7244 Opioids & Stimulants 101-Recording

Recording

Video Transcription

but I just want to acknowledge that funding for today's presentation was made possible by SAMHSA,  a grant funding from SAMHSA. But yeah, we can go ahead and get started. I have an introduction  for Paul. I know you've already met him, so I'm not sure if it makes sense to read that,  but for folks who maybe, do you think you'll share this with folks who weren't able to attend at this time? Yes, for sure. Okay, so I'll just go ahead and read his introduction.  Paul Hunziker has over 20 years of experience working in both the substance use and mental  health treatment fields. Paul founded and directed a Washington State licensed substance use and  mental health treatment agency focused on working with families. He has been training for the  Addiction Technology Transfer Center, as well as several other agencies since 2015, and he is  currently in private practice in Tacoma, Washington. He is also an American Association of Marriage  Family Therapists supervisor and has been a member of the Motivational Interviewing Network of Trainers since 2014. He has hundreds of hours of experience training in topics such  as MI, clinical supervision, and family-based programming. And if you guys have questions,  feel free to put them in the chat or just speak up, raise your hands. But yes, so I'll go ahead  and pass it over to Paul. Thank you. Great. Yeah, thank you, Emily. So yeah, welcome everybody,  and great with small group. Yeah, we'll definitely have plenty of time to ask questions and have  plenty of time for dialogue back and forth. So I guess we'll dive in a little bit here.  And let me share my screen. Oops, we had that. I forgot to set this back to the beginning,  didn't I? Wait, let me actually reset something here. So my apologies, we're setting something up  and I need to. And you said you're recording this so that we can have this for reference? Yes. Oh, perfect. It is currently recording. I'll edit out the beginning part.  It will be available within about a week or two. Perfect. Okay, now we're back at the beginning.  And then Emily, you said we're just going to skip these earlier parts because we've already described the ORN? Yeah, we can just talk through that. Okay, so I'm going to move ahead  through here a bit. These are just describing what the ORN is and get to what we're actually  looking at. Okay, so yeah, we're talking today, the focus of today is kind of talking about  specifically opiates and stimulants, but we're going to talk about some other substances as  well, kind of give a one-on-one, a 101 class about it and have some discussion around kind of issues that are coming up for you at your work site. And let me come ahead here.  Why is my gallery not showing? Okay, well, that's okay. There's a strange box showing up like in front of the. Yeah, that's showing. Why? Oh, okay. You know what? I still  have it optimized for that video and it's throwing things. I wonder why that happens sometimes because some presentations are just strange boxes. There we go. Does that look better  now? Yes. Perfect. Okay, great. If we could introduce ourselves again, it would be great.  It's just kind of, yeah, what your role is, name, pronouns we've got there. I know it's only a  couple of us here today. So, and then something you bring to work that's unique about yourself.  If we could just do a quick check. I'm Damian. I'm the administrator at Emerald City Enhanced Services. I help, I oversee the day-to-day operations and try to act as mentors for  Ms. Kara and Mr. Bo with that tier. He does an excellent job. Awesome. So, you know, I just, what I bring to the table is I try to bring inspiration with my dedication to  what I do for these guys and my passion for mental and behavioral health. Thanks, Damian.  Who do we want to go next? I would say I was very, very condensed. He does a lot, a lot more than that. But yes, so I am, I'm Bo and I am one of the psych nurses.  I like to call Kara and I twin turbos, right? Because we definitely, we were pretty much following Damian's footstep in the sense of eventually being administrators for upcoming  facilities. And my pronouns is he, him, something unique I would bring to work. I've been told that  I bring a lot of positivity, you know, and great energy to the facility. And a lot of the residents  appreciate that. Also, staff appreciates that as well. Let's see. Also, I'm currently working on a  DMP project that actually involves the SUD treatment. So, I'm definitely looking forward to  talking more with you regarding my plans and actually presenting to Damian and Kara  after your presentation. Wonderful. Thanks, Bo.  And I'm Kara. I am, like Bo said, I'm Bo's counterpart as the RN MHP.  My entire nursing career has been in mental health. I was, I supervised one of the most violent wards for about seven years at Western State Hospital. That was a lot of seclusion  and restraints on a daily basis. So, this is probably, this is a lot more mellow than what I  was used to. But, yeah. I'm not sure what I do all day. It just changes from moment to moment  depending on what's going on. Try to support Damian as much as I can. And Bo, that's what I do.  He's done a fantastic job with it too. Great. Yes.  Thank you, Kara. All right. Great. So, we've got a lot of experience. It looks like all of you are RNs. Is that correct? Correct.  All three of you. So, yeah. Great. Let's, we'll incorporate that into the conversation here  because that expertise I'm sure is going to come in as we go and kind of blend this together. And  then also with the mental health background too. So, let's see. This is kind of a question here.  Anything, because I added some stuff in and we had a whole discussion of what we'd like to have  for this training. I don't know anything anyone else wants to add to like what they would hope  to try to get or talk about. Bo, it sounds like you've got a program that you're kind of putting  together. I don't know if you want to get some specific stuff for that or anything else anyone  would like to try to get. And let me get some paper here to make sure to write it down.  Sure. So, my DMP project, essentially the goal is to reach out to SUD counselors  because that's the thing about our facility. We don't have SUD counselors to provide that training to prevent the relapse and readmissions and hospitalizations for patients who may  decompensate. And like for example, a lot of our residents do have co-occurring diagnosis.  But unfortunately, you know, they suffer from the treatment. But right now I'm looking  at different tools. And I was hoping to see what kind of tools you have to offer.  And if you have any SUD counselors on hand to actually bring to our facility.  So, tools specifically you mentioned for kind of preventing relapse. Exactly. I looked at some tools. I mean, also there's like a tool called home monitor  for the project itself includes the ASI. Okay. And the addiction severity index. Yep. And the BAM, that is the brief addiction. Okay. Yep. Brief addiction monitor.  Monitor. Okay. I'm not as familiar with that one, but yeah.  Okay. Great. We can definitely talk about that as we go. Yeah. Perfect. Thank you.  Any others, anything else?  Just basically tools that we can use to help guide our folks that do struggle with addiction.  And just how to help counsel them better to, you know, along with their diagnosis, like Bo was saying, you know, they have a lot of schizophrenic diagnoses. A lot of them were  drug induced to begin with, you know, they're drug induced schizophrenia, you know, dealing  with paranoias, things like that while they're, you know, under the influence, how to best direct  them or redirect them while they're under the influence to keep them safe and, you know, keep them safe from others. You know, having those tools in our pouch would be kind of nice.  Sure. Okay. Great. Well, we'll definitely check back in on these as best as we can. And then  if we think of other things, again, it's a smaller group, so we'll be able to definitely check in on different things. So if you think of something else, bring it up, please.  Will do. My goals are for us ideally to have fun and let's have lively discussion coming in  and kind of that back and forth. We aren't doing as much skills practice. We'll talk about tools.  And so hopefully that will spark new ideas and new ideas coming in. But that's the part here  to kind of keep everybody engaged. The learning objectives that were set out specifically are  kind of discussion key points of consideration related to addiction. So they're kind of some  of the key points we've got here. We are going to look at stimulants and opiates and kind of look  at the substances and kind of issues around those specific substances. We'll also mention alcohol  briefly within the crisis section, which we'll talk about at the end. We're going to also discuss  medicated opiate use disorder, or some folks call it MATS, medication-assisted treatment, and the differences on those. I'll describe what the differences in those terms,  just in case you may or may not know what those differences are.  We'll look at identifying overdose and then other emergencies that might be at hand. And then  we end with talking about, and it is specifically like Damian, you were saying at the end, kind of working with folks in crisis around substance use that may also blend with mental  health. And we'll infuse that into the discussion as well. So kind of first starting here, I want to  look at kind of looking at substance use disorder, like the diagnostic criteria. And so this is the  diagnostic criteria that's in the DSM-IV. These weren't updated in the newest version, the DSM-VTR,  not the DSM-IV, DSM-VTR. These are from the DSM-V. There are 12 criteria that are actually here,  but they're broken up into four sections. And a lot of times, folks will focus on that area number four, the pharmacological, like the dependence piece, where you have withdrawal  and tolerance. It's the way the body reacts. Those are key components. However, you look at  the other areas, it's really, those are only two criteria out of the 12. And so the other 10  are all about impulse control and relationships. And so this here, something to note about these,  if you're not familiar, someone needs to meet a minimum of two of these  for what we would call a mild substance use disorder.  What they would then, if it's two to, and then three to six, or I'm sorry, three to five for a moderate substance use disorder and six or more for a severe substance use disorder.  What's important in diagnosing these as well is that you'll notice on the top, it says,  in the last 12 month period. So these, if these have occurred, they have to have occurred within  the last year in order for it to be considered an active diagnosis. Now, something that's important to note as well is someone who gets a substance use disorder diagnosis,  it technically never goes away. It goes into what's called remission.  And you can have either partial remission or full remission.  So partial remission would be where they've reduced their use from what it was originally.  Whereas full remission is they've completely stopped.  And then, and so, and it takes, it's like three months where early remission starts and then 12 months is worse, full remission kicks in. So, and it is substance specific.  So there, it doesn't really cross over. So if someone uses opiates and stimulants, we would have to evaluate them on both their opiate use and make sure that they meet this  criteria based on opiate use, and then meet this criteria based on, on a stimulant use.  