So, welcome. My name is Paul Hunziker. I'm going to be working with you today on opioids and stimulant use disorders, and we're going to have a skills workshop associated with this. Let me introduce myself briefly here. I'm a licensed marriage and family therapist in the state of Washington, as well as an addictions counselor or a substance use disorder professional in the state of Washington. I am in private practice in Tacoma, Washington, but I spend about 70% of my time doing trainings. I've trained for many different organizations, including the Opioid Response Network. I've been training for over 10 years now in many different subjects around substance use disorder, family-based programming, as well as mental health, motivational interviewing, clinical supervision. So, I've worked quite a bit in several different settings with that. I've also been teaching on Zoom since at least 2017, so a couple of years even before the pandemic. I've really worked to try to figure out ways to make Zoom trainings, online trainings, more engaging and more interactive. So, enough about me there. Let's talk a little bit here about and orient you to the Opioid Response Network, or ORN. So, the ORN is funded through SAMHSA, which is part of the Health and Human Services Department, so it's connected to the federal government. And it was created mainly to help in providing resources and technical assistance related to the opioid crisis, as well as stimulant use to local agencies and get them out all across the country. And so, the ORN offers technical assistance, specifically in evidence-based treatments and also recovery and harm reduction techniques, again, specifically for opioids and stimulants, so it can cover other substances as well. So, the ORN looks to get local consultants, so folks that have special understanding and expertise in the areas and also the geographical locations where the trainings are happening, so that people are on the ground and kind of understand how things work, where we're teaching. Now, the ORN accepts requests on an ongoing basis for education as well as training, and each state and territory has its own team. We are in Region 10, which is Washington, Oregon, Idaho, and Alaska, and each state and territory or region has specialists that can help with us. If you're interested in getting any further training or have any other questions, feel free to reach out to the ORN. Here is their contact information, and they do, like I mentioned earlier, take requests on an ongoing basis. Here is the specific grant information that's associated with the ORN and what's coming through SAMHSA. It just gives you a little bit of background on kind of how the funding that helps the ORN operate. And then, one of the goals in getting folks that are local, we're looking to, we also add in, we have a huge repository of information that we pull from. Our goal really is to make sure that we don't reinvent the wheel, and so we're constantly trying to build and create new trainings to make sure that we remain on the cutting edge and are providing the most current information possible. Our overall mission is, again, to provide technical assistance and training, specifically to enhance prevention, as well as recovery, harm reduction, and treatment focuses, and we're looking to make sure to address local and specific needs of organizations. So what we've got here, we're going to start moving into our presentation meeting at this point. So talking about substance use disorder, so here is a definition put forward by the National Institute of Drug Abuse, so the NIH, and it is one of the more simple ones. It's a chronic relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. Pretty general, there's actually a lot in that sentence, but we'll talk about another definition that's going to be put forward by another organization that goes into a little more detail. This, being so simple and straightforward, is really overarching, and we're going to talk a little about each component of this as we go through the day. So just checking in here, I've already introduced myself here. I'm going to move through that slide. So our learning objectives for today. So we're going to be looking at how substance use disorder changes the brain, and talking about that definition that we just saw a moment ago and how that comes into being. We're going to talk about and identifying what a substance use disorder looks like, what are the things that we are looking for to see whether or not someone has one. We're also going to be looking at risk factors associated with substance use disorder. So now we're going to move into addiction and the brain. So addiction, we're going to use addiction and substance use disorder interchangeably here. I want to add addiction is a pretty broad topic because it does include things other than just substance use. It includes compulsive behaviors and many, many other things. We are going to be using that terminology here, though the more scientifically accurate version would be the substance use disorder in the brain. So staying with that addiction verbiage here, this is that other definition I was just mentioning. It's from the American Society of Addiction Medicine, so ASAM. ASAM has been around and was founded in the 1950s, and it's been around for some time. The goal of ASAM is to produce or to move addiction treatment into the most effective and looking at making it as effective as possible and giving us the broadest range of possible treatment options possible. So