Hello everyone, thank you for joining. I would like to welcome you to today's training, the training that has to do with the treatment of consumption disorders. from substance to general principles of harm reduction. This is an event promoted by the Opioid Response Network. I'm Jenna Full and I work with the New England region. ORN is funded by a grant from the Mental Services Administration and the Academy of Psychiatry. Next slide, please. I already said, we provide, so We offer evidence-based technical support to groups of individuals and organizations with a view to the treatment of recovery from opioid use disorders and stimulants, and everything that has to do with harm reduction, treatment and recovery of opioid use disorders. Next slide, please. Next slide. Today we are lucky, we are lucky because we have Dr. Georgie Suzuki. Dr. Suzuki is the director funding of the Division of Psychiatry and the Department of Psychiatry of the Hospital of Regan Women and associate chair of Psychiatry at Harvard Medical School, Harvard School. As a consulting psychiatrist, his clinical work has consisted of performing consultations with patients in the hospital setting. She has also launched several programs treatment, which includes the patient clinic at Dr. Hopkins Hospital and also what is the reduction clinic. And next page, please. We would also like to give to all of our contact information in case you would like to submit a request in the future. Here is our website, our email, our phone number. We give welcome anyone who wants to make a request. And finally, before giving the word to Dr. Suzuki, I would like to review the Zoom controls that you will be using. As we have already mentioned, we have allowed interpretation services. So, If you have never used interpretation, just look for the bubble at the bottom of the screen and select Spanish Input. We also have what is the transcript. If you wish to use it, please register, give your name, your role and Please tell us which organization you come from. You can also use the chat to talk about any need for technical support for any feedback and also to submit questions. We will be monitoring the chat throughout the presentation to answer questions. Also you can use your hand if we have questions at the end. We're going to record the presentation portion of today's training and share it with outside sources. So, If you don't feel comfortable, you can remove your name and you can turn off your camera. We will then stop the recording for the question and answer portion. When it's over, We're going to share instructions on how to request continuing education credit. I'm also going to send a follow-up email on how to request credit and how to access the slides. We really appreciate you being here today and I'm going to turn the floor over to Dr. Suzuki. Thank you very much. Thank you for that kind introduction. I too am very impressed and very inspired. for all the work of its network offering support for the whole country, actually. It is truly The work they do is incredible. It is an honour for me to be invited and to be able to participate in this meeting today. And please, if anyone has any questions, just let me know and I'll try to help. make sure we have enough time to have a question and answer session afterwards. And if you want to hear the learning objectives, well, let's see a little bit what it would be like to explain the neurobiology of substance use disorder. And we're also going to acknowledge the controversies around the harm reduction approach. So, first let's start with what would be neurobiology, addiction as a chronic disease. The crisis was initially fueled by what was the over-prescription of opioids as a treatment for chronic pain. And this is a reminder, at least for me. When I was a medical student, I vividly remember writing prescription after prescription during medical rotation, When people, for example, had to undergo surgery, an appendectomy or a hernia, everyone went home with a lot of medication. And now, reflecting on this, I remember very few times when we even talked, but this is certain, we need to give so many medicines to our patients. I like to argue that the opioid crisis was caused, at least in part, by our own behavior. And this is a humble admission. If we have been causing it, then I think it is right now that we play a role in addressing the consequences. As we all know, the increase in prescriptions also led to an increase in heroin and an increase in fentanyl, which are synthetic opioids, And this is causing a real crisis at the national and local level. Now, we do have a glimmer of good news. Some people have heard in recent weeks that the CDC has announced that in the last year we may have finally seen a drop, a drastic drop. in terms of the brutality of overdose. And this is true locally and we have seen this from public health information. So, this is a good decline. And the numbers here in Massachusetts also seem to be doing that and it's reflected across the country. That's good news. The bad news is that the numbers are still high, very high. Very high. So, for example, when we look at this chart from 2001, That was when I was finishing what was the information as a doctor. We are looking at the heroin epidemic at that time, the Boston area, in other parts of the country. At that time, compared to now, it wasn't that bad, but it was very bad. And you have to remember, for every one of those deaths that happen, There are many, many hundreds of overdoses and people who are suffering the consequences of opioid overdose and this cascading effect is felt in all regions. So again, we have good news here, but let's hope that this is the start of a trend that is not going to happen, but rather to continue. And one of the main contributors to this epidemic that we have right now is the rise of fentanyl. Here in Massachusetts we've seen the transition from heroin to fentanyl. 