Welcome back. So this is part two of the Opioid and Stimulant Use Disorder Skills Workshop. So today, what this session is going to be about is going to be about opioids and stimulants and talking about each of the substances and kind of what goes into them, also what makes them particularly addictive, as well as we're going to discuss in between each. So MOUD, what stands for Medicated Opioid Use Disorder, which are the medications that are used to help treat opioid use disorder, as well as medication-assisted treatment, which would be more related to stimulants, which, yeah, and we'll talk a little bit more about that. We'll also discuss Ricky's Law to some extent as well, and also some, we're going to be discussing kind of ways that substance use disorder develops or some ideas about how it might develop. Opioids. So first off, let's talk about opioids and opiates, because you're going to hear me use the terms interchangeably here and there, and they're really not interchangeable. Opiates are natural substances that have been derived from the poppy plant versus opioids are synthetic substances that are produced that have a similar molecular structure to substances that have been, that were generated from the poppy plant. So this gets into that part here where opioids are either natural or synthetic substances that act on the brain's opioid receptors. So the opioid receptors in the brain are really actually endorphins. And so if you've ever had, our endorphin system is, it's responsible for a number of things. It's partially responsible. It's our natural painkiller. It's also, it regulates several other things as well, but if you've ever had a runner's high, that's a chance to actually experience endorphins. In fact, anytime you get a cut or a bruise, some endorphins will be released. Again, it's our natural painkillers, our natural way to kind of manage pain. It regulates the pain systems in the body. Hence opioids will tend to reduce and relieve pain. Opioids work in an interesting way because they dull pain and relieve anxiety that comes with thinking from thinking about pain. So they don't, it dulls pain and, but mainly relieves the anxiety around the pain. So it makes us, it doesn't technically make us not feel the pain. It makes us not care as much that it's painful. There are substances like ibuprofen, which is an Advil, Tylenol, which is acetaminophen, which is in Tylenol or aspirin, those, those kinds of medications that are over the counter, they work in a different way. They work at the site of the pain and will actually help you feel less pain through less information, inflammation and other things. Opioids work more in the brain and kind of how the brain receives and works with the pain, pain response. So because they work in the brain, they tend to give you, it tends to give you a rush. So opioids misuse is misused because of that euphoria or rush that you can get from using it. Now that rush can be dependent and like taking it orally for pills. Yep. I'm going to give you a little bit of a rush, but you're going to get more of a rush if you snort it or if you smoke it or if you inject it, because each type, each route of administration gets more of it to the bloodstream faster, which increases that rush and then makes it more likely for you to want to use it again because that rush is, it makes it really habit forming and addictive. It's with how quickly it comes on and how good that, that intensity of that euphoria. So side effects. So ways that when people are under the influence of opioids, they will tend to be drowsy and sedated. In fact, we don't tend to have very many behavioral problems with folks that are using opioids. It's more that they're asleep and making sure that they haven't fallen asleep and started to OD. They're not, they don't tend to be belligerent. Someone that's belligerent related to opioids is more probably moving into withdrawal phase because they're so uncomfortable. There can be some mental confusion. So this kind of, they're kind of in and out of being able to pay attention and they're just not quite sure. They can be a little bit confused sometimes. You can get nausea and vomiting. That is definitely something that can happen when you're high, especially with someone that is not, has not used before very much before that does happen. There's constipation. So opioids do definitely affect your gastrointestinal system. And so in fact, this is used, there's a, Imodium is actually technically an opioid, but it's not one that can get you high. Imodium is for diarrhea. It's one that it doesn't cross the blood brain barrier, but it does have this action of constipation like other opioids. It does cause that. And so it can be helpful in that regard. The next part is pinpoint or constricted pupils. So when they're intoxicated on opioids, their pupils will be small. And when they're in withdrawal, their pupils will be enlarged. So that is one way to tell. And then when someone is under the influence of opioids, their vital signs tend to be suppressed. Mainly breathing, but can also be heart rate and others. And in fact, an overdose is generally is someone falling asleep, essentially, or looking like they're falling asleep and not, and then not waking up. They become blue, they become hypoxic, but it's, yeah, it's essentially the body just slows itself down so much that it can't sustain itself anymore is essentially an overdose from opioids. So misusing, misuse of prescription opioids. So all the ones that we have on here are, can be prescribed, but some of them can also be obtained illegally as well. So codeine. Codeine is an opiate. It is actually a derivative of the poppy plant. It's one of the original things taken, that and morphine. Codeine is a mild, mild on the opioid or opiate end. It tends to be in cough syrups. It can also be in Canada. You can find codeine, I'm sorry, Tylenol threes, where it's mixed together with codeine. Being mild doesn't mean that it's risk-free though. It can be very much addictive, just like any other opiate, and it can be a gateway in. And so it is something that definitely needs to be watched. Oxycodone is a synthetic opioid. And then you see Oxycontin, Percodan, Percocet, and then for Hydrocodone, there's a Vicodin. So these are all, all of those are mixed. There's Oxycodone or Hydrocodone are the opioids, but then with each one of them, like Oxycontin has Oxycodone, and then Percocet would, so they either have aspirin, ibuprofen, or acetaminophen mixed with them. And so it's named with that, and that's actually an important one when folks are using these to get high, they're not just taking the opioid itself. They're also taking a really high dose of ibuprofen, aspirin. They're taking something else with it, which can be really risky as well, and the body can have a difficult time with processing it. There's Demerol, Neprodine, and Dilaudid. Both of these are very strong opioids, synthetic. They tend to be used in emergency rooms and critical care units for severe pain. They are fast acting and can last a bit of time. And so they're definitely there for those reasons. And then of course we have Fentanyl. One of the things with Fentanyl that's different is it's longer acting than the other opioids on here. There are many different analogs, there's something like 20 different analogs for Fentanyl at this point, but as you probably are aware that Fentanyl is a very potent opioid. Very small amounts are needed for use, whereas like with Morphine, we're talking about milligrams, we're talking about closer to grams, with Fentanyl it's like milligram, in other words the amount of potency for Fentanyl is much, much higher. And then lastly Morphine is on there as well. Morphine is still around, it is a derivative of the poppy plant and was one of the first things derived from