Hi everyone. Again, thank you for joining us today. I'd like to welcome you all to today's training, Addiction Treatment and Policy. This training is brought to you on behalf of the City of New Britain and sponsored by the New England Region Opioid Response Network. Next slide please. My name is Jenna Fold, Technology Transfer Specialist working with the New England Region of the ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Services Administration, and our grant prime is the American Academy of Addiction Psychiatry. Next slide please. We provide technical assistance to individuals, groups, and organizations in the form of education and training regarding opioid and stimulant use disorders, and we cover the areas of prevention, treatment, recovery, and harm reduction. This is provided at no cost as it's covered through the SAMHSA grant. Next slide please. And this is just our contact information. If you wish to submit another request in the future, you can find our email, our website, and our number, and we'd love to chat with you and see how we can help you with whatever you are looking for in terms of training, education, resources, and so on and so forth. So here we go onto the star of the show. Today we are fortunate to have Dr. John Kelly. Dr. Kelly is the Elizabeth R. Spallin Professor of Psychiatry and Addiction Medicine at Harvard Medical School. He is the Founder and Director of the Recovery Research Institute at the Massachusetts General MGH, for short, the Associate Director of the Center for Addiction Medicine at MGH, and the Founder and Director of the National Center on Youth Prevention, Treatment, and Recovery. Dr. Kelly is a former President of the American Psychological Association's Society of Addiction Psychology, the current President of the American Board of Addiction Psychology, and a Fellow of the APA. He has served as a consultant to U.S. federal agencies and non-federal institutions, as well as foreign governments, the United Nations, and the World Health Organization. Dr. Kelly has published over 250 peer-reviewed articles, chapters, and books in the field of addiction medicine, and been honored with National and International Lifetime Achievement Awards for his research. His work has focused on addiction treatment and the recovery process, mechanisms of behavior change, and reducing stigma and discrimination among individuals suffering from addiction. Before I turn the meeting over to him, I just wanted to review a few of the Zoom controls that you'll be using. I have enabled the live transcript feature if you wish to use it. Please use the chat to sign in and provide your name, your role, and what organization you are here from. You can also use the chat to discuss any need for technical support for any topic-related comments and to submit questions. We'll be monitoring the chat throughout the presentation to answer questions, or you can use the raise hand feature and we will address all of the questions at the end. We are also going to be recording the didactic portion of today's training, which may be shared to outside sources, so for privacy purposes, if you're not comfortable, you can remove your name and your picture from Zoom. We will then stop the recording for the Q&A portion. At the conclusion, I will also share instructions on how to claim continuing education credit through our learning management system, and I will also then be sending a follow-up email on how to claim CME and how to access the slides. We thank you again for joining us today, and I will now turn it over to Dr. Kelly. Great, thank you, Jenna. Good morning, everybody. Really great to see you. Thanks for joining. Yeah, just delighted to be here, honored, as always, to be invited and have the opportunity to talk with you this morning. This is one, part one of a two-part series. We'll do part two next week at the same time on next Wednesday. I believe it's the same time, right? 10.30 to 12.30, I think. Yep. Yes. Eastern time. Welcome, and thanks for joining. Today, we will cover a couple of topics, mainly. I'm going to talk about addiction broadly, first of all, talk about some of the nuances about the construct of addiction and substance-related concerns. Some of the common questions that are asked around this topic that you may have also. I'll also talk about stigma, discrimination, and how far we've come in the last 50 years in learning about these phenomena. Next week, I will talk more about treatment and recovery support services, as well as harm reduction and those kinds of topics. Again, looking at historical overview over the last 50 years, as well as present day and where we're going in the future. These are the learning objectives for the course for this week and next week. In terms of an overview then for this morning, I'm going to focus on the top two here, concept, terminology, taxonomy, and what we know about addiction and related concerns. I'm using, as I'll tell you, I'm using that term addiction loosely, not in its technical sense, and we'll talk about that. Then I'll talk about stigma next week. We'll talk about treatment and recovery. We are in an epidemic, of course, regarding the opioid crisis, which is occurring in an endemic, an endemic problem related to alcohol and other drug disorders. These are pervasive, endemic, intransigent problems, not just in the United States, but in practically every middle and income country around the world. Increasingly in developing nations as well, as there is more access to and industry influence in developing nations as industry, tobacco and alcohol in particular, try to open up new markets for product sales. You can see here, of course, and I don't think this is unfamiliar to any of you here, just what we hear every day in the media about the increasing fentanyl, mostly fentanyl induced poisoning deaths, but also you can see this increase in other opioid related deaths. We're also seeing, I think very importantly from a public health outreach standpoint is to let people know that smoking can kill you just as much as injection in terms of poisoning deaths. This is showing the increase in overdose deaths from smoking as people more are smoking opioids as opposed to injecting them. You can see here this increase in deaths related to smoking opioids as opposed to injection. Part of the perception here is that smoking isn't as bad, so it may not kill you, but of course you can still get, in fact, it's more rapid than injection through the lungs. It gets to the brain quicker and to the extent that this can induce unconsciousness and shut down the breathing system and the heart, it can lead to deaths, overdose deaths, poisoning deaths, of course, just as much. This is what we've seen. Alcohol is, again, as I mentioned, not so much epidemic. This is always with us, but we have now 178,000, according to the CDC, deaths related to alcohol each year, so about 1.8 times that of the opioid poisoning and other drug poisoning deaths. Around