some of the big pushes from ASAM, one is to look at the available treatments in any geographical area and figure out what are the what are the levels of treatment or the types of treatment that are missing and then figure out how to work with local governments and other entities to make to fill the gaps, because we want to have a complete array of treatment options available for everyone is their ideal. Part of this, which is what they're most well known for, is what we call their levels of care assessment, and so that is where someone using that tool would be able to tell someone whether they need inpatient, whether they need outpatient, detox, what type of treatment they would need. So they've been at this in their first level of care criteria or at least in the late 80s, early 90s, and they've been developing it ever since. There's a definition here that they have for addiction that's important to note. Addiction is in the title of their organization. So addiction is a primary chronic disease of brain reward, motivation and memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathology pursuing and or relief by substance use or other behaviors. So there's even more packed into this statement here and noting that part at the bottom there, they note other behaviors. So they they're acknowledging that addiction is broader than just substance use, though. Also, when you look in here, it talks about it does mention a disease and many of you might be familiar or you may be familiar with the disease model. Pretty well known, but it's not universally accepted. There are some differences in opinion around this, though it also talks about brain reward, motivation, memory, related circuitry. All of this talks about how the brain is changed by by addiction. And that actually is is fact at this point, we know that brain our brain structures, our brain is changed through substance use and especially regular chronic substance use. And so no one will argue with that. Now, going into this further, it talks a little bit about what happens. So dysfunction in the circuits creates characteristic biological, psychological, social and spiritual manifestations. So it talks about some of the the fallout from those changes or outcomes or consequences of those changes. It also is reflected in the pathology and reward relief of substance use and other behaviors. So just talking about how there's that cycle that happens. So looking at brain imaging, and so in the late 2000s into really the 2010s, it's really like 2005 to 2015, but it's really been longer than that, was really kind of looked at as the decade of the brain. And what was really happened then is we really started through MRI imaging and other methods, we really started to be able to see into more of what was happening with our brains for various things. But but one of the things that jumped to the front of the line was looking at addiction. And so those brain imaging studies have shown that there are physical brain changes that occur due to substance use and the areas that are impacted are mainly judgment, decision making, as well as learning and memory and then ultimately behavior control. So they change and alter the way that we are, these changes alter the way the brain works and helps explain the compulsion that of and continued use despite negative consequences. So let's go a little bit further into this. This is a pretty complex slide that we've got here. So let me describe some of what's happening here. So we've got the frontal cortex here. So it's this part. You've got the green part at the very front of the brain. It's at the very front of the brain. This is the largely known as the judgment center, because this is the part of the brain that can kind of think ahead and kind of think in a more abstract way of like, what will happen down the line if I do this? So like I'll give an example of I won't want to eat that candy bar because I might feel bad later on. That would be my frontal cortex. Telling me even though I'd enjoy that candy bar right now, I might regret it later. So then we've got these other sections here, these which are more towards the center of the brain. I'm not going to name each one of them, but they the things that are largely encapsulated in this center are a couple of things. There's what's called the pleasure pathway. So this is it's a number of these structures that are associated, you may be familiar with dopamine. It's also sometimes called the dopamine pathway. This is the part of the brain that feels pleasure, but more importantly, we call it reinforcing anything that activates that part of the brain. You're going to want to do again because it felt good. And so that's in the in the center here, there's also other things like emotion control, temperature control, all kinds of things are centered in that brain. Now, the outer part of the brain, the wrinkly part on the outside here, that's the the outer side, that's the cortex. That's really the center that can think. So whereas the pleasure part of the brain is the central part of the brain, that's the so whereas the pleasure pathways and all that are embedded in what we call the lizard brain, which is very impulsive, the the wrinkly parts are the part that kind of do a lot of the thought and a lot of the extra piece. And then this green part, the frontal cortex is the part of the brain that kind of regulates is supposed to regulate between the thoughts and the emotions. So let me walk through kind of what's the what's being described on