2016, 2015, 2016 is when we see the beginning of fentanyl. We can see that dark blue line. 2014 looked low. However, there is a dramatic moment, 2015, 2016, where it surpassed heroin as the most common opioid. that could be found widely. In fact, today fentanyl remains the main opioid where we find the most overdoses. The light blue line is heroin. In fact, we see that heroin across the list is at an all-time low. Truly, heroin right now looks that is less available, but that heroin has been replaced with fentanyl. And the scariest thing is that we really don't know what's there, because if you don't test it, you don't know what's there. For example, there is, for example, Sílenel. Sílenel does have research, but even with that We don't quite understand what's in it and we don't quite understand how it got into the supply of, well, this, yes, along with fentanyl. Fentanyl right now This is what is killing people and continues to kill people. And unfortunately we continue to see this trend in general in the United States. We see that It's advancing on the West Coast. For example, fentanyl is predominant and now in the central part as well. And this is the epidemic that we are seeing. For me, as an addiction specialist, one of the most important aspects is that, although the medicines are better now, This has not changed much. And what this shows is that the government conducts national surveys every year of the general population to try to understand how many people are out there who have substance abuse disorder or problems mental health. Along with this comes the question, okay, so there are a certain number of people who use substances or who have mental illnesses. How are these people? How many of these people actually receive any kind of formal treatment? So when we talk about drug abuse, of substances, we believe that there are many millions of Americans who possibly have a substance abuse disorder. Of that number, 92.3% have not received any formal treatment for that disorder in that given year. And this percentage, that is, less than 10% of individuals who have a disorder substance abusers come without receiving formal treatment. And when we talk about formal treatment, here in this survey it is defined very broadly. For example, going to a program specialty, go to a toxicology unit, go to therapy, go to outpatient visits. What this suggests is that despite all the efforts we make, We have to increase awareness, access to treatment, etc., most individuals either cannot access this treatment or they cannot find places that are available for that treatment they cannot afford it. Of course there can be many other reasons that have to do with other complications and so on, but this is something that we are working hard on, we are trying change. If we compare this with mental illnesses, we are talking about 50%, the percentage in fact is a little lower. What this means is that only up to 50% of individuals who have psychiatric or mental health problems receive any kind of formal treatment, depression, trauma, etc. So, there we need to do a much better job as well. Now what we see is that for mental health treatment Most treatment comes from primary care physicians, nurses, etc., in community settings. Not from specialists, not necessarily mental health specialists, in specialized clinics. And something similar would have to happen for substance treatments, where It is not just a matter for specialists. One of the things that has happened over the last two decades has been that we have needed to change our way of thinking about these diseases and start thinking that these are chronic diseases. We all know about chronic diseases. Things like hypertension, like diabetes, obesity, those are diseases that we cannot cure. You can put it into remission, but even if you get normal blood pressure, it doesn't mean you won't get hypertension again. I think we all struggle with weight to a greater or lesser degree and if you lose weight, that doesn't mean you never have to worry about gaining weight again. This is something that you always have to keep working on to keep it at bay. So relapses are common. This requires ongoing management. Over time, most people will Chronic disease pathways are influenced by lifestyle choices and behaviors. Exercise, diet, consumption of things like alcohol and drugs, and guerrilla warfare. These behaviors and lifestyle choices are probably