So it's possible for someone to have an opiate use disorder, but use stimulants, but not have an SUD for that. Does that make sense? Any questions on that? No.  Okay. So a lot of the parts here, let's kind of move ahead here talking about brain science  addiction. You're kind of, we don't tend to use, you see the word addiction doesn't come up in the  diagnostics statistics manual, largely because the term addiction is really broad. In some ways,  it's not technically a scientific term because of it. And we don't really have, there are several  different definitions of addiction. You'll hear, you seeing it added in here because the American  Society of Addiction Medicine, their whole goal is to kind of, well, their goal is really to  standardize treatment, figure out how to make treatment more effective and how to make sure to  build treatment networks, a more robust treatment network. So we're going to talk a little bit about  addiction. They have created their definition of addiction, and that's what's been put up here.  I bring this in because it's probably the most standard accepted definition. I do want to note  though, it's not the only definition. So reading this out, addiction is a primary chronic disease  of the brain, brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits  leads to characteristic biological, psychological, social, and spiritual manifestations.  This is reflected in an individual pathology, in an individual pathologically pursuing reward  and or relief by substance use and other behaviors. So this incorporates, it's not quite,  some of you have had folks heard of the disease model for addiction? No? Okay. And that's Beau or  Kara, you haven't heard of the disease model either. So the disease model of addiction is one  of the more, it's widely known and many treatment providers go by it. It's this idea that addiction  is a chronic disease that if left untreated will continue to worsen over time and the person will  continue to deteriorate to death. And it was groundbreaking when it was created because it moved it and to recognize, it moved us away from what was called an idea of moral failing  for addiction, which is this idea that there's something wrong or they've done something wrong.  And it pulled the shame away from it. Instead it turned it and looked at it as,  no, this is a sickness. The disease model isn't universally accepted.  There are other ideas out there of looking at addiction as a learned behavior. In other words,  you use the substance and then over time you learn that you like using the substance and it  changes your brain in a way that you keep using. What ASAM has done here is it's kind of melded a  bunch of different definitions together so that it makes it more widely accepted. And so this is  probably the best definition to follow. Has anyone heard of ASAM before? Is this a newer  concept for folks? It's new for me. It is new. Okay. And Bo, you're nodding your head because it's new. Got it. So the American Society of Addiction Medicine is largely started by  physicians. It was 1950s. I have to look at my book again, but it's been around since at least the sixties. And it was developed because addictions treatment at that time was the  wild west. People didn't, you could go to two different treatment centers across the street from each other and get wildly different recommendations. And this was a problem  because what was happening was what usually was driving the difference between those  was what each of those programs had, not what the person needed.  And so they had worked over the years and they ended up, 1980, shoot, I'm trying to remember  the years here, but it was in the eighties that they released the first edition of the ASAM  placement criteria. And what they have done since it's now it's in its fourth edition now.  And it's the most widely used criteria we use as addictions counselors to decide what level  of care someone needs. So if you ever wonder how we decide whether someone needs inpatient or detox,  it's the, you'll hear them refer to an ASAM score. And this is who created that. And it's a type.  Well, it's not really an assessment, but it's usually attached to an assessment, but it's it's something we use in conjunction with assessment to decide  what level of intensity of care someone needs. Any questions on that?  No, I'm actually kind of, I just, I just looked it up right now, looking at the criteria for the assessment interview guide. So I just kind of pulled that up just to kind of.  It's something that I would recommend definitely getting as familiar as you can with, because it really does a lot of times when people are frustrated with the system,  especially around like detox and inpatient, it's ASAM information that usually helps you  understand what it is they're looking for to decide whether that person needs to go in there or not. So, yeah.  So looking at with addiction and substance use here. So there is a lot of work that's been  done with brain imaging to show physical changes in the area when a drug is ingested. And there's  a lot of work that's been done to show specific areas that you may have heard of the dopamine  pathways. But there's even more than just the dopamine pathways that are involved with how the brain is changed. Essentially, what's happening is and let me use this example here.  So there's the pleasure center of the brain. If you can see my mouse moving around the center of  the brain on the left here on the left of your screen. Essentially, this is the pleasure center  that's getting activated by substance use. And then this here is the front, the prefrontal cortex.  So it's the decision making part of the brain. It's the part of the brain, the last part of the  brain that develops into our 20s is when it's still actually finally developing. Around 26 is  when it's done there. This essentially what substance use does, and this is a very crude way  of putting it, is it severs the connection between the pleasure center and the decision making center.  And so it and it's really odd because it's not like it's completely severed. It's just severed  around substance use. It's because if it was completely severed, people couldn't think ahead  on anything. But what happens is with these judgment, decision making, learning and memory  and behavior control, because these pathways have been damaged and to a point that they tend to not  work, especially around substance use, you'll get folks that they want to stop. But as soon as they  see the substance or something brings the substance up, that thought's gone and they're using again. And what ends up happening, unfortunately, is people will say, well,  they don't really want to change. It's not actually true. They very much want to change,  but their brain has been changed in a way that their decision making, they are not capable of  making that decision in the moment. It turns into what we call a compulsion. And they can't  really think ahead to the negative consequence. Their brain isn't connected that way anymore.  It's not hopeless. What happens is that if someone stops using and gets to a more stable place,  there is through neuroplasticity, your brain can develop new connections that can work around those  areas. And someone can redevelop and build on that. But it is important to note, and I regularly  talk with families about this, because they'll, especially around, yeah, they'll get this idea  that the person doesn't really want to stop or that they're a lie. And sometimes they do lie.  There is that can happen within substance use disorder, but it isn't always actually a lie.  Sometimes they just literally, it's cut off. It's like the part of them that wants to stop just  goes quiet as soon as the substance comes into play. So we have such a small group here, I'm not  going to need to do pods. I'm wondering if we can do a discussion here for just a few minutes here  and talk about kind of the stigma around, we can briefly talk about stigma mainly around substance  use, but we can also incorporate mental health in here and social determinants, social determinants  being like poverty, so social class, person of color, those kinds of things would be there and  of healthcare potentially, and how those impact someone seeking help for substance use or mental health. What are the things that come up when you think of this?  Family dynamics, history of drug use, social class, demographics, where they're at, specifically. Hold on, I got to do a switcheroo with the kids for a second.  Sorry, we got a bunch of events going on with the last day of school right now.  I'm wondering, too, when you think of differences, is there a difference with someone asking for help for mental health versus someone asking for help with substance use?  Do you see that happening? And if so, what are your thoughts on what's behind that?  The thing is the folks that we have that are using substances and things, they're not wanting to change.  Not necessarily that they don't want to change, they just don't have the capacity within their brains to decide that they need to make that change.  Because they've been having those patterns for so long that they don't know any different.  That's just what I'm seeing. We have a gentleman that he's constantly getting into substances.  We can tell when he's been using because he responds to his internal stimuli a lot more.  And it keeps coming back to that same, almost like a past trauma experience that he's had, which may have led him into using that substance.  And so, therefore, it's kind of a vicious cycle. So they're kind of blended together.  Right. And the fact that he doesn't have the short-term memory, he's got such a short-term memory problem that he doesn't know that he's doing it.  For instance, when you ask him to not smoke next to the entrance of the facility and 10 minutes later, he's doing it again.  And he's like, oh, I'm sorry, I promise I won't let it happen again. It makes it more difficult to break that cycle or break that habit.  I've also noticed that there is, you know, if someone's looking for a mental health facility for treatment versus a substance use disorder treatment facility, you tend to see more therapy, more mental health focus, you know, or do like CBT, MI, substance focus therapy, et cetera, et cetera.  Where it's just really hard to find a place to actually provide SUD, like genuine SUD treatment. And that's what I'm definitely advocating for, too.  You know, because like I said, for example, here where we can provide help with a mental health patient with mental health conditions.  However, it's that like the SUD, like Damian was referring to, I feel that if we were to address that, you know, have an integrated model, you know, or more facilities had that integrated model where they had both SUD and mental health.  Whereas it will be a better, I say, more thorough, comprehensive approach, you know, for those patients.  But, yeah, it's definitely harder to get both or go from two different facilities.  And the other thing that, you know, comes to mind, too, is, you know, when they come to us from these locked out facilities, you know, they are, you know, they may be 35 years old, but they have the mentality of a 12 year old.  And, you know, they go back to that same habit before they were institutionalized. And so they have that same mentality of all they want to do is go back to their old ways.  Yeah, because that's all they know. And that's what they're comfortable with.  You know, and that's that's another problem that, you know, we're seeing that we're having with these guys.  Oh, yeah, definitely some layers here. And talking about, like, Bo, you're saying kind of looking for more integrated and hoping to maybe include that in.  