I think we'll go ahead and get started now. I still see people coming in, but we'll let them in as we go here. So good morning, everyone. My name is Chelsea Kimura. I'm a training and technical specialist for the Opioid Response Network. The Opioid Response Network is grant funded by SAMHSA to provide free training and consultation to Native communities and other communities across the country. Today, we're gonna be sharing a session about risk and prevention factors in substance use. And I would like to open our session today in a good way by sharing the land acknowledgement. Our work intends to reach the addiction workforce in the Northwest TOR region. This includes Alaska, Idaho, Oregon, and Washington. This region rests on the ancestral homelands of the indigenous peoples who have lived on these lands since time immemorial. Please join us in support of efforts to affirm tribal sovereignty and in displaying respect and gratitude for our indigenous neighbors. We respectfully acknowledge and honor all indigenous communities past, present, and future. Thank you all. And with that, it is my honor to reintroduce our presenter for today's session, Stephanie Stilwell. Stephanie is a registered nurse with a diverse background in the healthcare industry, including addiction treatment and healthcare consulting. Her passion is promoting community health and wellness and disease prevention. She has facilitated multiple local and statewide coalitions throughout the state of Alaska. Stephanie is an Anishinaabe woman from Lac La Croix First Nation in Ontario, Canada. And I will go ahead and pass this over to Stephanie to get us started today. Thank you. All right. Hi, everybody. It's nice to be here with you again. As Chelsea mentioned, I am going to talk about risk and prevention factors in substance use disorder today. So we're just gonna kick this off. Again, I have no disclosures, and this is just another slide about the Opioid Response Network. Again, so today is the second of our series of our, I think four or five series of trainings on opioids and substance use disorder. Today, we're gonna dive into something called risk and protective factors, meaning we're gonna kind of talk about what things might cause or lead a person to develop a substance use disorder. And also, what are some of the ways that we can really be proactive in helping to prevent substance use disorders in people? So again, today we're gonna look at identifying key risk factors linked to different mental health challenges and substance use disorders, including something called ACEs, Adverse Childhood Experiences, genetics, and other risk factors. Additionally, we're gonna talk about the protective factors and things that can really help promote mental health. And that will also include talking about culture. So I think before we can really get into a lot, I just really want us to define together what trauma is. So it can be defined as an event, a series of events, or a set of circumstances that is experienced or are experienced by individuals, both physically and emotionally harmful or life-threatening that has long-lasting adverse effects on those people on their either functioning, their mental health, physical health, social, emotional, or even spiritual wellbeing. And the same diagnostic manual that we talked about before that has those criteria to diagnose substance use disorders also has different criteria that can actually diagnose trauma. And those things include exposure to actual or threatened death or serious injury, different types of violence for adults. It includes like repeated exposure to violence or children. It can be just recurring events. So there's a number of different ways to kind of diagnose actual trauma in folks. And there's a multiple different types and levels of trauma as well. So if we look at kind of looking at this graph here, we start out as kind of individual trauma, and this is just something that happens to one person. So this could be somebody experienced an injury, an illness, or something that only impacts them. And then we move into kind of more family and group trauma. And this is kind of, of course, family is something that happens within a particular family, group trauma. And this is kind of something that occurs that really impacts a particular group. Maybe it's somebody, the military service folks or first responders or people in LGBTQ community. And then we kind of move more into this community trauma. This includes things like cultural trauma, historical trauma, and racial trauma. And we're gonna kind of dive into that in just a minute as well. And then there's like mass trauma, this is more kind of like that impacts on a large scale, a number of people, even bigger than just a specific race or a specific group. This is an example of a mass trauma that we all recently experienced together is the COVID-19 pandemic. That's something that was kind of a wide scale impact to a lot of people. And then there's kind of different layers of trauma as well. We have the interpersonal traumas, which this can include things like domestic violence, developmental trauma. This includes things that happen kind of early in childhood. Again, we're gonna talk more about that in the presentation in a little bit. And then systems oriented trauma, this kind of also fits into some of our cultural and historical trauma as well, but it's kind of like institutional actions and policies that perpetuate and continue to perpetuate traumas and inequity amongst certain populations. So I really wanna start out by sharing that a big part of trauma in our country is this historical and cultural trauma and some that impacts all of us and in fact, in this photo, this is my grandmother here. She was in a boarding school back in the early 19, I think that was like 1960s, 1950s, sorry. And so as indigenous people, we have really always understood that our earth is our mother and we're really connected to the earth. And this connection is not just