the slide here, it's talking about here, you've got response to the drug. So let's start here. It's probably the part that makes the most sense. So what's happening, you've got these arrows that kind of go both ways. Let me come down to neuro adaptations. So one, the the drug is introduced, the neuro circuits and synaptic systems are are impacted by the molecules that come in the molecules of the drug. And then there's an epigenetic effect of the the body has to respond to the drug. We call it the hedonistic set point. In other words, the drug, most like most drug and opioids and stimulants would fall into this this range where they they tend to feel good. There's a euphoria or a rush. And so the body is like we are like, oh, that feels nice. But our brain is like, whoa, I need to we need to change up. We can't keep going this way. And so those epigenetics eventually cause there to be these neuro adaptations where the brain will start to kind of prune off or make it so that it's harder for the substance to get to have an effect because our body wants to stay in what we call homeostasis, feeling normal. And the brain has to adjust to that. So that's that's kind of overarching for response to the drug. So when we get high or feel the effect, we see this intoxication. It may move on. We may have negative effect. In other words, this is before someone is in the addiction phase where there might be a high, but then there can be a crash like stimulants will have this. There's frequently a significant crash as the stimulant wears off. Well, what then can happen is and it branches off to stress and reward, but also could go to to anticipation here. There can be an anticipation of, oh, my next hit will make me feel good again. And I'd like to feel the way I did in the beginning, the first time I felt it, which then causes you to go back to intoxication and go back in the cycle. You go enough times through the cycle. Eventually you'll start binging, which means that you're using a lot more for a longer period of time trying to stay in that good feeling. And eventually that it will change to having withdrawals. So withdrawal starts to set in when the body has made changes to itself in order to get used to having the drug on board. We're going to go into more detail of what what's happening there in a moment. But yeah, that after repeated use, that will start to potentially set in. And it also is tied to the neuroadaptations. So there's a cycle that a continuous cycle that leads up to this. What's being described on the bottom here, it kind of talks some of the cycle stages of addiction. So in the binge and intoxication phase, someone is feeling euphoric, good, maybe escaping dysphoria or escaping a negative feeling. During the withdrawal negative or negative effect phase, they may have less energy because either because they're they've been using and that's depleted them to a point or they have other reduced energy for another reason. They may be feeling less excitement and eventually may be feeling depressed and anxious will want which would cause them to want to take more. And eventually that will lead to preoccupation and anticipation. So they're looking forward, they're desiring, they know that the drug is going to help them feel better, and then they start to obsess and plan. And then the bottom part here, behavioral changes, you've got voluntary action. So in other words, where the person can choose, they've got the ability to decide whether or not to use abstinence, where they stay free from it. Constrained use is there. And so these are all within this. They can they're in control. And then we move to the next phase, sometimes taking when not intending, sometimes having trouble stopping, sometimes taking more than intended. This is where they're starting to lose control, but it's not always you know, it says sometimes they're not always having that problem, but they do sometimes and it tends to increase over time. And eventually we move to impulsive action where they can't stop even if they want to. It's impulsive, they're relapsing on a regular basis. There's a compulsion or a compulsive consumption. So they're drawn to it. They even if they want to stop, they can't. So we're going to talk now about criteria for looking at diagnosing or what goes into deciding whether or not someone has a substance use disorder. So I want to start with the dependence criteria, because this is an important one. It is possible for someone to be dependent without being addicted. And there's a couple of examples of this. I can think of someone who is a cancer patient who has been suffering with cancer and has been prescribed opioids. And they're using their opioids and they become physically dependent on the opioids. But I wouldn't say that they're addicted. And the reason is, is that if they stop using their opioids, they're not going to feel well. But they may not even connect how the med is. What's not having the med is what's not making them feel well. And even if they do, they're not someone who's in this state won't be going out to find it from other sources. They'll they're going to just stay with that and kind of recognize, OK, this is just from the medications. And so they're also not hopeful. They're not going to be having struggles because they'll be taking the medicine as prescribed. So they hopefully won't be getting into arguments with other people around their substance use. They're not going to be having a lot of the problems or a lot of the chaos that can fit into