Hi, everyone. Thanks for joining us today. I'd like to welcome you all to today's training, the Treatment of Substance Use Disorders, General Principles of Harm Reduction. This training is brought to you on behalf of Neighbor Health and sponsored by the New England Region Opioid Response Network. I'm Jenna Fold, technology transfer specialist, working with the New England region of the ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Services Administration. And our grant prime is the American Academy of Addiction Psychiatry. Next slide, please. So through our grant, we provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulant use disorders. And we cover all areas of the treatment of prevention, treatment, recovery, and harm reduction. And this is provided at absolutely no cost as it's covered through the SAMHSA grant. Next slide, please. Next slide. Today, we are fortunate to have Dr. Joji Suzuki. Dr. Suzuki is the founding director of the Division of Addiction Psychiatry in the Department of Psychiatry at Brigham Women's Hospital and an associate professor of psychiatry at Harvard Medical School. As an addiction psychiatrist on the psychiatric consultation service, his clinical work has consisted largely of conducting inpatient addiction consults in the hospital setting. He has also successfully launched numerous treatment programs, including the Comprehensive Outpatient Addiction Clinic at Brigham and Women's Faulkner Hospital and the Low Barrier, Low Threshold Harm Reduction Bridge Clinic. Next slide, please. We just like to give everybody our contact information if you wish to submit a request in the future. So here is our website, our email, and our phone number. We welcome anybody to submit a request. And then one last thing is before I turn this meeting over to Dr. Suzuki, I wanted to review of the few of the Zoom controls that you'll be using. As we mentioned, we have enabled interpretation services. So if you have not done so, click on the globe icon along the bottom of your screen and choose either English or Spanish. I've also enabled the live transcript feature if you wish to use it. Please use the chat to sign in and provide your name and your role and what organization you are from. You can also use the chat to discuss any need for technical support, for any topic related comments, and to submit questions. We will be monitoring the chat throughout the presentation to answer questions, or you can use the hand raise feature when we address questions at the end. We are going to record the presentation portion of today's training, and it may be shared outside to outside sources. So for privacy purposes, if you're not comfortable, you can remove your name and turn off your camera. We will then stop the recording for the Q&A portions. At the conclusion, we will share instructions on how to claim continuing education credit, and that will be through our learning management system. I will also be sending a follow-up email with how to claim your credit, as well as how to access the slides and the recording. We thank you again for joining us today, and I will now turn it over to Dr. Suzuki. Thank you so much for the really kind introduction, and I'm also very impressed and inspired by the ORN's work in really spreading the word and providing support for all of the country, actually. So it's really terrific what you guys do. So I'm really just really honored to be invited to be able to provide this talk today. And please, at any point, if somebody has a question, just let me know, and I'll try to make sure that we have plenty of time for Q&A at the end. And so here are the learning objectives, and so we're gonna go over a little bit about the sort of basics of substance use disorder, and then really, you know, second half, talking about really what harm reduction is, and some of the controversies that really come along with that. So we're gonna start here. We're gonna start with talking about substance use disorder as a chronic disease, and this comes as no surprise to I think everybody in here already that we're in the midst of a opioid crisis that really started off initially with a rise in prescription opioid misuse in the context of, you know, prescription opioid chronic pain treatment. And, you know, I always, it's a stark reminder, at least for me, because, you know, even when I was a medical student, I remember very vividly writing prescription after prescription during my surgical rotation, you know, after people left for surgery, let's say a hernia repair or appendectomy or gallbladder surgery. Everybody left with large amounts of Percocets, for example, and reflecting on it, you know, I remember very few times when we even discussed, you know, is this safe? Is this, do we need to give this many to our patients? And so I like to argue that the current opioid crisis was caused at least in part by our own behaviors. And, you know, it's a humbling sort of a recognition of that. And if we had a hand in causing it, I think it's really important that we play a role in sort of addressing it, the consequences. As we all know, as the rise in prescription for opioid misuse increased, that led to an increase in heroin, and then eventually to the rise in synthetic opioids, specifically fentanyl, and which continues to wreak havoc locally here, but also nationally as well. Now, amidst of this, you know, really terrible news, of course, there's been some good news. I'm sure people have heard in the last couple