about our culture or part of us, it's really a foundation of kind of who as indigenous people we really are. And so in the indigenous communities, cultures, regardless of type of what tribe you belong to or where you are at the root, traditions and practices being passed down through generations really has been what has kept us indigenous people close to not only our earth and each other, but it also helps to guide us to care for ourselves, each other and all kind of the living beings on the planet. However, because of this deep or our deep connection to this culture at one point in time was really disrupted by something we call colonization. Particularly this was really devastating through the impact of residential schools and boarding schools. These institutions were really designed to strip indigenous people of their identities, languages and cultural practices that helps to serve their connection to each other, to their family and to the earth, which really does cause a lot of disruption. And this is not just impacting the people who experienced the boarding schools, but it's really an intergenerational trauma because this disruption continues to impact people today, not just those who survived the boarding schools, but it just continues to perpetuate some of these cycles today in our communities, which really does put us at an increased risk for developing things like substance use disorder. When our sense of identity and our connection is weakened, it becomes a lot easier to kind of fall into some of these harmful behaviors that kind of help mask or cope with some of the trauma that our family and our culture experienced at one point. And so really without addressing the root cause, which is actually working to reclaim our traditions and languages and cultural practices, it can mean that we're continuing to stay vulnerable to this cycles of kind of this harm from this historical event that occurred. You know, and in addition to residential schools, indigenous people across the United States and Canada were also subject to things like biological warfare and warfare in general, loss of land base and resources, different treaty violations, relocations and removal, reservation, confinement, prohibition of spiritual and cultural practices and forced sterilization or even massacres at times. You know, so it's important to recognize that the trauma that our ancestors and our grandparents and those before us have gone through is still impacting us in our communities today. And the path to kind of preventing more people from turning down a path or developing a substance use disorder really does lie in reconnecting people with our heritage and healing that intergenerational trauma that has kind of been passed down. So kind of working to reclaim what was once ours and restoring that connection to earth, to each other and to ourselves. So the reconnection is actually not just a means of like prevention, but it's the foundation of healing for our communities and our culture. So by strengthening our cultural ties, we can really help to break that cycle of trauma and create new cycles of healing to ensure future generations thrive. Meaning what has happened does not have to continue to harm us. We can actually do something to break that. And in addition to historical trauma, there's a number of other things that really can impact a person's risk of developing a substance use disorder later on in life. Some of these are called ACEs, Early Adverse Childhood Experiences. And the early experiences of a child generally play just a really crucial role in our brain development. So genes provide kind of the basic components and kind of the basic framework. And then our environment influences some of those shaping connections in our genetic makeup. So there's different types of stress. Positive stress is healthy, but then there's the chronic uncontrolled stress that leads to these adverse childhood experiences. So some of the ACEs that people can experience are things like physical abuse, emotional abuse, sexual abuse, physical neglect, and emotional neglect. And then others are things like living with somebody or living in a home that has domestic violence present, living with an adult who has a substance use disorder, living with an adult with an untreated mental health condition, even just going through a separation or divorce of parents or living in a home where somebody has been incarcerated. Those are all different types of adverse childhood experiences. And so we have kind of found that the number, the higher the number of ACEs, the more likely somebody is to have some negative outcomes later in life. And we'll talk more about that specifically in a few minutes. But these ACEs can really impact how our brain functions later on in life, causing actual changes in our brain. And I'm sure that nature versus nurture is something that everybody has heard at one point in time, but I'd kind of like to dive into what that really looks like for a second. So let's talk about biological factors and genetic factors that can really impact substance use disorders. So biological factors include things like their genes, genetic makeup, the stage of development. So for example, teenagers who use drugs and alcohol are more at risk for developing a substance use disorder due to the age or the stage at which their brain is developed when they start using substances. And sometimes gender or ethnicity can play a part as well. And scientists estimate that genes, including the effects of environmental factors have on a person's gene expression can account for between 40 to 60% of the risk, person's risk of developing a substance use disorder. So what that means is sometimes we all are born with certain genetic makeup and certain people are born with genes that kind of make them more at risk for developing certain things like a substance use disorder. And sometimes with a particular genetic makeup or mutation, it kind of lies dormant until something is