the biggest contributors to chronic disease. So substance use is similar to chronic disease. in many ways. And once we start looking at them that way, what's really interesting is that the results What we experience, what patients experience when receiving treatment is that they do quite well compared to other chronic diseases such as diabetes, hypertension, asthma, obesity. Patients respond to addiction treatment really well. And there is a perception that somehow addiction responds less to treatment. And I would argue with the results of other colleagues that substance use treatment works better than treatments for, say, diabetes or hypertension. The point is that if we move away We start to see substance use as an acute illness, such as an infection, and start to think of it as a chronic illness. and we learn to manage it over a long period of time we do better. Now I want to briefly mention, I don't want to go into so much detail, but I want us to understand a little bit about what substance use disorder is and why we think it is a chronic disease and why it is so difficult to change behaviors? This is a the criteria, the diagnostic criteria for substance use, particularly opioids. But this is similar with alcohol and cannabis. They are very similar and depending on what one reads, this indicates the severity of the disorder. It is the most important concept is physiological dependence, which is characterized by two things, tolerance and withdrawal symptoms. Tolerance means that one develops a resistance to the substance and to get the same effect, one has to consume more. And that happens with most substances. The opposite is when one reduces or stops using it. Then one feels withdrawal symptoms. This is very prominent with alcohol, opioids and other substances with less degree in other substances, but these two represent what we represent. The really important physiological dependence is to understand that physiological dependence It is often part of a substance use disorder, but it is only a peripheral part of it. The key when we think about substance use disorder is the other categories. This yellow box represents this inability to control behavior. For example, using more than one catches. The desire to use more and more. And that one continues to use despite knowing that it is harmful. And you spend a lot of time using and getting and recovering from substance use. It's a loss of control. To me, this is the core feature of substance use disorder. It's the inability to control behavior. That's a core feature of the disorder. And it is maintained by this urgent desire to consume. And that is no different than, for example, hunger. The desire for hunger is what motivates the body to go and get some food. If one is hungry, one goes and eats. If one is thirsty, one goes and drinks. The same is true for cravings. And the final category of things that define substance use disorder is that it causes harm. Substance use when it comes to, say, drunk driving is important, isn't it? Social activities, occupations. You give those things up in favor of other things. Give up those things in favor of using substances. A student, for example, can't get to school on time. Or a person doesn't get to work. Or some other things. These are characteristics of substance use where it does harm. And the last three mentioned here are the most important. We sometimes call these the three Cs. The loss of control, the urgent desires, which is with a C in English, and also the consequences. The reason I mention this is because physiological dependence is sometimes thought of as an addiction. For example, if someone is taking medications that can cause physiological dependence. Let's say they're taking opioids for chronic pain. Naturally, one is going to develop a dependency. But it's not the same as a substance use disorder. That's very important when we're talking about treatment alternatives. For example, giving methadone, because that also causes physiological dependence, but it does not manifest the disease. When we characterize substance use disorder syndrome. When we talk briefly about how substances affect the brain, there is a part of the brain that a person focuses on a lot. That is the reward pathway. This is the center where the brain experiences pleasure or gratification. In general, humans avoid pain and seek gratification. And the part of the brain that handles reward. And this part of the brain sends chemicals to other parts of the brain. Which is called the alcohol core. And when it comes to activating this alcoholic core. Certain substances like alcohol and drugs activate this part of the brain. So there are some natural things like food, sexual intercourse. Enjoying a movie with friends. Anything that feels rewarding. In general, it activates this part of the brain. Not just substances. So eating a piece of cake. It also gives you gratification. It also gives you a pleasurable experience. And you say, oh, I like this, I enjoy this. If you keep doing this, it releases dopamine into the brain. You've probably heard that. Dopamine is a pleasure chemical. And when dopamine is released, you feel pleasure. And that's