Hi, good afternoon, everybody. My name is Chris McGinnis. I'm with Dillon Research International. I apologize, I'm in a house full of kids because it is summer break now. I just yelled a disclaimer before I got on. But we have partnered with the ORN to put on these speaker workshops for our peers all over. So welcome. I'm so glad you guys are on today. And today we have Nick Chubiak, who is going to talk to us today about addiction science. So if you guys have any questions, feel free to put them in the chat or use the Q&A function. I'll keep an eye out on that as we're going around. So, yeah, Nick really enjoys interaction. So let's make this a really fun and lively two hours. OK, so, Nick, I'll go ahead and turn it over to you. Thanks, Chris. And thanks, Debbie. Yeah. So I just put in the chat, too, as you as Chris was kind of inviting that I really want to welcome folks to use the chat as a way to get side conversations going and discussion. It's not just about questions, but also all of you bring such important experience in this work. And we really want to welcome that into the room and open it up. I'm also going to stop sharing my screen for a second. And I just want to say hello to everybody, because if we're in a room together, we'd be able to kind of see each other. So I'm just going to invite you. You don't have to keep yourself on camera, but just for a second to put yourself on camera and give a wave to say hello would be. Hi, Melissa. I saw that wave. Naomi, I saw your wave. Hi, Paige. Hi, Maria. It's great to see you. Two Marias. Taisha, thanks for the wave. Hi, Danny. I see you. Hi, Joanne. It's cool. It's just cool to say hello. Hi, Amanda. I see you smiling. So just cool to say hello and you don't have to stay on video. I love it. If you do, I'm going to have like our screen up to get some like nonverbal feedback and stuff. So, you know, that's really helpful to me. But you don't you don't have to do that. All right. I'm going to go ahead and get my screen back up here. But really, again, invite folks to to share in the. In the chat. And now I'm just if you see me looking over here. Hi, Maria. Good morning. Welcome. So I think I saw Idaho represented Wyoming, which is really cool. And then everybody else looks like they're from Maryland, which is kind of fun. And I also am in Maryland. I'm in Bethesda. And I'm really stoked to also be connected with kind of like my home state folks, too, as well. So that's kind of fun for me. Danny's in Danny or Danny and Danny in North Carolina. Yes. Taisha, we're going to share the slides so you'll have access to all this stuff. And we'll make sure that you you it's all available to you. Anything that we talk about or that you see up here. So just a couple of pieces around this. This is, you know, I'm what's called an advanced implementation specialist for the opioid response network, which means that I get to do consulting and support and training for folks all across the country. So it's a great privilege and honor to get to be here with you all and to work as part of the ORN. The ORN is a state funded, SAMHSA funded network that really supports states all across the country to provide training and technical assistance in the areas of prevention, treatment and recovery. The opioid response network was developed as a direct way to address the opioid crisis. And since that time, the crisis has evolved that we're going to talk about and now also very much includes as a major part of its stimulant use disorder. So in some ways, our name opioid response goes well beyond opioids and is really pointed out addressing substance use disorders and addiction in all communities across the country. Also, really encourage you if you hear some things and think about some things that you could maybe find as a support. We encourage you to put a request into the ORN. We accept requests. It's a very easy process, actually. And someone will get back to you. I think it's in like 24, 48 hours. A technology transfer specialist will give you a call back and to talk to you about that. That is from your region and from your area. Great. So I'm just looking over here in the chat. There's a question from Tasha. Is this VCB approved training? I'm not sure what that means. But maybe one of my colleagues on the call can also help me out with that to know if we're VCB approved training. OK, so our objectives, we're going to talk about ways to utilize the new understanding that we have around addiction and substance use disorders to impact the existing models that we work in, but also start to think about how we need to change those things. So we're going to take a huge dive today into the neuroscience, which I think gives us a lot of core important information to start to challenge things around treatment and prevention and policy. We'll blend in and talk a little bit about how that impacts trauma informed care, how we need to utilize recovery oriented systems of care and really individualizing and treating and supporting, not just treating addiction, but how do we treat and support people with substance use disorders. And so we'll dive into the complexities and hopefully the challenges around this complex problem and look at it in ways that I think also are understandable and digestible for us. This is my contact information. I love it when folks reach out to me if you want to. So that's my cell phone number. You can text me. And also, I'm pretty active on LinkedIn. I used to be active on Twitter, but I'm not anymore because I found it to be just like a, I don't know, toxic place. Anyway, so today we're going to challenge ourselves a little bit. And for some of you, this may be review. Some of you, this may be new information. Some of us, it may be a combination of those pieces. One of the things to think about if some of this information maybe is somewhat of a review to you is how do I take this information and bring it to my community? How do I take this information and bring it to people who have or are impacted by substance use disorders? Likely they have not heard some of these pieces, some of this information, some of this understanding. And why is that so important? Well, it's so important because we know the tremendous role that shame plays for many people who have addiction. And this training directly addresses provider shame around that and also client shame and how we can really start to bring the science to transform that view. So we're going to challenge ourselves a little bit about thinking about some of the old ways of addiction and substance use disorders, even some of the words that we use and the way that we talk to some of these new ways. And that's going to challenge maybe some of the things that we believe, maybe some of our perceptions and the way that we see things. And I really want to welcome that. I want to welcome things in the chat that maybe if I say, don't jive with you or don't reflect the experience that you've had in your own life or in the field. I really want to welcome those kinds of conversations because what's most important is that we talk about what's important to you all, not necessarily what's in these slides. So I'm going to really be relying on folks in the chat to bring in some of that new information. And I was just looking at the Q&A. We got a question in there, but that looks like it's for Chris or something else that Chris can take care of. OK, so we're going to talk about bias, stigma, discrimination to kind of to kind of start us off. Right. And so when we talk about. For us today, when we talk about bias and stigma, what we're talking about are the negative stereotypes associated with people who have substance use disorders. And and and and stigma and bias is different than discrimination because stigma is kind of like the way that we think. Right. Our thinking or the cognitive framework of a stereotype. Right. Except stigma transforms into discrimination when we actually behave differently towards people. And so when we treat people in the world in an actionable way differently because they have a disability, that's discriminatory. So we're going to talk from the reference of how do we address stigma? Because if we can if we can impact the way that we think, if we if we can challenge the things in the ways that we see, think about people, then that's going to impact the way that we behave and the things that we do. And so we're going to really bring in part of our challenge around the way that we we think about people with addiction and substance use disorders. So for us, stigma is defined as an attribute of behavior or condition that is socially discrediting. And so stigma is influenced by two main factors. Cause and controllability. So we talk about cause, what we're saying is basically to simplify it, when we say something is not a person's fault, when we say it's not your fault, stigma is diminished. Like even just say that to yourself right now because it feels good. Whatever happened this morning, it's not your fault. That feels nice, right? And so this is the extent that people believe that an individual or person is not responsible for the behavior or the thing that we're talking about, right? So if you think about substance use disorders, we don't often use terminology, it's not your fault. And we're going to talk about how this is really applicable, especially when we understand the neuroscience of addiction and substance use disorders. And then the other factor, controllability. And that's kind of like when we say they can't help it, a person can't help it, right? It's beyond that individual's personal control. When we say a person can't help it, they can't help it, right? And what we're talking about here is not having choice, stigma is lessened. Again, not something that we often hear when we talk about people with substance use disorders, right? And a lot of time this is connected to a lot of blame, judgment, and non-evidence based labels and judgments around people with addiction and substance use disorders, right? So ultimately, this kind of leads to that continued stigma that many people believe or perceive that addiction is ultimately a choice. And that addicted individuals really can control it. You know, we hear it all the time. And maybe things that I've thought to myself, like why can't they just stop? My gosh, right? We're seeing all these consequences. We're seeing all this legal involvement. You're losing your family. You're losing your body, your organs. You're losing your health. All these things, but why can't you just stop? Why wouldn't you stop? What's wrong with a person like that? Do you not love your children enough, right? And so we're going to talk a little bit about how to answer that question. And I love this quote here. For every complex problem, there's an answer that is clear, simple, and wrong. And unfortunately, that's been our approach for 30 years of policy as a country around addiction. Just say no. Just stop. The only way to stop is abstinence only. That is one way to stop. That's a really important way to stop. But there's many others, too, that we really need to consider. So we're going to talk about this issue around addiction and substance use disorder. We're going to talk a little bit about data because it's helpful to understand the numbers and what data is telling us. We're going to talk about our history of what we have inherited over the years that has really shaped our policy. And we're going to talk about some of the science and put those pieces together, which really does start to help us walk into the complexity of this problem. But also, there are answers that are also not too complex and simple and make a lot of sense for us. Okay. So this is a look at overdose death rates. This is nothing new that you all are aware. We see this continuing trend upward. There's been some, you know, in 2021, we topped 100,000 deaths. There's been some recent data out now that this is actually dropping, which is good news. Not too dissimilar from what we saw. I'm just going to get my pen out