the world, alcohol kills 10 times more than all illicit drugs combined. We've also seen an increased risk of death from alcohol in the last 10 years, eight to 10 years, see here, a substantial increase in alcohol deaths. I'm sure that's not news to you. We've been hearing about these things for a long time. We hear about them. This is a perennial endemic problem, of course. The question is, how do we deal with it? How do we approach these problems in society, in most middle and high-income countries, in particular? How do we address them through policy, through prevention, through treatment, through recovery, through harm reduction? These are just a list of questions that I came up with that I hear a lot, that people often ask. You may have others. I look forward to discussion at the end. Please post your questions in the chat. We'll have about a half an hour at the end today to talk about any questions you have over the course of what I deliver, but in general as well. These are some of the more common questions that come up. What is addiction? Why do people become addicted? Why do some people don't at the same level of exposure? It's not just a function of exposure. Many people are exposed, but only a subgroup of those become addicted. Is addiction a disease? Is it a disease of the brain? Is it a chronically relapsing brain disease? I was interviewed by the New York Times, and I was on an NPR interview a couple of days ago on this very topic of, should we describe it as a chronically relapsing brain disease, or what utility does that have? Is it helpful? Is it harmful? Should drugs be legal? Does AA work? Should everyone go to rehab? Is it a waste of money? Do harm reduction strategies assist in remission or enable continued use? Are methadone and buprenorphine just, quote, liquid handcuffs? What treatments work best? Is abstinence necessary? Is it the best outcome? Can people with addiction be taught to control or reduce their drug or alcohol use? Is addiction a good or bad prognosis disorder? Do people get well, or do they never get well? Is it always chronically relapsing, or do people actually get into remission and recovery? Is cannabis medicine or menace? Is it addictive? Do people really recover? Should alcohol and drug addicted people be encouraged to quit smoking at the same time, smoking cigarettes, that is, at the same time as quitting others? These are many questions that you may have. You may have these yourself. They often get asked in the general public, as well as among people that I teach and clinicians and beginning clinicians as many different segments of society. We can answer some of those if you wish and address those. I will be covering a lot of those in the course of this week and next week. If I don't get to them and you want the answer, we can talk about it as well. Look forward to the discussion there. A quick word on terminology. As you know, and as I alluded to at the beginning, I used that word addiction loosely. I said, talking about addiction and related problems. Addiction, technically, you can see in the list here, addiction, of course, really implies this impaired control over use despite harmful consequences. That's the hallmark of addiction is that there is an involuntariness to it. The people are actually using against their will. They want to cut down, they want to stop, but they find themselves unable to despite severe consequences. We can talk about how that shift occurs from more voluntary to involuntary use, but that's when it becomes a psychiatric illness. Addiction though, technically speaking, of course, is just the severe end of that spectrum. When we talk about an addicted person as someone who has lost or has that impaired control over use despite harmful consequences. You can see here that there are other terms often used. We often use the term substance use disorder to describe the spectrum of substance impairment and involvement. The term substance itself sometimes is used to apply to all drugs, including alcohol. Sometimes it's used, some people use it only to apply to drugs other than alcohol. They talk about alcohol use and then substance use as separate. You have to inquire as to what people mean. This is part of the problem we have in our field, isn't it? In communication, clinical and public health communication, what are we actually talking about when we use this different terminology? In the DSM, for example, substance use disorder is used to cover the entire spectrum, correct? In terms of alcohol and other drugs as well. You have to look closely to see what people are talking about, even in published scientific literature when they use the term, because there is no true consensus. People have not agreed that when we use the term substance, it includes alcohol. Sometimes it doesn't, sometimes it does, even in published manuscripts. Drug use disorder is, of course, more specific to drugs other than alcohol, typically. Misuse, that's a term that's often applied to describe the broad levels of impairment and involvement. Substance use disorder, as I mentioned, alcoholism is an older term from 1856. Magnus Hus, a Swedish person, invented that term describing essentially alcohol addiction. You can see there's potential here for confusion in terms of how we communicate. I think it's important to look and see, what am I talking about? What are we talking about? Are we talking about a disorder? We're talking about substance use disorder, which has a vast, vast spectrum of involvement and impairment. Someone with two symptoms is very different than someone who has 10 or 11. Yet we talk about substance use disorder as one thing. We do have these specifiers, of course, in DSM. We have mild, moderate, severe. Two to three for mild, four to five for moderate, six plus for severe, which we normally associate with addiction. I think we need to think about, are we being precise in our communication? What are the complications of not being precise? I say here addiction, it's complicated. It is complicated. And as I mentioned, there's a spectrum of drug and alcohol involvement and impairment and different manifestations of the illness at the same level of symptoms. This is what makes it even more confusing. When we think about this spectrum of substance involvement, we know if you are a clinician, you work with people or in a recovery support service setting, you will notice this high degree of heterogeneity even at the same symptom level. You can have people at mild, moderate, and severe levels, but the manifestation of the disorder is very different even at those same levels. There's high heterogeneity in the expression, the phenotype, the expression of the illness in real time, and it affects people in different ways. It also affects men and women differently depending on, again, who they are. It affects people across the life stage differently. Are you talking about an adolescent, an emerging adult, a young adult, an adult, an older adult? There are