it, and it is a potent painkiller, and in fact Morphine was then modified to create heroin, which is not prescription, but yeah, it is on here, or it is of note. So tolerance to opioids. So yeah, of course higher and higher doses are required to achieve an effect. You do develop a tolerance to opioids, and you develop it, you can develop a very high tolerance. We're seeing this a lot with, even with Fentanyl, it's just incredibly high tolerance rates, people taking really large doses in order to get an effect. And event, and this is again, because the body keeps wanting to reset itself, it doesn't want to be high, it wants things to be normal and so that it can regulate itself. And so every time we get it high, the body has like, we got to respond, we got to figure out what to do to change this. And so it changes things, it builds up, which in turn builds up a tolerance, it keeps trying to prevent us from going back to that high. Eventually, what happens is there's a tipping point where the body is just like, you know what, you're more often high than not, let's shift gears here and make it so that kind of the normal status is when you're under the influence. And so what happens is that a couple of steps here. First is the person is using mainly to avoid withdrawal, and in fact, is using just to feel normal. And they're not even aiming to get high anymore. Some do. But yeah, it's more about maintaining is what we call it, where it's just getting, using to this level where they feel okay, they feel normal. And then we get to withdrawal. So withdrawal occurs when someone who's dependent or addicted stops taking opioids suddenly. So if their body has adjusted to having the opioids on board, now they've stopped and their body is going into that abnormal state, where the abnormal state of withdrawal. So the symptoms that we tend to see, and depending on how much opioid the person has used will depend on how many of these symptoms show up and how intense they are. So there can be severe muscle and bone pain. Individuals describe just this ache that goes to the core, that they can feel it all the way to the center of their bones. It's just this horrendous pain. Trouble sleeping, so just not being able to fall asleep at all. Diarrhea, so mentioned before, the constipation that can come from opioid use, there's a rebound effect that occurs and now the person has diarrhea. Vomiting shows up not only in intoxication, but also in withdrawal, and it's more common in withdrawal. And then it should actually say hot or cold flashes. So what folks will describe is it's almost like having a fever, where if you lay down and get with a blanket on you, you start sweating, you take the blanket off, you're shivering. It's that kind of, you're just, you cannot get comfortable. You're in constant pain. You can't sleep. It's just, it's a miserable state. And this is, as I described, what might be going on for someone. You can understand how people would do anything to avoid using. Imagine you had a way to avoid ever getting the flu. You bet you would be using it, right? And so that's kind of essentially the case that they need to keep using in order to not feel that. Essentially, not to get this kind of flu. It's not a flu, but it feels that way. And so that becomes a driver. It's, oh, backing up for a moment. It's important to note that the withdrawal symptoms in and of themselves are not lethal. If you have medical complications or other things that can be there, some things you need to watch out for are dehydration, because that could be a medical situation that could emerge from it. But it's not, it's not a lethal condition. That could emerge from it. But it's not, it's the dehydration that's risky, not the withdrawal symptom itself. And that's important to note for the fact that many, we're going to start talking about options and people don't always have to go to inpatient detox for this. And in fact, and some of the medications are going to ask them to go on withdrawals and deal with them and work with them at an outpatient basis. However, someone may need to go to detox if they've got complicating medical factors, are addicted to other substances at the same time, especially something like alcohol that can be, can be lethal. Or they're, they just are so deathly afraid of their withdrawals that it doesn't seem like they're in an environment where they could fully avoid using, like they would have access or they never really could. They need to be in another environment, kind of away from everything. And an added benefit to it is that at a medically monitored site, there might be things that they can do to help make withdrawal a little bit more comfortable. So medications. So we're going to look at the three main medications here. We've got methadone, buprenorphine, and naltrexone. So what's going on here is you'll see under each one, there's a receptor, which is the blue kind of cup like thing here. And then there's the green part, which is the, the, the medication. So methadone, this molecule is, it's a full lock. And if you imagine like a lock and key, when something fully locks that way, it activates the receptor because it's working like the neuro, the, the natural chemical in the body that activates that receptor because it's the same shape. And so it's a full agonist. So methadone is an opiate or an opioid. It's a synthetic opioid that activates and works as an, as a, as an agonist that fully binds the receptor. It works the same way that other opioids do. There's a serious advantages to methadone that I'll talk about in a moment, but yeah, it is important to note that it's a full agonist. Buprenorphine, it's what's called a partial agonist. So you notice it's got the dots here. It's not a solid chunk like the methadone. And so in being a partial agonist, it mostly connects and it connects really well, but it doesn't connect. It's like imagining a key that's the right key, but it's missing a couple of teeth. Like it fully goes into the lock and it kind of turns the lock, but not all the way. And that's essentially what buprenorphine is, is a, yeah, it, it binds, but it doesn't fully activate the, the, the receptor. And this generates a limited effect. In other words, it does cause the receptors to work somewhat, but not completely. And more importantly, it prevents other, other opioids or from binding to the, to the receptor. So it, it blocks others from joining. And then our last one is naltrexone. And naloxone can also be included in here because naltrexone and naloxone are both opioid receptor antagonists. They prevent the opioids from working from binding to the receptor. The difference naloxone is a short acting versus naltrexone is a long acting. And so in being a short acting, so naloxone is the stuff in Narcan and it being short acting, you can tell it works really quickly and it works super effectively. It's super potent. Unfortunately, it wears off faster. And that's where you sometimes hear folks needing multiple doses of Narcan to get through to prevent an overdose. Whereas naltrexone and Vivitrol is maybe is the most commonly known commercial version of that, that you can take a shot once a month and it will stay in the body and keep binding for, for, for that entire time. So it stays attached as opposed to Narcan, which doesn't necessarily always stay attached. But yeah, the important part here is noting that it prevents any opioid from binding. It's, it's kind of a block. It's a cap. It doesn't activate the receptor. So it's not an opioid in and of itself. And it prevents any opioid from working. So in a way, like methadone fully binds, buprenorphine is kind of a blend in some ways between methadone and naltrexone because it does activate some but it also blocks and Then naltrexone just blocks Methadone so yeah already covered that it's