of weeks that the CDC has announced that in the last, what we believe in the last year, we may have finally seen a pretty big drop in overdose mortality. And this is true locally. So this is from the latest Department of Public Health data suggesting that there's been a, you know, a good decline in the number of overdose deaths here in Massachusetts. And this trend has been mirrored across the country, which is the good news. The bad news is that these numbers are still extremely high. When you look at this graph at the 2001, you know, all the way on the left side of the graph, that's when I was finishing medical school. We were already talking about the heroin epidemic in the Boston area and other places in the country. So even though compared to what it is today, it wasn't as bad, but it was already bad enough. And so we're, you know, we're happy to see a decline in overdose mortality, but what we need to remember is that for each overdose death that occurs, there are many, many hundreds of non-fatal overdoses and people who suffer from consequences from the opioid use disorder itself and ripple effect that goes across the entire community, you know, and their region. So again, this is good news, but we can't let up. And this is still hopefully the start of a trend that we want to see going forward. One of the major contributors I've already alluded to is a rise in fentanyl. And here in Massachusetts, we saw the transition from heroin to fentanyl quite a while ago. It's already been since 2016, 2015, 2016. As you see, the darker blue line back in 2014 was pretty low. And there was a dramatic increase in 2015 and 2016 where it overtook heroin as the most common opioid found in the illicit supply. And fast forward to today, fentanyl remains the top, you know, illicit opioid found in those who have a fatal overdose. The light blue line is heroin. So in fact, heroin, the entire list, it's the lowest ever. So it's really heroin is virtually unattainable or unavailable, and it's really replaced with fentanyl and other types of drugs in the supply. And what's scary is that we don't actually know what's truly in the supply because if you don't test for it, you don't know what's there. Xylosine is a good example. You know, the state does conduct some surveillance on xylosine, but we don't have a full understanding of the extent to which xylosine and other adulterants have, you know, penetrated the drug supply, which likely has been a major contributor to the overdose test as well, in addition to the fentanyl. But fentanyl alone is what's killing people and it's hurting people. And this is, you know, unfortunately, we're seeing this trend across the entire United States where gradually moved all across towards the West. And now in the West Coast, for example, fentanyl is predominant and it's turning into what we're seeing here today. Now, one of the, you know, for me as an addiction specialist, one of the concerning things that hasn't really changed, you know, despite many things are better today, this thing hasn't changed a lot. And what this graph shows is that the government conducts a national survey each year of the general population to try to understand, you know, how many folks are out there who suffer from a substance use disorder or mental health conditions, you know, et cetera. And in addition to that, they ask a question. Okay, there's a certain number of people who have a substance use disorder or a mental illness. Out of those people, how many of them actually receive any kind of formal treatment? And so when it comes to substance use disorders, we believe that there's, you know, many millions of, you know, Americans who likely suffer from a substance use disorder. So here it suggests maybe 20 million or so. Out of that, 92.3% did not receive any formal treatment for that disorder in that given year. And this proportion, meaning less than 10% of individuals who have a substance disorder received any kind of formal treatment. And formal treatment, in fact, for this survey is defined extremely broadly. Going to see a primary care doctor for the substance use disorder, you know, going to a specialty program, you know, detox unit, outpatient counseling, even AA meetings, Tulsa, you know, Tulsa meetings, for example, they all count. What this suggests is that despite all our efforts to try to increase awareness and access to treatment, the majority of individuals actually either are unable to access it, cannot find places that are, you know, available, or can't afford it. And of course, there are many other reasons that complicate, you know, why the vast majority of individuals do not receive treatment, but this is something that we're working very hard to try to change. If you compare that to mental illness, it's always been about 50%. The proportion is actually lower. What that means is only up to about 50% of individuals with a psychiatric illness or mental health issue receive any kind of formal treatment. So depression, anxiety, trauma, et cetera. And so there too, we need to do a much better job. And one thing I'll point out is that when it comes to mental health treatment, the majority of treatment actually comes from general health practitioners. You know, these are primary care physicians and nurse practitioners, et cetera, in places, in community settings, not specialists, or certainly not necessarily mental health specialists in a specialty sort of clinic, for example. And so something similar really needs