why we seek out things that are pleasurable. So we look for things that are pleasurable. But if you do too much, you don't eat a whole cake. Several times a day, what happens? What happens is that the brain develops tolerance. As I just mentioned. This is a natural phenomenon. If you flood the brain with a gratification. There's another reaction which is, I enjoyed that, but we're not going to be overwhelmed by that anymore. And the brain starts to adapt to that. And tolerate it. And if that was all that happened, Then you would stop doing pleasurable things because you no longer enjoy them. But the trick here is, what we sometimes think, how can substances hijack the brain? When dopamine is released, not only do you experience reward, but it also teaches your brain that this is important. And the term that is used in the scientific literature is incentives. And the signal is incentives. And the dopamine die is a signal in the brain that tells the brain, This thing I'm doing is important. So this gives you pleasure, but it also teaches the brain that this is important. And the reason why this is important It's that as the body begins to tolerate the substance, one does it less, but one wants it more. One craves it more, one seeks it more. Because dopamine tells the brain that this is important. So this becomes very evident. when that drug is no longer available. Then the brain starts screaming, where is that thing you gave me? That's important, I need it, I want it, I crave it. And this is the paradox of substance use disorder. Even as we continue to use this particular drug, your body starts to say, we're not going to enjoy this as much, we don't enjoy it as much. But paradoxically, the brain wants it more, more intensely. So as the addiction increases, the challenge is that the person will say, And you've probably heard that, I don't enjoy snorting heroin or taking fentanyl as much as I used to, but I can't stop. And that is precisely why substance use disorder can be so difficult to stop. because the brain wants it. Another thing that happens is that the gratification that one enjoys, happens, and if one floods the brain with gratifications, the brain adapts. Unfortunately what happens with that is that the person's brain can no longer enjoy joy or enjoyment or gratification from other things. So even though the brain is saying, I don't want to enjoy heroin as much, and that's also true of other natural gratifications like food, or sex, or watching a movie, or spending time with friends. Those things become less pleasant. These changes I'm describing take time to develop and they take time to develop. And they are permanently formed in the brain. These are memories that are forged in the brain. And just because you stop using drugs, they don't go away. Those connections that we make in the brain actually take years, if not decades, to change. So that's one of the reasons why we typically think in substance use disorder as a chronic disease. Because these changes that are established do not reverse. In fact, it is like memories. If one cannot... It's like a bad memory. A bad memory doesn't go away. Addiction is similar in that sense. You can make the connection, but it's never going to go away. So I used to smoke, for example, and it's been a while since I last smoked, but I know I can't just have a cigarette so I just do it. Why? Because that's just going to make me want another one and another one and another one. And before you know it, I've been smoking a pack a day. My brain isn't the same as it used to be. before I started smoking. This is a challenge that I think patients have to face. That the symptoms don't go away. And these strong desires They are no different than the desire one has when one is hungry, for example. The purpose of hunger as an experience is to motivate us, to compel us to work and to seek out food. That's precisely why your brain is wired to experience hunger. Substance use disorder taps into that same part of the brain. When you have those cravings, it's really, really hard to resist them. And we can always see the physical effects of substance use disorder on the brain, too. Here we are looking at dopamine receptors. On the left side, you see a healthy brain that does not have substance use disorder. In the center, We have someone who is developing substance use disorder. And on the right we have that over time, during treatment. So the bright red dots are the receptors. So when you flood the brain with gratification, the brain eliminates some of those receptors of gratification. And so that's why they don't experience joy. But with treatment and rehabilitation, they recover. Right? And here are the images of the brain again. showing that the brain improves over time, but it takes some time to recover. The general approach we take, And this is true for all substance use disorders, there are three components to treatment. We have the biological aspect with medications. So with opioid use disorder, we have some key alternatives, like methadone. We'll talk more about that in a moment. Withdrawal is not the same as rehabilitation. And rehabilitation can happen in many forms. Obviously