different implications of the same substance involvement pertaining to different life stages. Of course, those life stages intersect with these other elements in terms of sex and gender as well as co-occurring other drug use disorders. Many people, for example, who meet criteria for alcohol use disorder also smoke cigarettes. They may use other drugs. People who use heroin also use stimulants oftentimes as well as other drugs. There's also other drug comorbidities in addition to their primary presenting drug problem, drug use disorder. There are also often psychiatric comorbidities as well as medical comorbidities. There may be hepatitis. There may be other liver disease. There could be cancer. There could be other kinds of infectious disease present in addition to the substance use disorder as well as other kinds of psychiatric illnesses. Some of those may be catalyzed by exposure to drugs, particularly during the adolescent years, which we know is a critical period of development, a so-called critical period, after which time exposure to the same drug will not catalyze, not produce that genetic epigenetic effect that can turn on certain genes at certain times. Delay of use is very important in terms of preventing both substance use disorder itself as well as other psychiatric illnesses. We call these epigenetic effects during critical periods of development. There's a lot there we can do in terms of prevention among young people where we know most of the onset of these disorders occur during late adolescence and emerging adulthood. Then the phenotypes, the phenotypes of addiction I alluded to. Again, this is just a different expression. There's been different typologies that have been detailed, analyzed, investigated to understand more about, again, these different expressions and different types of disorder that can occur. Probably the most famous one historically was Alvin Jelinek. Some of you may know that term, named Jelinek, who published back in 1960, a book called The Disease Concept of Alcoholism. In that book, he describes five different phenotypes. He designated them alpha, beta, gamma, delta, epsilon. He had these five different what he called species of alcohol involvement, only two of which he described as a disease process. That was the gamma and delta, which is really the inability to stop and inability to regulate use. What we classically would think about as addiction. Again, this was back in the 1950s before, just after the first DSM, DSM-1 was published in 1952. That was the first designation of an articulation of alcohol and drug disorders. Those of you who are historically inclined, if you go back and look at DSM-1 published in 1952, alcoholism was a single paragraph, descriptive paragraph of three sentences describing what alcoholism was. Drug addiction was viewed as a personality disorder. That's where it was back then. Both of these were viewed principally as not primary conditions, but rather secondary conditions that overlay other kinds of problems, mental health or other problems. Jelinek was probably the first to really delineate these in the scientific literature in a detailed way based on 2000 interviews. He established these five different phenotypes. I'm not going to go into those in a lot of detail, but again, he just called them letters of the Greek alphabet, alpha, beta, gamma, delta, epsilon, to describe these different phenotypes. Others like Thomas Babor and Cloninger have also designated type A, type B, type 1, type 2 species or subgroups of addiction with early onset principally delineated along lines of early onset versus late onset, with early onset being more severe and complex, later onset being less severe, less complex, more treatable. There are lots of different ways that this has been tried to be looked at across this spectrum of substance impairment, which makes things very interesting, of course, but also very complex, isn't it? When you look at all these different intersecting factors, yes, we are dealing with a substance use disorder, whatever that is, but look at all the other factors that need to be considered when we're thinking about how best to address this person as a whole person, all things considered, right? Their demographics, their living situation, their life stage, any co-occurring medical, psychiatric illnesses, history of use, onset of use, all of these things are important to think about when we think about addressing these phenomena clinically and in the public health realm. The other thing to remember is that substances cause harm in different ways. This is a nice figure by Tom Baber, which really delineates the three major pathways through which substances cause harm. You can see here on the right-hand side is what we normally think of when we think of addiction, which is our cultural default when we talk about drugs or alcohol, we think about addiction and that kind of pattern of compulsive use despite harmful consequences. And as you can see, disorder here on the right is one of the pathways, but there are two independent but related pathways through which substances cause harm, that is intoxication and toxicity. So intoxication, for example, people can have lots of incidents and accidents, never become addicted, never have a alcohol or other drug use disorder, but nevertheless fall down the stairs, intoxicated, break their neck, crash their car, kill other people through intoxication without ever being addicted as well as toxicity. So you can, for example, drink heavily without ever meeting criteria for an alcohol use disorder, right? But you're a heavy drinker and suffer from liver disease. In fact, from studies that have been done on alcohol-associated liver disease, half of patients who meet criteria for alcohol-associated liver disease do not meet criteria for alcohol addiction. Interesting. Those that do meet it at a lower level. Now, one of the reasons why, of course, is that people who actually manifest the more florid presentation of alcohol addiction are more likely to be locked up, dead, or sober because they have manifested the more florid expression of the illness. People who are able to get exposed to the substance over long periods are more likely to suffer these toxicity-related effects. Another piece of the toxicity and intoxication, of course, is poisoning. So you can take so much, again, you don't have to ever be addicted to die from poisoning. We see this 5,000 people a year die from poisoning from alcohol every year, young people. There are many other, of course, we've seen the case with opioids, of course, more recently, how easy it is to die on exposure. Just one use of a drug like fentanyl can increase risk of poisoning deaths. For example, that's through toxicity-related effects. So you can see here, I think it's helpful to think about this because somebody actually may be in recovery. Let's say they're in remission from the substance use disorder, but they may be in non-abstinent remission and