here for a second and draw on this to help us see a little bit. So bear with me while I do that, please. There's my pen. So we talked about it's similar to in these years here. I don't like that color. All right. Let's see if I can get a different color. Let's do red. We can see a little better. Okay. So here we go. So in these years here, right, we started to see an impact in the overdose death rate here, which we're kind of seeing now in 2024 a little bit. The preliminary data is showing that after this continued trajectory upward. What do we think? Any guesses in the chat what happened in, like, 2017 and 18 to kind of start to help level things off here? And also just take yourself off mute and shout it out, too, if you're risky, willing to risk it all. Narcan. Yeah, Chris, that's a great one. I think Narcan played a big role. And there's no right or wrong answers necessarily here. We're just brainstorming on some stuff. Harm reduction, definitely. Melissa, I love it. Mental health focus. Yeah, I think integrated care really started to pick up and has moved to the forefront. Chris, again, mobile crisis units, definitely. Right. I think MOUD medications getting out there. Right. MAT implementation. A lot of focus on that. Yeah. So, yep. And so a lot of good stuff happening here. There's some other stuff, too. We're going to talk about our history that I think also made an impact as well. But that's good. That's some good stuff here. And then what do you think happened here where we start to shoot back up again? We were just talking about this dynamic that occurred in 2020 before we started the webinar that impacted everybody. Fentanyl. Fentanyl, definitely. Right. That was part of it. Exilamine. Yeah. That's a definite part of it, too. Right. Isolation. COVID. COVID. Right. COVID. Yeah. COVID made everything worse. Right. And so it's just a look at some of our data that helps us understand the story here a little bit of what's going on. Okay. I am going to ‑‑ I forget how to clear the screen. I haven't done it in a minute. Just bear with me while I do that. There we go. Okay. Clear all drawings. Okay. Good. That should be clear for us. So this is an interesting kind of look, too, at the overdose deaths according to the drugs that were used. Okay? and so this is kind of interesting here, right? Because what did the opioid crisis start out with? Does anybody remember which opioid, maybe? Heroin? That's part of it, but that wasn't the start of it. Oxycontin. Yeah, Oxy, right? Prescription opioids. We had a prescription pain pill problem. Remember that, right? And so you can see how the blue line is prescription pain opioids, and you can see how in the earlier part how the overdose death rate really was impacted by that, and then starts to drop off, right? And start to drop off. And when it drops off, so then we had a second problem. Anyone know what the second wave was? I think someone might've already said it. Fentanyl in exilamate. Yeah, heroin. Yeah, so fentanyl and xylamine, definitely part of the story, but there's one big part of the story before those two, and someone said it. Heroin, yeah, yeah, Tasha's got it, right? Heroin. So you can see, look at this, right? Here's heroin all in the early 2000s down here in the silver, and then something happens where our prescription pain pill problem is still rising, but then starts coming down, but look at heroin coming up here, right? Look at that rise, tremendous, right? So we had a heroin problem. Jesus. So yeah, and then the third wave, someone said already were synthetic opioids, right? And look at this, right? So here we get our rise in heroin coming up, our decrease in prescription pain pill problem, but right around these years, look at this. This is fentanyl, xylazine, synthetic opioids, right? And so by 2022, ultimately, because of this rise, we have a poison drug supply, like all of our drugs, right? There's no more dangerous. There's never been a more dangerous time in our country's history than right now to be using drugs, right? And so we're gonna talk about the fourth wave. There is a fourth wave of drugs, but we're gonna talk, we're gonna say, you can put it in the chat or shout it out if you think you know, but we're gonna save that for a little bit later. Okay, so that's an interesting look at, and we're gonna look at the history of kind of some of the policies and what was going on with that stuff. Okay, here we go. So this is another easier look at that graph. I forgot I had this one in here, so I'm sorry about that. And then I gave it away, right? We talked about the fourth wave. We talked about, it was a pain pill problem, right? Then we see how it moved to heroin. We saw how it moved to fentanyl. And now- Xylazine. Xylazine is in here, yep. Yep, in here, part of that, it's synthetics. These are synthetics, so we're putting xylazine, and there's other stuff coming out too. I don't know the names of them yet. Go ahead. There's midazines and midazines and- Right, so we're gonna keep those as the synthetics, right? That's the synthetics that you're talking about, all in this line here. But we're seeing an emergence of a fourth wave, and it's this blue one here. What's this blue one? Cocaine. Cocaine, methamphetamine, stimulants, right? Stimulant use disorder. Yeah. Yep. Okay, cool. So, I mean, not cool. Very scary, very scary picture. And this is an interesting look at, this is that fourth wave, right? And what you're looking at in the gray part are what we really understand as the poisoning of that drug supply, where we're seeing methamphetamine-related deaths with heroin or fentanyl co-involvement. So methanol and opioids together, right? That makes up this gray part here, in here, right? But what's this black part? This is concerning. This is methamphetamine-related deaths without opioids. So we have a very specific stimulant use disorder problem going on and emerging as the fourth wave of our drug crisis, our opioid crisis. So it's an oxymoron, but what I'm saying is it's the fourth wave of the opioid crisis is a stimulant. And so something I'm curious, are folks seeing that in your community? And for many folks, they're saying, hey, meth never was not a wave. We've had this meth problem for a long time. It's never gone away, especially for a lot of rural areas. And that's true. So I'm just curious, you can put it in the chat if that's what you're seeing out there in your experience, in your communities. All right, so we talked about some data and what that's telling us, what that story is. And we also talked about how we wanna get into a little bit of our history and looking into the past, right? And we saw those numbers. We talked about some of these pieces, right? So part of the challenge that we have in addiction treatment and treating not just addiction, but also substance use disorders is that we've pulled substance use disorders and addiction, which is a chronic health condition out of the healthcare continuum, meaning that we've made it for years and years and decades and decades. Like, oh, if you have this problem, you need to go to the specialty treatment provider over there in that building with those people, right? And part of why we see this separation and we're working so hard now to reintegrate it, right? Someone put it in here too, addressing mental health issues, right? Because we know that these things are so closely that they are interconnected. Why is there that separation? Well, part of the separation is because of this issue here called the Harrison Act. And this was in the early 1900s, but it's a Supreme Court decision that declared for physicians to maintain or to treat a person with a substance use disorder on a medication, right, is not in good faith. And we indicted somewhere around 25,000 physicians for violations of the Harrison Act. So basically what we said is that providers, prescribers can't prescribe medications to treat people with addiction. And now what are we doing? We're begging our providers and our prescribers to treat people with addiction with using these life-saving MAT medications and they're reluctant. And they don't necessarily feel like it's their responsibility and wanna do those sorts of things. And so it's a really big challenge that we are, I think, moving through now, but still is an issue in many, many communities. Those are not my patients. I don't treat addiction. And that comes from a historical place where we didn't just like ask our physicians not to do it, we punished them for doing it. So I think understanding that history also helps us understand why we see what we call resistance or a culture of not wanting to get involved. It doesn't come from nowhere. There are roots in some of our own policy. The other piece that we know played a major role in the opioid crisis was the impact that the bad players in the pharmaceutical industry had in promoting and pumping opioids into our communities, right? So is anyone familiar with the Porter and Jick letter? And we got some great comments in here in the chat too. Meth is becoming a big deal in Washington, DC. So right, Kendrick, that's new too for urban areas because historically meth in many ways has not shown up in our urban cities and it's certainly making its way. And Debbie's saying fentanyl's cheap to make. Yep, adding it to everything, right. You can pretty much assume that if you're buying a street drug, there's fentanyl in it. So the Porter and Jick letter and poison drugs in Baltimore rampant. Thanks, Melissa. Yeah, so the Porter and Jick letter was a letter that was published in the New England Journal of Medicine in 1980. And it cited, it was cited and used by the commercial detailing efforts of the pharmaceutical industries, especially and specifically around OxyContin, which was brought to market in 1996. And so what the Porter and Jick letter was, was just a letter that was sent to the New England Journal of Medicine that said, hey, you know, Dr. Porter, Dr. Jick here, we treated about, I think it was about 30 people in the emergency room for pain with opioids and they did not come back to the hospital with a drug problem. That's all the letter said. In summary, that's what the letter said. Why was this letter sent? Well, we're gonna talk about in a minute, there was a, we were in the history of time where we were under treating pain and as a whole in the medical community. So this letter was mythologically transformed into a study. And in that study, it was mythologically transformed into an outcome that was said that opioids are non-addictive and safe to use. And so you're likely familiar with the rest of the story, how this letter was used as a main way to support the lie that opioids were non-addictive and not dangerous and supported the overwhelming amount of opioids that were then started to pump into our communities in the mid 90s. At the same time, we talked about it, we had this problem of untreated pain. Docs really didn't want, were concerned about treating pain and so there was a movement to make pain as the fifth vital sign. So there's a national initiative, this gets rolled out. I don't know if you've experienced this or not. There was a time when you go to your primary care provider and they ask you your pain level. I remember in the mid 90s, I just graduated from social work school and I took a job in New York City in a drug and alcohol rehab program. I took that job, by the way, with no academic training in addiction or substance use disorders. My concentration as a social worker was children and families. And the only reason I took the job, because I grew up in New Jersey, I was living there at the time and I wanted to party at the Jersey Shore. And they said I could work there on Tuesdays, Wednesdays and Thursdays. They were just happy to have a social worker. And I was like, cool, I'll do that. I don't even want anything to do with addiction. I realized I had a lot to learn and I ended up staying there for three and a half years or so to learn more about addiction. And then I spent a lot of my career