we are talking about the eruption of damage. Rehabilitation is very important. Counselling is also important for how to conduct oneself, how to avoid relapses, the conditions. I think counseling plays a very important point. And the third component is recovery supports, which is not just the biology of the person, not only the psychology of the person, but also the use of medications, the use of medications. These are all important effects when thinking about treatment. substance use disorder. Medications can be very powerful and can reduce the effects of cravings. But they can also affect withdrawal symptoms. Counseling is very important in dealing with withdrawal symptoms. It's very important to have a systematic approach. And when it comes to recovery, there is no one-size-fits-all formula. As I said, these three components are basic principles, but ultimately, each individual's journey is particular and individual. And you have to be able to observe each individual's withdrawal symptoms. It's unique and individual. And you have to be able to honor and respect all paths to recovery. And people's choices, if they choose to take a certain path, we should honor that and respect that. Counseling takes the same approach. Sometimes people don't want counseling, for example. That's fine, but we certainly offer it if they want it. And treatment from a recovery-oriented system It's very important. One of the key things we tell patients is the idea that we need to create a healthy support network. And sometimes that's not easy. Many of our patients need to navigate their system and figure out for themselves how to create a supportive environment for themselves. Now let's talk a little bit about how this fits in. with the concept of harm reduction. In short, this is the typical definition. It is a concept that we recognize that drug use is part of our world. and we should seek to minimize their harmful effects. And that seems, if it just seems obvious, it seems like there should be no controversy about that. But, in reality, I think that often Harm reduction is contrasted with abstinence or other types of treatment. Harm reduction is basically an approach that we adopt for all kinds of treatments, whether it's substance use or something else. And it's adopted in many public health settings for chronic disease management. Harm reduction is one of the ways that we address a lot of diseases. And it's the idea that... And again, this is what I think this is where the controversy comes in, the idea that abstinence is not the only or not the only outcome that we should embrace. Not everyone wants abstinence. Not everyone wants a structured abstinence program. That's okay. Again, honoring and respecting all paths to recovery suggests that in time, For now, this is what the person wants. And any movement towards harm reduction should be celebrated. So when we think, for example, about alcohol use, And I've had a lot of patients over the years who are heavy drinkers, who drink 15, 20 drinks a day, that's very large amounts of alcohol a day. If a person tells me, doctor, I've brought abstinence, it doesn't work for me. I just want to reduce my use and only drink five drinks a day. instead of 20. In an earlier era, addiction specialists would tell us, that's not possible, that's not desirable, and you're not going to normally do that. It's not even a good goal. The only goal is to stop drinking. We now understand that any reduction in the amount you drink is a good thing and should be celebrated. And even if the person is thinking about cutting back, that is already a step in the right direction and I would honor that. And in fact, I think in alcohol we have a bigger recognition of that. Many of us drink alcohol alone socially and we say that being able to control drinking in a social sense, that's good. But that, some say that applies to all substances, heroin, cocaine, others. Maybe harm reduction is a good thing. Anything that reduces the harm of that substance is a good thing and we should honor and celebrate it. In fact, again, This is something we have adopted in many spheres of life. Here are some examples of harm reduction that are very successful. For example, seats or helmets or bicycles. These are all examples. These are examples where we can argue that the best way to reduce harm is to not drive or not ride a bike. or don't go out in the sun. One can say that, but that's not realistic. As we all know, some of us have to drive and we have to be somewhere and we have to be in the sun. Any approach that can reduce harm, we think is a good thing. Believe it or not, seats, seat belts, When they were first introduced, they were controversial. I mean, not today, but there was a time, and I'm sure many of you remember it, when we were riding in cars, in cars, that we weren't wearing the seat belt. When these were first introduced. I think they were adopted in Europe earlier than in the United States. And it was a very simple requirement. One of the criticisms was that it might lead to more risky driving. Many drivers were going to say, Okay, so now I can drive more riskily. And this led to some criticism. When in fact, one of