actually functioning well, but maybe they're still drinking heavily, but they're not actually meeting, they're not symptomatic. So they may actually have toxicity-related illnesses despite the fact that they're in remission from an alcohol disorder. Interesting. So think about that. It's not just about the disorder itself, but also these other factors, toxicity and intoxication, related pathways to harm. Of course, any improvement in any of these realms is a positive move. And I think when we think about harm reduction, we want to think about how can we move people in a way towards better health and functioning. So moving on a little bit to addiction and how it occurs. And again, I'm using the word addiction here loosely, mostly around the term substance use disorder. So how do we get into this disorder category, which I'll come to in more detail in a second. But when we think about human development, the human organism moving through time from birth to death, it is an epigenetic psychobiological dynamic system. In other words, there are genetics involved moving through time and the environment will, the environmental exposure over time will lead to different expressions of those genetic, that genetic predisposition. It'll also shape the brain. You know, our experience shapes a brain and influences our brain, our brain's neurocircuitry. It's psychobiological, in other words. It's dynamic, it's moving, and it's systemic. In other words, there are multiple factors that influence the epigenesis of the organism through time. You know, social, cultural, economic, traumatic, all of these things, the kinds of things that happen to us early on in our lives can shape us for the rest of our lives or influence us for the rest of our life. It does not mean that we are destined to be that way forever because our brain can rechange. It can recalibrate based on different inputs, correct? Right, in terms of treatment and recovery and all the things that we think about when we think about people being able to return to normal life and get back into remission and function well in society. As David Best often talks about being better than well, people in recovery kind of have this new kind of technicolored version of life that they appreciate life more, that they're more present for life. They're firing more on all cylinders because they kind of feel like they've been given a new lease on life in recovery. So when we think about the factors involved, initial exposure is an important one. I mentioned this already. So early exposure increases risk for disorder. For example, about 60% of people exposed to alcohol prior to the age of 15 will meet criteria for alcohol use disorder at some point in their life. Only 4% of people who start alcohol exposure, get alcohol exposure after the age of 21 will meet lifetime criteria for alcohol use disorder. So the time of exposure is very important, particularly during these adolescent years from 10 to 20. That period of development can produce early exposure to cannabis, alcohol, other drugs, can turn on genes that would not be turned on if people wait beyond that developmental period, that was so-called critical period of development. You know, the reasons why people use substances, of course, is another factor in terms of the onset. The reason why these are a thing at all is that they produce this immediate, potent, predictable effect. Very few things in life are as immediate, potent, and predictable as alcohol or other drugs. I know if I take a drink, if I smoke a joint, if I take a pill, inject myself with something, I'm gonna feel something very deep, profound, and fairly immediate. And it's that immediacy, potency, and predictability which makes drugs such an allure because they produce that euphoria or relief or performance enhancement or social acceptance. So there's those four main reasons why people use, again, to feel good, to feel better, to do better, or because other people are doing it. Genetics, we have found to be a very important piece of the picture in the last 50 years in particular. We know roughly half the risk for complex illnesses, psychiatric illnesses, including addiction, is conferred by genetics. So some of us are protected, some of us are more vulnerable right out of the gate by virtue of our DNA. As I mentioned, why is it that on exposure to different substances, take alcohol as a prime example because it's legal, it's potent, it's immediate, it's predictable, only about 15% will actually meet criteria during their life for alcohol addiction despite the fact that 90% of the population is exposed. So there is some vulnerability, susceptibility within individuals as well as, again, it's not just addiction that causes harm, as I mentioned, because you can drink heavily and be exposed using intoxication as in toxicity-related risk independent of addiction. But I'm talking about addiction here in terms of the disease of addiction or disorder of alcohol or the drug use disorder is that genetic modulation increases or decreases risk. Some people find exposure to alcohol aversive just right out of the gate. They don't like the way it makes them feel. Other people will drink themselves to death. The abnormal priority part, of course, pertains to the fact that that's what happens in the process of becoming addicted is that the drug, the substance use takes on an abnormally high priority. It's never meant to take the kind of priority that it assumes as the disorder develops. So people start using it because they see other people, they're around other people who are using the substance. So they take some, they use it just because that's what's happening. But as again, the interaction between that initial exposure and what's inside of the person will increase the risk. How much profound reinforcement one gets from that on these initial exposures or relief, or how much relief or how much performance enhancement you start to be able to do things that you can't do without the drug present, that will reinforce people. And again, that is genetically modulated, the degree to which that reinforcement and reward occurs. Some people, again, will say, I really don't like the way this went. Some people are saying, wow, wow, this is amazing. This stuff is amazing. I never knew anything about how, I never knew how this would make me feel. And they don't know that they're responding differently. This is one of the catches is that when people are exposed to alcohol or other drugs at an early age, they don't know they're getting a much more profound effect than somebody who's taking the same amount who's standing right next to them, just by virtue of their DNA. And again, the last part here, this impaired control over a reward-seeking behavior from which harm ensues, that's just a classic definition of what we think about as addiction, this impaired control over a reward-seeking behavior from which harm ensues. And you can think about that, kind of wraps up this notion of