to happen, likely, for substance use disorder treatment as well, where it's not just an issue that's handled by specialists. One of the things that we've learned, you know, very acutely in the last couple of decades is to really shift our way of thinking about substance use disorder from thinking of it as an acute illness that you can sort of fix into thinking of it as a chronic illness. And, you know, we're all very familiar with chronic illnesses listed on the bottom there, things like hypertension, diabetes, obesity. These are illnesses that you can't cure by going to treatment. Now, you can put it into remission, for example, but even if you attain normal blood pressure, it doesn't mean you're never gonna get hypertension again. And, you know, I'm sure everybody struggles with weight to some degree. You know, it'd be nice if once you lose weight, you're never worried about getting weight again. That's not true. We all know that. And so what that means is that chronic illness is something that you have to constantly sort of work at to keep it in check. And so relapses are common. It requires management, sustained management over time. And many of these, most chronic illnesses, actually, are influenced largely by personal lifestyle, you know, choices and behaviors. Diet, exercise, consumption of certain things like alcohol or drugs, smoking, cigarettes, et cetera. These behaviors, you know, lifestyle choices, actually, are likely the most important contributing factors to chronic illnesses. And so substance use disorders is actually very similar to other chronic illnesses that we manage, you know, each and every day. And when you start to see it that way, what's really interesting is that the actual outcomes that we experience, that patients experience when they receive treatment, is that they actually do pretty well compared to other chronic illnesses. Again, if you compare it to diabetes, hypertension, asthma, obesity, patients respond to addiction treatment. They actually do really well. And there's a perception that somehow, you know, addiction is less responsive to treatment. And I would argue, and, you know, when I compare notes with my medical colleagues in primary care, for example, we would argue that treatment for substance use may in fact work even better than compared to things like diabetes or obesity or hypertension. But again, the point is, you know, we've really transitioned away from thinking substance use disorder as a acute illness, like an infection, that you can just fix by, you know, going to a two-week program, to thinking of it as a chronic illness that you have to learn how to manage over a long period of time. I wanna just go into it very briefly, and, you know, I don't wanna get into too much of a detail, but really understanding the, you know, what is substance use disorder? And why is it that we think of it as a chronic illness? And why is it so hard, you know, to change behavior? This is a current DSM diagnostic criteria for substance use disorder. It's listed opioids, but it's virtually the same, whether it's alcohol, cocaine, you know, cannabis, opioids, the criteria are the same. And there are currently 11 of them. And then depending on how many you meet, it kind of signifies the severity of your substance use disorder. What's common across all substances is this concept of physiologic dependence, characterized by two critical things, tolerance and withdrawal. Tolerance means that you build up, you know, resistance in a way to the substance. And then to get, in order to get the same effect, you have to keep using more. And this is largely true for all the substances. And the flip side is that when you stop using or, you know, cut back on your use, many times you experience withdrawal symptoms. And this is very prominent with alcohol, opioids, benzos, et cetera, and less so in some of the others, but these two represent what we call physiologic dependence. What's really important to understand is that the physiologic dependence is often a part of substance use disorder, but it's actually only a peripheral part of it. The key things about, when we think about substance use disorder, are the other categories. And this yellow component represents this inability to control this particular behavior. So using more than intended, persistent desire to cut back, but inability to do so. You keep using despite knowing that it's actually harmful, and then spending a lot of time obtaining and using and recovering from substance. And so loss of control, in my mind, is probably the central feature of a substance use disorder sort of presentation. It's this inability to control that's a central feature of a substance use disorder. And this is maintained by the sense of this subjective urge to want to use, and we call it cravings, but it's actually no different than let's say hunger. Cravings and hunger are subjective experiences that drive the organism to seek out that particular behavior. And that's how you know to get up and go get that thing. And if it's hungry, then you know to eat. If you're thirsty, you know to drink. And for substance use disorder, it's really the cravings. And I'll talk a little bit more about why that happens. And then finally, the last category of the things that really define a substance use disorder really is that it's causing harm. So using substances when it's harmful to do so, or hazardous. So drinking and driving is sort of a classic example. Important things are given