the criticisms that was made of many of these interventions, was that they were actually going to get people to engage in riskier behavior. There are some people who do that, but that's not generally true. So most of us don't drive more recklessly just because we have a seat belt and any fact that we're going to a bar It doesn't mean that we're going to drink more and more recklessly. I think we can all agree. We can all agree that alcohol isn't going anywhere. We've tried, we've tried banning it, but it hasn't worked. In fact, what it's done is lead to worse habits. I think we can all agree. that alcohol isn't going away. In fact, many of us like to drink in a social situation. We've incorporated it into the fabric of our daily lives. I think that there are bars where people can consume alcohol, buy a legally produced, quality product, and that there are some safeguards. about where you can buy it and have them look at your driver's license or ID card, your age, etc., that if they see that you have drunk too much call you a taxi or an Uber. There are ways, there are ways to reduce the damage of alcohol consumption. And we think that having bars is possibly a better option than saying, no, you can't drink, and people drinking in public, that's bad, right? Because a harm-focused approach is now the norm. And this is not unique to substance use. There is sometimes tension around harm reduction. As for people saying, why do we have to talk about harm reduction when we talk about substance use? But we don't hear about how harm reduction is an approach in itself. For example, providing clean syringes, providing medicines that work. to reduce naloxone overdose, medications to test for drug abuse or safe injections or specific places where drugs can be consumed, such as bars. All of this can reduce harm, harm from substance abuse. And we can say that all of this can actually be beneficial. So from a perspective point of view, They are harm reduction strategies. They are strategies that do not cure exactly what is underlying, for example, opioid abuse disorder. There are risks associated with opioid abuse. It can lead to dependency, it can lead to, as we talked about before, one can decide to use other opioids, right? Or you can, for example, Use, for example, can be diverted for profit or to buy drugs. However, 20 years of research and clinical experience have robustly demonstrated that people, we think that possibly 60 to 70% of mortality can be reduced, can be reduced. And if we take people, for example, sentinel effects, In recovery, people can be around for much longer and everything is connected to health outcomes. In fact, it can be improved, it can be improved. And just because one is taking, You can use drugs in combination, but what this does is reduce the damage, reduce consumption, reduce mortality, improve health outcomes across the board. We accept this for the treatment of diabetes, we accept this for the treatment of obesity. and it's the same concept for addiction treatment. So again, when we talk about substance abuse and any kind of reduction, we have to honor, honor this. And because neurobiology It draws so much attention And let's say, people's desire is so powerful that even if a person is highly motivated to cut back, to cut back on the dose, that's difficult, it's very difficult to do. So, it is truly What relapses are, in some ways, is a normal part of recovery. It is difficult to avoid relapse. We should not immediately assume that a relapse is a failure. We would not have said this about diabetes treatment simply because a person has low blood sugar levels. It doesn't mean that person has a sugar problem. And what is critical to understand is that when we try to achieve abstinence That's part of harm reduction. Harm reduction doesn't mean that absence doesn't have to be the norm for a person who wants it. Definitely, if a person wants it, we have to encourage them and we have to support them, we have to support that goal. But the truth, again, is that it may be That is not the specific goal for everyone at a specific point in time. Even if a patient right now is saying Look, I don't want to stop completely. That can change, that can change in one year now, in five years now. That can happen all the time. and we see this, we see it in treatment. Goals can change. They can deviate and that's okay. So, right now, maybe abstinence It is not the objective and we can support that, we can honour it. And when we listened to the presentation we were talking about, for example, clinics. Clinics are something that... Bridging clinics. That's something that a lot of people have been advocating for a long time. Putting lower barriers, lower thresholds. Whether a person wants abstinence or not. Whether the person is still using substances or not. The doors should always be open. Patients are welcome. The goal is to have a... If the goal is to have a conversation, have a coffee with us, that's fine. Again, just the fact of participating, participating with us, that will already be seen as progress. Now, the reality is that harm reduction, as a term, has remained quite controversial. I finished medical school