and thank you all so much for being here with us this morning. My name is Chelsea Kimura. Today, we're gonna be sharing the third session in our series, and we'll be talking about navigating medication for addiction treatment and embracing harm reduction and substance use disorder. Before I pass this over to Stephanie to get started, I would like to open our session in a good way today by sharing a 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 supportive 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. And with that, I would like to again turn it over to Stephanie to go ahead and get started for us today. All right, hi, everybody. Good morning. As Chelsea mentioned, I am going to be talking more about navigating medications for addiction treatment and talking about harm reduction as it relates to substance use disorder. So the next few slides, I'm just gonna kind of slowly pass by. There are opioid response network slides. And then we will dig in. So today, again, we're gonna dive into medication for addiction treatment, also known as MAT. And sometimes you will hear it referred to as MOUD, which is medications for opioid use disorder. So we're gonna kind of do a little bit diving into understanding what MAT is, how it works, why it works. We'll talk about harm reduction, and then we'll have an opportunity at the end to also kind of engage in a case study, whether we're going to be doing this together today or just something for you to chew on afterward where I really wanna take what we're learning and apply it to real life situations. So again, medication for addiction treatment, MAT. Make sure you're not saying medications for, or medication-assisted treatment. That is no longer the terminology. So medication for addiction treatment is what we're talking about today. So before we kind of dive into MAT and harm reduction, I really want us to start to consider thinking about substance use disorder and addiction in as a chronic disease. So to help with that, I'm gonna propose this scenario. So I want you all to really think about, if you were just diagnosed with type 2 diabetes, you're still in your doctor's office and they give you the information and you have officially been diagnosed with type 2 diabetes, what kind of things would you expect that doctor to do next? Possibly refer to a specialist, maybe to an endocrinologist, depending on how challenging or how sick you've been. Otherwise, they will take you on as a patient to follow up the treatment there in your office. You'll likely be prescribed a medication that will help you stabilize your blood sugar and kind of decrease all of the other risks that can come along with having a diabetes. They might refer you to a nutritionist so they can really help you understand how to holistically treat your new diagnosis, what foods you should eat, what foods to avoid, and also talk about lifestyle changes. So what are some of the things that you can do to really help yourself and your family to really help yourself feel better and get healthier? But regardless, we know that this is going to be something that you'll be following up with your provider on a long-term, every regular basis for probably forever. So it's just, there's this expectation that it's something you have and you will have to work with and manage for the rest of your life. So that's how we, in our health system, kind of really approach different types of chronic diseases, right? So there's the diabetes and the hypertension and other types of diseases. So there's this full care and this expectation that this is something that's going to be managed for a long time. And what we really need to start doing is understanding that substance use disorder is also a chronic disease, and it also has something that needs to be managed forever in our lives. So understanding that substance use disorder is also a chronic disease is really crucial for reshaping our perceptions of how we kind of guide effective interventions and healthcare for people with substance use disorder. So unlike acute conditions, like a cold or a virus, substance use disorder, it's generally characterized by having long-term patterns of substance use. And often we see cycles of recurrence or relapse or remissions. So this really is no different than if somebody with hypertension is experiencing high blood pressure when they stop taking their medications or they change their lifestyle and they were once controlled with their blood pressure medication, then they choose to stop taking it or something happens and their blood pressure spikes. So it's really kind of, we start to think of it as one in the same, we can start to understand why we need to consider substance use disorder a chronic disease. And this recognition really does just help us to emphasize that it's an ongoing condition. It requires ongoing management and support. And so by adopting this perspective as a society, we can move away from struggling or stigmatizing some of those individuals with substance use disorder and instead start treating them more with empathy, understanding and more evidence-based treatments. So again, approaching substance use disorder as a chronic disease just helps us to really align with principles of holistic care. It emphasizes the long-term strategies used to treat it, such as medications for addiction treatment and even harm reduction, which has proven effective in managing and improving outcomes for individuals with substance use disorder. So I like looking at this rate comparison rates here. So we have relapse or recurrence of symptoms percentage in substance use disorder is usually between 40 and 60%, but when we look at hypertension and asthma, that's 50 to 70. So, you know, really we're, you know, we really need to start looking at the realities of substance use disorder as a chronic disease, no different than hypertension, asthma, diabetes. And so this is just an example of what the treatment or care plan might look like for somebody that has another chronic