unlearning a lot of what I learned there because it was wrong. But I would give a pain, I had to, the joint commission came in and said, I have to give on the drug and alcohol rehab, the 21 day program, the pain scale weekly to the patients that were there. And so we see this swing from not treating pain to there's a, something came up on my screen and says meeting summary with AI companion is on. So I'm just gonna say that's okay. And so we had, we swung from not treating pain to starting to pump these pills, right? Then we see the emergence of pill mills in our communities where we have bad acting doctors writing tremendous amounts of scripts and pumping these opioids into our communities. But we did something about that, right? We shut that down in many ways because we saw how that prescription pill problem shifted, right? And one of the ways that we shifted it was CDC passed a morphine milligram equivalency which gave restrictions to docs on how much opioids they can be prescribing. Unfortunately, again, we went from one extreme to the other. We had no regulation to a very oppressive regulation that didn't take into consideration folks who need to be on opioids for chronic pain which caused a lot of problems. And we also had things like the prescription drug monitoring programs come into play which help docs understand and see in a computer base if other doctors were prescribing opioids or benzodiazepines or any medications for any of their patients. And so that became a way to stop the quote unquote doctor shopping where people were getting different medications from many different doctors. Yet, we saw the overdose death rate. If you remember, I'm gonna go back really quick here and we're gonna look at this. So this is right around the time where we're stopping the, we stopped the overdose death rate, the prescription pain pill problem, but we see the overdose death rate continue to climb. And part of the problem of just stopping these pills from getting into the community is that we didn't address the addiction issue in this country. And so you'll see on this slide here that right now, I think this is up to maybe 12%, which is horrific. Maybe a little bit higher. That only 10% of the people who need treatment for addiction and substance use disorders in this country get it. And so we actually may have exacerbated the overdose death problem because when's the most dangerous time for a person who has opioid use disorder? When's one of the most dangerous times that they're at risk for overdose death? Does anyone wanna take a stab at that or throw that out there? I'm looking over here. I can see my screen. So it's actually when, great, yep. Carson put post-incarceration when they come out of rehab. So exactly. Abram, that's so good to see you. I'm so glad that you're here. It's, I haven't, I think that's you, Dr. Brown, and I haven't seen you in a while. So, right, so what everyone's saying here is that the most, one of the most dangerous times for a person who doesn't have, for overdose death is when they don't have opioids in their system. So we ended up cutting off a very safe supply of drugs, we knew that the medications that people were using were regulated and ended up cutting off a safer supply of drugs without addressing opioid use disorder. And so the market shifted and very wise business people from Mexico and the Mexican drug cartel saw a business opportunity and a need in this country for opioids. And so that's when we started to see the movement of black tar heroin moving into this country that could be accessed in cheaper ways, easier ways than the safer prescription opioid problem that we had. And not only that, but drug dealers were very sophisticated and it was not the harsh drug environment that we think of when we think about the crack epidemic of the 90s and the violence. It was much more of a modern business model where I could call my drug dealer and my drug dealer would be able to bring the drugs right to my house. It was 24 hours a day, seven days a week services. And in fact, it's easier to get heroin than it is to get the treatment for opioid use disorder, which is Suboxone, right? Easier to get those drugs. And so we see that shift in that second wave of the overdose crisis. That really moves us into opioids becoming the leading cause of accidental death in this country. And then we see the influx of synthetic opioids and now methamphetamine and cocaine and stimulant use disorder as being the fourth wave. And so we have kind of here are in the 90s prescription opioids. We see 2010, the rise in heroin. Here's our synthetic opioids in around 2013. And now we are into stimulant use disorder. So now we're gonna dive into, so I just wanna check in and see if there's any questions around that, you can throw them in the chat, but now we're gonna, I'm gonna clear my screen here. Oops. Now we're gonna talk about some of the neurobiology. And this, I'm not a neurobiologist, I'm a social worker. And so this part of the presentation, it kind of comes from years of learning about addiction as a chronic health condition. And it's really based in these works. It's based in this journal article, which is one of the seminal articles in understanding addiction as a neurobiological brain disease. It comes from the Surgeon General's report, Dr. Vivek Murthy under the Obama administration and then Dr. Jerome Adams under the Trump administration with specific focus on addiction and substance use disorders that bases itself on this journal article. And then a specific focus in the Surgeon General's report on opioids and how that all connects in the shift that we saw from DSM-IV to DSM-V. So we're gonna dive into some of the neuroscience around this. And does anybody remember this? Like these commercials, right? This is your brain on drugs, right? And people are remembering this less, I guess, as I'm getting older, but there's a great example. Danny, right? Yes. So like, it's a great example of how we really undermined our drug messaging for decades in this country. We tried to scare the crap out of our teenagers. Don't do drugs. They'll burn a hole in your head. You'll lose your mind. And then what happened is, is that like kids in high schools were using drugs and drinking. And they were then like going to college and getting okay grades. And they were saying this messaging is bullshit. And we missed an opportunity and undermined the honesty of a true message around what really happens to a person with substance use disorders. The other big mistake in this is that it just tried to simplify things. Like, oh, drugs are just bad. And just don't do them. Well, it's not that simple. And actually drugs have tremendously bad consequences. And they also do a lot of things that are helpful for people. They make them feel, people feel better. They elevate mood. If I have a co-occurring condition, they make me feel not depressed anymore. So we also need to talk honestly about the impact that drugs and the reasons why people use drugs to really have an effective policy around this. And so we're gonna actually talk about the brain on drugs. And this is your brain on drugs. And we're gonna talk about these three main areas. We're gonna talk about the three components of addiction, of binge and intoxication, preoccupation, anticipation, and negative affect and withdrawal. And we're gonna talk about these as the three stages of addiction. And here's a look from the journal article that we referenced. This looks a little overwhelming and complicated. And I wish we had more time to really dive in and talk about some more of the nuances around this sort of thing. But you can see from the three stages of addiction, typically in our history, the thing that we focus most on is this part, is the intoxication part, right? When you hear about drugs, whenever someone says it's all about getting what? Getting? High. High, right. Yes, right? Exactly, right? So it's about this part here, feeling euphoric, right? And a lot of times we leave out this part, which is what happens when I don't have that drug in my system, which is withdrawal and negative affect. And then also cognitively, what's going on in my brain and the changing parts of the brain of preoccupation, anticipation of getting me back to using the drug again. So in our diagram here, this is binge and intoxication of kind of where it occurs in the brain. Over here is kind of where withdrawal, oops, sorry, I missed my mark there, withdrawal and negative affect are. And down here, this got smushed on here, sorry about that. This is preoccupation and anticipation of getting back to using the drug again. I also took the liberty of taking in the orange here, these are the criteria of kind of where it occurs in the brain of the DSM-5 criteria, the 11 criteria that we use to diagnose a mild, moderate or severe substance use disorder. So we're gonna talk about all three parts of the stages of addiction and how also getting high for when a person first uses a substance to when they have a severe substance use disorder are two entirely different things that often are missed and misunderstood. So we're gonna focus on the neuroadaptions and the changes that occur in the brain. And that's why this thing's a big circle because it's not linear and just starts here and happens over here. It's what happens over time to these shifting drivers and changes in the brain. And we're gonna talk about this bottom part from left to right over time of what happens in the brain and what happens behavior wise to the person. So let's go ahead and dive in. The specific part of the brain that we're gonna focus on in a much more simplified way is the limbic system, also known as kind of like our survival hardwiring, right? This is where we get those urges to do pro-social positive things, like to eat food, to drink water, to take care of our kids, to have relationships, to live in a safe environment with shelter. And we get dopamine for doing these things. When we get dopamine, we feel good and also that connects to our memory. And our memory says, oh, we felt good when we ate that food, when we drank that water, when we had relationships and have sex. We get rewards for doing all those things. So we're gonna remember how to keep doing them We're gonna get on that train and keep doing it. And basically what we're talking about is Maslow's hierarchy of needs. The bottom part and the basic building block of the pyramids, things that we do to promote safety needs and physiological needs, like food, water, warmth, and rest. That's the part of the brain that we're gonna talk about that gets impacted by addiction. The other part is the prefrontal cortex. And this is the beautiful part of your brain that helps you with impulse control, decision-making, abstract thinking. And we're gonna talk about how substances can hijack and really usurp those primary drivers. Ultimately for a person with addiction, they believe that the need to survive, that bottom part of that Maslow's hierarchy of needs is to actually use the drug, not to do those things. So this is the bottom part of this picture here. So we're gonna take this here and we're gonna blow it up on the next screen and we're gonna dive into it and talk a little bit about it. Okay. So here we go. So these are the neuroadaptions, right? This is the changes that occur over time and the parts of the brain that are impacted because we know the brain is malleable, it's changeable, it's flexible, right? And it's amazing, right? We know too, especially from trauma research right now that because of epigenetics, certain parts of our genes and certain parts of the brain get turned on and off, not just what happened to us in our life or the environment that we live in, but what happened to my grandma, that her brain is impacting what's going on for me in the here and now, which is just an amazing thing, right? So we're gonna go left to right and look at, here's again, our how many stages of addiction? Three, right? Our three stages of addiction, here they are. And this