with spice – no other substance found

65. In 2011…
According to the U.S. Drug Abuse Warning Network, some 28,000 emergency room visits in were caused by known synthetic cannabinoids, more than double the 2010 number.

66. Sold As… “Code Words” not tobacco…
Potpourri
Herbal incense
Glass cleaner
Plant fertilizer
Insect repellent
Souvenir
Bath salts

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

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 2010
3 federally banned chemicals: mephedrone, methylone, methylenedioxypyrovalerone (MDPV)

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

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

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

72. Signs and Symptoms Sleep depravation Agitation Extreme anxiety
Hallucinations
Teeth grinding
Excessive water drinking
Tremors
Seizures

73. Bath Salts Common Names
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

74. Synthetic Cathinones “Bath Salts”
Flesh eating bacteria

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, :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

76. Can you still purchase? http://bath-salts-direct.com/
direct.com/acatalog/stimulating-bath-salts- powder-blends.html
Spice Gold Direct shared a link.

77. Synthetics in the News…
ABC 20/20 Synthetic Drugs - 9 minutes
Bath Salt Use - Good Morning America
Synthetic Drugs - shorter version 2 minutes

78. How do we respond? Community awareness Treatment Law Enforcement
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.

79. Resources http://www.tascaz.org/
Banner Good Samaritan Poison and Drug Information Center 24-hour phone:

80. Helpful Websites www.communitybridgesaz.org www.partnerupaz.org

81. Where can you find more information?
Call your local poison center at 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.

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

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

84. Possible Solutions Education for Providers, cont’d
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

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

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

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

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

89. Where We Serve Maricopa County Phoenix Mesa Winslow Level IV
Holbrook Level IV
WV Triage Level III
Payson Level IV
Phoenix
Glendale OP
Central City Level I
Ctr for Excellence OP
Probation OP
Globe Level IV
DRC/CASS OP
Drug Court OP
Steele Commons OP
Mesa
East Valley Level I
ADMIN
East Valley Triage Level III
Center for Hope Level II
Prevention
Partnership
Casa Grande Level IV
Journey/OP
Clinical Ops Admin.
Az Bridge to Recovery
Aspire OP for Women
Supportive Housing
Benson Level II
Yuma Level III
Benson Level IV

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

91. Thanks for your attention
Questions? Greenberg & Sucher, PC Michel A Sucher MD FASAM PO 1420 Scottsdale, AZ ; Cell

92. Thanks for your attention
Questions?
Stephanie Siete
24/7 Access to Care

93. News videos, articles, upcoming presentations
Community Bridges AZ
News videos, articles, upcoming presentations