someone's life that comes with addiction. And so these two criteria would be met by them because they would have a tolerance. They're gonna need to likely take more opiate or opioid over time in order to feel the effect. And that's what tolerance is, is the body adjusting and it keeps getting it so that it's more and more of the substances needed in order to feel the effect. And what that is, is the body either creating liver enzymes or reducing the number of neurotransmitter receptor sites or the body can make several changes to itself to increase tolerance. And then what we have, the other criteria that might be met is withdrawal. And this can be met, someone without, that's not technically addicted but dependent could have withdrawal syndrome in that they, yeah, they would feel one within hours or sometimes a little bit more than that of last use, they will start to feel symptoms of what kind of sounds like a flu. And we'll talk about them more in detail in a moment. So those are two, these are the two physical dependence criteria. Now, the rest of these would be the parts that we would look at that would go into the substance use disorder or addiction if you wanna use that terminology. So, and it can be any number of these that can show up but at least one or two of them will at a minimum. So someone, and this is impaired control. So someone who's using larger than they meant to or than they originally intended. So alcohol might be a great example for this, someone who goes out to have and says, I'm gonna have one beer tonight and that's it. And they end up drinking a 12 pack. That's, there's a loss of control, it's impaired. They had this plan that fell apart. Persistent desire to cut down. So this is people that are saying they want to stop or even trying to stop and they can't. So that's an important one there. A great deal of time spent obtaining the substance, using the substance, recovering from the substance. Essentially, the drug consumes them. And this is a lot of times where when we talk about people being addicted, we say that they're self-centered. This is actually largely, this criteria here is largely why we say that. Because they're putting the drug before everything else. It becomes the most important thing. And for some, it's the only thing. And so it looks like they're very self-centered. Really what's happening is that the drug, for various reasons, has become the most important thing because without it, they'll feel awful. And so it can help us shift a little bit, have hopefully a little bit more compassion. But yeah, generally folks with impaired control here will, most of their time is spent either using, recovering from, or getting the substance. And then the last one here is intense craving. So this is where they can not think of anything else other than using. So then social impairment is the next round. So failure to fulfill work or school obligations or even home obligations. So any responsibilities that they have that they are not, they're failing to meet because of substance use would fall under this. Recurrent social or interpersonal problems. So any fights or arguments or disagreements that they're getting into with those that are close to them about their substance use would fall into this. Withdrawal and withdrawal from social or recreational activities. So they're pulling away. A lot of times when I talk with folks, they've maybe had a group of friends that used to play golf. And they started drinking when they were playing golf, but now they don't even do that because the folks will judge them too much or there's just not enough time or for whatever reason, they're pulling away. They're not involved in things that they used to be. And then we get to risky use. So this is recurrent use in situations that can be physically hazardous. We most often think of driving and it is included in here. Though there are other things that are in here that are important to note too. Operating other heavy machinery, such as a lawnmower. Mowing the lawn and having a beer, which is interesting because there's lawnmower beers, they even market them. And that's actually using in a hazardous situation. The other one that cuts a little close for many is having a few drinks while cooking. It's technically a hazardous situation because you've got knives, ovens, you've got all kinds of things that are potentially hazardous. Something to note with this is just because you have maybe meet one, it doesn't mean that you have a use disorder. And we're gonna talk about this in a moment. There's a lot more that goes into it. But yeah, it is really important to note that there are many different situations that could be hazardous. One that it does apply for many times for opioids and stimulants. Are they using in situations where they could be assaulted? Are they using in situations where they could be robbed? Are they, because those are also hazardous situations. Are they continuing to use despite persistent physical and psychological problems that have been caused or exacerbated by use? So in other words, they know that it's causing them either a physical or a mental health problem, and they keep going. This is a major marker for this. And this is, there's usually that part of awareness that it's a problem and that it's making things worse, but they can't stop. In some ways, this is not just risky use. It's also impaired control. There's a crossover here. But yeah, it's definitely an important one there. So we just went through, and there's actually 11 