up. So social activities, occupational, interpersonal issues are given up in favor of the substance use. Failed role obligations. So, you know, if you're a student on the inability to, you know, get your schoolwork done, or missing work, or parental, you know, responsibilities, those are another, you know, feature of the harms that can come with substance use, and then finally social conflict. And so the bottom three actually are the more important sort of elements of a substance use disorder, and sometimes we call this the three Cs. Loss of control, cravings, and accumulating negative consequences. And so, and the reason I do that is that physiologic dependence often is sometimes thought of as the same thing as addiction, or a substance use disorder. So for example, if somebody is taking a medication that can cause physiologic dependence, let's say you're taking opiates for chronic pain, you're naturally gonna develop physiologic dependence, but it's not the same thing as a substance use disorder. And that's really important when it comes to when we talk about treatment options, like buprenorphine or methadone, because they too can cause physiologic dependence, but actually you don't manifest the three Cs, which again, really characterizes behavioral syndrome that we call substance use disorder. And very, very briefly, so when we think about how substances affect the brain, there's one part of the brain that really people have focused a lot on in research, and it's called the mesolimbic reward pathway, or your brain's way, the brain's mechanism of experiencing pleasure or reward. And we humans, we'd like to generally avoid pain and move towards things that are pleasurable and rewarding. And the part of the brain that mediates that is called the mesolimbic reward pathway. And VTA stands for ventral tegmental area, which is deep inside in the brainstem. And it sends chemicals into this other part of the brain called the nucleus accumbens. And basically all substances that people can get addicted to, like opioids, alcohol, cocaine, et cetera, activate this part of the brain, including natural rewards. So food, sex, enjoying a nice movie with friends, social comfort, anything that's rewarding actually will generally activate this part of the brain, not just substances of misuse. So eating a cake will actually activate this pathway very nicely. And that leads to the subjective experience of, ooh, I like this. This is enjoyable. Now, if you keep doing this, and so in fact, that's mediated through the release of dopamine. So dopamine is sometimes, I'm sure you've heard, is a pleasure chemical. And so when dopamine is released, you generally experience pleasure. And we're designed that way. You know, we're made that way. And that's why we seek out things that are pleasurable. Now, if you overdo it, and if you, let's say you just ate a whole cake, you know, multiple times a day, generally what happens is that your brain develops tolerance, like I just mentioned. This is a natural phenomenon. If you flood the brain with a reward, there's a counteractivity that occurs in the brain, which is to say, okay, that was enjoyable, but let's not get overwhelmed by that. And so the brain actually begins to tolerate to it and adapt to it. And if that's all that happened, actually we would stop doing, you know, pleasurable things actually, because they're no longer enjoyable. The trick here, and what's in a way, sometimes what we think of how substances can hijack the brain is that when the dopamine is being released, not only are you experiencing reward, but it's teaching the brain that this is important. And the term that's used in the scientific literature is incentive salience. And it simply means that it's, the dopamine is a signal to the brain that says that this thing that you're doing is important. So it's both giving pleasure, but also teaching the brain that it's important. And the reason why this is important distinction is that as your body begins to tolerate to the substance, you actually enjoy less, but you want it more, you crave it more, you seek it more, because the dopamine is telling the brain this is important. And so, and this becomes very apparent when that particular drug is no longer available, then the brain starts to scream out, where's that thing that you've been telling me is really important? I need that. I want that. I crave that. And so this is the paradox of addiction or substance use disorder. Even as you continue to use this particular drug, for example, your body actually starts to say, let's not get too much enjoyment out of this. But paradoxically, the brain wants it more. And so as the addiction progresses, the challenge is that the person might say, and I'm sure you've heard this from patients say, I don't really enjoy snorting heroin or fentanyl as much as I used to anymore, but I can't stop. And that's exactly why addiction, substance use disorders can be so hard to stop is that the brain craves it. And the other thing that happens, I'll just quickly point out, is that I mentioned that the reward you experience goes down. Because again, if you flood the brain with rewarding chemicals, the natural response of the brain is to actually adapt to it. What's really unfortunate that happens with that is that the person's brain is unable to experience joy or reward from other types of natural rewards. So even as your brain is starting to say, I don't wanna enjoy the heroin as much anymore, it does the