addiction. I mentioned this, already alluded to this, but I think it's very interesting when we think about the process of addiction. People use initially for four main reasons, to feel good, to feel better, to do better, as I mentioned, performance enhancement, or because others are doing it. So there's some kind of social norm that's going on that people will use. What do you think the four main reasons are why people stop using substances? They're exactly the same. People stop using to feel good, to feel better, to do better, or because other people are not doing it. Wow, well, that's an odd turn of events, isn't it? Because wait a minute, I'm using here to feel good, to feel better, to do better, because other people are doing it. But something happens between the start and the end, which is what we know to be these brain changes. The brain changes through processes of neuroadaptation and neurotoxicity. So as we expose our brains to a substance, mother nature will try to adapt to this abnormally high level of reward and reinforcement, because oftentimes these drugs that the brain is exposed to are concentrated. They're not in the level that mother nature is used to dealing with in terms of our brain, because we're used to our brain's neurocircuitry, our reward neurocircuitry is typically for sex and food, water, social interaction. That's what it's designed for. And to have those levels go up and down in response to those, because those elements are necessary for human survival. Drugs are not necessary for human survival. And we often use that term hijacked, that it gets hijacked by these abnormally high levels of reward and reinforcement. So what happens? Mother nature will try to adapt to this abnormally high release of chemical cascade that's produced by different substances, whether that's alcohol or cannabis or opioids or amphetamine, cocaine. It produces this cascade of chemical, which people will find either pleasurable, relieving, an escape, performance enhancing, or to fit in. And you can see here, now we've been able to identify the neurocircuitry involved in this process, reward, memory, motivation, impulse control, and judgment. And you can see memory and reward here in the hippocampus and nucleus accumbens. And this is where we get the pleasurable effects, the release of dopamine into these areas, produces an endogenous opioids into these areas, produce this liking and wanting, this pleasant experience that leads to repetition, as well as dysregulation in these prefrontal areas. Now there is two processes, as I mentioned, there's neuroadaptations as mother nature tries to respond, it adapts, the brain adapts to the presence of these abnormally high levels of reward and reinforcement. You can think of this as kind of like when you, if you go to the gym and you're working out with weights, your body changes, you will build muscle. In other words, your body will adapt to this abnormally high level of weight, right? In terms of the weights. So what does it do? Your body adapts, it builds muscle to cope with, it adapts to these abnormally high levels of weight, which are produced at the gym, right? If you're lifting weights, for example. So our bodies adapt, we see it every day in different ways. Mother nature has given us this ability to be able, our bodies can adapt in the same way the brain does exactly the same thing. It adapts to the presence, abnormally high presence of these levels of reward and reinforcement. Now that's all well and good, right? So what's wrong with that? It adapts and the problem is, is that it becomes dependent then on these higher levels. There's a process, what some people call allostasis. So this stability through change. So the brain then becomes upregulated in terms of, it becomes accustomed to the presence of the drug. So if you're taking it a lot, now it's abnormal for the brain to be without that substance because it's adapted to the higher level. So this is what happens, of course, in withdrawal. So people feel blah, they feel like, wait a minute, I'm just not getting what I used to. I'm not feeling right, I'm not feeling good. I don't, you know, a sunny day is not a sunny day anymore. Everything seems very blah, kind of dystonia, dysphoria, the anhedonia that people feel in acute and post-acute withdrawal periods. It's because of that process of neuroadaptation. Now, the brain can recalibrate. Once you remove the drug, the brain will recalibrate, but it can take time, it can take weeks, months, and for some people, even years for that recalibration to occur. So that's the neuroadaptation process that leads people for the same reasons, to feel good, to feel better, to do better because other people are doing it, to want to stop, I want to stop because I want to feel better, I want to do better, I want to, because other people are not doing it. And this is why recovery happens, of course, is because oftentimes we see role models around us, and this is one of the reasons why there's such an emphasis on peer support because an exposure to peers with lived experience because it can attract and engage people into recovery when they see other people who've had similar problems living successfully and happily without the drug on the other side of it. But it's an interesting paradox is that the same reasons why people start are the same reasons why people stop. So the train leaves the station and it's an enjoyable ride, an exhilarating ride, but at some point, the train gets derailed, gets out of control, people want to get off the train because it's really taken them for a ride they don't no longer want to be on. Again, taxonomy, we have this continuous laundry list, if you will, of symptoms, right? From two to 11 in current DSM nomenclature that originated in DSM-5. So now instead of having two categories of abuse and dependence, we have this single category of SUD, right? So anywhere from two to 11 symptoms with subspecifiers of mild, moderate, and severe. And this was generated, this new single dimensional construct category was delineated on the basis that the old abuse criteria, you may remember those, some of you have been in the field for a while and have worked with these criteria. The abuse criteria, you only had to meet one or four, one or more of four. And these tended to be consequences of substance use like impaired control, overuse, social problems or psychological problems related to the substance. And then you had the dependence criteria, which were the kind of more physiological, so tolerance and withdrawal, as well as continued use despite harmful consequences, unsuccessful attempts to cut down, et cetera. But what they realized when they analyzed these is that these abuse criteria tended to occur at the higher levels of dependence. So they thought, well, why don't we just put them all together then in one single category? Is that a good idea? What do you guys think? We can talk about this, but we have, again, we have this big long spectrum, as