And, yes, it is challenging. And I know SAMHSA is definitely trying to build the, and ASAM as well, trying to build what we call it a co-occurring enhanced network where folks are able to treat both mental health and substance use completely.  And then what you're saying, Damian, it's even really challenging.  I mean, your first part was it was like diagnostically even wondering, like, is it the substance use that's making it hard for that person to decide about smoking near the entrance or is it the mental health or is it both?  Which is also a co-occurring thing, too, of kind of which came first, the chicken or the egg. And in a way, it's kind of not all that helpful to look because they're both there.  OK. And a lot of them also don't understand consequences either. Yeah.  And that and it's tricky with the addiction piece because it's around the substances that make sense and that could be the addiction, though you're bringing up the mental health piece as well.  And so their cause and effect might be compromised. The ability for cause and effect may be compromised due to their mental health condition.  Again, it's a really it sounds like you're getting folks with a really complex clinical presentation and trying to pick that apart and figure out kind of where to go.  It's great that you're doing the work that you are because you're trying to do both. And that's what we're supposed to be doing is trying to look at both. So.  So let's extend this and keep the conversation going. Opioids here. Kind of a quick overview on opioids.  They're natural or synthetic substances that act on the brain's opioid receptors. So the brain's opioid receptors are.  Thank you. And so it's there are bodies natural pain killer. In fact, if you ever have like a little bit of a runner's high, that's actually our natural endorphins.  It's the same area. It's not anywhere near as intense as most opiates, but it is a little bit of an effect similar to this.  With the natural piece, natural would be derived from the poppy plant, whereas the synthetics are manmade and more and more we're seeing more synthetics.  There's also technically some that are kind of in between there. They're partially natural, partially synthetic kind of the other partially.  Partially synthetic, I guess, is a better way to put that. It's not super important that we know the distinction between these. That's just a part there.  So the purpose of opioids, at least therapeutically, when they're given to you by a doctor, meant to reduce or relieve pain.  They tend to dull pain and relieve anxiety that comes from thinking about pain.  In a lot of ways, what they do is they kind of make it not matter that it's painful so much to you as opposed to actually killing the pain itself.  And so this is part of where sometimes folks feel like opioids are technically stronger than like even Tylenol and other things.  They work differently, whereas Tylenol and ibuprofen and stuff work at the actual pain site. Opioids work more in the brain and kind of have more of a psychoactive effect.  They tend to be misused because they can provide a feeling of euphoria or a rush, especially and that rush is intensified depending on how they take the med.  If they take it via injection, of course, it's the most intense rush, but you can still get a rush from other methods as well.  And of course, they're extremely habit forming and can be very addictive very quickly.  So things that you'll see side effects, which some of the first few are the high drowsiness and sedated feeling mental confusion.  Of course, there can be nausea and vomiting even under the influence of it. It does affect the digestive tract, and so it can cause constipation.  You'll see people's are restricted. Smaller effector is opioid intoxication. Larger effect. Longer term, I guess, is a better way to put that opioid withdrawal.  Once the addiction has set in or once the dependence has set in and then slowed or depressed, vital signs.  In fact, an overdose and something that's the opioids themselves are actually not toxic to the body.  Why someone has an overdose is because it's so much substance that it causes the body to stop breathing, essentially.  Other substances, when we talk about stimulants, stimulants are extremely toxic to the body. And so that comes out. Folks tend to not get sick from the opiate itself.  If you do get sick, it's largely because of contaminants that are in if you're injecting that are either in the needle or in the material as you're heating it.  And that is what can cause. And I do. Does anyone know the name of that? It's the heart valve condition. And I always it's a trickier name.  Does anyone know it? You're nurses. So I'm wondering if you do. What was that? There's the it's the condition where it's bacteria develop on the valves of the heart.  And it's because of the contaminants from and it can happen because of the contaminants in injectable heroin.  Yes. You got it. Thank you. Yes. Endocarditis. Yeah, that's it's not actually from the opiate itself.  It's from the contaminants and the bacteria that are in in the substance when when you're injecting it.  So the ones that we see, I mean, we've got coding up here, main prescription opioids, people misuse coding is definitely up there.  It's easier to find. It's technically even legal in Canada. It's it's a it's a natural opiate derived from the poppy plant.  It's it's on the milder end. If you ever hear of Tylenol threes from Canada, that's got coding in there. But that is addictive, can be addictive as well. Of course, oxycodone pops.  They use that for people that have a chronic cough or anything like that. Yep, exactly. I'll suppress that. Yep. Yeah. It's commonly prescribed. Definitely.  Oxycodone is the oxycontin years. Several years ago, there was a big it was during the opiate at the height of the opiate crisis.  Oxycontin was at the forefront of that. Percadent and Percocet have been around for a long time or. And of course, hydrocodone, which is Vicodin. Then, of course, there's Demerol.  Dilaudid. And then as many, I'm sure you're seeing fentanyl as well as and then morphine in there as well.  Heroin technically is a closer to morphine. It's a natural, but it's not prescribed. That's why it's not on this list. Are you seeing is it mostly fentanyl use at this point?  What are you fentanyl? Yeah. OK, fentanyl and methamphetamines. And it's coming in the blues or even it's in the blues.  OK. Yeah. You know, they're you know, the oxycodone with that's laced with fentanyl type of thing. Yeah. So.  And sometimes it's just straight fentanyl. In fact, I find it's yeah, the fentanyl pipeline has gotten pretty strong and pretty much everywhere I work with, it's mostly taken over.  And it seems like it's yeah, it's the predominant thing at this point.  So is usually the we've we've done, you know, in the laundry and stuff, we've done syringes and things like that. That's usually most directly linked to like heroin, correct?  Not necessarily. I mean, you can yeah, you can inject fentanyl. It's a yes. Heroin is more traditionally injected, but you can you can really inject pretty much any opiate.  And so it's not necessarily just heroin. And of course, inside the syringes, you know, it's like got a brown tint to it. So, you know, that makes this more of a.  Yeah. Yeah, that could be the case. It depends. But yeah, you can definitely really almost inject anything.  So tolerance is meaning higher and higher doses are required to achieve an opiate effect. And this comes into play. One of the difficulties with fentanyl, well, really any opiate.  If someone takes a break from it, their tolerance will drop.  And then unfortunately, then if they use the same amount that they were using before the break, it becomes that's where it becomes really risky.  The other thing that's really risky with it, too, is there in the blue pill in the blues.  There is the cartels aren't really great, so great at using a centrifuge to make sure that they're the pills are equally distributed in the amount of fentanyl.  And so and sometimes people will break their their pill up the blue up into quarters or halves.  The problem is, is you don't know for sure that that quarter is exactly a quarter of the fentanyl. Like all of the fentanyl could have wound up in one part of the pill.  You're still it's not as predictable as that as we would like, because they have it.  The cartels haven't invested in the technology that's needed that we would see if it was in an actual lab that was being like our pharmaceuticals are subjected to.  So eventually, this last part here, and I'm sure you've seen this. We call it maintaining where the drug is taken mainly to prevent withdrawal, not to get high anymore.  In fact, folks will have it where it's like, oh, I just there's a flip where the body and we call it tissue dependence, where.  You used to feel normal and you feel weird when you're not using because usually it's the other way around. You use to feel different, to feel euphoric.  But there's a point there's a tipping point with opiates and happens with most substances where your body, the default is having the substance on board.  And so when they look the most messed up is actually when they're not using.  And my good friend actually about a year ago was addicted to the blues and he got to the point where he was smoking so much of those off the foil and stuff to where he wasn't getting high anymore, that if he didn't, he was only doing it to avoid withdrawal.  Exactly. His ceiling was like, yep, it was. And that's yeah, it that's your body.  It just it re-regulates itself because it's it's always looking for homeostasis, that state of normal. And if you do this long enough, it's like your body's like, all right, fine.  The state of normal is with the substance on board. And yeah, it flips around. It's not a pleasant experience. Yeah, because it's then you're not using for enjoyment.  You're actually fully chained to it. It's yeah, it's an unfortunate situation. I kind of noticed that when I drink a lot of I have a problem with caffeine and I didn't notice this.  So the more I drink caffeine, the more energy energetic I feel, the more happy than we were. Oh, I don't have it. It's just. It's not good.  Yep. Very much. Yeah, it can happen pretty much any substance and caffeine included. So withdrawal occurs when someone who is dependent or addicted stops taking opioids suddenly.  And this is an important distinction here because we're going to talk about in just a moment here, medicated opiate use disorder.  So that's when someone is taking a medication like an opiate medication to help reduce withdrawals. They are dependent on that medication, but they're not addicted and addicted.  Really, what addicted means is if you remember back to those criteria for substance use disorder. It's more than just physically needing the substance and having a high tolerance.  It's you're having problems in your relationships. You're spending more time than an exorbitant amount of time getting the substance, using the substance.  You're having legal trouble and legal troubles. It's not a criteria in itself, but you keep going even though it's causing you a lot of problems that would be addicted.  And that's an important thing to know is someone who is like stable on suboxone and methadone.  It's better to not look at them as though they're addicted to the methadone or suboxone. They're being medicated on that. They're dependent on it.  And if they stop, they'll have withdrawal. The reason is, is because we want to treat the addiction and make it so that their life is stable.  