triggering that gene to essentially wake up. Meaning you may have the gene that makes you more at risk for a substance use disorder. However, if you grew up in a home and didn't experience a lot of toxic stress or something like that, that may not have ever been triggered. But if you have that same genetic makeup and are exposed to something potentially like stress that can trigger that gene to kind of wake up. And again, teens and people with mental health conditions, generally speaking, are more at risk of developing a substance use disorder than others. And something that's kind of becoming more known as the universal ACE is even though a lot of people aren't experiencing it as there are a lot of children currently, but also as adults, we all experience this as well, but is the COVID-19 pandemic. As you can see here, so of course the isolation took away our connections to a lot of people, places and things that we were once connected to during that time. Unemployment was at a high, more and more people developed clinical depression and we had the highest record of overdose deaths during that time as well. Again, the highest rates of overdose deaths in by, this is just sorted by race, the highest rates are unfortunately disproportionately occurring within our non-Hispanic, American Indian and Alaska Native populations. And so we have a lot of people who are experiencing the highest rates of overdose deaths within our non-Hispanic, American Indian and Alaska Native populations. And so as you can see, the risk factors increased with the number of ACEs that a person has. So if somebody has zero ACEs, meaning that they have never experienced their chances of becoming, you know, somebody who uses nicotine or uses IV drugs is much lower than somebody who uses or with somebody with seven or more ACEs. So the more adverse childhood experiences somebody experiences, the more likely somebody is to develop mental health conditions, substance use disorders, or even things like attempting suicide. So understanding the link between ACEs and addiction is really important. And as we kind of move forward, looking beyond the ACEs and beyond the trauma, looking at how to provide trauma-informed care and early intervention and providing support to people who experienced or are currently experiencing ACEs is really important in addressing the root causes of substance use disorder. So recognizing the impact of trauma and implementing interventions, kind of think of things as the sum. That's teeter-totter. So even though, you know, we've got all these negative risk factors over here, we have a lot of positive things that we can do to really prevent people from, prevent children from becoming or be impacted with substance use disorder later on in life and or recovering. So we are now, get my screen. There we go. To kind of talk more about some of the protective factors. And so let's see. Again, all people have the biological and psychological characteristics that make them potentially vulnerable to or resilient in the face of behavioral or mental health challenges. Because people have kind of, we have to look at this as relationships within our self, our community, and in our society to look at the different types of risk and protection factors in each of those levels. So generally kind of speaking here, we have in relationships and families, some of the risk factors that we kind of talked about before, parents who use drugs or alcohol or have a different mental health challenge. That's the risk factor, but an example of a protective factor in relationships and families is having a parent or somebody in their family, in their life, an adult in their life that's really involved and is a part of their development. That's a protective factor. In communities, a risk factor could be living in a neighborhood that has a high level of poverty or violence, but a protective factor could also be having the availability of either some sort of afterschool activities, support, faith-based resources, or some other cultural or spiritual support as a community. And then in the bigger society, some of those risk factors can include things like racism, lack of economic opportunities, whereas protective factors could include having laws that protect people against hate crimes and or policies that limit the availability of alcohol generally. And then when we're working specifically with like indigenous communities, we really wanna take a look at some of the different types of risks and protective factors that are specific. So again, according to something called the Strategic Prevention Technical Assistance, there's a report that was done on cultural factors. They found that in the United States, where there's over 9.7 million people that are indigenous or Alaska Native or Native American, sorry, my brain is glitching out here. So there is just this very, very large number of people who are disproportionately impacted negatively in regard to having risk factors for substance use disorder and developing other issues. But we also want to recognize that all of these, what, 9.7 million individuals also come from communities that have such strong protective factors, and we really want to highlight the strengths and the strengths that these communities have within them currently that can help promote and protect children and families as they grow. So these are things like really engaging in cultural activities, traditional games, being just socially connected across generations within the community. So really having our children and youth interact with our elders and learning from them, reclaiming our indigenous languages, sorry, my dogs are going to bark for a second, reclaiming our indigenous languages, engaging in spirituality and ceremonies, and just really having more of a relationship with the land and our subsistence life that we once were really what kept us alive and thriving. So although indigenous people might face a lot, you know, higher risk in regard