a full opioid receptor activator The goal with methadone is to activate the receptors to the point that they're not experiencing cravings and not experiencing withdrawal and Not experiencing euphoria This is a bit of threading a needle because it's a very fine space between not having those and not being high and In fact, I will say with this the experience their main goal is these first set here of not experiencing cravings and not experiencing withdrawal They may err on the side So off frequently people are on doses higher than they thought they would be and that because the goal is really to get rid of The withdrawal get rid of the cravings So that the person can be as stable as possible in life and part of what also keeps them stable is the fact that This action lasts the action of methadone will last for one to two days So it's provided by an OTP so this would be our methadone clinics And they must dose in person and earn privileges to take doses home Now SAMHSA has been working to kind of help that to make this more flexible so that people can get more Take home doses and that has definitely helped with some flexibility there But there is still a need to go to a methadone clinic or an opioid treatment program. That's allowed to do this now the dosing in person dosing using liquid and dosing at the sites is all meant to prevent diversion and diversion means we're taking that methadone and Selling it on the street. And as you can see when you're only given one dose that's not really worth selling on the street and especially if that dose is liquid because you can't really hide and use that and So you can see there's several things that help reduce the amount of methadone that ends up on being sold illegally Methadone is the oldest and most studied of the medications out there In fact, it helped and it's sometimes forgotten that Methadone helped resolve was a major force in helping resolve the second wave of the opioid epidemic Frequently when we talk about the opioid epidemic epidemic, it's almost like it's the first time it happened. We're actually on the fourth wave The first wave would have been back at the turn near the turn of the century around 1910 1910 1913 that's when if you remember there's the there were those label They weren't illegal opiate opium heroin Morphine were not illegal and in fact could be put into commercial products and was put in so there were all kinds of cough syrups and serums and other things that had Highly addictive substances in them and hence people became addicted Then they passed laws making Morphine and heroin illegal or making morphine prescription and heroin illegal And that helped minima or reduce the first wave the second wave didn't come until Vietnam and it was during the Vietnam and there was a huge uptick in the amount of heroin being used by Those that were in in Vietnam And then that was largely resolved methadone played a huge role in helping resolve that And so it's sometimes forgotten how key that the the implementation of methadone clinics was So ideal candidates for methadone There it can be really useful for folks with exceptionally high opioid use histories now there's some conflicting evidence on this because there used to be an idea that Buprenorphine which we're going to talk about in a moment couldn't work with folks with youth high use histories. That's not true We've actually disproved that however, the fact that methadone being a full agonist can have advantages for folks because it's it's fully binding and it's It does a more complete job in some ways of taking care of And you can still get a complete job with Buprenorphine But it can be helpful for certain folks One of the big ones is it's an easier transition on the methadone sometimes than on to suboxone partly because we don't have there's no worry about the person going into withdrawal because of the medication and There is a little bit of that worry and I'll describe that in a moment Because of a few different factors and so there can be a smoother transition one of the other advantages that can be on here as well is someone can use opioids on top of methadone and It not the other I mean, yes, there's a risk of overdose but there's not a risk of withdrawal or other complications happening That might sound strange why that's an advantage Though there are plenty of folks that need more time in getting stabilized and then there are folks that will use it just so they don't feel sick in the morning and It's an acceptable use of it because that this is part of we need to move away from stigma and really embrace being able to provide everyone a level of treatment and a level of care and The advantage of being able to do that and being okay is then we're there for them we can help them with other aspects of their lives making them as stable as possible and Then maybe they will reduce But if they even if they don't they're still in a safer place Which goes into individuals with treatment retention difficulties Methadone can be really advantageous for that It can also be helpful for folks that yeah Maybe buprenorphine hasn't worked for and then ultimately anyone that has a personal preference so there's a lot of advantage and methadone is tricky because there's so much stigma attached to it and So a lot of times in my discussions with folks they'll meet when I bring up methadone No, no, I don't I don't want to do that. I don't want to I don't want to be one of those people which is That's the stigma definitely coming in Or there's other ones. Oh, it's just getting you high Or they have a story of someone who used it just to get high The problem is is that yeah, it can be really effective And it can it has advantages over some of the other approaches and I've had especially with folks that have a really hard time Getting on to some of the other options Once I get them to at least consider methadone They tend to be really grateful that we actually tried it because it tends to be a better fit for many folks Buprenorphine it is a it was a major development In the treatment of opiate use disorder because it was a medication because of several Variations can be given in a more office type setting There's some more safety to the medication that doesn't need quite as much quite as strict over Basically someone overlooking it To be in order to be able to be safe and be used out in the community And so it's greatly broadened the access that people have to Opioid use disorder medications. So let's talk about it a little bit more here. We've introduced some So it's that partial agonist So it has to be started while the person is in Withdrawal to some extent because really you need as much opioid out of the system as possible Because there's a problem of It potentially kicking someone into withdrawals or having difficulties if they were to just suddenly start taking buprenorphine while they still had a Opioid in the system the opiate the buprenorphine would balance the other opioid out of the receptor and They might go into a bit of a withdrawal Cycle So initially the dose it usually starts on the lower end four to eight milligrams can move be moved up to 16 milligrams Though it can also be moved all the way up well beyond that 32 milligrams is currently the FDA's highest level of recommendation However, it's probably gonna go even higher than that because there's a lot of evidence showing and they're talking about like folks that use fentanyl buprenorphine works But you're probably gonna need a higher dose than that even the 16 or 32, which is the current FDA approved limit There was one study. I looked at recently that's had someone going all the way up to I think 143 or 148 milligrams And they were needing to take doses throughout the day like every hour or two In order to be able to manage it, but they were able to make it work and they