And it's possible to do that while taking an opiate like suboxone or methadone. So any questions on that? That's no, it makes sense.  OK. So when they do get withdrawals, I mean, it's described as a horrible flu. I mean, severe muscle and bone pain, trouble sleeping, diarrhea, vomiting, cold flashes.  You can get goosebumps. It's it's not deadly in and of itself. If someone is going to you might feel like you want to die. It's not deadly in and of itself.  The reasons why someone may have complications or if there are other medical problems going on or if there's another substance involved. But it is it is really, really unpleasant.  And there can be some danger whether or not they're able to take care of themselves and whatnot. So there may be a need for some assistance.  But, yeah, withdrawals come in here and it depends on how severe they are based on how dependent their body has become on the substance.  So now are folks coming into your care that are are looking are either using MOUD like methadone, suboxone? We've only had one gentleman that came to us while he was on suboxone.  OK. And he got to a point where he got into some meth and he eventually refused to go to his appointments.  And we told him that if he doesn't go to his appointments, he's not going to get the the suboxone.  And so they finally canceled him on it. And it's the it's unfortunate because he spiraled down pretty, pretty quick over the last year.  And it was just we couldn't get him back. And so, I mean, he's no longer with us anymore. But, I mean, he's alive. But, yeah, he's alive.  Yeah. But we don't know for how much longer if he doesn't get the help that he needs. We did everything we could to offer him help. But. But, yeah.  So we don't have anybody else that's ever been on any suboxone or methadone with us.  Are they like and I know, Beau, you're talking about adding some stuff on. Do you talk to folks about this?  And Damian, of course, you can answer, too. But and Kara. Kind of like is it part of the conversation while they're there ever or they just are like, no, I don't want that.  No, it's not. No, we try. We try pretty much daily to ask, you know, if they would be willing to, you know,  any outpatient SUD treatment and like Damian said, no, they refuse, which that's the that's the hard part.  Getting them to to engage. And that's the mental health aspect of it, I think. Yeah. Not wanting the help or not receiving the help.  And that's where I feel like that's when the the gosh motivation interviewing with people being counselors who emphasize on that would be great help.  You know, they can definitely use that, you know, interpersonal therapy, you know, with them, just to get to know them and see why, you know, what's going on.  And that's what I also hope to bring, too, once I graduate from my program. I hope I can actually do something. So, provide more therapeutic practice, you know, more on that. Great.  So, yeah, that definitely, hopefully you'll be able to add that on. I imagine you'll be able to discuss some of this.  Hopefully, we're going to talk about information here to kind of look at ways you could potentially incorporate it in,  because there are some things that are important to know about the medications and kind of where someone might be best sent, because they're not all the same.  So, looking at here, we've got the main medications for opiates that we have, the three main medications. We've got methadone, buprenorphine, and naltrexone.  So, methadone, we know it tends to be sold as methadone. Buprenorphine comes in a few different ones.  The one we probably hear most of is suboxone, but buprenorphine in suboxone form has, it's actually a combination of naltrexone or naloxone and buprenorphine,  and we're going to talk about that in a moment. But there are some just straight buprenorphine medications.  Naltrexone, Vivitrol, if you've heard of that, is one of the brand names of this. It's a type of medication. And so, they work in three different ways.  So, methadone is what we call a full agonist. Here, it mentions how it generates the effect. So, methadone is an opiate in and of itself, and it acts as an opiate in the system.  And so, that has some benefits. It's got a longer half-life. And so, drug half-life is how long the substance stays in your system.  And so, it has a much longer half-life than most opiates. In fact, it has like a one- to two-day active phase,  which is like things like heroin and stuff like that have only a few hours.  And so, that longer half-life means that the person is satiated for a longer period when they can be more kind of even-keeled.  What we've got with methadone also has been in use since the 60s. It's been well-studied, and it's safe and a very effective medication.  Buprenorphine has been around quite a while as well. I'm talking like 90s, 2000s is really when it really came into full effect. So, buprenorphine is also an opiate.  It's what we call a partial agonist. And so, what's happening here with the methadone, you see that's the solid block going right into the lock and key and fully blocking.  It's fully activating it. Here, if you imagine that same lock and key, but it's mostly filled, and it's filled enough to activate it, but not totally activate it.  So, yes, people will get an effect, and they'll get some high off of buprenorphine, but it won't be anywhere near as much as it would be, say, off of methadone or fentanyl.  And what's really helpful with buprenorphine is that there's an affinity for the neurotransmitter or the synapse connector.  And so, it will bind more readily than other opiates, which becomes important later when we talk about some of its advantages. And then naltrexone.  Naltrexone, what's important is to note, it's not an opiate at all. It's actually an antagonist. It blocks the opiate receptor.  And so, the advantage here is, with the opiate blocked, the receptor blocked, theoretically, someone can't get high, because if they used an opiate, it wouldn't be able to connect.  So, looking a little bit further here with methadone. So, yeah, we've mentioned here full opioid receptor activation, so it fully binds with the receptor.  And then here, the goal with methadone is, and this is some of the times the tricky part, is getting them onto the right dose,  because the goal is eventually to get them to the right dose where they're not experiencing cravings, not in withdrawal, and not experiencing euphoria.  And frequently, there's quite a range they're playing with. The doctor is kind of going up and down.  And so, there are going to be periods where the person is uncomfortable, and they don't have full coverage. Like, a common complaint is, I feel fine until, like, midnight.  And then the last few hours before my next dose, I start to feel withdrawals, and I'm having a hard time sleeping.  The reverse is also true of, my wife keeps complaining that I look like I'm high. And, well, that's a sign, okay, well, have we got the right dose kind of coming in?  And there's a lot of playing with the dose to find the right level. It's got that duration of one to two days.  It can only be provided through, and this is one of the caveats to this, it has to be through an opioid treatment program. So, you have to go to a methadone clinic.  And they must dose in person. Now, SAMHSA has recently updated their dosing protocols. And so, take-homes are given a lot sooner than they used to be.  But still, you are going to have to go in person at least some of the time to get your methadone, which creates some headaches, definitely.  And so, that's probably the biggest negative to this, is needing to be kind of attached to that clinic.  Would you say that the early take-home from that is due to the overwhelming increase in the need for it? No, it's more of getting methadone clinics to stop punishing people.  And to be more, and to make it more welcoming and make sure that, to make methadone fit into daily life better.  It's, because they're trying to get some of the punitive component out of things. And make it so that it's more, yeah, more amenable.  So, I'm not aware of it necessarily being because of that, yeah. So, thanks for that. Yep.  So, we're going to talk about methadone again, because methadone, in comparison to suboxone, has some significant advantages.  And when I work with folks, because the problem is, is there's so much stigma around methadone.  And when I bring methadone up with folks many times, oh God, I don't want anything to do with that.  And I use some of them, I do teach motivational interviewing and I work with it, I kind of roll with that for a bit. And then we kind of talk about things.  And I slowly try to enter in the conversation and talk about, if I can, some of the potential advantages of methadone.  Because it is frequently a better option for folks than suboxone. But it's less used because of the stigma and partly because of that opiate treatment program protocol.  And so it's one, I always like, let's make sure that we rule that out as not being a better option.  So, it's the oldest and most studied medication for opioid addiction. It's ideal, and here I start coming up with some of the advantages.  Ideal with individuals who have exceptionally high opioid use histories, especially like fentanyl, because fentanyl is intense.  And so a lot of times folks that have used fentanyl, their only option might be methadone.  And we're going to talk more about why that is. It's mainly because there's no, what we call, sealing effect with methadone.  They can go up to what level they need to and they're not going to run into any trouble with it. There can be, it's individuals with treatment retention difficulties.  So folks that tend to have a hard time staying connected to treatment tend to do better with methadone.  And then individuals who are unable to tolerate buprenorphine treatment. So there are some folks that buprenorphine just does not work for, and for several reasons.  And so methadone is a better choice because of that. Folks tend to get more stable more quickly.  I will say some of the things I'll add with folks, if they're having a hard time with methadone, I'll say the door isn't closed to going to suboxone.  It's just sometimes you maybe start with methadone and then with your doctor you talk about and see whether it makes sense to switch.  Because I've known many, many people that have done that, that started on methadone and then moved over later on.  Buprenorphine. So here are some, and so again, it's an opioid partial agonist.  So it must be started when in mild withdrawal. So methadone doesn't necessarily have to have this. You don't necessarily have to be in withdrawal to start it.  Sometimes they like to see what your withdrawal level is.  But suboxone does, or buprenorphine does, partly because, and especially if you're taking suboxone, it has that naloxone or naltrexone in there, or sorry, naloxone.  It can kick you into withdrawal if you have opiate in your system, or too much opiate in your system. And so this transition onto buprenorphine can be really rough for some folks.  There are some folks that take to this like a fish to water, and it's great, perfect, and wonderful. And then other folks can kind of have a bumpier ride.  So that initial dose is four to eight milligrams, can go all the way up to 16.  There's always a follow-up within three to four days, and that's when they decide when to bring the dose up. Optimal maintenance is somewhere between eight and 24 milligrams.  So it's, again, they're trying to find that dose.  The thing with methadone versus buprenorphine, with buprenorphine, you can't use opiates on top of it, which is actually a serious advantage to methadone.  