is gonna take us from left to right over time about what happens to a person with a substance use disorder. So I'm gonna use kind of a made up example here to talk about this of the shifting drivers that result from neuroadaptions of a person who takes a drug. And then we're also gonna talk about and interweave the behavior changes along this continuum. So here we go. So right, we go to a party, we take oxycodone and we get high, we feel euphoric, right? We feel that euphoria. And we're like, wow, I have a little social anxiety. I don't usually like to go to parties, but that was the best party ever. And I had so much fun and I met so many more people. And that oxycodone really helped me out with my depression and I don't feel depressed anymore. And I noticed I've been really going to all the parties where Jim is, cause Jim has the oxycodone and I wanna make sure I go to those parties cause that feels good. But I'm only doing this on the weekends because I still gotta go to work and I don't wanna lose sight of all the responsibilities that I have. But I do notice that when I don't have the drug in my system, I have reduced energy. I don't feel as good. And I really am excited to be going to parties with Jim. I look forward to the weekends where I can use the oxycodone. So right now, behaviorally, I'm in voluntary action. I have periods of abstinence where I don't take the drug, like Mondays and Fridays, Monday through Friday. And I can kind of control the drug, but something's starting to happen. In fact, I don't go to the parties anymore and Jim is such a nice guy. He brings the drugs right to my house, but I'm noticing I'm needing to use the drugs more and more because I'm not getting that same euphoria now that I'm a year or two into this. And I still have my job, but now I end up kind of stretching the weekend into Mondays and Tuesdays and Thursdays and Fridays. And something different's happening to me. Not only when I don't have the drug in my system, do I feel reduced energy, but now I feel reduced excitement about everything. Like all the things that I used to do that I enjoyed to do in my life, I don't like to do them anymore. Like go to church, like have sex, like eat pepperoni pizza. Those things just don't interest me anymore. What interests me predominantly is oxycodone. And so now it's shifted. I'm not just looking forward to the drug. I desire the drug because I don't feel good when I don't have the drug in my system. So now I'm starting to take the drug when I don't intend to take it, or I'm having trouble stopping it when I started, or taking way more than I planned to take. So now we're gonna fast forward a few more years, and now it's shifted where I have to take an opioid just to not feel awful. For me, the days of getting high in the way we usually think about it when it comes to addiction have long since passed. And you know this, if you've worked with someone with a substance use disorder, a severe substance use disorder and addiction, they will grieve in the discussion of how they cannot get back to that feeling that they once had, right? So, but they're compelled to continue to keep using the drug, right? And now when they don't have the drug in their system, it's not that they just have reduced excitement. They feel down, they feel depressed, they feel anxious, they feel restless. And now it's shifted to impulsive action, where they're obsessing and planning to get the drug all the time. And they're in the continual cycle of relapse and compulsive consumption over and over again. And so this is what happens over time to a person with addiction. So we're gonna, so I'm gonna pause to see if there's any questions on that, because we're gonna move into now and talk about how that occurs. And we're gonna talk about the eight steps along the pathway to addiction. A little more specificity of what happens along that continuum that we just looked at. Anyone know what this is, this picture? It's the Wizard of Oz. Yeah, the Wizard of Oz, right? And so where's Dorothy headed? To Oz. To see the wizard. See the wizard, right? Because why? She wants to go home. She just wants to go home, right? And she's on the yellow brick road, right? And does anybody know what happened a few scenes before this? Well, what's on the left and the right, these beautiful flowers that she's walking through? Poppies. Yeah, right? They're poppies, right? Anybody remember what happened right before this scene? They're drunk. They were drunk, right? They pass out. They pass out, right? They were high from the opium, right? The opioids, the poppies, right? Does anybody remember how they woke up? Snow. Snow, right? How did the snow happen? Glenda the Good Witch. Glenda the Good Witch brought the snow down, right? So yes, Dorothy did it in 8-Ball, right? And I bring this in to demonstrate too that drugs have always been part of our culture, right? These metaphors can be found always in civilization, in humans. Humans have always looked to alter their state, alter their minds. And I also think that this becomes a really, I'm just gonna ask if folks can put the, you can jump in if you have something to say, but if you could put yourselves on mute just to keep the integrity of the sound for our virtual room here, that would be helpful. Thank you. So this also is a great, I think, metaphor for recovery because on the way to Oz, right? Dorothy thinks she needs to get to see the great and powerful Oz. And she needs her friends with her, right? She's got to bring the Tin Man because this pathway is really about what's going on in your heart, right? And it also, as we were talking about, is really addressing what's going on in the brain. And this path also requires tremendous courage because all Dorothy wants to get back to is home. And ultimately, how does she get home? The air, the balloon, right? No, she clicks her heels together and wishes. Nothing outside helps Dorothy get home. Home has always been where she is. And she needs to address what's going on in her heart. She needs to address what's going on in her brain. She needs the courage to do it, ultimately knowing that the wizard or anything else isn't going to take her there. And I just think that that's a really wonderful metaphor for the path that many people find themselves on when it comes to recovery and how we need to provide all supports in all those areas for each individual person to be able to choose what's most important for them along this pathway. So, okay, cool. So let's take a look at, we're gonna look at the normal way our brain, normal dopamine functioning in our brain. So let's take a look at that, hopefully. Our brains are finely tuned machines. Inside, cells called neurons are constantly communicating to shape how we think, feel, and act. Let's eavesdrop on their conversation. These are the ends of two neurons. The one on the right sends a message, and the one on the left receives it. At first they look connected, but they are actually separated by a tiny space called a synapse, where messages are relayed. What we'll see next is how we normally experience pleasure. The sending neuron contains dopamine, the brain's pleasure chemical. When something good happens to us, this feel-good chemical is released into the synapse, where it connects with receptors. There, dopamine activates the receiving neuron, which in turn conveys the message onto the next neuron, creating a chain reaction that produces pleasure. After the message is sent, dopamine is recycled by transporters to be reused. This conversation repeating itself again and again gives us the feeling of pleasure. Okay, so that's just to kind of remind us a little bit about kind of the way the brain works. I think this is such a cool video that helps us understand that. And so when we talk in this brain, there's a disruption of this system, right? These addictive substances start to disrupt that function of the brain circuits that are involved in our natural rewards around food, water, but they also impact the areas around motivation, decision-making, and memory, right? They're shifting all those pieces, right? Those parts that allow us to experience pleasure in response to all those pro-social positive things are starting to get disrupted. And that's a little bit where we start to appropriately use the word hijacking, right? We hear that a lot, the brain gets hijacked. That's what we're talking about. These systems are getting hijacked from and disconnected from these pro-social positive things to the drug itself, right? And so the other piece is that the natural rewards elevate dopamine, right? They give us dopamine. This is a look at, this is rats, but a study that shows on the left, this is the dopamine concentration. And so you can look at this as like normal functioning is around 100. And when we have food, it goes up to 150. When on the right hand side is the same, but for sex. And so when the rat has sex, it goes up to 200. Some might say this is the scientific study we needed to answer the age old question, is sex better than a cheeseburger? And apparently according to rats, it is. And so, but that's often why also too, you see when it comes to dopamine, we like to combine things, right? So adding sex and a cigarette makes a lot of sense because we're getting that dopamine up into higher levels. So in step two, we're seeing changes to this system, right? These addictive substances start to mimic and interfere with our brain's natural chemicals, literally changing the reward system. And this is where that primary need for survival is starting to change to the drug, literally that will to live. Imagine yourself, you go on a hike and it's one of those beautiful days in the winter where you don't need a jacket when the sun's out, but you're on a hike and so you're walking around and you realize that you're lost and the temperature is plummeting well below freezing. And you know that you only have a limited amount of time before hypothermia sets in. And so you start thinking about your bucket list and all the things that you've never gotten to do that you want to do. And you start thinking about your family and your friends and that drive to keep moving and to keep going for yourself, for them. It pushes you and up on a ridge, you see a light and you know, if you just make it to that cabin, you're going to survive. And so you push through and you trudge through and you're coming up on that cabin, you know, if you get inside, you're going to live. If you don't, you're not going to make it. And I don't want anyone to answer this or put it in the chat, this is just for your own exploration, but as you come up to that door, think about what would you do to get inside if the person inside didn't let you in. It's the only way you're going to live. That's what it's like for a person with addiction, that their brain is telling them they need to continue to use. It's why we see the craving so salient, so strong, because this is the part of the brain that's being interfered with and changed. So step three, we start to see changes to the cues and the triggers, right? So there's this, this connection between the dopamine and our memory. Our memory remembers where to go do pro-social positive things. Like I know where the potato chips are stashed in my, potato chips are stashed in my, in my kitchen, right? We associate those behaviors with people, places, and things. The 12-step community has been talking about people, places, and things for decades, because there's a strong connection between those and, and those behaviors to do things, right? So we start to see the changes in memory where we're not hanging out with people that, you know, we enjoy and want to be around. We're hanging out with people that we know are going to have access to the drug that we so desperately need. So, so these cues are changing, our memory's changing. So I ask you to step back for a second and look into this slide and, and, and just to see, you know, what are you seeing? What are you experiencing? What, what's happening for