disease like diabetes. So we need to treat substance use disorder in our healthcare system, just like any other disease, which means giving it the same attention, resources, passion that conditions like diabetes or hypertension receive. So by integrating addiction medicine into our mainstream healthcare system, we're ensuring that the individuals who have substance use disorders actually get the comprehensive and evidence-based care they deserve. So this also helps to do, you know, continue to fight the stigma that surrounds SUD and just generally leading to better treatment and care for folks. So, yeah, so now that we kind of have this idea of how we can treat folks with substance use disorder, the same as we would treat folks with any other chronic health condition, we can kind of dive into the importance of using medications to treat substance use disorder, especially as we're thinking of long-term treatment. So for those of you who joined one of our previous sessions, you might remember this guy here. He talked about the three things that we need to survive, food, water, and of course, dopamine. Dopamine is really, it just plays such a crucial role in substance use disorders, mainly due to its involvement in the brain's reward system. So many addictive substances, drugs, alcohol, and or even things like gambling, sex, anything like that that increases the dopamine levels in our brain creates this pleasurable sensation in our bodies, gives us that energy and that boost. So this heightened dopamine activity reinforces that association between the substance or activity and the use of reward or use and reward. So this contributes to the development of the addiction because over time, our brain adapts to having these elevated dopamine levels by reducing the amount of natural dopamine we create in our brains. So this neurobiological change contributes to the cycle of cravings. So when we don't have, our brain isn't naturally creating the dopamine it once was because we started to introduce substances into it that heightened our dopamine levels on a regular basis. So now when we don't introduce that substance, our bodies, our brains are not making that substance anymore, those dopamine, that dopamine anymore, which is going to cause us to experience things like cravings, or we're going to compulsively seek that substance to help kind of reduce the craving. So just really understanding the role that dopamine plays in addiction and substance use disorders really helps us with creating better treatment and interventions like medication for addiction treatments, which that aims to restore the balance in the brain's reward system and our dopamine system and alleviate a lot of the challenges that are associated with the substance use disorders. So I'm going to let this guy tell us again a little bit more about why medication for addiction treatment works. So let's make sure I've got my computer sound shared. Yep, okay, great. Consistently among patients who have had the disease of addiction. So if dopamine is lacking in the nucleus accumbens, and this is the basis for driving this behavior, then augmentation of dopamine might make sense, right? If we raise dopamine back up to normal levels, then they won't feel craving and they won't be starving for the drug. That can then allow us to have an appropriate conversation with a patient, allow them to be engaged in treatment. So when we look at how we do that, we found that the two medications, at least for opioid use disorder that do this, are buprenorphine and methadone. By giving those medications, we actually can raise the dopamine back up to normal levels so that this person doesn't have to think about, I need my drug, I need my drug, because what they're really thinking is I need dopamine, I need dopamine, I need dopamine. And that starts in the morning from the second they wake up and it is there all day. So we're not able to get patients stable enough to have therapy do anything for them because without dopamine in the brain, what you're not getting is even onboarding of emotional memory because it's required for that. And so when they go into therapy without having their dopamine in the right place, what they're hearing is, They're not getting anything from that. We have three major medications for opioids and one of those is naltrexone which blocks opioids so it doesn't necessarily increase dopamine. But for some people with a less severe substance use disorder or motivation, again, there's that term motivation. When we talk about motivation, I always want you to think dopamine. If you hear dopamine, I want you to think motivation. Motivation equals dopamine. Dopamine equals motivation. So when we talk about, I really want a motivated patient or client to go get their therapy, we're talking about someone who has enough dopamine to have that motivation. Without it, they're not motivated. We talk about this in a number of different ways. We talk about it in stages of change. Are they pre-contemplative? You know, are they in the action phase? Do they wanna come and do something positive for themselves? We use these really pejorative terms in addiction medicine like, well, they need to hit rock bottom first. I don't think that's an option anymore given that we had 50,000 people die last year of overdose because that's rock bottom for an opioid use disorder. But for those patients who have a lesser version of opioid use disorder, maybe something like an altrexone, which is a chemical that blocks this opioid can be really helpful for them because they already have that intrinsic motivation. They're already ready to move forward because they have this dopamine. We also have other parts of the brain like where alcohol works. It works on another part of the brain other than the opioid receptors. It works in the gamma-aminobutyric acid receptors, right? These really specific receptors that they're the ones that make you feel super happy after one or two drinks and then not so super happy after four or