same thing for other natural rewards like food or sex or watching a nice movie or hanging out with friends. Those things become less enjoyable as well. And these changes that I'm describing take time to develop and they are actually permanently wired into your brain. Basically, these are memories being laid down in a way. And just because you stop using drugs doesn't mean they suddenly go away. In fact, those connections that you've made in the brain actually take years, if not decades to change. And so that's one of the reasons why, again, we think of substance use disorder as a chronic illness because these changes that have put into place don't revert back. In fact, there may be some things that are likely to be permanent. Again, it's like memories, right? If you can't erase a bad memory from your brain, it's actually, it's always gonna be there. And you have to figure out how to sort of navigate around that. And addiction is, substance use disorder is similar in that way that once you lay down those connections, it's never gonna go away. So I used to be a smoker and it's been a while since I've smoked, but I know that I can't just pick up a cigarette and have a cigarette because that will lead to me wanting another one. And before you know it, I'll be smoking a pack a day again. And so my brain is not the same as it was before I had my cigarette. And so this is the challenge that I think our patients face is that once you lay down those connections, they actually don't go away. And these cravings that people experience, again, are no different than the hunger you experience when you're hungry. The whole point of hunger as a subjective experience is that it's pretty compelling, right? And it makes you get up and go look for food. That's precisely the reason why your brain is designed for you to experience hunger. And substance use disorder really taps into the same part of the brain. When you feel those cravings, actually it's really, really, really hard to resist. And we can also see physical effects of substance use disorder as you progress. And these are looking at the dopamine receptors actually in the brain. On the left side, you see a healthy individual who doesn't have a substance use disorder. And then in the middle, that's somebody who's actually developed a substance use disorder. And then on the right, you see actually over time during treatment. And so the bright red suggests there's a lot of dopamine receptors. And actually, as you flood the brain with the reward, actually the brain actually removes some of those dopamine receptors so that you don't experience as much of the reward. But with treatment and recovery, it actually can revert over time, but it does take time. So how does active treatment work? So, like I said, this is the brain image showing that the brain will get better over time, but it does take a lot of time to recover. The general approach that we adopt, and this is true for all substances that we think about, is that there are three legs to the treatment. We think about addressing the biological aspect using medications. And so with opioid use disorder, we're very lucky that we have some excellent treatment options, including buprenorphine and methadone. I'll talk more about buprenorphine in a second. Counseling remains important. Abstinence is not the same as recovery. And recovery can come in all kinds of forms. And talk about harm reduction, obviously, and recovery is all kinds of things, not just abstinence. And counseling plays an important role for people to understand how to be safer, how to reduce harm, how to actually prevent relapse, treating concurrent mental health conditions, et cetera. Counseling, I think, plays a very big role. And then the third leg is this concept of creating a recovery-supportive environment. So it's not just a person's biology, it's not just a person's psychology, but also the person's entire physical and social environment are all important aspects to think about when we think of treatment for substance use disorders. And medications can be very powerful in really reducing the effects of cravings that I just mentioned, but also addressing any kind of withdrawal that can emerge. Again, counseling is very important for people to understand how to approach this. And then finally, again, the recovery-oriented system is very, very important to recovery. When it comes to counseling, we think of all kinds of, there's no one right way. And that's another, I think, an important concept when we think about the three legs is that these are basic principles that we adopt, but ultimately the individual's journey is highly individualized. They take many forms, and it's really being able to honor and respect all pathways to recovery, however they look, and however the person's choice, actually, if they're choosing to adopt a certain pathway, we should honor that, we should respect that. And counseling takes the same sort of approach. There are many types of sort of counseling that people can engage in. Sometimes people don't want counseling, that's okay. We wouldn't certainly offer it if people certainly want it. And then creating a recovery-oriented system or recovery supports is really, really important. One of the key things that we talk to our patients, for example, is the idea that you probably do need to create a healthy support network for you. And sometimes that's not easy to do. And a lot of our patients have to navigate that and figure out on their own