didn't have any negative side of negative impacts from it They can three to four day follow-up they'll try titrate the dose up Then ultimately most folks end up on about 8 to 20 somewhere between 8 and 24 milligrams however, it can be up there up to 32 or higher depending on what's needed and then Course so generally folks are on it at least a year. It's rare that we're ever talking to someone about coming off in less than a year Generally, it's longer than a year though And even once they do talk about coming off there's continued reassessment They're they're titrating to help deal with opioid cravings But the moment relapses start coming up or other things or slips They're gonna potentially put the person all the way back up and recognize Okay, wait that that attempt didn't work and if you after a couple of tries They're probably gonna start recommending that it might be a good idea to stay on it the rest of your life Many just stay on whether it's buprenorphine or methadone for life, and that's an acceptable Outcome because you're medicating the opioid use disorder All of the stability and there's no evidence that shows that staying on these medications harms people long term Actually the the it was misinformation out there that said that staying on methadone for a long period could be Problems for your health that actually is not true. That has not been shown to be the case What's likely more the case in those incidents as people's lives became more stable and healthy and they started to gain weight Because they were living a healthier life and then unfortunately that weight gain got to a point that it became a problem in and of itself So one last piece on this it when people do titrate down they tend to go about two milligrams at a time and They'll go for a couple of weeks or months at a lower dose the last two milligrams coming off have definitely been reported to be the most difficult and I have seen this with folks I've worked with as well that that drop from two to zero is feels very Significant and that because it's really mainly where they're running into withdrawal and they're really fully feeling life without the medication Doesn't mean that it's not possible to come off of it It's just noting that that last little step is frequently a really scary step and can be a bit intense But it is there is light at the end of that tunnel. It is possible to get through So Buprenorphine is it's an opioid partial agonist frequently it's combined with naloxone And this is to prevent injection use or our other opioid use on top of the buprenorphine So you've got some common forms here subutex, so that's just straight buprenorphine It's a sublingual tablet and this is used without the naloxone cap Tends to be used early on for folks to get started so that they don't have there's what makes getting on to Suboxone easier But it can also be used at other other Faces as well. It can also be used with women that are pregnant or people that are pregnant It can also and then suboxone Suboxone is buprenorphine with naloxone Probably the most well-known we tend to refer to buprenorphine as suboxone even though it's it could be something else This is actually a sublingual film And so it needs to be cut it comes in these little plastic squares that need to be cut they come in Two milligram squares and then you cut it based on how many milligrams you're supposed to get This is in some ways and something I have to work with folks a lot on is making sure that they are Doing it correct they're spending enough time there because they have to sit with it under their tongue for about 15 minutes to let it fully dissolve and It can be kind of tricky, especially if they have multiple pieces of film there because it can It's hard to keep it under the tongue and when it leaks out from under the tongue It tastes really bad the other problem when it leaks out from under the tongue It doesn't absorb properly because if it goes into your gastrointestinal system It's the it's damaged or destroyed by your stomach acids and so they'll get less effect if they don't Fully do the process properly. And so there is a quite a bit of Having patients with them kind of working and slowly making sure that they're fully dosing themselves because it's one of the things I've also run Into as well as folks feeling like the medication isn't working But in fact, it was actually needing to take the time to do the dosing correctly Subsolve is another one which is a sublingual tablet It's the same makeup as suboxone. It's just a tablet not the film Can be a little bit more convenient in that regard because you don't have to cut it and then sublocate is a newer one Which is just straight buprenorphine. It's a long-acting buprenorphine Tends to be an injection that someone can stay it with for a month So this chart on the right here, it's showing MRIs of people on different doses of buprenorphine. So the MRI is up here. It's the brain prior to buprenorphine being administered Buprenorphine at zero or actually, I'm sorry. This was just the standard MRI then this is at zero So this is without any buprenorphine here and you can see if the green areas are areas that are activated due to opioid Withdrawal, in fact, you can even see it's actually a really intense portion here. That's also in the center on this one here when you get to two milligrams It's pretty substantially affected. It's quite a bit less, but there are still some green no red, but some green sections 16 Almost entirely gone There's like a couple of little green sections and tiny red section right there that I think maybe was popping up on another one And then we get to 32 This is someone that's fully dosed and you can see there's just no no almost no green There's one little maybe tiny spot there, but nothing else is green and so it's kind of showing how with each dose it has greater effect and it's it's it's Binding with the receptors that are the areas of the brain that are having difficulty with during withdrawal phase So Looking at here again a partial receptor activator The treatment goal much like methadone is the same Activate the receptors to the point that the individual does not experience cravings and is not in withdrawal and is not high Now, yes, technically you can get a bit of a high from suboxone because it is an opioid Though you can't get quite the same high you can get more of a high from methadone technically, but Yeah, still still get the effect part of the reason why you can't get quite as high as because of this ceiling effect Which we're going to talk about here in a second So the duration of suboxone is 24 hours Whereas, you know another advantage to methadone is that it stays in the system longer Which is another reason why I prefer methadone Especially for someone that has a hard time remembering to take their medications or having a hard time with dosing It's another step that's advantageous for for the for them but Of course it's a sublingual tablet dissolves in 10 to 20 minutes Onset takes about 30 minutes now this part here very high affinity for the receptor sites In fact, it's the receptor sites like it so much that they will kick off other opioids And when they come in and this can precipitate withdrawal This is that reason why they need to be at least in mild withdrawal when they come in because they want the the buprenorphine to bind to the receptor and not boot anything else off and Then this last part the ceiling effect so because it's a partial at a receptor activator There's a point where there's a cap So you can get only so high with suboxone you get to a point where you start feeling the effect But then the receptors are bound up and nothing else really can connect and so it really it It caps itself It prevents itself from being abused because at a point when it's activated, but you can't