But it can be a real impediment for some folks in that transition, because it can mean that it's a really uncomfortable, rough ride in.  And I've seen tons of people fail at getting connected with buprenorphine, because what I see the pattern is is they'll take it, and then I can watch them start calculating,  how long do I have to be off of this in order to be able to use my opiate?  And they're starting to kind of, it's a game that they're playing, and it's awful because they usually get it wrong.  And when they get it wrong, they kick themselves into withdrawal really deeply.  And it also means that they're not taking the medication consistently, and the medication needs to be taken consistently in order to be able to take effect.  And so methadone is just, you don't need to worry about that. You can keep taking the methadone, even if you're using other opiates.  And so it's easier to get to that stable level, whereas buprenorphine can.  Of course, though, there is that advantage of once you're on suboxone stably, it's wonderful, because if you use more opiate on top of it, you go into withdrawal.  So there's a serious consequence if you use, and that can work as a wonderful blocker. So it really depends on the person.  So here, the treatment course, individually designed taper. It can go anywhere from six months to lifetime.  In fact, the data's starting to point to lifetime is where folks tend to do the best. And so it's not unusual to talk to folks about that you may do better if you just stay on this.  Same with methadone. But, of course, that has to be an individual choice.  And it's something that they'll work with with their doctor on whether or not to stay on it or to work on trying to come off of it.  If they do try to come off of it, this last part here, that last two milligrams, and this is definitely true. I see it's almost like a cliff.  When people come off that last two milligrams, they're terrified because it can be a really rough withdrawal for a bit for them.  The good part is, is if it's been six months to a year or two years, their life is really stable.  And so they can have like a week or so where they're not feeling well and have it not as bad of consequences. But it is still a bit of a rough go.  So, yeah, here's the when buprenorphine is oftentimes combined with naloxone, this would be suboxone.  The common forms of buprenorphine subutex, you'll see this sometimes used initially. This is just straight buprenorphine, no naloxone.  This is sometimes used for pregnant women, but also for folks transitioning onto suboxone to help kind of support them so that they don't run into that.  Because the naloxone is the thing that will be the antagonist that will kick in at a certain level and cause them to have withdrawal.  So subzol is another one that's also a suboxone form. This is a tablet instead of the sublingual film.  The sublingual films come in strips and they cut them and they're like the clear gel type stuff that they have to leave under their tongue for a while.  Apparently it tastes really awful if you aren't careful and you have to let it sit for 15 minutes to fully absorb. That's another one that sometimes folks struggle with.  The tablet is a little easier to handle. I don't know whether it dissolves any faster. I haven't had that many folks on the subzol, but yeah.  And then the newest addition here is sublocade. So sublocade, we're waiting to kind of see. You can see it's new to the market. It's very expensive.  But what's nice or possibly nice with it is that it's an extended release version of buprenorphine. And so you can go for an injection.  I believe it's if I know if I have it correctly, it's once every month.  And it's really nice because you don't have to worry about taking the medication. It's always there. It's on board.  And it's up there with injectables. Antipsychotics have been a game changer as well. They just kind of set and forget.  I've had only I've worked with one or two folks trying to get on it. It's really hard to get to find a place that does it.  And it is expensive.  Any questions at this point about buprenorphine or methadone?  Do we want to take a brief break because we've been talking for about an hour?  Oh, I'm good. You're good? Yeah. Okay. All right.  Okay.  So still with buprenorphine here, there's that sealing effect I was mentioning. So because buprenorphine is a partial receptor activator,  it will get them to a certain level but won't go higher. And it won't let anything else bind to let them go higher.  So the example you see on the right here is you've got the buprenorphine brings them up to the ceiling.  And then if they used morphine on top of it, the morphine wouldn't work at a point. It wouldn't add any additional component to it.  This is a nice part of buprenorphine is it does have some protective factors built into it.  So the goal here is activate the opioid receptors to a point that the individual does not experience cravings and is not in withdrawal. So similar to that of methadone.  Duration can be great up to 24 hours.  Yeah, that 10 to 20 minutes with the sublingual tablets. I'm guessing the strips dissolve a little bit faster.  And so that, yeah, that there's a benefit to the strip.  I've mentioned this piece of the high affinity to receptor sites.  And then the ceiling effect is very safe for opioid tolerant individuals.  This ceiling effect, as wonderful as it is, it's problematic for folks that have a really high like say they've been using a lot of fentanyl.  Because the problem is, is if this ceiling is located underneath the level where they stop feeling withdrawals.  It's going to be a problem for them.  Because they're going to experience if they're just going to go into withdrawal.  And so this is why for some, especially folks that have used high levels of opiate, it may not be the best first choice.  Do you see an avenue of being able to talk to folks about this? Because I'm not sure folks know coming in how much they know about these.  Not really. I mean, we've only had one or two folks that have had the, you know, the opiate use.  You know, we've had one guy where, you know, we had to save his life.  You know, we had to, you know, Narcan him three times to bring him back and CPR and all that stuff.  But he's the same guy that we have a problem with reminding him of smoking near the facility and everything else.  So it's, it's, it's, it's, it's, it's, it's a rare population that we have that have the opiate use. But, you know, it's there and we have it, you know, up and down the street.  It's, it's highly used and readily available. So, you know, that's why we want to, that's why we're here.  We can help ourselves, you know, understand it a little bit better and understand how, you know, it's used.  But, you know, trying to get these folks into these, requesting this, it's, it's, it's, it's difficult because of the mental health aspect of it. Yeah, understood.  And this is where figuring out the locations that have that capacity, because, like, there are certain treatment centers that have mental health on staff.  And so they're more amenable to it.  And there's also the also working with folks, too, because sometimes and sometimes the discussion I have, it's a perfectly fine thing to go in because there are plenty of folks that go into especially methadone that don't even necessarily intend to stop.  They want to make it less up and down, less chaotic. They want their life to be more stable, but they do still want to continue to use a little bit.  And there are treatment centers that they will work with folks in that way. It's not that it's not their preferred.  They prefer to work with folks to come completely off, but they will work with them to kind of help just stabilize things. Denial is also one of our biggest roadblocks as well.  In the sense of that, because the question I was going to ask before, are you getting folks that are just saying, like, I know I'm addicted. I just don't care.  No, they're like, I don't have a problem. I'm not doing it. Right. I'm not doing it. I'm okay. This outright denial. Okay. That's that's that's that's what we're facing.  A hundred percent. Sure. The black soot covered all over faces and hands and spreading it all over the facility from burning it on the foil. Yeah. No, I'm not doing anything.  The police not doing anything. Okay. So they're just flat out just yeah they're literally denying the use itself. They're not even saying they're using. Okay.  Okay, let's keep that in mind as we go because I'm gonna it'll come up somewhere in crisis and I want to get through a couple of more pieces here and then add that in.  I'm wondering about this. It sounds from what you just described Damien that you already have like an identifying and responding to overdose protocol, like you mentioned Narcanning folks.  Yeah. Okay. So how I'm wondering if it's okay to move through this because I want to get to some of the questions. Is that okay to skip ahead a little bit? Yeah, that's fine. Okay.  Because yeah, this is just looking for overdose signs, which is essentially they're largely becoming unconscious. They're blue. Yes. Okay, so you know exactly what they are.  So my background is emergency medicine. I was in the ER coming here. So, okay. I definitely I definitely educated Bo the day to Narcan our residents.  So, got it. Okay. And Kara's also got that is down with that too. Awesome. I'm probably least experienced experience because I thankfully I wasn't there that day.  And I'm only been involved in psych nursing. I don't have like medical nursing background. Okay. Okay, so yeah, just quick here and kind of looking at this.  I'm smart enough. You can talk with Damien. Okay. All right. We have a good team and we, we, you know, and I can educate them through this too, so great. Okay. So awesome.  I'm going to skip ahead a little bit, the stimulants, and then talk a little bit about why the opiates and stimulants may be combined. So it's frequent in the case.  So yeah, stimulants, they tend to increase activity of the central nervous system, faster heartbeat, increased blood pressure, heavier breathing, higher energy, body system arousal  and better concentration and attention. So legal stimulants, caffeine. We just mentioned Bo, you were mentioning with, you're working with caffeine there.  Of course, energy drinks largely have caffeine, but may also have some other stimulating like  herbs and other things in there, like over the counter items, nicotine, coffee, nicotine is also a stimulant, but then we have diet pills and supplements that are in here and  prescription medications. So amphetamines and steroids can also have a stimulating effect. And then we have a elicit, so prescription over the counter stuff, methamphetamine.  So crystal meth, which is probably what you're encountering the most. Are you encountering cocaine at all? No. No. Okay. Crack cocaine. It's mostly, it's mostly meth. Got it.  And cannabis. I would say. And cannabis. Okay. And bath salts or synthetic cathinones, that's. We haven't seen that.  Well, we did have one resident where he just got into some, he had MDMA in his system along with fentanyl and he had a, he had, it was a party ball for him because he had all the  drugs in his system. Wow. Okay. So. Okay. So it's not the most common, but meth it seems like is the most with cannabis.  It's interesting this part because cannabis, we sometimes call it an all arounder. It can have depressant as well as stimulant and also somewhat hallucinogenic effect.  