with help to try to create a supportive environment for them. So let's transition now to thinking about, how does this all fit in with this concept of harm reduction? And in a nutshell, this is sort of the textbook sort of definition of it. It's a concept that we recognize that drug use is part of our world. And we shouldn't work to minimize the harmful effects of it. And on its own, this seems very obvious. Seems like there should be no controversy around that. But I think too often, harm reduction is put in opposition to abstinence or other types of treatment. Harm reduction is a basic approach that we adopt in all kinds of treatments, whether it's substance use or not. And it's certainly an approach that we adopt in public health approaches, as well as chronic disease management. Harm reduction is sort of the mainstay of the way we approach many of the chronic illnesses. And it's the idea that, and again, this is where I think the greatest controversy arises, is the idea that abstinence is not the only desirable or appropriate goal to adopt. This is a really, really important concept. Not everybody wants abstinence. Not everybody wants the structured program or abstinence model of care. That's okay. Again, honoring and respecting all pathways of recovery suggests that for the time being, this is what the person wants. And any movement towards reducing harm should be celebrated and honored. So for example, when we think about alcohol use, and I've had many patients over the years who drink very, very heavily, 15 drinks a day, 20 drinks a day. I mean, those are very large amounts of alcohol being consumed and if a person were to tell me, doctor, I've tried abstinence, it doesn't work for me. You know, I just want to cut back to only drinking, you know, five drinks a day down from 20. There was a time when addiction specialists like us would actually say, that's actually not possible. That's actually not desirable and you probably couldn't do it anyway and it's not even an appropriate goal. The only appropriate goal is to stop completely. We now understand that actually any reduction in drinking is a good thing to celebrate. And even just having a person think about cutting back is already, you know, a step in the right, you know, a step in a good direction that we would honor. And in fact, the, you know, I think for alcohol, we have a greater recognition of that. Many of us drink alcohol socially, right? We would say that being able to control your drinking in that way is actually, you know, a good thing. There's a greater recognition now that this applies to all substances, whether it's heroin, fentanyl, cocaine, you know, et cetera. Any reduction is actually a good thing. Anything that can reduce the harm of that substance is a good thing and we should honor that and celebrate that. In fact, again, this is an approach that we adopt in many spheres in life. So these are some examples of harm reduction approaches that are quite successful. Seatbelts, helmets when riding bicycles, designated drivers using sunscreens, you know, bars. That's my favorite example in a way. But all of these are examples in which, you know, we could argue that the best way to reduce harm is to say, don't drive, don't ride a bike, you know, don't drink, don't go out in the sun. You know, you could say that, but that's, you know, unrealistic as we all know. We all, you know, some of us do have to drive and some of us do have to, you know, be out in the sun. And so, but any, you know, any approach that can reduce the harm of that we think is a good thing. Believe it or not, seatbelts, when they were first introduced were controversial. You know, it's sort of not controversial today, but there was a time, and of course, I'm sure many of you remember a time of driving in cars where we didn't wear seatbelts. But when they were first being introduced, I think in Europe, Sweden or somewhere, so long before the U.S. adopted, you know, a seatbelt requirement, one of the criticisms was that it may, it may actually lead to more risky driving. Then now drivers would say, oh, now I can just drive recklessly. Now that seems like an odd criticism, but that in fact was one of the criticisms that was made earlier on with many of these interventions that it would actually lead people to engage in more risky behavior. There are some people who do, but by and large, it is not true. So the vast majority of us do not drive more recklessly just because we have a seatbelt. And just because there are bars, it doesn't mean people drink more recklessly. I think we can all agree that alcohol is not going away. We've tried, as we all know, that we've tried efforts to prohibit it, but it hasn't worked. In fact, that likely leads to worse outcomes. I think we can all agree that alcohol is not going away. In fact, many of us enjoy drinking occasionally in social situations. It's weaved into the fabric of our lives in so many settings. I think having bars where people are designated to be able to consume alcohol, purchase a legally produced, you know, quality products, and there's some safeguards in place about who can buy, you know, they check IDs, and if you're completely intoxicated, they're not supposed to give you more beverages, you know, et cetera. And they can try to call an Uber for you, you know, if they knew you drove to the bar. There are ways to reduce the harm from alcohol consumption. And we think having bars is probably a better, you know, option than simply