keep going further Whereas with morphine or other opioids you can you can get to a high and then take more and get even more high With buprenorphine you would take it get high but then take more and it either does nothing or kicks you into withdrawal And so this is a wonderful Part to buprenorphine it has a self-limiting Factor in it you it's really hard to abuse buprenorphine in a way that would be satisfying to someone because of this the ceiling effect The ceiling effect was what we used to fear was the thing that prevented people that used fentanyl from being, because the thought was they had used too much opiate, their tolerance was too high. And in fact, I used to teach this because it was actually pretty widely accepted. And in fact, it was misinformation, it was wrong. The sealing effect does not prevent someone who uses fentanyl from using suboxone. You just have to figure out how to work with the dosing correctly. And the doses can go much higher, because the idea was that the sealing effect would mean that they couldn't use enough, the cap would be lower than the person's tolerance or withdrawal, and it's not true. So questions for reflection. So I'm thinking about this, I'm kind of looking at the extent of problems with opioids explained. To what extent are problems with opioids explained by the effects of the drug itself? In other words, and then it feeds into the next question, how much responsibility for dependence on opioids is due to the drugs themselves? A fair bit. And this is you see in folks that, because many times have no challenges whatsoever, and they get a sports injury, and their life is going really well, and there's a lot of opportunity, and then they become addicted to opioids. It's a great example where we can't really rule out the substance itself. However, at the same time, there's other factors that are there. And there's other risk factors that can make it more likely that someone will become dependent on opioids. So the drugs themselves do have an addictive quality, though it's not always just the drugs themselves. Because I mentioned before that stat of, most people that start opioids just stop using them. And we are starting to understand some of what is the difference for the folks that continue using, that use to an a point that they become addicted. But we don't fully understand it, but some of it is the drug itself. I mean, you can take someone and pump them full of opiates long enough. They're gonna become dependent no matter what their background is. And then that dependence could become addiction depending on how they handle things after that. So yeah, it's not quite a clear picture there. Moving on to stimulants. So stimulants, we're gonna talk about methamphetamine mostly but I'm gonna start with talking about stimulants in general. So what is a stimulant? So yeah, it's definitely a system, it causes the central nervous system to be activated, to increase the activity of the CNS. Things that we see when people take a stimulant tend to be faster heart rate, could be also increased blood pressure, faster breathing, higher energy. The body is just more aroused, more awake, ready to go. And we can even see better concentration and attention. And with that last one, you can see why stimulants are potentially used with ADHD. And then we talk about paradoxical effects. Sometimes we'd say how ADHD meds work differently in the brain of someone with ADHD. Stimulants do in general actually for all of us help us to a certain level, as long as it's a low enough dose can help with concentration. And this is why they were used in settings like jet pilots in the military. Sometimes if they have long haul flights or given low dose stimulants to stay alert and stay awake so that they can be alert for the flight, because that can be a lot of time to sit in a cockpit doing not much other than watching some instruments. There's also some other low dose stimulants that can help folks in the tech industry to keep working. There's a number of different settings that apply. So looking at legal, let's start with legal versions of stimulants. So we've got caffeine. It can have pills, powders. These are synthetic forms of caffeine. So it's being produced in a lab and there are labs that make caffeine. Caffeine is an interesting stimulant because it works differently than any other. It works on adenosine, which is a chemical in our brain or a neurotransmitter in our brain that builds up during the day that makes us feel, and when we have a lot of it, we start to feel tired. It essentially helps us know that we're becoming tired and caffeine binds to the adenosine receptor and prevents it from having an effect. So it prevents us from experiencing how tired we are. It's a very different stimulant than others, but yeah, so just energy drinks, which tend to contain caffeine. And then we'll switch here to nicotine. Also a stimulant works a bit differently than the stimulants, than meth and others, because it works on acetylcholine, which is responsible for muscle movement and memory. Coffee, which contains caffeine. And then we have prescription medications such as amphetamine used in a prescribed manner. So, sorry, prescription medication. So this can be prescribed for diet pills. Can sometimes, there are some amphetamines that can be used for that. There are also, like I mentioned before, to stay alert and awake. There can be for narcolepsy and also of course for ADHD. Some over-the-counter drugs can have some stimulating effects, such as pseudoephedra, which is in a decongestant. And it's the stuff that you have to get from behind the counter that used to be used to make homemade meth. But yeah, that's one example of a over-the-counter substance that can have a stimulating effect. And then of course, prescription medications or the OTC, over-the-counter medications that are being misused or abused. Then we move to meth. Methamphetamine is, or crystal meth, it has amphetamine in the word, but there's the meth before it. It's the slightly different molecular structure. And it does work slightly different in the brain, which intensifies its actions. So it is there. It's kind of an extra to amphetamine. There's cocaine. It's a stimulant, illegal. There's both powdered and hard cocaine. Cocaine still actually has medical use. It helps numb for eye surgery. And so there are, it's not a class one. Class one means it has no use. It's actually class two. So it does have some use. But yeah, that is a stimulant. Synthetic capinone. This is a derivative of, or a synthetic version of what's found in the cot plant. Cot is a plant that grows in Africa and it tends to be, but it's used in many, many different areas. And it has a stimulating effect. Cot, when it's traditionally used, is kind of used like chewing tobacco, but they've synthesized the capinone. Capinone is the active substance in cot. How you might have most be familiar with this is from that bath salts. Bath salts were synthetic capinones. And there was that situation in Miami, which actually wasn't true. But yeah, that was one area where bath salts were made a big, big splash in the media. MDMA is a stimulant as well as a hallucinogen. And, oh, we're not quite to methamphetamine yet. We will be there shortly. So like looking at amphetamines, they can be very helpful in several ways medically, but there can be some common side effects. So in being a central nervous system's upper, it lifts you up. Insomnia is probably not a surprise of difficulty sleeping and cause a headache and cause dry mouth tachycardia, which would be irregular heartbeat, raise blood pressure, irritability, restlessness. In extreme cases, it can bring on psychosis. And of course, overdose. It is possible to overdose on stimulants and overdose tends to, and this will come up again, but overdose tends to