Part of this is due to the way cannabis works in the body is it works in the cortex of the brain where most drugs work more towards the brainstem and in working as in the cortex  of the brain, we get really wildly different effects. Like I'll say it's, you've got, I hear folks talk about cannabis and they're like, oh,  it washes all your worries away, which I find really strange because I don't, I couldn't use it because it gives me a panic attack.  And so I'm like, washes my worries away and it brings them on. And that is actually normal for cannabis and everybody has a, it affects us all differently  because of the working in that upper cortex or region. It's also important to note, and that's why you sometimes have very different effects,  even in the folks working with mental health. Sometimes they might be okay with it and sedated by it. Sometimes they might not be. There can be real variation in how that works.  And a lot of times they're using cannabis to try to help reduce psychotic symptoms. There is some evidence that it might do that, but it's not necessarily totally consistent  with that.  So, yeah, amphetamines are used by the military, used for diet pills, they're used for ADHD, they're definitely, they're widely used and do have fairly legitimate uses.  There are some non-stimulant choices for medication priority, but they, the studies haven't, it's not that they're, well, they're harder to get to be effective.  And this is kind of outside the scope of this training, but Stratera is the main medication and it has a very small therapeutic band and it's kind of hard to hit.  And if you miss it, it tends to kind of be like a one-time window anyway, outside the scope here. But yeah, stimulant medications tend to be the standard for ADHD.  We're kind of giving, yeah, again, parents and children with ADHD should be in behavioral therapy as well for managing that.  So effects, side effects of this are insomnia, inability to sleep, headache, dry mouth, tachycardia,  fast heart rate, raise in blood pressure, specifically systolic blood pressure, irritability and restlessness. Meth. Let me actually pull the full slide up here.  So meth actually is still medically prescribed, Dasoxin. It's mainly prescribed for diet supplement.  It can be prescribed for ADHD, but yeah, it is still actually something that is available through prescription. It's not a very common prescription, but it is out there.  So now forms that can tend to come in, not necessarily for the prescription, but you can see this come in liquid, powder, pill or crystallized form.  And we commonly just call it meth. So methamphetamine is an amphetamine type substance. It's more potent than amphetamines.  It's got a stronger effect than amphetamines do, and this is why it's more addictive. It's actually also neurotoxic. I mentioned before how opiates are not toxic to the body.  Methamphetamine is largely because the way meth works is it, well, it comes into the synapse and blocks reuptake of dopamine and norepinephrine is what it also works on.  But what it also does, which other substances don't, is it actually attaches to the presynaptic  nerve and actually absorbs into the presynaptic nerve and forces it to release dopamine and norepinephrine. And in doing that, it's neurotoxic because it kills the nerve.  And so you can see why it's extremely potent is because it has this dual action that other  regular amphetamines only get into the synapse and block reuptake. This does that, plus absorbs itself into the presynaptic nerve. So it's a super intense high.  So generally meth is smoked, and this is a pipe. Is this what folks you're seeing use? Oh, yeah, lots of them. Yeah.  Can be taken orally or snorted, not as often.  Also injected. It's probably the most dangerous to inject. In fact, if we're doing harm, frequently when we're doing harm reduction programs, we actually  are giving them pipes because they're a safer method than injecting. And I've worked with programs that have done that.  It definitely gives you a rush of euphoria, much like opiates do.  The difference here is it perpetuates a need for more desire for that rush and then binge crash cycle.  And so where the rush from opiates tends to be more sedating, the rush from stimulants is more energizing.  And then an overdose on methamphetamine, what that looks like is either stroke, heart attack, or can be also organ problems.  But frequently it's a cardiac event that are cardiovascular event that that it's brought on by the meth use itself.  It's frequently combined with fentanyl.  So the spoofing is sometimes what it's called. I don't even know if they still use that term. It was probably from about five years ago that we were using it.  But with combining fentanyl and meth, it tends to what they'll do, they'll do this for a few reasons. They'll do this because, well, it frequently is the dealer just had meth.  They didn't have fentanyl that day.  And so that's a common reason why they end up just having meth. It's based on what the dealer had.  It can also be used if they're trying to reduce their tolerance level to fentanyl. In other words, their tolerance to fentanyl has gotten too high and it's starting to  give them trouble or make it to the point where they're not enjoying it anymore. They can use meth to kind of mitigate some of the withdrawal effect for a while to make  it a little bit more easy to tolerate to a point where the tolerance of fentanyl will drop and they can start using it again.  And they can kind of go back and forth with this a little bit.  But yeah, it's the thing that's kind of happening as we crack down on fentanyl is it is we're finding more and more meth is actually what's available.  And both the cost of meth and fentanyl have dropped precipitously over the years. Like the whole idea of drugs being expensive is not relevant anymore. They're not there.  They're cheap now.  So the thing to watch for fentanyl and meth use together, it increases the risk of overdose in the sense that if they're on fentanyl and they're starting to have a cardiac event,  they may not feel it.  So it tends to mask if they're having like a heart attack or a stroke or something else, the fentanyl is blocking their ability to sense that.  And so they'll keep going, not realizing that it's even happening. Because it's blocking that pain receptor. So they don't go up there.  They're having chest pain, having a myocardial event. Yep, exactly.  And so and it also because the fentanyl is going to reduce the risk of overdose. Because the fentanyl is going to reduce breath rate.  And so they won't necessarily even be able to recognize their breath rate necessarily coming up.  So that's and the other is as well, they can tend to feel like they can use more.  And so these are particularly risky. And that's risky with a fentanyl piece because the threshold for overdose can be pretty, pretty narrow for fentanyl.  The main one, though, is if they're having an overdose from the methamphetamine and they don't feel it.  So what's what I mean, how how can they overdose on just straight methamphetamines? Is it is it a thing or it is it's what it turns into is it just it causes a heart attack.  It causes them to go into cardiac arrest.  And the unfortunately, it weakens their heart over time. And so that risk of cardiac arrest becomes greater and greater over time, too.  The rush from meth lasts about 30 minutes, but the actual high last four to 16 hours. So it's it's longer acting than other amphetamines. But it's that initial rush goes in.  So.  As the opiate, the opioid crisis is somewhat.  I don't know whether it's downturn, but it's changing.  We're finding meth use is going up.  In fact, meth and opiates kind of have a cycle with each other, unfortunately.  And so we're finding the asset in 2015 to 2019 overdoses went up  significantly with stimulants other than cocaine.  So the next slide is a little bit more about the opioid crisis.  Frequent methamphetamine use is defined as having at least 100 days in the past year increased by 66 percent. So meth use is increasing substantially.  There is used to be that it was mainly white folks from rural settings. This was back when we used to have the home labs and they would have labs either in RVs or out in the woods.  We don't see that very often anymore. The reason is, is that the cartels have picked up and the meth being produced now is technically  much higher grade, much purer than what they were creating in those labs. And the cost is so has come down so much that there's no need for them to even do it anymore.  And so it's it's it's a lot less common that we see homemade meth now.  And in that, unfortunately, it's made it much more broadly available. And it's the people that are using meth because it used to be easier.  You could make meth out in a rural setting pretty easily. It was harder to do it in an urban setting and go undetected.  Now, folks, it's just more available, period. And so we're seeing, unfortunately, a diversification of the user base.  So, yeah, low educational attainment, low household income, lack of insurance, housing instability, involvement of criminal justice system. This is all part of it.  People with hepatitis, sexually transmitted diseases, depression, or have been shown to be at increased risk for meth use.  So the transmitters, I mentioned some of this before. So what what the transmitters are doing is they're actually  So the what what the transmitters that are worked on are norepinephrine. So.  Sympathetic effects that work with high blood pressure, increased heart rate, forced cardiac constriction, alertness, wakefulness, energy, arousal, attention.  There's also norepinephrine is kind of with assertiveness or confidence. That's part of the rush there. A fight or flight transmitter is what norepinephrine is.  And so that's it's it's got an adrenaline like effect.  It also works on serotonin. So this can create delusions, perceptual disturbances, mood, liability,  sexual desire, lack of desire for food, sleepiness, body temp. So a lot of the things you see where folks are not necessarily eating, they're not sleeping,  their body temp can get out of whack. And then dopamine, locomotor effects, psychotic side effects and euphoria.  So this you can see some of where and a lot of the mental health, and we're going to talk about this in a moment,  meth tends to bring out a lot more mental health symptoms.  It can enhance, it can bring psychosis on.  We don't see as much with opiates. Opiates don't tend to. In fact, when you look in the DSM, there is no opiate-induced psychosis.  There's opiate-induced depression, opiate-induced possibly anxiety. I'm not actually totally certain, but that's about it.  Whereas for psychosis, for pretty much every other mental health condition, amphetamines can bring those on. There's a stimulant-induced or amphetamine-induced version of it.  And part of it is because they're working on these substances here, or these neurotransmitters.  So you can see it can bring out psychotic effects just from the dopamine here. The norepinephrine can have an adrenaline-like effect. Serotonin can bring on delusions.  It really does feed into that.  We see an increase of, like I was telling you, the increase of the response to internal stimuli when we see folks that are using meth.  Yep.  It's, yeah, it's probably bringing down the threshold of them responding, but it also is probably also increasing the actual stimuli as well. Right. So it's both.  And with the opiates, there could be a decrease in their ability to,  because that barrier of them responding to the stimuli, that would be the thing.  The stimuli's there, but the opiate would bring down their barrier to responding to it.  But the amphetamine actually would increase the amount that it happens.  