to things that contribute to development of substance use disorders, it's really important, like I said, to look at these as a teeter-totter, right? So we want to view the risk factors alongside all of our protective factors. So while risk factors may weigh heavily on one side, there's many actions that indigenous communities can really take to kind of restore that balance or even tip the scale in favor of protection. So strengthening relationships within our families and fostering that community support while empowering, you know, our individual identities and deepening spiritual connections are all ways to really add weight to that protective side. So focusing on these elements, indigenous peoples can bolster resilience and safeguard their communities against challenges of substance use disorder. So I'm going to kind of go through some of these next slides and understand that, like, every tribe is very different and every community has their own sets of values and things that they do and different cultural practices. And so as I'm kind of talking about this, think about the things in your community and your tribe specifically that are really, you know, protective factors that are local to you and how you can kind of bolster those in your community. So individual protective factors. This is kind of looking at the aspect of just the self. So having, you know, more awareness of self, working on living, helping others, honoring your gift or speaking from the heart. And in some communities, things like having an Indian name or an Anishinaabe name in my community is a big part of kind of that sense of bringing back that sense of belonging and individual kind of empowerment. And I really like these quotes in here, so I'm going to read them. So within the community, everybody's got a gift and we're taught that you need to honor that gift. If you don't use it, the creators want to take that gift away. Whether it's your voice or speaking from your heart or whether you're a cook or a hunter, those are the gifts that the creator gave you to help your people. So then we move into relationships and family protective factors. This is, of course, looking at how, like, we can connect with our elders and our family to pass down some of the teachings. Looking at the different family roles and rituals, being just parents who are, you know, this says protective parenting, but something that's really big in my community is, you know, really connecting with all the uncles and aunties in the community. Basically nobody is a stranger, everybody's an auntie and uncle who can really help and reach out to be a part of children's lives, calling on our ancestors, the women in our family and really connecting in with our grandparents. And again, this quote is beautiful, just, I have to be proud of who I am because my grandmother said so. Community protective factors. This is, again, looking at things as an entire community. So looking for those opportunities for learning and healing as a community, finding more ways to increase those social connections, having elders that are strong and willing and able to really reconnect the community and reconnect with those youth, having traditional laws, sharing and harvesting resources, and then really finding ways to develop some of those healthy connections to the past and those traditions that carry forward. Again, it's important that we continue to carry out these traditional laws. And they said if we talk long enough and we can find out how we're all related, we can tie ourselves together when there's something that happens in the community as part of our family. So we act appropriately. Just a traditional law. And then finally, this spiritual protective factor. So again, this is a bit different depending on where you're from and what your community beliefs are, but welcoming the spirit, belief and prayer, having gatherings, ceremonies, any types of rites of passage, and or just being on the land and water. So in this in this quote, it's welcoming the spirit. I don't think our spirit wants to be in our body as long as it's being abused. So it leaves. So when I sobered up, it was like the spirit came back in and it wants to live in this house again. That's what it's that's what's really lonely. I think when they're when we're using is there's not a spirit inside living inside of you. And we're more spirit driven people than we are human driven people. The spiritual is going to live forever. So it feels good to welcome that spirit. So that's somebody's quote on just how. It they were able to connect more with their spiritual side, being sober. As opposed to when they were in abuse. Right, and I have a video on risk and protective factors just to kind of like summarize a lot of the things that we already discussed, but I just always like to share a little bit more. So one of the questions that I get asked pretty regularly, especially when I was younger, was how did you turn out? OK, you had sort of a difficult upbringing, child impacted by substance use disorders. When I get asked this question, very simply, the answer is it's science. This is not a miracle. It is not magic. It was science and counterbalancing all of the risk factors that I came into life with with protective factors. So if you think of it as as a seesaw, I had a lot of risk factors on this side of it coming into this world and for about the first 10 years. But then there were things that happened, interventions and people that cared about me that counterbalanced that seesaw to put protective factors on the other side. So it not only leveled out, but it went in the opposite direction. And I think it's really important for us to remember that no child is unsavable, right? Regardless of the risks and the home life and the difficulties that our children are faced with because of addiction, because of substance use disorder, that we have the science and the tools to intervene and help to improve their outcomes. And we talk about why some