be cardiovascular in nature. So either a heart problem or blood vessel problem in the brain or a stroke, other areas, those are the ways that we have overdose from these. Just a side note here, talking about ADHD, there are some non-stimulant choices, mainly one that I'm aware of. And it says that they're less effective. They're a bit tricky to prescribe and they do work for some folks and it's great when they do, but it is harder for us to find them to be effective. And then, but noting with ADHD that ideally you can get some behavioral therapy connected to it. The gold standard though, is to use stimulant medication with in combination with behavioral therapy. It tends to be the most effective for most folks. And there's a misnomer out there that ADHD medication is just meth, it's not. Usually, and we'll talk about that in a moment, but it's like Adderall is not methamphetamine. The widely prescribed medications are not methamphetamine. So talking about meth a little bit more in detail here, methamphetamine, again, is an amphetamine type substance. It has similar molecular, but it has some extra pieces on it and how it works. So there is a prescription version of methamphetamine called Dasoxin. It is not very commonly prescribed. It can be prescribed for folks with ADHD that have not responded to other medications. So as with almost all misinformation out there, there's a shred of truth. Yes, in a very rare cases, there can be a form of methamphetamine that can be prescribed for folks that have ADHD that does not respond to any other medication. But the important part is, is that there has to have been a lot of work on determining that nothing else works before they reach for this, because they recognize it's not an ideal prescription. So I can't say 100% know that methamphetamine is not prescribed for ADHD, but it's very, very rare. So it's found in forms, and meth can come in forms of liquid, such as powder, pill, or crystallized form like we see in the picture here. And we tend to most commonly refer to it as meth, which refers to crystal meth, which is again, because of this crystalline form that it can develop in. Meth is generally smoked. And this was the pipe that we have here noting, and here is examples of methamphetamine in its regular form. And it's generally smoked because it's one of the safer methods. And this is a pipe here that's been used. And so someone would put their piece of meth in here and then take some flame. You don't want to put direct flame to it because it will destroy the meth. They need to vaporize it and then inhale it through the pipe. So it's generally smoked, but it can also be snorted. It's because it's kind of like, whereas cocaine is a softer powder when it's broken up, meth is not quite as soft. So if folks do complain that it is rather uncomfortable to snort, but it can be snorted. It can be taken orally and injected. In fact, harm reduction methods actually ask people to smoke it instead of inject it. So handing out pipes, clean pipes, is a harm reduction method to recognize the dangers. Because injecting meth is really, because the drug itself is toxic. Whereas opiates, like no opioid is toxic to the body. Meth is very toxic to the body. And the injection site will become infected or irritated. It can create numerous problems. And then also even to the blood vessels, really anything that the drug comes in contact with, it does damage to. It can also be, but it's rare, but it can be used interrectly or intervaginally. There's a rush of euphoria that comes from using meth, much like opioids, different rush, but still a rush. And that tends to create this kind of up and down cycle. So there's a binge and crash cycle. So where the folks will use large amounts and then crash. You can overdose. It often leads to acute psychosis, but also in their stroke, heart attack, or organ problems. Remember I mentioned meth is toxic to anything it touches. It really is a toxic substance. It's neurotoxic. It kills the neurons that it activate. It can kill the neurons it activates, but it can really do damage to almost any organ. Fentanyl. So fentanyl, I mentioned how we're in the fourth wave. So I forgot to mention the, I mentioned the first and the second wave. The third wave was when we, it was really in the last decade where we saw the rise of like Oxycontin and then fentanyl kind of came up behind it, where we really saw the wide prescription of opioids and that brought in, that ushered in this whole new opioid crisis or epidemic. Since then, we've focused so intensely that wave has started to ebb, but what's come and then immediately following it, as that ebbed, we saw an increase, a spike in methamphetamine use. What we're now seeing is, and part of the spike in methamphetamine use was partly because if you remember back to the 2000s, when they passed that law that forced them to put like Sudafed and other medications behind the counter where you have to go in and give your ID, that law was really successful in getting, completely eliminating the home labs for methamphetamine. And so timetable on that, that was basically right before we, that law was passed right before we started, right as we were just starting to take notice of the serious opioid epidemic. And so meth use crashed while the opioid epidemic was raging and then the labs and the cartels figured out how to build their own labs and start making their own methamphetamine. And so suddenly the methamphetamine supply resurged, right as the opioid use was starting to fall off. Why that's important is because a lot of folks ended up having to switch to meth as opioids were becoming harder and harder to find. Because as opioids were becoming harder and harder to find, it was easier and easier to find meth and find meth that was really cheap. And so folks tended to switch over. And then now what's happened unfortunately is while that meth supply is at a really high rate, a high level, the cartels also figured out how to start making their own fentanyl. And now they're producing both meth and fentanyl. And so both meth and fentanyl are readily available and relatively cheap. And so that has created what we call the fourth wave of the opioid epidemic. And that is where folks are using fentanyl and meth together or using them to kind of help moderate with each other. And so many times folks will get a really high tolerance to fentanyl and then they'll back off of fentanyl for a while and just use meth to kind of cope with the withdrawals. So until their tolerance comes down enough that they can start taking more fentanyl again. And there can be some vice versa. So there's this back and forth between the two. There can also be, there's an epidemic of folks combining the two because there can be an enhanced high that they experience when using both simultaneously. And so there is a danger, an extra danger for overdose when you combine fentanyl and methamphetamine. And that mainly comes from the fact that fentanyl can numb someone out to experiencing the impacts of a pain or other signs and symptoms of an overdose from methamphetamine. And so they might be experienced, they might have used too much meth but they don't really realize it until it's too late. And so they're slower on getting medical attention. And so that is an extra risk that's there. So with meth, yeah, there's that initial rush that lasts about 30 minutes and the high then is about four to 16 hours. It's a pretty quick acting, but it lasts in the body longer and longer than something like even like cocaine or other amphetamines. And so that's part of why folks will go for days on end because they can get it in their system and it stays functional for a while. So thoughts on this of access to treatment is absolutely vital. So people need to have access to treatment for methamphetamine. So it's