saying, no, you can't drink, and then people end up drinking out in the public. That's probably, you know, probably not a good solution. So again, the harm reduction approach is a norm. And this is not unique to substance use. And so sometimes I actually feel tension or this conflict in why should we talk about harm reduction when it comes to substance use? Because that's the only time I hear it, you know, most predominantly. We don't hear about harm reduction when it comes to these other approaches, you know, as often. And when it comes to substance use specifically, there are many things that we do, like providing clean needles, you know, overdose reversal with Naloxone, medications for OUD, or drug testing services, or safe injection, or safe, you know, use supplies, or even supervised consumption sites. Again, I would argue that bars are already supervised consumption sites for alcohol. And all of these interventions may not fix the underlying illness, but are working towards reducing the harms associated with that substance use. And we would say that all of these are actually beneficial, you know, to our patients. So put in that, you know, perspective, buprenorphine itself is a harm reduction strategy in a way that it doesn't actually cure the underlying opioid use disorder. It has risks associated with it. If you mix it with other substances like alcohol or benzodiazepines, it can be potentially dangerous. It can cause physical dependence, like I talked about earlier. You can still, you know, choose to use, you know, other opioids, and inject it with buprenorphine, for example. It can be diverted for, you know, for profit or for to buy drugs, et cetera. However, 20 years of research and clinical experience has demonstrated extremely robustly that buprenorphine reduces overdose mortality. We think probably 60 to 70% overdose mortality and all-cause mortality goes down by using buprenorphine. If you're taking buprenorphine, it's actually hard to experience the effects, the euphoric effects of things like fentanyl and heroin. And it keeps people, you know, in recovery much, much, much longer. All related medical outcomes actually improve on buprenorphine. And just because you're on buprenorphine doesn't mean you stop using other drugs. Like I said, you can still use, you know, drugs in combination with buprenorphine, but the net effect is reduced harm, reduced use, you know, reduced mortality. I improved health outcomes across the board. We accept this for diabetes treatment. We accept this for obesity treatment, and it's the same concept in addiction treatment as well. So again, when it comes to substance use, it's a chronic illness, and any sort of reduction in use or desire to use actually is terrific, and we should honor that and celebrate that. And because the neurobiology is so compelling, you know, the cravings that people experience are so powerful that even if somebody's highly motivated to cut back or stop, it's still difficult to do. And so, you know, it's really, you know, ongoing drug use or relapses are in a way thought of as a normal part of recovery. In fact, it's hard to avoid that. And so we shouldn't immediately assume that a relapse or ongoing drug use is a failure. We wouldn't say that about, let's say, diabetes treatment. Just because somebody's, you know, blood sugar is not perfect, it doesn't mean treatment has failed. Any movement to get healthier, we would celebrate and honor and respect. And what's critical to understand is that sort of, you know, aiming for abstinence or, you know, encouraging that is part of harm reduction. You know, abstinence can be a goal. It doesn't mean, harm reduction does not imply that abstinence should not be the goal. For somebody who wants that, we should definitely, you know, encourage that and support that goal. But the reality, again, is it may not be the right goal for everybody for that particular point in time. You know, even if a patient right now is saying, look, I don't want to completely stop, that could change, you know, a year from now, five years from now, 10 years from now. And that happens all the time. We see this in treatment all the time. Goals can shift and goals can change, and that's okay. So right now, abstinence may not be the goal. We can still support that and honor that. In introduction, you know, you heard that we have a bridge clinic. It's many, you know, hospital systems and health organizations have launched our bridge clinics. And one of the defining feature of a bridge clinic is this concept of a low barrier, low threshold. And whether somebody wants abstinence or not, whether they choose to continue to use substances or not, our doors are open. Our patients are welcome. If the goal is to just have a conversation, just have coffee with us, we'll do that. And again, just engaging with us, we would see as a positive. Now, the reality is, you know, harm reduction as a term has remained controversial. And, you know, I finished medical school in 2002, so it's been over 20 years that I've been in practice. But I remember even back then, the harm reduction was a sort of a controversial H word. You know, you have to be careful to whom you said that word because it could be very, you know, some people get very upset because there's a perception that it's ineffective or that it enables, you know, poor lifestyle choices or behavior, or that somehow we're accepting unhealthy behaviors or that it sends the wrong message about drug use. Now, I'm