you? What are you feeling? You can shout it out or put, Chris, you, you, can we see your hand up? We'll get to this right after this slide, okay? And so you can put this in the chat or yell it out. Oh my gosh, I'm salivating. I'm getting hungry again. Craving, yeah. Craving? Hungry? I'm thinking I want it, but I shouldn't have it. So there's guilt coming in. We're doubting what we're thinking. I'm going against what I feel, right? I, my mouth's watering too. Cheryl's triggered. Danny's saying not good. Guilty pleasures. I wish I had it right now. The chat's never been so active for the last hour until right now. Look at all the energy we got going, right? People coming off of mute, not hesitating to jump in and talk. I'm on a diet. I'm going off my diet. There's all sorts of things happening here. You can't even smell this, everybody. It's a PowerPoint slide. It's not even real. And look at, look at the impact that this has on our brain and me too. It's my PowerPoint slide. I've seen it 300 times and it still gets me. And I have the sweet and savory on here for me. It's the pepperoni pizza that puts me over the edge. But this is, this is just an example of how strong those cravings are for us around food, right? We know that we're getting dopamine. It's activating all different parts of our brain. Some of you are not even here anymore. And you're thinking about how you're going to get off this webinar and get to lunch and get something to eat. It's a, it's, it's amazingly powerful, right? When a person's using drugs, those areas are being activated in ways that are way beyond how those systems were intended to be impacted. And so the, the, the drugs like oxycodone, methamphetamine are impacting those natural rewards off the charts, right? Way off the charts, higher and higher and higher. So this is a take, we're going to take a look at how the brain responds to methamphetamine. How does meth change our brain? When we use meth, it enters the bloodstream and travels to the reward center of the brain, where it invades the sending neuron. Meth causes dopamine to unnaturally leak into the neuron, then spill into the synapse, making matters worse. Meth blocks the transporters, which recycle dopamine back into the sending neuron. This keeps levels abnormally high, overstimulating our brains. We feel a powerful wave of pleasure. The rush can last eight to 12 hours from just one dose. So that, that's what's going on, you know, an example of, of, um, uh, methamphetamine. This is a look at that same chart again that we looked at, and you can see, um, again, like our baseline is a hundred. Um, this is what happens in the brain. Again, this is just rats, but a look at the brain of like what happens, um, after, uh, ingesting, uh, alcohol goes up to 200. Nicotine takes us up a little bit higher, say 225. Um, cocaine brings us up to, uh, about 325, 350, I would say. And then look what happens in this bottom, right. With methamphetamine, we need a whole new chart. Wow. This is like 1250, right? Yeah. So that's why we're also seeing the impact of methamphetamine drugs like methamphetamine. And we're seeing that rise in, in, in overdose death around stimulants because the purity and the potency of methamphetamine has never been stronger. Um, and, and, and also why you may be having a very difficult time treating people with methamphetamine use disorder, um, because it impacts the brain in so much. One of the reasons is so, so much of a more severe, severe way. We see higher, higher levels of anhedonia, um, and, and the parts of the brain that, that get hijacked, that we typically see respond back to those pro-social positive behaviors are taking longer for people on methamphetamine. So our step five, and by the way, someone, uh, Melanie put in here, I can smell the sweets. Melanie could smell from our PowerPoint, right. And we call that euphoric recall, right. Where we can actually smell something that's not there and have that experience, right. Again, so powerful. So we, it just gives us a little bit of a glimpse into, um, uh, what, what, what, what it might even be like, uh, for a person, uh, using these much more powerful substances where the brain chemistry is altered. And so in step five, and this is where we start to get into the, the dastardly devilish part of addiction, what goes up must come down. So what we mean by this here is that in a person with a substance use disorder, that pathway is responding to the cues that addictive substances are available, right? So it's saying, that's a way of saying cravings, go use the drug, go get more oxy, go, go, go get more meth. While at the same time, the response that I have to the drug and to those natural rewards for using the drug diminish. So the more and more I use of the drug, the more and more I crave the drug, the less and less I'm going to move the further and further. I'm going to move from that original feeling of euphoria from euphoria down to feeling good down to feeling just using the drug to not feel awful. So it is true for the person in their brain that they need, or they must have more of the drug to have activate the same level of reward that they will never get back to. While at the same time, the more drugs I use, the brain tissues and those systems become increasingly damaged, right? That prefrontal cortex that helps me say, stop, do something. It helps me with impulse control, judgment, right? Those things I'm losing more and more control, right? And so we're really seeing how the bottom part of the pyramid in Maslow's hierarchy of needs has changed from safety and physiological needs to the drug itself. And the go and stop parts of their brain, well, they've been damaged, right? The parts of my brain that say do something, it's kind of like taking the gas pedal in a car and putting a cinder block on it. And the parts of my brain that say, slow down, don't do this anymore. Well, we've snipped the brake lines. And that's what's happening to a person that ultimately ends up in one of the hallmarks of addiction, which is erosion of voluntary control. That simultaneously repeated substance use erodes the ability to exert inhibitory control. So we'll bring back in, when we talked about bias and discrimination, the two cornerstones of those things were cause and controllability. Is this my fault? Is this something I can control? And we see how the neuroscience is starting to help us understand that the answer to that is no. And then in step seven, we say here that time both increases and decreases. So over time, those substance related cues, those cravings get stronger and stronger and stronger, more compelling to use, while at the same time, I'm less able to inhibit impulse control to say, just say no. And the experience of the high continues to diminish, even though my brain is telling me I must get back to that euphoria and I never will. In fact, the more I use, the further I get away from that feeling. I mean, it is a dynamic design by the devil themselves. That over time, I crave the drug more, I lose more and more control to stop using the drug, and I no longer feel high. I no longer feel just lose the feeling of good and doing good things around me that drops off. Now I need to use the drug just to escape feeling absolutely awful and bad. So ultimately, that leads us to the last step of the erosion of voluntary control. And this is where we hear the hallmark of definition of addiction is continued use, despite harmful consequences. And this is where we see the erosion of voluntary control, again, cause and controllability, right? Is this something that I can choose? Is this something that I can use my will or the drive in my life of what gets me to do things? Is this is this something that I can actually use the strengths that I know are within me to stop using and the neuroscience says, no, that you've lost voluntary control around that. And this is the pathway that leads to many of the symptoms that we see in DSM-5. So we had some, I'm going to pause here for a second. We had some hands up and maybe some questions. Chris, I'll check back in. I forgot to check back in after that last slide. So I'm checking back in now on your question. No, it's okay. But, but, but Tiesha Clark was just wanting to remember what step one was. Yeah. So we'll go back and look at it. Sorry for the whiplash here. Sorry for the pizza. So step one is disruption, right? So, so step one, that we're taking that substance and it's beginning to disrupt those brain circuits, right? It's starting to impact them. It's starting to move in on the normal brain that we looked at and, and kind of that, that hijacking is started, right? Step two, it's start, now it's changing the system, right? The addictive substance starts to mimic and interfere and literally change it. Right. And this is where we kind of think about the need to survive changes from living to using drugs, right? Step three is the shift in cues and triggers. So now instead of getting cues to eat pizza or to have sex or take care of my children or go to church on Sunday to be with my community, now those cues and those memory, the memory part of our brain are shifting to don't go to church, get oxycodone, right? And these are the people places and things, right? And then our, our experience of that step four is now with continued use, we're activating those systems at a higher level, right? Way higher than those pro-social positive behaviors could ever impact the brain. Right. And, and, and so the, the, that dopamine pathway is being acted, activated way more powerfully than those natural rewards. And so this is where we talk about what goes up, must come down where now the more drug I use, the less I'm actually going to get back to that initial experience of euphoria. I'm losing it's the erosion of control over my brain. And then we're seeing how tolerance has built up. And so over time it's increasing my need to use the drug while my control decreases. And then step eight, we see the kind of culmination of all these dynamics as the erosion of voluntary control. So that's kind of a quick, a quick overview. Checking back in. I'll just pause here for a second. Can you can you go back to, um, step six for Melissa. I got it. Okay, I got it. Thank you. Yeah, no worries. Erosion of control. I love that statement. All right. We'll keep I'll keep going. And then we have some time also for maybe some. Oh, here's a comment. Please comment on the difference between tolerance, that is not substance use disorder. If I'm if I'm if I'm understanding the point that you want, you want to make is that just because a person builds up a tolerance for a drug, or in the case of, say, opioids, builds up a dependence, a physical dependence. That doesn't mean that a person has addiction, right? It's two different, really different things. And so a person can have a physical. Great, thanks. So, yeah, it's a great point to bring out for us right that just just because a person has a physical dependence on a drug and there's many examples of this right. Where a person is physically dependent on a drug, but does not mean they meet criteria for addiction, which would mean that they have to meet the criteria here in DSM. And so that's a really important distinction for us to make. So thanks for bringing that out. So we now know right from from this neuroscience and this is from SAMHSA that that that substance use disorders are not a moral or spiritual failing. That people with substance use disorders not using substances is not because they're not responsible or because they have some lack or gap in their willpower. That that addiction is not a character defect. There's no such thing in DSM as an addictive personality type. We use these socially to talk about things, but but they are harmful in the way that sometimes we judge and evaluate people with addiction and substance use disorders. And ultimately, and this these were some of these were really challenging for me because they even were the base of many treatment plans that I wrote when I first started