I mentioned, of substance involvement and impairment across the spectrum, anywhere from two to 11. I think the way to think about this, the way I think about it is like a kind of the temperature of water. When we think about, again, this pertains to not just degrees of substance use disorder, but also getting from heavy use into disordered use. I think about it in terms of a temperature gauge. So if you think about the temperature of water, right? If you go down from boiling point, it gets cooler and cooler. The water will get cooler. Somewhere between 33 and 32 degrees, the water will change, not just in temperature, but in structure. It changed from water to ice somewhere between 33 and 32 degrees. So not only is there a quantitative change in terms of the temperature of the water, but a qualitative change going from water to ice. It changes structure. There's a structural, and the same, I think, occurs in the brain. You can have certain degrees of exposure. Over time, there are more fundamental qualitative changes in the brain that moves people from heavy to disordered use. And this may be one way to think about it in a similar way that we think about this temperature gauge of water. I've been alluding to this, you know, the nature of addiction and substance use disorder, that it's multifactorial. It's what we call a complex disorder. It is not a simple gene. You have the gene, you got the disorder. No, it's not like that with addiction. Genes confer a risk, but even if you have certain genes, it does not mean that you are destined to become addicted or have the disorder. And this is why we call it complex. It's dependent on multiple factors dynamically existing over time. And it depends on what you're exposed to as a kid, how early you're exposed to different substances, and the interaction of those, et cetera. And as you can see here is this, again, psychobiological dynamic system of epigenetics, where you have certain biology and genes and environment, what happens to you as a kid, trauma, what happens in your home, attitudes, parental influence, what their attitude is towards drug and alcohol use, early exposure, et cetera, root of administration, type of drug, how quickly it reaches the brain, root of administration, whether it's smoked or injected or consumed. And then, of course, exposure, as I mentioned, it changes the brain, right, through neuroadaptation and necrosis, killing brain cells. So it kills brain cells through neurotoxicity, certain drugs like amphetamine and alcohol, for example, in particular, as well as mother nature's attempt to adapt to these abnormally high levels. And those neuroadaptations or neuroplasticity or actually maladaptations produce addiction. It's those changes which produce this cycle of dependence that produces this repetition, which is a losing battle over time, as people need more to get the same effect, and it creates this chemical cascade, neuronal changes that produce addiction, makes it very difficult to get off the train. We turn to addiction here, recovery, addiction recovery. It's a dynamic, long-term process. You can see here, again, just like addiction, recovery, the process of recovery and movement towards health and wellbeing also involves multiple factors, right? Genes and biology, environment. What kind of environment are people in when we treat them? What are they living in? Where are they? Because it's much more about the environment than it is about anything we do at any single point in treatment, because just like a plant organism needs, in order to photosynthesize, a plant needs to be placed in the right environment, light, moisture, and temperature, in order for the plant to be able to survive and thrive. Human beings to heal after they've suffered this chronic poisoning over time, they need an environment which is conducive and supportive to long-term healing and change. And this is why these environments, recovery-supportive environments are so key in recovery from this chronic illness. And as you can see, there's many other factors, recovery capital is the catchphrase these days that we use to describe recovery resources. So you think about recovery capital as the total set of internal and external resources that people can draw on to enable them to get into remission and recovery. And you can see here these psychological factors. Do I believe I can get well? Is there hope? Do I have optimism that I can get well, get out of this, stop the train and get off when I'm ready to do so? Do I have confidence that I can do it? Do I have meaning and purpose in my life? Do I have values that I can draw on? Do I feel empowered to make these changes? As well as access to resources, healthcare, employment, housing, jobs, education, the kinds of things that people need to build self-esteem, confidence, have economic ability, financial ability to be able to make ends meet and move forwards and so on. So that's kind of a one-on-one on kind of addiction, just to kind of put you in the picture of this, again, this spectrum, there's sometimes the confusion that we all suffer from, and I'm guilty of it myself when I'm using terms like addiction loosely. And I try to be careful of the terminology that I use because it has implications in terms of the clarity and precision of what we are talking about, who we are talking about, what it means for public opinion, for public policy. So I think this is something that we should pay attention to. The next thing I wanna talk about this morning is stigma. So the second part of what we're gonna talk about today is stigma and discrimination and what we can do about that, just given that whenever we're talking about addiction, we are also unfortunately addressing stigma and discrimination. I've been just thinking about the last 50 years in part because we reached a milestone in 2021 since the initial declaration, so-called Declaration of the War on Drugs under Nixon. Some of you may remember this, Nixon famously describing, quote, drug abuse as public enemy number one. And I think we have come a long way in the last 50 years, and I'll talk about why I think that. But the initial rhetoric, of course, was one of a kind of a harsh, a punitive militaristic attempt to defeat the enemy, as it were, public enemy number one, being drugs and drug abuse. And so this was a concerted focus. It marked a concerted focus here in the United States, but also actually internationally. There at the same time, there was an update to the single convention on narcotic drugs from 1961 that had been agreed upon by about 150 countries around the world, including the United States. So it coincided with this international move, again, to try and address these problems around, these endemic problems around drugs and alcohol. Now, the last 50 years, we've seen a shift. In part, the shift has been driven by the new knowledge that's been gained from the National Institutes of Health pertaining to addiction, understanding its