criteria that we just went through. Noting here, these are the criteria for diagnosing a substance use disorder. You would need to meet a minimum of two. Two means that you've had met them within the last year. Now, meeting them really means that you have to have that full threshold and that this has to be happening on a regular basis and to a point that it's really, really, truly risky. So there's a certain level here where we're really needing to look at it as truly being a challenge. So two would be mild. Now, if they were, two to three would be mild. Four to five would be considered moderate. And then six or more of these is considered severe. Now, we like using a substance use disorder because we have these 11 criteria. We have some really specific ways of looking at this. It's a really solid way of determining whether or not someone has the disorder. And so because of that, it's a more scientifically accurate term than say addiction because addiction is a broader spectrum. There's a lot that can fit under it. And so this is why we like to use this. So we don't have groups, but we are gonna, let's talk about what we have here. When we do have groups, they're generally, we set folks out for a discussion and we have four slides that we're gonna walk through here and walk through reactions. I'm gonna open each slide up, read it, and then I'll discuss some of the possible reactions that folks might have. Of course, please think about for yourself as well what your personal reactions are because the purpose in these is really to start looking at your own personal views about substance use and addiction and all of this because it's gonna be really important in our later sessions when we start to move into how to talk to people about substance use. So the first statement is, substance use is a normal part of life. It's a pretty broad statement there. And yes, it does depend. And most groups, when they talk about this, they do talk about how it can be subjective, how there can be, there are certain, depends on culture. There are many cultures where no, it's not a normal part of use. You think of Muslim culture, there can be where alcohol is not the norm or even Mormon culture where there's really, really no substance use. In fact, they really look to even reduce caffeine and other things that we forget are substances. And then there's other cultures where substance use is very in the norm. We think of a lot of European cultures where alcohol is there. Now, there was a discussion of a grandma putting down a pitcher of diluted wine on the kid's table at lunch, that normalizing of that. So it really depends on the person and the culture that they're in. Now, you know, it doesn't say substance abuse. It just says substance use. And so that's a difference here too, just noting that's there. Generally in US culture, it is, there is a norm. I mean, we use caffeine, nicotine is used by many. There's also many over-the-counter painkillers and other things that we use. So yeah, using and relying on substances can be a normal part of life. The next part here, substance use is a moral failing or sin. Many will react right away when they see this because we've been trained a lot to avoid looking at substance use as both a moral failing and or sin. Though it is important to note that it still works its way into a lot of the things that we do. When we look at stigma around substance use, a lot of the stigma for substance use disorder, it tends to go towards the moral failing, meaning that the person has done something wrong. When we look at moral failing, it's the idea that bad things happen to bad people. And it's that there's something wrong with the person. There's something flawed about their character or them. And when we look, a lot of them label them as criminal, other things are addict or even addict sometimes can be, but it's as though the person, there's something that they've done wrong. So that in a way, and there's an unsaid message that they deserve it. And so we really do need to figure out ways to kind of pull this back. And this comes up a lot of times around putting in safe injection sites and other things that we know are effective that can be really helpful for keeping people alive and create very good solid doorways into treatment. And what we get is the, no, I don't want those kinds of people here. And so as much as we try to pull back from it, it can still be there. And it is important for us to think about this too, of where we fall in this, how much is there, because the folks that we work with will pick up on what our beliefs are, whether or not we tell them what they are. Also connected in this is the sin part, which the sin is interesting because we see that as many times as judgment. Though there may be folks that we work with that seeing the substance use as a sin is actually helpful for them for accountability. And so we really need to know who the individual is. Are they going to see it, viewing it as a sin, as a problem, or is it something that's going to be a strength? Generally, I lean towards not viewing it that way because yeah, many, if not most will view it judgmentally, but there can be some folks that find it there. And even with the moral failing, AA talks about in step four, doing a moral inventory, which kind of moves in that moral failing way, but possibly in a way that might be useful for some folks. Next one, people who use drugs. So PWUD, they should be considered a group with rights that need to be protected. So this comes out of