five drinks. It's also the same part of the brain that drugs like benzodiazepines, which are like Ativan and Valium or diazepam. You know, these are things that change that part of the brain. What about parts of the brain that are affected by marijuana? So marijuana releases dopamine from the nucleus accumbens. And we found that we have a drug that actually blocks that extra release of dopamine. So for people with a marijuana use disorder, we even have medication that can change the way that that dopamine is released. So for certain drugs, it's all about dopamine. And for other drugs, it's indirectly about dopamine. But the final common pathway is dopamine. And whether you have the, consistently among patients. All right. So he does a great job really explaining the why, again, why dopamine is at the center of substance use disorders and why, how medications for addiction treatment can really help restore our dopamine levels so that we can actually get to a point where we are able to do the behavioral modifications that we need to really kick our substance use disorder and recover. So the medications that he talked about in this video, he mentioned methadone and buprenorphine. These are both medications that actually do kind of sit inside the receptors. So this, let's see, here we go. So let's pretend this is our natural opioid receptor in our brain. And the medications that are opioid receptor agonists actually go right inside our receptor sites. So methadone is a receptor agonist, which means it kind of actually fits perfectly right inside our opioid receptors. And so this medication does attach directly to our opioid receptors in the brain. And it really is good at blocking withdrawal symptoms and decreasing our cravings for the opioids. Buprenorphine or Suboxone, as you all might know it as, is also a receptor agonist, but it's a partial. So this medication fits right into our receptor sites. However, there is a cap. So it only works to a certain extent, but it also is one of the more popular medications for addiction treatment for opioid use disorder and is very successful with decreasing withdrawal symptoms and cravings as well. And then he talked about something called Naltrexone. And this is one that actually goes into our bodies and it creates a blockage. So nothing can actually get into our receptor sites whatsoever. So if you were to be taking Naltrexone, which is also known as Vivitrol, so you all might have heard of the Vivitrol shot that people can get as a monthly injection. There's also daily Naltrexone medications that folks can take. But what this does is it actually blocks that receptor. So if somebody were to be on Naltrexone and then they go out and try to use an opioid, what's going to happen is nothing. Their bodies will not allow, or that medication will not allow their bodies to absorb the opioids whatsoever. So this completely prevents that. So as he mentioned, this does nothing to help reduce those cravings. So if somebody has a less severe opioid use disorder, this is a good option for a treatment. But again, if they have a severe opioid use disorder, a provider might choose a methadone or buprenorphine over the Naltrexone. So when we are talking about successful treatment with medications, we want to really look at who is really staying in treatment for opioid use disorder. So when we looked at folks who use the abstinence method, meaning just saying no or cold turkeying their opioid use disorder treatment, that has a pretty low success rate, less than 10%. So I think that's about 5% success rate. With Naltrexone, specifically the monthly injection, this has only about a 35% rate of success in treatment. Buprenorphine and Suboxone, we're at a 50%. And with methadone, we are at 60% success rates. So this shows that the more we are treating folks with medications, the better chances they have at long-term success for recovery from their substance use disorder. And again, this is just another comparison of relapse rates between substance use disorder and other chronic diseases. So again, substance use disorder, we're at that 40% to 60%. And we're comparing to that 50% to 70% for folks with hypertension and asthma. So it's common across the illnesses. Therefore, substance use disorders continue to need to be treated just like the others. Other benefits of medication for addiction treatment is decreased death rates. So especially during that initial first two weeks post-treatment for substance use disorder, particularly opioid use disorder, if somebody walks out of a treatment facility, they are at a heightened risk of an overdose, 10 to 30 times greater than any other time in their life, because while they were in that treatment facility, they have now a reduced tolerance to the medications and also an increased relapse vulnerability. So one way to really help curb the risk for overdosing during that period of time is to have a patient using some sort of medication for addiction treatment. So the risk, as you can see on this graph here, the risk for somebody having an overdose death after treatment is much higher than when they're on some sort of medication for addiction treatment. So this is old terminology on this slide. But yeah, so again, the benefit of getting people on medication for addiction treatment early in their treatment is tenfold in helping to save lives and prevent overdoses. So now we're going to move into something called harm reduction. So what harm reduction is, it's actually a public health strategy and set of different practical types of approaches that are aimed at minimizing the negative consequences that are associated with certain behaviors, risky behaviors in this context of substance use. So rather than focusing solely on abstinence, but just say no method, harm reduction acknowledges that some individuals may not be ready or to stop or they are going to continue to engage in these risky behaviors. So harm reduction incorporates a different kind of spectrum of strategies that include safer