etiology, epidemiology, typologies, clinical course, et cetera, how we can best address these. And the shift in rhetoric and the shift in our approach has been reflected in the legislation that's been passed. For example, when we look at the legislation that's been passed over the last 50 years, it's moved from the initial kind of draconian mandatory minimum sentencing laws that disproportionately affected young black and brown men, in particular, that had these mandatory minimum sentences. Remember that under Bush Senior in particular, there was this tough on crime approach in the 80s, including these mandatory minimum sentences for possession, for example, of crack cocaine, disproportionately affecting black men. And that's moved towards more laws passed to do with access to treatment. So it's moved from this punitive criminal justice stance more towards a public health and clinical stance. And this is reflected in the Mental Health Parity Addiction Equity Act, as well as the Affordable Care Act, which necessitated coverage for mental health and substance use disorders. I was at this conference back in 2013, where it marked a formal shift away from the war on drugs towards this broader public health approach. And this was done in 2013. We've seen it reflected also in the criminal justice system with the birth and growth of treatment courts and recovery courts. So these are leveraging the criminal justice system to be able to help people with substance use disorder, whose really crime was driven by their addiction, to be able not to just get punishment and be locked up, but rather to be diverted into treatment and undergo treatment through the criminal justice system, which has been helpful in addressing these problems earlier for many people than would otherwise be dealt with. We've seen also changes, not just in the criminal justice system or legal system writ large, but also at the front lines of police enforcement and policing. This was a guy you may remember, Chief Campanello made headline news around the country about, what is it now, 11 years ago, through his so-called angel program in Gloucester. He recognized that people with addiction weren't criminals, but rather needed help. And he said, basically, if anybody has an addiction problem, they come to the police station, we will take them to treatment. We won't arrest them. We'll help them get the treatment that they need. So this was this notion of help, not handcuffs. And here was Chief Campanello acting more like a public health commissioner than a police officer. Why? Because he observed, saw the futility of locking people up and the utility of helping people access treatment. I think this is also telling, and again, a mark of the shift. I was at the United Nations a few years back for this symposium addressing drugs internationally. And this was outside, you see on the right-hand side here, this was outside the United Nations building in Vienna. It says, dedicated to all those affected by drug problems worldwide. Drug problems are preventable and treatable. Now, I thought that was quite telling. It's a compassionate monument with a compassionate inscription here, really talking about prevention and treatment, not criminal justice or legal aspects. But again, I think it marks a shift. And this is the only monument outside that I could see outside this building. So very interesting that that has occurred. We've seen also shifts in policy around drugs. And this is a nice graphic from the Canadian Drug Policy Coalition, which really, I think for me, nicely delineates the different policy positions for different types of drugs and also what the implications are of those different policy positions. And this, I think, is useful for helping to understand more about different policy positions and what that can mean for population exposure and the kinds of harms that can occur. You can see on the left-hand side of the bottom axis here are the different policy positions. Across the bottom axis and up the side are different kinds of problems that can occur in society. And across the bottom axis are these different policy positions ranging from prohibition, that is, you know, banning the sale, distribution, manufacture of certain substances, up through commercialization, legalization and commercialization, like we see with alcohol and tobacco, for example. And you can see different types of harms associated with different types of policy positions. For example, when you ban a substance, you tend to, to the extent that people want it or some people want access to it, then you create a black market. That creates a crime and gangs and all the rest of it, a black market, illicit trade, which produces oftentimes, produces violence and all the things that we associate with illicit drugs and drug markets. Conversely, if you go on to the other extreme, where you have largely unmitigated commercialization of a substance, again, to the degree to which a substance can cause harm, then you have lots of harms. It may not be the type of, you know, cartel crime that we normally associate with illicit drugs, but you have other kinds of harms. As I mentioned, we have 178,000 deaths from alcohol every year. We have 400,000 deaths from tobacco. These are the leading causes of preventable death in most middle and high income countries, as well as other drugs, as well. We've seen an increase, as I mentioned, in opioid deaths, but it's not just the deaths, it's the human misery, the family misery, it's the unpredictability and the gravity of these problems. If you know or have experienced living with someone who has been addicted, you know it's not just about death, but it's about living with these problems in real time, which creates all kinds of chaos and heartache and impairment, functional impairment in people's lives. So you've got this other extreme here associated with commercialization, and you've got kind of sweet spots in the middle, right? Decriminalization, market regulation, prescription. Now, these are theoretical sweet spots, which normally work, but we've seen here, as we saw with the opioid crisis, even prescriptions can go wrong, right? What was the stem? What was the origin of the opioid crisis? Opioids were the number one prescribed drug in the United States. There was more, Vicodin was more prescribed than statins. Can you believe that? So people were more likely to get a prescription for an opioid analgesic than they were to get a statin in the United States. 