out in the field. But but people with addiction don't have personality components such as denial or rationalization, defensiveness, manipulation or resistance more than other folks with chronic conditions. So what that means is, you know. They lie just like I lie to my primary care provider when she asks me how Nick, how much are you exercising? And I know exactly what to say, you know, three to four times a week, about 30 minutes a time. And we both know I'm full of you know what. Right. But she doesn't throw me out of the office and tell me I'm a liar. And then if I really cared about my family, I'd start exercising. Now, granted, the impact of me not exercising has many fewer social impacts in my community, my family, to myself. Right. So it's it's not a totally fair comparison in that way. But the point of it is to really think about how effective is the confrontational style around addressing substance use disorders with people that it's not it's not effective. And what we know from the neuroscience is it also doesn't make any sense because it's continued use despite consequences. So really, this this is about challenging ourselves out of some of those old antiquated ways of talking and thinking and evaluating and judging people with with with substance substance use disorders. So Danny says it's DSM. So thank you. I didn't explain what DSM, which is Danny explained to us. It's the diagnostic and statistical manual that we use. Let's talk about it for a second here. Because there was a huge shift from DSM for I think it was right around 2013. I've been 16. I was mixed that up. If someone knows in the chat, let me know. We went from DSM for DSM five. But we went from DSM for DSM five. And what we got rid of. Was the axes and how we used the diagnosis, but the word substance dependence and substance abuse were removed. Avram's example in question points out the misunderstanding of of substance dependence. That was the most severe. Of the two diagnoses. Yeah, we now know that the 11 criteria, the dependency piece only consists of two of those 11 criteria. So it's actually a much more smaller component when we evaluate substance use disorders, which shows our antiquated over reliance on dependence as a core issue. For addiction. The other term abuse was removed, thankfully. We removed abuse because we now know from the neuroscience that if anybody is being abused in the situation of addiction, it is the person by the substance, not the other way around. It's loss of voluntary control. Right. And when we use the term abuse, what do we think of? We think of the worst things. We think of child abuse. We think of intimate partner and domestic violence. And the stigma associated with that. And so, gratefully, we've gotten rid of abuse. And we now use a spectrum to help us better understand the complexities and the multitudes and different variations of having a substance use disorder. And so depending on the number of criteria that you need for a substance use disorder depends on whether we diagnose it with mild, moderate, severe. There was a lot of uproar in this shift. When because people looked at mild saying, oh, my gosh, we're going to be diagnosing everybody with the substance use disorder. Two to three symptoms. That's many, many people. And yes, exactly. That's the point that supports interventions like SBIRT, which is a proactive preventative approach to screen for and provide a brief intervention to reduce alcohol and drug use. And what's also interesting was the outrage and the fear of being called or labeled with a substance use disorder, which speaks to the tremendous amount of work that we need to do in the field to undo the stigmatization around being labeled as a substance use, having a substance use disorder. So in a healthy environment, we look at this is great. This is going to allow us to bill and code for mild substance use disorders so that we can provide the interventions and the discussions and the treatment, maybe in a proactive way before they develop into more severe levels of a substance use disorder, like a moderate or severe. Also interesting to note, DSM-IV didn't include in the criteria drug cravings. Can you imagine not having drug cravings as part of the criteria? I point that out to show it wasn't so long ago how antiquated even our diagnostic criteria was around addiction and substance use disorders. So we've seen some good changes, I think, that come along. There's not many big differences between DSM-V and DSM-V, the treatment revision. The big shift was four to five. So now looking at addiction and substance use disorders, these are some of our evidence-based perspectives that we now know from maybe our policy history, some of the data that we looked at, and certainly from the neuroscience. And so I'll invite you to bring in the core components of stigma, right? Cause and controllability. Is that my fault? You can't help it. We know, depending on the studies that we look at, half the risk for addiction is conferred by genetics. Somewhere like 40 to 60% of the people who have a severe substance use disorder inherited it. Is that my fault? Is that their fault? The other piece that I think really contributes to stigma around addiction is that most people who use drugs do not develop an addiction. So the example is kind of like this. We had a hundred people and we put them in a room and we gave them, you know, well, we didn't put them in a room, but we gave them heroin for three or four months. They would all develop a physical dependence. 80% of them would be like, wow, I love this stuff. It's great. I like how it makes me feel, but I'm getting in trouble at home and I have my job and there's all these reasons I need to stop. I'm going to stop using this stuff. And they do. The 20% say, wow, I love this stuff. It's great. It really works for me, but I got to stop it. It's messing up my marriage and my partner's mad at me. I'm in trouble with my job. All these negative things are happening. I'm going to stop and I can't. And that's the difference. The 20% have addiction. They can't stop and they want to stop just like the other 80% do and know they need to, but something's different in their brain. And I think that's a really important thing for us to remember. It's kind of like when I was younger, I was like, I could definitely be a waiter. I eat out to dinner all the time. I know how this thing goes. You walk over and there's a lot more to it than just eating dinner as a waiter. And I think that's a bias that comes out in a lot of our communities that just because you use drugs or you're around drugs that you understand addiction. And that may not necessarily be the case. And so we know that with repeated exposure, typically to what happens is going on in the brain. It's unaware by the person. That person with addiction, their ability to self-regulate their impulses is slowly impaired over time. So there's this erosion of it. It's not like all of a sudden that happens. And so many folks find themselves using drugs against their own will, against their own sincere desire to stop, genuine desire and promises to their family. I was in a focus group like four months ago with a group of folks in early recovery. Many of them in that room had been in and out of periods of abstinence and recovery and returned to use over their lifetimes, as is common and expected. We got through asking about access to recovery supports and MAT and all these things that we wanted to learn about the community from their lived experience. And we ended up, and we were just kind of nonchalantly chatting, and I forget how it was asked, but one of them said, there's no way I'm ever going to use again. And me as a clinician, all my alarms and bells go off when I hear that. I get worried. I get concerned because I've heard it so many times. And then the next person said, me either. There's no way I'm going back to that lifestyle. There's no way I want to do it. And pretty soon the whole room was talking like that. Were they lying to me? Were they trying to get over on me so they could get back out there and continue the destructive path that's a wake of pain behind them? No, I don't think so. I think they meant it with all their heart that they did not want to return to use. Yet when there is a return to use, which is expected, and part of what we know from the ASAM definition of addiction is that return to use and recurrence is part of it. So why are we not just prepared for it in our treatment planning and treat people with respect and dignity to support them even more, maybe provide more resources for them when they return to use rather than pulling them away or at worst kicking them out of treatment? It really, I think, speaks to how we need to shift in our judgment around people with addiction and how we now know that that type of thinking is just not based in the neuroscience of how addiction works. So that is our answer, about choice. We understand now that substance use disorders are the radical decay in our rational ability to make choices, to regulate impulses, despite consequences, despite the threat of harm. And that's the other problem. We've based our drug policy for decades in this country on punishment, as if the old adage, you got to hit rock bottom, which is not true, which is not accurate, because the neuroscience tells us it's continued use despite the bottom, the many bottoms along the path. It's continued use despite the threats of harm, of consequences, of all these bad things, right? And so that's ultimately why people don't stop, because the functional and structural changes in the brain have impacted that neural circuitry around impulse control, around judgment. The reward system changed. The memory and motivation systems have changed. That's what's been impacted. And that is not about choice. That's about what happens to a person who has addiction and the changes in their brain. Okay. So a couple of good stuff in the chat. I don't know where to start. Someone help me. Chris, I don't know. I don't mean to put you on the spot. Can you help me out a little bit? Oh, this is great. We have like a whole discussion going on. Yeah. I want to kind of go back to this question. Kendra Kerr says, can a person that has changed from a drug addiction to something not harmful be led back to addiction from their new choice of use? Sure. So like switching drugs, like going from like cocaine to methamphetamine, and then from methamphetamine back to cocaine, something like that? No, for an example, like if they were, okay, so you know how alcoholics sometimes they switched over to sugar, like sugar cookies, any cakes, little debbies and things like that. Is it possible that from they're switching over and it's still kind of like the addictive behavior, can they go back into active use with drugs? So the way I would kind of answer that is to flip it a little bit around, right? And what I'm going to bring in is kind of like the new approach around harm reduction. Like if you're eating little debbies instead of like a pint of vodka, awesome. That's great. In fact, if you're instead of drinking a pint of vodka, you're drinking three beers, that's great too. Any shift that disrupts that pattern of behavior and starts to change that is a positive step and a place and an opportunity and a level of motivation that we can work with. And so those shifts and those changes, I think the old thinking was, oh my gosh, you have to get rid of all that stuff because it's a gateway back. And that's not exactly true. Anything can lead back towards a return to use. And that's why relapse prevention planning is so important. That's why really working individually on a person's individualized recovery plan is so key because those are the components that are going to be really important for me to learn other management skills that maybe alcohol and drugs work very effectively for, right? So the other part of this too is that if we're going to ask somebody to take something out of their life that does certain things for