the National Harm Reduction Alliance and it comes off of their website. And they're actually, they talk about how harm reduction is not just a treatment approach, it's actually a social justice movement as well. And so out of that, they really do actually try, one of their goals is to try to have people who use drugs identified as a group of people who tends to be targeted, tends to be oppressed, and tends to have their rights ignored. And they're right, they do. Because many times you talk about emergency medical folks, not necessarily responding as quickly as they should to the site of an overdose. Police officers not necessarily giving as much assistance again as they could, because they're like, they're just someone who uses. And we could go on and it's not, there's many, many different environments where you can think of their rights being taken away, folks being not allowed to congregate in certain places. And it goes even broader into looking at rights such as like complaining about someone smoking meth on a bus. Do they have a place that they can smoke meth that's okay? Probably not. And is it okay for us to be ragging on them when we haven't actually supplied them with a place where they can go? And that's a part of thinking about it. People who use drugs, should they have a place that's free for them or a place that's appropriate for them to be able to use? And so looking at that, and there may be different feelings on this because everyone reading this can come from this from a different angle. And so many are deeply concerned by the idea here. So it is also potentially helpful for us to think of them and recognize that this is a vulnerable group. And it is important to remember that they do have rights and we do need to support them in making sure that their rights are respected. Professor Carl Hart. Neuroscientist states that he uses heroin recreationally. Tends to have a lot of reaction to this one. So this is, Carl Hart is a professor from Columbia University. He has an author and written many books on like systemic racism within the substance use disorder treatment field and other topics as well. And his goal here with this, he does, he has claimed this at points that he does use to unwind, use heroin to unwind. And there can be a debate. Most of the times there's a debate, can someone use heroin recreationally? There is evidence that this is technically there. Some of the things that we see is Vietnam veterans coming back from Vietnam. Many needed to go to treatment and many needed methadone and other things to help them. But there were far more that just stopped. It was actually the most of the folks that used heroin in Vietnam came home and never used it again. So we don't really know, we're not quite sure totally the mechanisms on it. So it goes to that question, is it possible to use it recreationally? Carl Hart's not saying that heroin is not an addictive substance. And he's also not saying that it's not dangerous. He's just kind of saying with this, we do want to make sure to give it the right attention and recognize the balance of it, that it is really harmful for a lot of folks, but there's some balance there. There are folks that for whatever reason, and we don't totally understand, can use it and then let it go without any issue. So yeah, just definitely some points for consideration there. So spectrum of opinion about people who use substances. So there are different points on the spectrum. Some folks again would totally say you can use heroin recreationally. People who use drugs are definitely a group that needs their rights protected. We need safe injection sites. We need to figure out how to make it so that they have places where they can use safely. And then there's the other side of the spectrum that heroin, absolutely, you can not use that recreationally. That is a substance that is addictive and possibly addictive from the first time. And that really our goal is we really should be looking to stamp out substance use altogether. We really need to end it. It's a scourge to society. And so there's those two wide ends of the spectrum and then there's all kinds of different places in between. The hope in this, and hopefully you get some time to reflect on this of where you fall in that spectrum, because there's advantages and disadvantages to both. In that end of the spectrum where people are, their rights need to be protected. We need to have safe injection sites and all those. The real pro to that is that if people pick up on that, they're gonna be more open to you talking about your use because they're not gonna fear that you're gonna judge them. The downside to it though, is we may miss opportunities for them if they decide to stop or decide to cut down because we're so far on that end, we may miss those points. Vice versa, someone on the side that this is a scourge on society. We need to take the downside to that as folks will feel judgment and shut down. Though there can be a pro to it possibly too of the fact that, yeah, they're gonna be there and if someone wants to stop, there's gonna be a lot of effort you're gonna be able to put into that side of it. So there's pros and cons to no matter where you fall on the spectrum. And that's important to look at is kind of think about where you are. Okay. So this is the conclusion of part one. All right, let's stop the recording.

opioids

stimulant use disorders

Opioid Response Network

evidence-based treatments

substance use disorder

education and training

recovery techniques