in 2002. I have been practicing for several years. But I remember that even 20 years ago harm reduction was already a controversial topic. You had to be careful what you said that word to because a lot of people got very upset. Because there's a perception that harm reduction is ineffective, that what it does is fuel bad behaviors or bad decisions in life, or that it sends the wrong message. Now, I'm going to give a counterargument. And I'm going to say, just because harm reduction is a default position that we adopt in health care, This is not specific to substance abuse. If we want to diagnose someone with diabetes, what we do is reduce harm. What we do is that the person controls his/her sugar levels. The person is not being encouraged to have one behavior or another, but we are helping him to stay in a healthy state. I think it is important for a person who has high blood sugar give him the treatment he needs because that reduces the damage. I generally don't listen to anyone or I hear that insulin only feeds bad lifestyle habits. I don't hear that. I think insulin is now recognized as something that is essential, that must be provided. Just like medication for high blood pressure. If someone has high blood pressure because they smoke cigarettes or because they don't get enough exercise, whatever it is, one can argue for blood pressure medication. It implies that it is accepted that the person has to make decisions in life, that what that person has to do is stop smoking and play sports, etc. So you don't need that medication. That's not what you hear. What you hear is that you do need medication. for high blood pressure, then this medication must be provided. The person is not stigmatized. Even if a person is highly motivated to share their behaviors, whether it's exercising, smoking, etc. We all know how difficult that is. For that reason, we recognize and accept that treatments such as insulin or medication for high blood pressure help us because they reduce damage and can support the person, the person with their goals. The same can be said about, for example, It's a drug that's been promoted a lot. People lose weight without much effort. But we don't know. So this is sending the wrong message. I don't think so. I don't think anyone thinks so. I think that in general, even if it doesn't cure the health problem, it can still be very beneficial for the patients. One thing that must be recognized is that for substance abuse, We are less willing to accept this approach, in part because substance abuse behavior is, in fact, one of the most, if not the most, behavior. most stigmatized in the world. This is obviously based on questionnaires developed by the World Health Organization. Indeed, alcohol, excessive alcohol consumption and being drunk is one of the most stigmatized behaviors and health disorders compared to others. And another point would be, if one then tries to do harm reduction, everything will be fine. That's not it, that's a bad conception too, because harm reduction is an element, It is part of, but it is not by itself what will fix everything. Also, the availability of the service, the affordability, the availability. There are many other components. The fact that it exists is not in itself what is going to fix it. There is some that reduction can do, but there are other elements. From a public health perspective it is very important and the lesson we can learn, for example, In Oregon, some abatement approaches were being implemented, but it was done in the context of a larger change. And there are systemic issues that come into play as well. Stigma, for example, stigma itself can result in worse health outcomes, because substance abuse is what is most stigmatized. Stigma results in services not being as accepted or as available. And one last thing is that the words we use, even to describe some of the things that our patients experience are sometimes inherently stigmatizing. One of them, for example, is the term for a person who abuses substances or who has substance abuse or has substance abuse. What this does is give healthcare providers vignettes about what a patient is like. There are even two versions. One calls the person a person who has a disorder, a substance abuse disorder. And the other calls him a substance abuser. These health care personnel who received these vignettes had more negative perceptions and were less likely to provide treatment or were more skeptical of the work. Even something as simple as the use of words or the choice of words can affect what the outcome of health determinants is. Here we have an example of how another type of language can be introduced that is less stigmatizing because the words themselves can result in negative health effects. Sorry if I'm moving too quickly through some parts. I just want to mention that I have time for questions and answers. This is a very broad topic and I've touched on several areas. and I'm very happy to be here and I'm happy to answer some questions and I hope this has been helpful to you.

consumption disorders

harm reduction

opioid use

stimulant use

substance use disorders

fentanyl

stigma reduction

recovery network