use, managed use, can include abstinence, but it meets people who use drugs where they are at and addresses conditions that they might experience while they're using along with the use as they're actively using. It addresses the condition that they might experience while they're actively using. So really the main goal is to reduce the potential harm to the individuals by providing interventions and support along the way. So the principles of harm reduction are set by SAMHSA, which is the Substance Abuse and Mental Health Services Administration, are a set of guidelines that underlie the approach to addressing substance use and related issues. So the six pillars of harm reduction by SAMHSA include that this is a movement led by people who use drugs. That's what the PWUD stands for, if you see that, people who use drugs and those with lived experiences. So this recognizes that those people have leadership and are the subject matter experts and can really help make a difference. And so they are actively involved in the decision-making processes for harm reduction. Embraces inherent human value. So it treats all people with dignity and respect, avoiding judgment. Commits to community engagement and community building. Promotes equity, rights and social justice. And so this works to eliminate any inequities related to things like class, race, language, sexual orientation and gender. Offers accessible and non-coercive support. So again, this is just really making sure that folks are getting the support they need and are not being forced or coerced into anything that they're not comfortable with. And then focusing on positive change that's defined by the individuals themselves. And so the supporting principles of harm reduction are also a set of guidelines that really underlie the approach to addressing substance use and of course related issues. So SAMHSA's approach to harm reduction really centers around respecting the individual's autonomy and empowering personal decision-making, especially by some of those folks from marginalized communities. So it fosters trust and creating a supportive non-judgmental environment. SAMHSA also emphasizes the importance of offering compassionate and peer-led services. So this approach, again, involves that community involved engagement, ensuring that families and communities are involved and support strategies. So it also provides just different paths to well-being that can be grounded in both traditional research, community wisdom, focusing on holistic care. So looking at all aspects of the individual. So there's a lot of these really great principles of harm reduction that really work to create positive change, support the people who are still in active use. And it is a proven method to both reduce mortality for folks who are in active addiction and also is a great way for people when they are ready to seek services and treatment and reach out for help that they have a community of people that they trust and can reach out to. So generally speaking, harm reduction is aimed to mitigate risks and enhance overall safety. So we're often, especially just what we've just been talking about, is to think about harm reduction in terms of substance use. However, there are a lot of strategies, harm reduction strategies that we all use every single day. So we have things like bike helmets, face masks, speed limits, sunscreen, safety belts. Safety belts is inherently driving is a risk that we're taking, but something that we can do to make it safer is wear a seatbelt in the car. We have wearing gloves, washing our hands, using smoke detectors in our house, covering our ears, protecting our ears, having traffic lights. These are all just everyday examples of harm reduction strategies. So walking outside, going to the store, there's risks in everything we do. So we have every day already, we've all probably done something that is a harm reduction strategy. However, when we're looking at it from a substance use disorder lens, then we're talking about things like medication for addiction treatment, using naloxone, which is our drug reversal medication or overdose reversal medication, nicotine patches, syringe exchanges, and that sort of aspect. And also, you know, there's other types of harm reduction services that include things like drop-in centers, housing first initiatives, meaning we want to make sure that even though people might be struggling with substance use disorder, we are also making sure that their basic needs are met. So housing first initiatives are things that, you know, don't require people to be sober or in recovery to offer them housing. So there are opportunities for people to still be housed and still be in their active addiction. And then, you know, there's different types of peer support models. Of course, there's safer sex initiatives and more. So I just really want you to broaden your thinking from harm reduction is just needle exchange programs, syringe access programs, or safe use situations to bigger, broader thinking about what harm reduction services actually can include. So this is just another time. I know some of you all probably have to hop off for another meeting. So, you know, this is something that maybe we can just consider ourselves and chew on. But, you know, really start to think about why treatment for substance use disorders really need to be treated as a chronic disease and how medication for addiction treatment can play a crucial role in that overall treatment and retention of the client. And here is our wonderful ORN survey. So you can provide input on today's session. But I've wrapped up a little bit early. So for those of you who are still online, I'm happy to answer any questions. Or if we want to go back and actually have a discussion about the topic here, I'm happy to do that. So this is your time. And if there is no questions, I'm also happy to wrap this up.

medication

addiction treatment

harm reduction

substance use disorder

buprenorphine

methadone

chronic disease