gonna counter that and say, actually, you know, because harm reduction is a default position that we adopt in healthcare, this is not unique to substance use. If you give insulin to somebody with diabetes, it helps to control their blood sugars. It doesn't cure their diabetes. Insulin does not change their underlying behaviors that may contributing to their diabetes and hyperglycemia, like the diet, for example, but we still provide it. We think it's critically important to provide insulin treatment to somebody who has, you know, high sugars because it reduces harm. And so I generally don't hear people argue that insulin is, you know, enabling poor lifestyle choices. You could make the same argument, but I think there's a greater understanding and recognition that something like insulin is very important to provide. Same thing about blood pressure medication. You know, if somebody has high blood pressure because they smoke cigarettes and they don't exercise, you know, you could argue, you know, high blood pressure medications are, you know, accepting the hypertension and sending the wrong message about, you know, lifestyle choices. Shouldn't the person lose weight, exercise, stop smoking, and they may not need the blood pressure medications. You could make that same argument, but I think most of us would agree that if they need the medications, we should provide that. And we shouldn't stigmatize the treatment itself because even if, as we all know, even if somebody is highly motivated to change their behaviors when it comes to diet, exercise, smoking, we all know how difficult that is. So that's why we recognize and accept that treatments like insulin or high blood pressure medications are critically important because they reduce harm and they can support the person's overall, you know, health-related goals. Same thing can be said about the GLP-1s. That's a hot, you know, medication today. You know, the semaglutide and others, people lose weight without, seemingly without a lot of effort. Is that somehow sending the wrong message about obesity treatment? I don't think so. I think it's, we would all agree that, you know, treatment with medications, even if it doesn't cure the underlying illness, can actually be very, very beneficial and helpful to our patients. One thing to recognize is that part of the, I believe, and many other folks believe, is that for drug use and substance use, we're less willing to accept this concept of a harm reduction approach, partly because the underlying behavior, substance use, is actually one of the most, in fact, if not the most stigmatized behavior and health condition in the world. This is based on surveys done by the World Health Organization. And really alcohol, you know, over-consumption of alcohol and drug use especially are some of the most stigmatized behavior and health conditions compared to all other health conditions. And, you know, but another sort of flip side is to really, you know, not make it seem like if you just did harm reduction, everything would be fixed. That's a misconception also. Harm reduction is part of a larger effort overall, and it's simply an approach. You still have to implement the actual treatment services and provision of, you know, care, affordability, accessibility, availability. You know, there are so many other things that actually have to come into play that harm reduction alone is not a solution per se. But as a public health perspective, it's really important. And this is just, you know, sort of the lesson learned from, you know, Oregon, where, you know, certain harm reduction approaches were sort of, you know, implemented, but it has to be done in the context of a larger whole. Again, providing treatment services and making treatment available and accessible and affordable. These are systemic issues that also have to come into play. But the stigma issue is really important because stigma alone can actually lead to worse healthcare outcomes. And again, because substance use is the most stigmatized illness, that actually plays a big role in why harm reduction or treatment services are not as accepted or available. And just the final thing is that the words that we even use to describe, you know, some of the things that our patients experience are sometimes inherently stigmatizing. And the big one is sort of the term substance abuser versus, you know, an individual suffering from a substance use disorder. This particular study actually gave, you know, healthcare providers different vignettes about a particular patient. And all they did different, you know, there are two versions of it. One version, they call the person, you know, somebody having a substance use disorder. And the other version, they call this person a substance abuser. And those clinicians who received the vignette that said substance abuser actually had more negative perceptions or wasn't as willing to provide treatment or was much more skeptical that treatment would work. So even something as simple as, you know, certain choices of words can actually impact, you know, clinical care and healthcare outcomes. And so these are some of the examples of the words that we're trying to move away from and to really include, you know, non-stigmatizing and person-centered language because the words alone can actually lead to negative outcomes.

Substance Use Disorders

Harm Reduction

Addiction Psychiatry

Chronic Diseases

Relapse Prevention

Overdose Reversal

Stigma

Recovery Pathways