them, we really also have to provide alternatives. Like what are the ways that you are going to get some of the positive benefits of what it is that your drug or your alcohol use brings to you? We have to be comfortable in talking about the positives as much as the negatives in substance use disorder treatment. And that's a really important thing for us to get comfortable with as clinicians. I was taught not to do that, that that's enabling behavior. It's glorifying it. It's encouraging people to use and that's just not true. It's not accurate and it's not helpful to our clients. So that's kind of how I'd kind of answer that question a bit. Chris, should we keep going or? Yeah, I don't have any questions. Just a comment from Abram. You know, MOUD is usually lifelong. He did say usually, and that's important to know, right? It's not an absolute. But usually, yeah. And but may not be for everybody. Yep. I saw that note too and loved how Abram put in usually. Melissa, yes, say something. Hey, this is great. So super informative. So thank you. I am in recovery. So, you know, I've actually been on both sides of this. But I just wanted to say when you were talking about people saying, I'm never going to drink again, never going to, you know, and it just like, you know, that's always the intention for me. I'm an alcoholic in recovery, and I've got over a year of sobriety right now. But I just wanted to comment because my boyfriend who suffered from addiction as well, wanted me to actually say the phrase, I will never drink again. And that's something that I can't do. Because I've accepted within myself that I can't safely pick up a drink and trust myself to be able to stop. So it was just I found it pretty interesting as you were talking about that, that another addict who comes, you know, is made of the same, you know, material or fabric, would expect me to say that I will never do this again, although my intention is to never do it again. Those words don't, you know, they're, they're shallow, if I were to use them, you know, I have to do one day at a time, right? And really quick, just another side note, when when I see people filling the void of other things like food or whatever, you know, when you stop drinking or stop using or whatever, you know, it's really the intention behind the use that we need to look at and not the use itself. Because if you're if you're eating, or you're you're shopping, or you're doing whatever, and the intention is to make you feel good and get rid of a bad feeling or a negative emotion, then then there's a problem, you're really not doing the Dorothy thing and looking inside yourself, right? So, so it's really like the intention behind it. I've done a lot of work on myself. So I'm just so thankful for this. And I appreciate you listening. Thank you. Melissa, I love how you said that last piece. That was, that was great. And, and, you know, that's why this is also very personal, like, recovery needs to be individualized care. And that looks different for folks. And it sounds like what your partner wants, or maybe the way their path to recovery sounds a little different than yours. And that where we need to get to in the field is we need to say yes to everything that is working. And, and, and if that's what works for one person, then that then that's great. And the other place we need to go to is also not mandate that just because one approach works for some people that we make all people follow that pathway. And that's a little bit of the trouble that we've gotten into in the abstinence only approach in the field is that we believe that the only way to do it is through a 12 step model or an abstinence only. And we, we lock the door on many effective harm reduction strategies that are very effective for people with substance use disorders. And, you know, it's funny, like, harm reduction strategies, that's like how we do healthcare, really, with all the other chronic health conditions. They don't, we don't call it harm reduction. But like substance use disorder, we had to come up with a name for it. And everybody had to get all crazy about it and upset. And it means this and it means that it's been politicized and it's emotionally charged. It's simple, like harm reduction, actually, is just really good healthcare. And, and, and, and so, you know, sometimes, folks, Nick, are you anti 12 step? Absolutely not. I we need all those supports. We need abstinence only approaches. And we need other approaches to and need to be flexible based on the individual. And I think that's so key in how we're going to change things. So Melissa, thanks for that. Okay, I'm going to keep, I'm going to keep going. So just some things for us to think about, right? Like, so do, where you work, what it is that you do, or the individual treatment plan that maybe you're going to work on this week. Do our treatment approaches and policies match what you now know around the science and the evidence base for substance use disorders? Like, are you providing medication for opioid use disorder? And if you're treating addiction and you treat people with opioid use disorder, you need to be. And, and, and because it's the gold standard. And we know it's so effective in helping people. And if you are providing MAT, MOUD medications, and someone tests positive for marijuana in your program, do you take them off Suboxone? And if you do that, you're not following the evidence base. And so does that match the science of what we know around addiction and, and, and treating people based on what we now know around this neuroscience stuff? So those are some things to, to, to start to hopefully challenge. You know, whenever I talk about this, I see, I see faces of clients that when I worked in addiction treatment, that I discharged from the program. That's how we'd say it discharged from the program. For the very reason they sacrificed and struggled so much to get into that program for addiction. That's crazy. That's insanity. That's doing the same thing over and over again, expecting people to have different results from the provider side, from the provider side, to throw someone out of treatment because they're in substance use disorder treatment because they use the substance. Makes no sense yet. That was something that we did because we thought people weren't ready. That's what we'd say. You're not ready. They're not really committed to their recovery. We blame the individual. And we know that that makes no sense, right? Because it's loss of voluntary control. And that if we're treating people with addiction and substance use disorders, we need to have built into our treatment approach, a readiness to help support a person through a return to use and stay with them and connect with them. I mean, that's what meeting people, what social workers love to say that we want to meet people or that, well, this is what we're talking about. We're talking about meeting people where they're at and not leaving them there, staying with them. Critical, critical for us. Okay. And, and, and so some of the challenges that we've seen in the field, right? We talked about how this 10%, I think it's gone up a little bit, but it's, it's still abysmal. 10% of the people who need treatment get it. There's a lot, there's a SAMHSA study that's always referenced. It says, well, actually most people surveyed don't want addiction and substance use disorder treatment. They don't want it. Well, the question that needs to be asked is, would you go do what we ask people to do with addiction? Would you leave your family for six months to go to that residential program because you keep testing positive? Would you go stand online on Martin Luther King Boulevard in a dangerous section of the city every morning to get your dose of a lifesaving medication like methadone? I wouldn't do it. Right. I wouldn't even do like three hours a group, four days a week. How could I, I can imagine trying to fit that in to the schedule. Right. And the impact that that would have. So we need to think about are people refusing treatment or do we need to rethink treatment? Do we need to rethink care? How do we get the good things that we know are effective and helpful for people to the people and not just to the people like that show up at a certain building, but like where the people are. We need to get the care to them. Right. So really thinking about initiation rates and how do we stay, how do we stay connected? How do we keep you? And then now we're starting to move into trauma informed care, right? Really utilizing a trauma informed care approach where people feel welcome, that there's shared decision-making, that there's respect, that there's dignity. Those are the things that are going to really start making a difference for us in the systems that we work in. Right. We know that we talked about harm reduction, but ultimately harm reduction is health equity and health engagement. Right. And the, and the thing for us to really remember around health equity is not that we treat everybody the same. It's the, it's the difference totally from it's saying that some people are going to need more resources than others because of many different factors. How do we get them those factors? How do we get them those resources? How do we keep people engaged? How do we support people and create relationships with people? So they want to remain engaged in the treatment process. Right. And so I always bring into how SAMHSA's working definition of recovery really doesn't mention anything about abstinence. It's about living a self-directed life, achieving full potential. Right. Being overall, being in overall wellness. Right. These are the ways that we really need to start thinking about how we provide care. Right. And that really brings us into connection with utilizing recovery oriented systems of care. It's a great model. If you're not familiar with it in really looking at these key domains of social, physical, human, and cultural, and, and, and, and really bringing these strengths and supports that folks need in recovery from a whole health approach. Right. And the 10 guiding principles, things like their culture, things like peer supports, addressing trauma, all of these key pieces in the guiding principles are key. And, and so this kind of helps us bring a new perspective to recovery, right. Kind of getting us out of crisis oriented modality to a more stabilization management approach. The traditional way was professionally directed. You know, we, we, we told people what they needed to do, and if they didn't do it, it's because they, we blame them saying, well, they're being resistant or they're in denial to really shifting. Okay. Well, what motivates you? Oh, you, you, you don't, you don't, you don't want to talk about the heroin that you're using. You don't want to talk about that. You're the fact that you're homeless, but you're really concerned about your dog. Okay. Guess what we're going to talk about. Cause guess what's, what's motivating that person to come talk to me, the dog. Right. And that's a great intervention because it's, it's connecting to what motivates this person. It's what motivates them to, to, to get to my office, to talk with me. It's, it's the doorway for them, for their recovery plan, even though as the clinician, I'm like, okay, we're not going to talk about the eight bags of heroin you're shooting every day. Okay. We're not talking about the fact that you're homeless, but that's my treatment plan for them. That's what I think is important. And it's not that it's not important. And it's not that I don't abandon my clinical insights and interventions, but it also means that I'm willing to bracket those things in a professional way, because what's most important for the person in front of me and the pathway that motivates them is to talk about their dog. And so that's what I talk about because we know small steps in whole health impact all health, right? That, that wellness wheel one, anywhere we can impact that is going to impact that all those components, right? So, so