people develop a substance use disorder and some people don't. I talk about the triangle, sort of the three main factors, and at the tip of the spear is genetics. We have about 50 percent of the individuals today that have a substance use disorder have a genetic predisposition, right? We pass this down to our loved ones and you can't control that. But what you can do is know that you have a genetic load, that you have risk factors because of your genetic predisposition, like I do. So because of that and knowing that I have four generations of addiction before me, I know that I have higher genetic risks than, let's say, my next door neighbor or my best friend. So I make choices that counterbalance that. So that's on that genetic side. And then on the other side of the triangle, you have environmental factors. It's about the community that you come from, the environment that you live in, things like poverty level, crime level, availability of substances in that community. And we know that there are interventions that can impact that, the norms that we create in communities. And then you have the individual side, right? That's things that are unique to me and unique to my family and my household. Parental monitoring, really clear expectations that are set forward, positive adult relationships, all these protective factors on the individual side that also have correlating risk factors. But how we address those, particularly for all the kids that are impacted by substance use disorder, is critically important. So I come back to that teeter-totter. I came in to this world with probably every risk factor that you can account for, both on the genetic side, the tip of the spear, the environment I lived in and my individual factors. But I rebalance that by the interventions. Things like delaying the onset. I did not drink till I turned 21. And even till today at 41, I am very careful about alcohol consumption, intermittency and being careful about my own use. Clear relationships. I had not only my grandparents and aunts and uncles that engage as caring adults in my life, but was given a a mentor through our county behavioral health services when I was just a kid that helped with another caring adult. Mental health care. I was court mandated to see a psychologist when I was eight and continued that care to make sure that I had the mental health treatment that was necessary to deal with the trauma, the adverse childhood events and those risk factors that needed to be addressed. We even know how to prevent this illness for those that have the most risk factors for developing this disease. And we just need to make sure that we're deploying them to every community. So I really like that video. She does a great job just really summing everything up, and I feel like it leaves us with this idea of, you know, hope we can recover. And also that we can prevent. And so kind of moving into a little bit of a different concept here is how we can, as people who work in this in this industry, how we can really do our part to continue to help people heal as they're moving through their their treatment. And so using something called a trauma informed care approach is really something that we are encouraging folks who work in health care and other industries to be to learn about, because this is really moving from the focus of what's wrong with you to what happened to you. So. Asking that question, just. It's a lot more you get a lot more information, you can kind of realize, recognize and respond to resist re-traumatization for folks. So it recognizes that health care organizations and teams must understand a person's history to really provide effective, healing oriented health care. Additionally, again, we're working with indigenous communities where you really, really need to remember the historical trauma that has occurred in their communities and in their families, even if it's not impacted, even if they are somebody who is not. You know, a survivor of a boarding school themselves, they come from a family and a community that was at one point impacted and that is still impacting them today. So adopting some of these like more trauma informed practices really help us to understand and enhance patient engagement in treatment, which keeps them in treatment longer and ultimately provides better health outcomes. Additionally, it also benefits the well-being of the people and the providers providing the care. It reduces unnecessary care and costs for the patients, but it just, you know, trauma informed care recognizes the widespread impact of trauma, that we need to recognize the signs of trauma and integrate trauma knowledge into all of our policies and practices in our health care agencies to really actively avoid re-traumatization for our patients and also and our staff, too. And it's also important to recognize that even non-clinical people who are not working specifically with the patients as a provider, it's really important to have an understanding of trauma informed care as well, especially people who work at the front desk or in security, because it's all about making patients and people feel really safe. And that's a huge part of their care. OK, so one more quick video, and this is all about that concept of connection again and how important connection is. So when I play this video, you'll notice you might hear a few words that are kind of outdated or stigmatizing. So I just want you to pick up on that, recognize it, and we'll talk about what we should be saying instead of some of the things you might have heard in this video. But ultimately, I really want to show this because the opposite of addiction is connection. So. Our current theory of addiction comes in part from a series of experiments that were carried out earlier in the 20th century. The experiment is simple. You take a rat and put it in a cage with two water bottles. One is just water. The other is water laced with heroin or cocaine. Almost every time you run this experiment, the