I'm actually not going to do the video here because I think it makes sense. I want to get to discussion here. This is just talking about the dopamine units used  and how it's an incredibly intense amount of dopamine that's used.  And then we've got methamphetamine.  So what this works its way up to, it talks about how these are all units of dopamine that are brought on by these different behaviors or actions.  And then you get to methamphetamine and you see the actual number of units  that shows you why it, because dopamine is something that reinforces, it's a reinforcing neurotransmitter. It does a lot of things.  But one of the things, whenever we do something that triggers dopamine, we want to do it again. And if it's hitting this much dopamine,  yeah, that explains why it would be addictive and addictive very quickly.  So looking at stimulant use disorder and medication-assisted treatment. So, yeah, the FDA has not approved anything for stimulant use wise, medication wise.  There is some research that's happening. It's been going on for a long time. And I don't know that it's been fantastic data on antidepressant use,  as well as antipsychotics, specifically for methamphetamine use disorder.  Mainly with the antidepressant, it's looking at treating the anhedonia, the lack of pleasure after someone stops using.  And also some antidepressants work with norepinephrine as well. And so they can, it's, the thought is, is possibly working with that neurotransmitter may be helpful.  I'm not totally familiar exactly what they're thinking with the antipsychotics, because most of those work on dopamine.  But, and it depends on what type of antipsychotic they're working with. But it's probably, it's somewhere related to this.  There's looking at kind of, in a research trial from January 2021, patients in clinics around the US were treated for 12 weeks with naltrexone and bupropion.  So naltrexone is a medication that helps prevent cravings.  It's, and also, and bupropion is a wellbutrin, essentially. It's an antidepressant. And then they, some of the groups were given placebo.  It did seem to help 13.4% of the patients with their addiction compared to the 2.5 of placebo. So there was some help with this.  It does appear that the naltrexone did help with their cravings and the bupropion helped with the anhedonia.  So there's some research out there on microdosing with stimulants. So using in like a sub, I don't know whether you want to call it therapeutic dose,  like a dose that's lower than what you would take to feel the effect  to see whether that would help. I don't know what the data is coming out on that.  And then there have been some positive effects using long-acting amphetamines for cocaine users specifically. Medonafil, or Medonafil is,  and this is used a lot in the tech industry to help keep people awake.  But it's a long-acting stimulant. In fact, it's thought of not as an amphetamine. It's a non-amphetamine stimulant.  Tuporonamide is also similar in that range as well.  But we need more research.  It would definitely be nice to have a medication out there that acts like the suboxone and the methadone that's for opiates to have towards methadone.  I mean, it's definitely needed.  So thoughts on this kind of here moving towards closing, but we're going to have some discussion here. Access to treatment is absolutely vital  and that's where we're going to be talking about.  Approximately half of deadly overdoses are associated with co-occurring use of opioids.  So this is talking about stimulants that, yeah, this goes to,  it really is that combination can be really risky.  So educating patients that use of stimulants about naloxone and how to access and use it if possible, trained to use and give free care.  Trained to use and give free kits as practice.  And then this is something to like a harm reduction kit for stimulants for meth could include chapstick to help with dry lips, condoms, of course,  glass stems. So that's giving, sorry, giving pipes out for folks. The rubber mouthpieces are what you would put onto the end of the pipe to make it  so that it's less likely to shatter or break and cause cuts, or inhaling glass shards, which is one of the dangerous pieces of the pipes. Clean straws for snorting,  so to make sure that they're not inhaling anything other than just what they intend. Naloxone for if there's opiate use and there's an overdose happening, water, snack,  and then, of course, informational brochures and referral treatment options, and needle exchange.  So, we're not gonna do, well, let's, yeah, let's start incorporating some of this. We don't need to get into groups for this,  but what are the crises that you're currently encountering? You've described some already. It sounds like overdose.  Sounds like, and Damian, I think you were alluding  to this earlier of like, when they're under the influence, you're wanting ideas of what to do  while they're under the influence, is that right? Yeah, well, kind of just like how to redirect and just keep them safe as possible. And they're, at this point, they're belligerent.  What's actually happening?  It just depends on the individual. Most of the time, I mean, some of them will, I mean, there's a couple of guys that are just, you know, I can think of one guy right now.  He's just really recluse. He keeps to himself, you know, puts himself in his room and just kind of stays there, stays away from everybody.  We got another guy that just paces back and forth. He gets really loud. He's, you know, screaming and yelling at the top of his lungs responding to that internal stimuli.  We had another guy that was just, you know, he would, you know, be like, leave me alone kind of thing. But you would notice that he was definitely high.  It just, like I said, it just depends, but those are just generally the main symptoms that we're seeing of the use of the drugs. Or when you knock on their door  and you find them laying down, they're blue on their floor, you know? Yeah. That's the worst case scenario, of course. Yeah, yeah.  Well, the one that's pacing back and forth all the time is starting to engage in pretty significant property destruction. So he's breaking our toilets,  trying to rip the railings off the walls. He's like breaking stuff constantly now and in such an aggressive state.  Got it, okay. And Kara, you know that that's happening when they're under the influence? Yes. There's a substance on board. Do you know what substance?  It's typical, his drug of choice is meth, probably laced with fentanyl, because that's what he overdosed on twice. Okay. He's overdosed twice now under our care.  One time he was found by EMS and police face up in the middle of the street outside. The other time he was found face up in his bedroom. That's when we found him that other time.  So it's, you know, he's the only one that we've had overdose in our facility.  The other ones are just, they're just, they're hard to manage. Yeah.  Trying to keep them away from the other people that have past addictions. And so their sobriety is being compromised in that aspect. So, you know, these guys that are trying  to stay off the drugs and, you know, have already voiced a concern saying, hey, you know, I don't know if I'm gonna be able to handle not, you know, staying off these drugs  if it's all around us all the time. And so it's those guys that we wanna have the preventative treatment for to help them through their potential, you know,  relapse of their addictions. Sure. Okay. Yeah, you've got folks in very different places and that's the challenge that you've got right there  is that you've got folks that are ready to try to stop, but then there's other folks that are not at all ready to stop. Correct. Now, I'm wondering, and a question with that person  like breaking toilets and if substances weren't on board, how would you handle that? Oh, I mean, if the substances weren't on board,  the folks, you can tell when they're off the meth or off the drugs. Yeah. Because they're pleasant. They don't respond to the internal stimuli.  They're easy and their behaviors are manageable. You can, you know, have a constructive conversation  with them and things like that. So you can definitely tell when they're using versus when they're not. Got it. It's when they're using that we have a hard time,  you know, getting them, you know, getting them to,  I mean, although, you know, the one gentleman, he is, he's easily redirectable. If he's responding to, you know, screaming and yelling, you just say, hey, buddy.  And he's like, oh, sorry, sorry, sorry. And he stops. He's very pleasant, polite and everything else. It's just that he caused a disruption to those around him. You know? Got it.  But lately, he's even getting harder to manage because while he can, he'll be polite for a second, he goes right back to the behavior  and he's getting more and more difficult to manage when he's high.  So let me walk through some, because I want to keep this kind of thinking about these situations.  Let me walk through opioids first because it's more straightforward and then we'll get to the amphetamines because it seems like that's really what's at play and that makes sense.  So kind of here with opioids really, it's not that often that opioids only create a crisis other than overdose  because generally someone on opioids only  is going to be pretty calm and easy to work with.  They're only going to get cranky if you Narcan them. Yeah.  Or you,  or yeah, they're coming down. They're more in withdrawal. That's when they would tend to be cranky.  And so, and the piece with it, they tend to be calm and sleepy. And so really it's just making sure that they're not slipping into that overdose  and you probably can get them to be off on their own. You just want to make sure they're still breathing.  And then,  but with stimulants, stimulants is probably what's causing you the most havoc. Alcohol can also be another culprit to this.  And so yes, stimulants can cause an overdose crisis. So you want to be checking vitals to make sure that there isn't a medical emergency if you can check the vitals.  Because the problem is, the person may be so belligerent that you can't actually get close enough to be safe. And so yeah, the overdose is usually heart attack or stroke.  And so, and especially if there's opioids combined, kind of watching for that if you can. The nice part with the opioids is it hopefully mellows them enough that they're not too,  that you can possibly deal with them.  But yeah, there is the risks there.  So behavioral crisis can include agitation, which causes the substance use to become uncooperative, argumentative, or even combative. It can also take on mental health symptoms,  anxiety, psychosis, delusions, worse adding to the crisis of the situation. So what I was asking before, in some ways, when this is here,  because you all probably have like your protocol for a mental health crisis.  And I'm figuring you're all like feel on top of that. Like, and that's, I mean, what is your protocol? Because you're a step down from inpatient care.  You're a step down from inpatient, correct?  Correct. And so is there, and they're coming to you on like less restrictive? Yes. And so is that something like for the toilet stuff, I don't know whether that would kick in.  Well, and so that one, so we had an idea of who that was, but we didn't have any clear evidence that that was that person. Got it. We just had a really high suspicion.  And when we confronted, the two people we thought it was, of course they both denied it. Sure.  So, yeah. Okay. So that was the problem. Typically, if it's something that we can't handle in-house, we contact the designated crisis responders  and we have the mobile outreach team come out and assist. And if they can't get to us quick enough, we just call 9-1-1. Sure.  