really thinking about how do we support people in ongoing recovery management and understanding that there are many, many pathways to recovery, many pathways to wellness, right? So we, we see this shift, right? Using things like evidence-based care approaches. You know, I talk about SBIRT a lot and I wish they didn't use it. If you're not familiar with SBIRT, let me know, but like you talk about a brief intervention. We're getting away from interventions in addiction treatment, right? It like, you know, I hear intervention and I see Dr. Drew and like a bunch of my family members ready to confront me and yell at me in a very threatening manner, which is not an evidence-based approach, right? But was glorified on television as one of the most effective forms of treatment. It's not, right? So really moving into what we know, right? Medication first models, getting people on life-saving medications for opioid use disorder first, before requiring them to come to counseling. In fact, those medications are going to help them engage in counseling. So it behooves us all to use these evidence-based strategies, right? Utilizing recovery-oriented systems of care, we talked about trauma-informed care, also utilizing measurement-based care, population health management strategies, understanding data is what we are doing. Is it working? Is it effective? Are we measuring it? Those are really important things for our field because we're going to be called upon to justify the work that we do and how we do it. We're going to need data to tell that story, right? And then using things like medications to support people is so key. Things like MAT and MOUD. I'm going to go ahead and get us to, this is a look at just, you'll have the access to these slides, but a trauma-informed approach, some of the key concepts from SAMHSA for us. And then a reminder of my favorite quote, right? That for every complex problem, there's an answer that is clear, simple, and wrong. And today we talked about a lot of those complexities, but we also talked about some things that we can do that are simple and that are helpful, right? So when we're addressing substance use disorders, we acknowledge that it's complex and there are answers that are clear and that some are simple and we need all, and we need all. So lastly, I just want to thank you. Thank you for coming today. Really, you all are part of the shift in how we can change this, how we can impact those data curves that we saw and talked about around overdose death rate. You can today shift in how you treat addiction and how you treat people, maybe more importantly, treat people with addiction, right? You can change it by the way that you think and the way you treat people. And ultimately the most important thing that all this data and research and neuroscience opens the doorway for is love and compassion. Because the number one thing that you can do is not motivational interviewing or cognitive behavioral therapy or LEOPS prevention planning. It's strengthening the relationship that you have with the person that you work with. It's your relationship. How wonderful is that? That that holds up across all the science. So you are the shift in changing how we do this work. And so just by picking any one of these areas and shifting it up is going to make a difference. Okay. So lastly, I think we have some time to chat, but we also want to make sure that folks fill out the survey. You'll get a certificate of attendance. You can just scan the QR code. I don't know if there's anything else I need to say about the survey. I'll go back to this in a second. Also, this is the contact to submit a request for technical assistance. If you want help in any of the areas that we talked about today or other stuff, even you can go ahead. You'll have access to these slides. This is my contact information. I just want to, I want to thank you. I want to thank you for doing this work. You guys do incredibly difficult work to help support your communities in incredibly difficult systems. And I just hope that you hear it from me today that, you know, we appreciate you. I appreciate you. And you don't get to hear that enough in this work. And so I hope you hear it from me today. So thank you. Awesome. Thank you so much, Nick. We do have a couple of minutes. Are there any questions or comments or anything that you don't want to miss out on? Now's the time to speak up. I have something. Okay. You did a great job, Nick. I'm so appreciative. And I just wanted to say one of the things that wasn't touched on is the emotion that we avoid. And people, you know, myself that's in recovery, it's really important. I've learned through the years of this. I've only been in, had this where alcoholism has been a problem for the past eight years. And learning to sit in the emotion that feels bad is a huge part of the healing process. And I just think it's important for, for people on the call just to know that, that, you know, that's one of the main reasons why we use, because we don't want to feel the quote-unquote negative emotion. And so I, you know, that's definitely part of recovery. I believe that is, is one of the main keys that, you know, I focus on that works for me for sure. Melissa, I'm so glad you brought that. It's one of my favorite things to talk about when I get to do this work from like more of the clinical side of things. And it's, it's why your, your relationship in this work is so critical because every moment you provide an opportunity for a person to have what we would call a corrective emotional experience. And what that means is to experience the emotional energies that they have inside of them that maybe as a child they were taught they can't feel. They didn't maybe grow up in a family where they knew have, have the skills to do that sort of thing. And, you know, back to what we talked about in the question of like, is eating little debbies or moving, shifting from one addiction to another, you know, ultimately in recovery, it's the gift of people with addiction. They're brought to these places in a way that substances bring them into a collision course with these dynamics in recovery for many folks. Right. And so what is a curse is also a great gift that many people who aren't in that collision course can walk through life, never really taking a look at. And that's an incredible strength. And ultimately, what causes us all problems, recovery, not addiction, not whatever, what causes us all humans challenges is not what we feel. That's not the problem. It's the restriction of those emotional energies that cause us problems and all the things that we do not to feel them. So we eat too much. We drink too much. We smoke too much. We shop too much. We work too much. We something too much, right. That takes us out of those emotional experience in those emotional energies and congruent ways. So most of you said it so beautifully, right? Yeah. And I, they're there for a reason. I just wanted to say emotion, negative emotion is there for a reason. It's to warn us, at least for me, I believe it's to warn me. It's to say, Hey, something's wrong. Pay attention to me. And the emotion, the negative emotion, it never kills me. It never kills me when I sit in it. So it's a process, though. But you know, it's scary. But yeah, so thank you for listening. Yeah. And I've also worked with people that that's, that's not their thing. And they just need to be on Suboxone. And I'm on Suboxone. And I'm back with my life. And I'm going doing my family thing and whatever. And and that's not their personal recovery path. And that's okay, too. Thank you. And that's okay, too. Right. You know, yep. Yep. You're right. It's, it's all it's all all all of this, you know, it's all this is Wow, thank you. Thank you for that. Oh, thank you, Debbie. Debbie has all of the links in the chat. So please, please, please fill out that survey. It really helps us. Sade, did you have a comment? You have your hand raised? Yeah, I wanted to say thank you. And I'm going off of like, just listening to everybody talk. I wanted to say that I feel like everybody's own recovery in their own path is their own, you know, they have to make it in like, Nick was saying, you know, you have to do their recovery plan for them and what they need. And I think that's so big, because so many people are different. And I use marijuana, but I have three years clean, you know, and I'm not using hard drugs. And I got off of my prescribed medication, from like the pills for depression, anxiety, and I use marijuana now. And some people look at it as I'm not clean. And, you know, and that's like, na na, but to me, I am clean and to other people, I'm clean. So I think each person has their own recovery plan. And I think it's a great idea that, you know, that now thanks to neuroscience, that they're discovering that we each have our own way of recovery. So that's all I wanted to say. Awesome. Love that. And also, I'll just, you know, challenge you a little bit, that you were never not clean, because you were never dirty. And really being mindful of the language that we use, because that terminology is negative, clean and dirty. We don't, people are not, you know, saying that you're clean implies that you were once dirty. And that's just not, it's not accurate, right? I like that. So yeah, so like being really mindful of like, you know, even using terminology like addict, certainly in the 12 step community, that's part of the terminology and how people talk and that's okay in that cultural context. It's not okay in a professional context, right? It's not right. Not using the word abuse, right? Because what we talked about, right? Like there's court, there's research out there. I know we got to go. There's research that sentencing is longer when the court case uses the term abuse versus substance use disorder. Like the term. So yeah, this stuff really matters. This stuff. Yeah. Thank you. Okay. I know we only have a minute left, so we probably have to do something. Do we have to close out or something? There, well, I'm just going to reiterate that there is information in the chat for taking the survey, which is really important for ORN to keep doing what they're doing. So please take that survey. And there is an opportunity for you to get a certification of completion for being here today with us. And there's information in the chat for that as well. You will also be emailed about it. So not to be all like redundant, but we're going to make sure you get all the information you need. And then I will just go ahead and put my email in the chat one more time. If anything should happen or you have any other questions, you can email me. And I think that's it. Debbie, do you have anything to add? No, you pretty much said it. And like she said, I will email everybody who attended today. If you didn't get a chance to do the survey today, you do have to create a free account with PCSS. If you don't know about PCSS, it's also a great website. It's like a knowledge management system, and it does have trainings on there that you can take for free or a small fee for continuing education credits and stuff. But to get your certificate for this, it's free. And at some point, it might take a week or two to get the recording put up on that learning management system as well. And I can send you the link for that as well. But if you have any questions, email me or Chris. Yeah. And the PowerPoint from today will be emailed out as well to all the participants here today. So you will get those slides. All right, guys, I'm going to, I unfortunately have to jump off, but I just had a great time with you all. Thanks for all the energy and the conversation, discussions. We get to the good stuff. So if...

addiction science

impact on the brain

stages of addiction

brain's reward system

addictive substances

drug-seeking behavior

recovery process

neurobiological aspects

dopamine functioning

memory's role

cravings

methamphetamine's impact

individualized care

trauma-informed approaches

harm reduction strategies