rat will become obsessed with the drugged water and keep coming back for more and more until it kills itself. But in the 1970s, Bruce Alexander, a professor of psychology, noticed something odd about this experiment. The rat is put in the cage all alone. It has nothing to do but take the drugs. What would happen, he wondered, if we tried this differently? So he built Rat Park, which is basically heaven for rats. It's a lush cage where the rats would have colored balls, tunnels to scamper down, plenty tunnels to scamper down, plenty of friends to play with, and they could have loads of sex. Everything a rat about town could want. And they would have the drugged water and the normal water bottles. But here's the fascinating thing. In Rat Park, rats hardly ever use the drugged water. None of them ever use it compulsively. None of them ever overdose. But maybe this is a quirk of rats, right? Well, helpfully, there was a human experiment along the same lines. The Vietnam War. Twenty percent of American troops in Vietnam were using a lot of heroin. People back home were really panicked because they thought there would be hundreds of thousands of junkies on the streets of the United States when the war was over. But a study followed the soldiers home and found something striking. They didn't go to rehab. They didn't even go into withdrawal. Ninety five percent of them just stopped after they got home. If you believe the old theory of addiction, that makes no sense. But if you believe Professor Alexander's theory, it makes perfect sense, because if you're put into a horrific jungle in a foreign country where you don't want to be and you could be forced to kill or die at any moment, doing heroin is a great way to spend your time. But if you go back to your nice home with your friends and your family, it's the equivalent of being taken out of that first cage and put into a human rat park. It's not the chemicals. It's your cage. We need to think about addiction differently. Human beings have an innate need to bond and connect. When we are happy and healthy, we will bond with the people around us. But when we can't, because we're traumatized, isolated or beaten down by life, we will bond with something that gives us some sense of relief. It might be endlessly checking a smartphone. It might be pornography, video games, Reddit, gambling, or it might be cocaine. But we will bond with something because that is our human nature. The path out of unhealthy bonds is to form healthy bonds, to be connected to people you want to be present with. Addiction is just one symptom of the crisis of disconnection that's happening all around us. We all feel it. Since the 1950s, the average number of close friends an American has has been steadily declining. At the same time, the amount of floor space in their homes has been steadily increasing. To choose floor space over friends, to choose stuff over connection. The war on drugs we've been fighting for almost a century now has made everything worse. Instead of helping people heal and getting their life together, we have cast them out from society. We have made it harder for them to get jobs and become stable. We take benefits and support away from them if we catch them with drugs. We throw them in prison cells, which are literally cages. We put people who are not well in a situation that makes them feel worse and hate them for not recovering. For too long, we've talked only about individual recovery from addiction, but we need now to talk about social recovery because something has gone wrong with us as a group. We have to build a society that looks a lot more like Rat Park and a lot less like those isolated cages. We are going to have to change the unnatural way we live and rediscover each other. The opposite of addiction is not sobriety. The opposite of addiction is connection. So that just really highlights, again, everything that we've talked about, the importance of community and connection and how really all things kind of point into bringing us back to being more connected. And Rat Park was a real experiment that occurred. So here are some actual photos from the real Rat Park. And, you know, if we want to come up, people want to come off mute and do this discussion right now, that's that's great. But this is just an idea of something that we could discuss or you can take outside of here. But if you're thinking about that, if you're working with a client who's being treated for substance use disorder. They have a family that just doesn't understand why they just can't stop using, you know, last month or last week, we talked about kind of more of the brain science, you understand that a little bit more. And today we talked more about the risk factors and what possibly in their life led to the development of substance use disorders and now a little bit tough, a little bit about trauma informed approaches. So really just, you know, thinking about how you can really help a family member understand better or even a person that you're working with better understand why it's really so hard to to stop using a substance and or how you can how they can help the person work through that, their challenges. And that's all I have for my presentation today. Again, here is a survey that you all can take about today's presentation. I am going to stop sharing and if anybody has any questions or comments, you can come off mute and happy to answer any questions or engage in any kind of dialogue, folks. All right, and if there's no comments or questions, I'm happy to end the presentation now. Thank you so much, Stephanie. And if you guys do have comments or questions, you can also bring them to our next session. We have a couple more of these sessions coming up, so I will make sure that Jessica has the links for those. And we look forward to seeing you.

Opioid Response Network

Native communities

substance use disorder

historical trauma

resilience

trauma-informed care

social bonds

addiction prevention