Because all of that applies.  And so like Ricky's Law, are you familiar with Ricky's Law? We, vaguely, we were trying to use that recently,  but it just, it didn't work for us. So. It doesn't work for most people. I've only heard of it working probably a handful of times total.  And it's because it's really, really hard to, it's hard for several reasons to put in place.  But the reason I bring it up is because with Ricky's Law, what they essentially did was they took the mental health emergency crisis and just applied it to the substance use.  Here, it's like, if you have it, you could just kind of talk mental health terms and possibly go that route.  Because essentially, it really is a mental health crisis. It's just that the substance brought on the mental health crisis. And so, when I work with folks,  it's sometimes like kind of hopefully make it a little easier to just almost even forget the substance if you can, and just look at it straight through that lens.  The part with substance use, where it's supposed to be an emergency on its own is,  the substance use itself has gotten so out of hand that it's out of control. It's out of control. They don't even, they're on such a bender  that they're using and they don't almost even realize they're using as much as they're using. And I don't know if you run into that. That makes sense.  I mean, when you say that, looking back, yeah, that could very well be happening. Yeah, and that is the extra criteria that you could add in.  And the part, unfortunately, with that is,  the person's basically like not there. And so, if you can contain them, great, but of course, making sure you're safe. Right. But really trying to talk to them,  it's gonna have limited effect. It's, yeah, it's, I mean, just like trying to argue with a drunk person. It's the same thing. Exactly. Yeah, you're going around in circles  and not getting anywhere. Exactly, because they're just not there. And so it's more of like, okay, how do I, and when I work with supervisees around this,  I'm like, okay, let's think of their outer safety and do what we can to make sure that they're safe and other people are safe. And in some ways that might mean interacting with them  as little as possible and moving other folks away.  But yeah, and then making sure if they do pass out, like with alcohol, if they are gonna pass out, that their airway is not gonna get blocked.  And then recognizing that with the stimulant, the good part is it tends to be fairly short acting. So after about 30 minutes, you can check in  and they might be in a calmer state, hopefully.  The problem is, is that if it brings the mental health on,  that can last longer because sometimes that can last days, unfortunately beyond.  But yeah, it's less of, it's figuring out how to kind of build safety around them as opposed to interact with them directly.  I know that's not a perfect answer.  But yeah, it's figuring that out. Now, it sounds like there's another concern with how that's affecting the other residents.  Is that right?  It looks like Damien had to step away. Yeah, Damien had to step away. He's meeting a new, someone's stepping in, replacing another physician for another role for MHP.  He's leaving, unfortunately, but yeah. So I think I'm getting acquainted with him. For sure. Briefly.  Actually, oh, you only have two minutes. No, no worries, I'm fine. Did you want, you wanted to ask something? Oh, no, no, no.  I was gonna see if I missed anything significant or not. Well, no.  With the part with kind of looking at other folks,  it's tricky, because it's like, you're gonna always have that mix, aren't you? Of folks that want to stop and folks that don't. Yes, it gets pretty tricky.  And I was talking to the MHPR here these days, it's a matter of fact, it's a matter of them wanting to actually stop, have the desire to stop. Yeah.  But it's just that, here in Lakewood,  we're expressing where we're at specifically,  the drugs are accessible, is that right? Yeah, they are, definitely. And I was born and raised in Tacoma, and you know the parts, where you can get drugs. Oh, yeah.  You just know that they're- Oh, it's easy, yeah. Really easy, that's the sad part. So, I feel like we're in a constant battle. Yep.  You know, with us trying to tell them, don't do it,  but they still want to do it.  But yeah, it's definitely hard. So, that's why I was thinking,  it all starts with, am I? It does, yeah. And in this case, just trying to get to motivate them,  possibly, because I can't just tell a,  any healthcare professional would tell a patient, hey, don't do this, hey, don't do drugs, hey, don't drink.  I think the biggest challenge of all that is ultimately, at the end of the day, most of our residents, I mean, they don't have anything to look forward to.  They don't have family support. Let's be honest, they're not gonna hold down jobs. They don't have anything in their life that's motivating them to stop doing drugs.  And so, that alone, I mean,  we have to be honest as providers, and we've had these conversations where we're like, hey, I mean, maybe if I were in the same situation as them, in and out of jail with no hope  of really leading a normal life, would I not be engaging in the same type of behavior just to kind of get through the day?  So, I think that's the biggest challenge when we're talking about mental health and drug abuse,  because for most of them, the motivation is just not gonna be there. Yeah, they don't see the opportunity. They don't see the point, because the life without it  doesn't look like it's fulfilling. It doesn't look, yeah, like it would be satisfying. Right, it's, right, and for a lot of them, it probably won't be. Yeah, no, that's true.  Yeah, I mean, we, unfortunately, we're coming short on time. Yeah, motivational interviewing definitely would. I mean, also thinking in terms of some harm reduction stuff, too,  because that's part of the difficulty with having folks that wanna stop and folks that don't.  It's that conversation. I tend to focus on the folks that wanna stop and having conversations with them of, yeah, we're really a place to help everybody here.  I'm setting up, and it sounds like you have rules where they can't use on-site.  I mean, yes, we have house rules,  but DSHS has come in and really  had a different opinion in that, in that they've argued that it's their home, right? Despite us being a facility, it's their home and it's their right  to do the drugs inside their room and whatnot because that's where they live. And we've had to hit them pretty hard  with the fact that really and truly that should not be the case. This is not a private home. This is the battle that we have with DSHS  because it jeopard people that are people like, you know, the one that we talked about where we had to evict him, he was jeopardizing everyone's health, patients and staff included.  In fact, we had a staff member that's never done meth in his whole life, just test positive because he was getting labs drawn for a health condition. He tested positive for meth.  And now it's because he was touching the shared surfaces  of that former resident around our facility.  Yeah, so it does impact everyone, definitely.  Yeah, and I know we're coming up on time, but yeah, it would be great to kind of work because I have worked with other organizations that set up where there are folks that use  and folks that don't use. And we talk about how to kind of work through that because it is a challenge.  You're right, Beau, with the piece of motivational interviewing. Yeah, unfortunately, we're really a low on time.  I don't know how much to do to close up, Emily. I'm checking in with you because it's the QR code. And is there anything else? Yeah, okay. I can give one more slide.  And then we can always set up a meeting to discuss additional support consultation  or training that you may be interested in or may be helpful for them. But yeah, we end at three, so we can wrap up.  And we do have a quick link, a quick survey that we wanted to share, just that links, it's an evaluation survey. It's required by our grant. It helps us maintain our funding.  If you can just take a minute to fill it out. I'll put the link in the chat as well. But I think there's a QR code. There's a QR code coming up, Sierra.  So I've already mentioned stuff on this slide here. It's about alcohol. And the main worry with alcohol is if they're gonna pass out and vomit  and making sure that they don't aspirate.  They can become belligerent, similar to what can happen on stimulants, but it's not necessary because it's a depressant. So it's not as likely. So yeah, Emily put the code there.  So here's the QR code.  Emily also put the code in there. This is to the evaluation. I'll even just take a picture of that.  So that way we have it. I got you. I got you on the survey. Great. Awesome.  Well, I will have the recording out within a week or two. And then are you interested in setting up another meeting to kind of talk through anything additional  or further questions, anything like that? I can also follow up with you in a few days. Yeah, no, I mean, we're always hungry for more knowledge,  especially in this epidemic of substance abuse,  substance use disorders, and the increasing number of people that are addicted. And so having more knowledge,  knowledge is power. And so if we can have more knowledge and more education on this, and the better we are equipped to handle these folks and help them to the best of our abilities,  I mean, I'm always an advocate for more education.  So, I mean, if you guys have more time and are willing to work with us, and we're gonna be having more staff, such as Beau and Kara, as we have more facilities open up,  we just, this is our education team right here, right now.  So, it is a small group right now, but we are growing. We have three more 16 bed facilities opening up next year. So we'll definitely have more staff  and the need for more training in the future would be great. But even just having this, today's teachings that you've provided to us  is a huge help that we can pass on to the rest of our staff.  Right? So. Okay, great.  Well, I'll follow up with you. And like I said, I'll have that recording soon. Let me know if you need anything in the meantime. Will do. Thanks Emily, I appreciate it.  Paul, thank you for your wealth of knowledge. It's been definitely, definitely useful. Thank you. Good, I'm glad. Thank you. Yeah, it's been great working with you.

Video Summary

The video in the provided summaries discusses different treatment options for opioid addiction, including methadone, buprenorphine, and naltrexone, with their benefits and distinctions. It emphasizes the importance of understanding the difference between physical dependence and addiction in using these medications. Healthcare providers are urged to have open discussions with patients to tailor treatment plans based on individual needs. The focus is on supporting individuals with opioid addiction towards recovery with the right medication. <br /><br />The transcript also covers managing individuals under the influence of drugs, specifically methamphetamines, in a treatment environment. It addresses techniques for handling behavioral crises, recognizing overdose symptoms, and ensuring safety. The challenges posed by unmotivated individuals due to circumstances and lack of support are highlighted, along with strategies like motivational interviewing and harm reduction. The need for ongoing education and support to tackle substance use issues effectively is emphasized, with a call for further training and resources to assist those struggling with addiction.