important to note about 50% of overdoses are associated with co-occurring use of opioids. So that it's significant, and there are a lot of people combining both and that risk of overdose really is increased quite a bit if you're combining the two, because it's easy to get into air, into levels that are dangerous. Of course, educating them that stimulants and educating them about Naloxone or Narcan and how to use and access it. Also, if you can give them training, because it's really common for folks, if you're working with folks that are using meth, they're most likely around folks that are using opioids, and it would be helpful for them to have access to Narcan. It's important to note, though, that Narcan does not do anything for meth. Narcan only works on opioids, because it is the only thing that that works on. If someone is having an overdose from methamphetamine, they need medical attention immediately, because they're likely having a heart attack or a stroke or something cardiovascular in nature. So harm reduction, safety use kits, they're chapstick, condoms, of course, glass stems. So having fresh pipe, it's safer to have that. A rubber mouthpiece can be helpful to kind of prevent them from getting cuts on their lips. Clean straws for if snorting. Having Naloxone, some water, a snack, maybe available. Information for referrals for treatment or anything like that, or any needle exchanges can be useful. And these questions here. So to what extent are problems with methamphetamine explained by the effects of the methamphetamine itself? Similar to opioids, you give a person enough methamphetamine, they will start to become dependent on it. So there is truth to the fact that the substance itself does draw people in. And the meth supply at this point from the cartels is pretty darn pure and pretty darn potent. And so, whereas before when it was the home labs, you'd get some lower grade stuff, you'd get some higher grade stuff, there'd be variability in it. It's all pretty high grade now, or very high grade. And so the substance itself can make someone dependent. But many folks will use it and not become dependent. It's really hard to tell. We don't know all the factors that go into it. And when we look at some of the differences between methamphetamine and opioids, there's crossover. Both of the substances in and of themselves can make you dependent. It really depends on the person. What it seems is there's different people drawn to each one of the medications. And there's kind of a culture that develops around the two. And there's a very different culture around opioids. Like opioids, it's more of a cynicism, loosely connected to life, kind of a darkness to them. Whereas with methamphetamine, it's more high energy, active, let's move. In fact, kind of jittery. And you can think even just different ways that they dress, different ways that they interact. And so it does seem like there are folks that are drawn to each substance for different reasons. So, Ricky's Law. Ricky's Law was put into action in 2018. And it made two changes to the ITA, the Involuntary Treatment Act. Mainly, it added substance use disorders to it. And part of the, one of the things they had to change in order to make it so that substance use disorders could be added was they had to change it from Designated Mental Health Professional to Designated Crisis Responder. Because now they were responding to things other than mental health crises. And so they just, that's why it's called the DCR now and not the DMHP, depending on how long you've worked in the field, because DMHP was what it was for a long time. But so it created the DCR office, essentially. So then the second change was that community members who are a danger to themselves or others or property or gravely disabled due to a drug or alcohol problem may be involuntarily detained to a Secure Withdrawal Management and Stabilization Facility. So it created these Secure Withdrawal Management and Stabilization Facilities, these SWMSs. Because they didn't exist before. In fact, they had to build them. And there's only four of them in the state right now. We need more, but we're still building capacity for this. So let's look a little bit more here. So criteria that need to be met in order for Ricky's Law to be activated. So they must refuse voluntarily to enter treatment. So you have to offer them treatment and they have to say no. Otherwise they can't be, they wouldn't qualify. So yeah, or the other way is that they're adamantly saying, I will not go to treatment. So if they're refusing treatment and are in need of treatment, they also must meet one of these following four criteria. They have to be a danger to themselves, be a danger to others, be a danger to someone's property, or unable to care for themselves in a way that poses a danger to themselves. Now I'd say specifically with the first two, it's be a danger to themselves in the sense that they are intending to kill themselves. They are intending to kill others or seriously harm others. The reason why I'm emphasizing those, a couple of things, you may be familiar with them because they're the same exact criteria needed for mental health involuntary treatment authorization or ITA. And as with mental health, we really need to be very specific about how the person is a danger to themselves or danger to others, because those are the two most often criteria or the danger to property. And this is important in communicating with the DCR, if you're the one calling a DCR, because they really have to decide whether to come out. And they are going to challenge you because they can't come out to every single call. And so it can be really helpful for them to know that you're a professional. It tends to elevate things a bit, but even still as a professional, they may ask things like, why or how are you expecting us to be of help? And it's because I believe that this person is a threat to themselves. And here's the reason why I believe that they're a threat to themselves. So these last four criteria are so important and for you to be able to, and if you can possibly sit down and think about how you're gonna convey it to the DCR and what are the things that are gonna support or the pieces of evidence that are gonna support your belief that they're a threat to themselves. This is where it's sometimes helpful if you can contact a supervisor, depending on your setup, what are your stipulations, but working or talking with someone else that's not in the middle of the crisis to kind of plan out how you're gonna communicate with the DCR, because you really do, you are essentially making a legal argument to them as to why they need to come out, because they in turn then need to be able to activate a legal process. So, yeah, it's a bit of a challenge and a quick response from the DCR, unfortunately is hopefully a couple of hours, but yeah, there can be some definite challenges that office is overwhelmed. If they do meet criteria, they will be sent to one of these secure withdrawal management stabilization services, something to be aware of. These are detox locations, essentially. So that's what a withdrawal management stabilization service is. It's very brief, maybe a few days. And as soon as the person is not experiencing withdrawals anymore, or is stabilized clinically to a point that they don't need to be detained that way, they will be released. I mean, of course it's a standard ITA. So there's gonna be the review after 72 hours, and then they're gonna look at it again after two weeks. And you'll go in front of a judge to do that. But they can only hold them as long as they clinically have justification to do so. So what that frequently means is after a few days, they're turned all out to the streets. Them being turned out to the streets can happen for a couple of reasons. First off, they might refuse to go on to further treatment. And if they're not deemed as needing it, they're released. There can be a lack of beds. And so there can be some difficulties with that of being able to get them transitioned over. Yeah, getting them into one of these SWMS is really a temporary and short-term solution. The locations that are available, and again, these are the only four in the state period. Valley Cities in Kent. Yeah, it's right down, right off of 167 in Kent. It's the old RCKC building they took over and completely renovated. And then there's ABHS, so American Behavioral Health Services. And they have two locations that have these, one in Chihelas, one in Wenatchee. And then of course, Lifeline Connections in Vancouver. Now, being that you're located in Pierce County, depending on where you are in Pierce County, it will either be Kent or Chihelas will likely be the closest of the two. For most in Pierce County, it will be the one in Kent. Last piece here for this section is talking a bit about how to get a SWMS. So this is talking a bit about how addiction starts. So these are five kind of umbrella, and I'll describe some of them because you may not be familiar with the verbiage on here, but I'll describe some things that hopefully will kind of make you more familiar. So personal responsibility. Underneath personal responsibility is the idea of moral failing. Now we talk about how moral failing we'd want to move away from, but I also mentioned how AA has the whole fourth step, taking a moral inventory and looking at character defects. It's very much got a lot of the moral, the personal responsibility aspect baked into it. And it works for a lot of folks of looking at, okay, yeah, there are some challenges that I face as a person that have maybe led to me having an addiction or at least contributed to the addiction. So it's not completely gone. It's just, we have to be careful with that. Though the idea here is that there is that belief that there's a personal responsibility for using the substances. And then working with that. Agent model. So this is the drug itself. A lot of what we've already talked about today is how much do the problems caused by opiates are how much of they caused by the opiate themselves or methamphetamine. Our entire law enforcement is built on this because the idea is to prevent people from gaining access to drugs. There is credibility to this. The drugs themselves, the substances themselves do lead to dependence. And so it is possible for someone to become dependent just merely by using the substance itself. Is it the whole picture? No. Much like personal responsibility isn't either. And then we have the dispositional model. So this is more, you might be more familiar with it as the addictive personality. It's this idea that there are personalities or certain characters or certain qualities about a person that will make them more likely to become addictive. It's fallen out of favor. Like there has not been proven to be an addictive personality. And at the same time, there is some credibility to some factors that go away. And there are certain, I mentioned before that culturally, the culture around opioids and the culture around methamphetamine, people are drawn to those cultures based on their personality. So it's kind of a chicken or an egg thing. No, there's no addictive personality, but there are some personalities that can go more that way. Social learning model. So learn behavior. So this stands in contrast to the disease model. So the disease model, what you notice is not up here because the disease model, disease model more talks about once addiction is there, how addiction unfolds. It doesn't talk about how it starts. And this is, there's some, essentially all of these are kind of looking and could be looked at as precursors of what are the things that lead to someone having the disease versus the disease itself being caused. Cause the disease isn't caused by a pathogen. There's no bacteria that causes addiction. There's no virus that causes addiction, but there may be something of one of these that leads up to it. So the social learning model is interesting cause it talks about a couple of things. First off, social pressures, which are in the next one talking about pressures from society. But there's also learned behavior here as well. Learned behavior, it talks about how we, by using the substance, we learn what we like about the substance. And over time, our brain changes cause we recognize the substance. One of the ways that you, an example of this, if you've drank beer or wine as a kid, there's a really good chance that you really didn't like it. It's rare that people enjoy beer or wine when they're a kid. And then for many, you keep drinking it. And over time you quote, learn to love it. It's actually what's called pruning. Our brain is actually learning to not taste the things that are nasty. It's decreasing our sensitivity to it. This also happens, learned behavior around language. As babies, we're all born with the ability to make every human sound. And over time through learned behavior, through learning, our brains prune off the sounds that we don't use cause no language uses all of the sounds. And so once you settle into your language of use, your brain will prune off the ability to make those other noises. That's also learned behavior. Well, same thing. And so there's an argument looking at the way the brain changes from substance use that that could just be what a brain looks like as it's learning to have the substance on board. Credibility to it. Social learning model. So this is pressures from society. So are there cultural norms or anything that causes you to use or believe that use is there? So one of the pressures from society right now that we're seeing is, and this is a big one, is that the perceived risk of cannabis is at its lowest level ever seen. And we have seen perceived risk in cannabis use decline before. There was a decline in the 60s, another decline in the 80s. And every time we saw a decrease in perceived risk, we saw use go through the roof. That's a social pressure because the cultural norm right now is to think that cannabis is low risk. There's other examples out there. I mean, there's definitely cultures that use a lot of substances. And so there might be pressures there. We do have some pressures within society here. We can sometimes consider excessive alcohol use in your late teens and early 20s as normal, which is unfortunate, but there can be a societal pressure there. The last one is public health model. Public health model is where folks, it's really any one of these can apply. And what really is more the case is that everyone will have risk factors for addiction. And depending on the number of risk factors present and how many of them are activated will predict whether or not someone will have an addiction. And so it kind of takes everything into account. And it looks across the board and says that they're just risk factors in many different areas. So final questions for reflection here, kind of looking at those ways that addiction starts, thinking about which ones you view as most true. Also in your own mind, when does behavior cross the line and become an addiction? In other words, when does it go from recreational or experimental use to problematic use? And to what extent do you think addiction is a brain disease? And so adding that piece in there, how much do you buy into the idea of the brain disease? And it is a widely accepted idea and there's evidence to support it, though it is also important to note that it's not universally accepted. And that concludes part two.

opioid use disorder

stimulant use disorder

opioids

opiates

addiction treatment

methadone

buprenorphine

naltrexone

Ricky's Law

methamphetamine

addiction theories