4.1% of the world's population, consuming 60 to 80% of the world's opioids. So overprescribed, underappreciated is the seductive ability to seduce the human brain into repetition and addiction. And this is what, of course, led to, initially led to the current opioid crisis was this really negligence on the behalf of practitioners in recognizing how people can become addicted to these substances. Again, but this is useful in terms of understanding what some of the dimensions are of different policy positions and the kinds of harms that can be induced with different policy positions. So in the last 50 years, I would argue that we've gone from kind of the war on drugs to the war on the war on drugs. And again, a lot of this shifting has occurred in terms of moving from the harsh punitive rhetoric and sentencing and legislation around draconian sentencing and prison building towards more public health and treatment approaches and harm reduction approaches is through the knowledge that we've gained really through NIAAA and NIDA, which coincidentally were founded at the same time. Ironically, NIAAA was founded in 1970, NIDA in 1974. In 1992, SAMHSA came along, federally funded again to disseminate and fund implementation of best practices around the country to help people with these disorders as well as de-stigmatizing. And since for the last 35 years, we've had recovery month. We're in recovery month, of course, right now in September the 30, I think this is the 35th recovery month, celebrating people in recovery and families in recovery and supporting and de-stigmatizing these disorders through these federal efforts around the country. So again, I mentioned this earlier, but if you think about what we have learned and what I've been talking about, if I was giving this talk 50 years ago, we didn't know anything about the reward circuitry and how the brain has been affected by exposure, how the brain changes as a function of exposure to these abnormally high levels of reward and reinforcement, how the brain tries to adapt. We didn't understand about genes and how genes were so influential. We understood a little bit about how addiction tended to run in families, but we didn't understand how genetics played a role in that as well as role modeling and support. But you can see here, we've understood that therefore a lot more about the etiology of addiction and that's tended to reduce that blaming stigma that people, yes, they choose to take that first drink or drug, but because of their DNA, because of what's happened, the epigenetic effects of their development, they may get a very profound positive effect or a actual negative effect, which leads to different pathways. Neurobiology, as I mentioned, understanding the controllability in the brain, we can see much more clearly, this has tended to reduce stigma. We understand about the risk factors in the population a lot more clearly now, as well as the multiple pathways into, through, and out the other side of these disorders. We've also been privileged to now uncover some very important medications, as well as psychosocial treatments and recovery support services that we know can help people. Arguably the biggest impacts in the last 100 years in addiction has been methadone and buprenorphine and Alcoholics Anonymous. Those have had the three biggest impacts in terms of addressing these endemic problems around the country and around the world. So despite the fact that we now know a lot about this, there's still stigma and discrimination against people with active addiction and people in recovery. So what can we do about it? I think there's three things that we can do to address stigma around these conditions. One is through education. One is through personal witness or social exposure. And the other is through precision in accuracy in our language and terminology, how we describe people who have these disorders and suffer from them. And this has been an emphasis, all three of these have been an emphasis in the last 20 years. Education is important because it's helpful for helping people to understand. And this is what's happened to us all in the last 50 years. We've become educated through the research about the true nature of these disorders. As I'll show you in a minute though, that's not the complete answer in terms of addressing stigma, because while education can reduce blaming stigma, it can also increase other kinds of stigma. And I'll explain more about that in a minute. Personal witness, this has been a major thrust of the social movement towards self-disclosure. The idea here is to put a face and a voice on recovery for people, if they're willing to talk about their experiences with addiction, that they can put a face and a voice on recovery because we generally only hear about the disasters, the deaths, the misery, the heartache. We don't hear about the successes, the remission, the recovery, the positive aspects that we know occur now. We know that roughly 75% of people who meet criteria, lifetime criteria for an alcohol or other drug use disorder, will achieve full sustained remission. So this is a good prognosis disorder. And so people have been advocating, particularly through Faces and Voices of Recovery, favor putting a face and a voice on recovery so that people are out there talking about it. Tom Coderre is a prime example, is a Deputy Secretary of Health and Human Services, and out there putting a face on recovery and talking about it openly, again, in an attempt to destigmatize. And this is happening more and more as people encounter people who are in recovery. So they say, wait a minute, this person looks normal to me. How could they have had that history? Well, yeah, that's the point, is that people can remit, they can get into recovery and lead normal lives and contribute to society. And then the other thing is change our language and terminology to be consistent with the nature of the condition. This has been a major emphasis in the last 20 years is really shifting our language. We still have a problem, of course, with our own national institutes and federations. This still needs to be changed, including the National Institute of Drug Abuse, as we've learned, and the National Institute of Alcohol Abuse and Alcoholism and the Substance Abuse and Mental Health Services Administration. All of these have abuse, which we now, in the title, which we now know to be stigmatizing, and I'll tell you why. So we still got to work on those changes. It takes an act of Congress to change those federal names. So it almost happened a couple of years ago, but just didn't quite make it into the bill at the last minute. So we need to get those names changed, and you'll learn why if you don't already know why, what the basis for that is. So what is stigma? Formally, you can think of stigma as an attribute, behavior, or condition that is socially discrediting. It discredits people. That's what a stigma is. Discrimination, what is that? It's the unfair treatment of people who have that stigmatized condition problem attribute. Here's an example of discrimination. Please see if you can correctly identify all of the pictures which feature addiction treatment facilities and which treat other conditions. I'm sure you're used to seeing these recapture-type things on the internet where you have to click, I'm not a robot, and you have to identify. Usually it's like a bridge or a bicycle or something you have to identify and pick out the pictures. But here, I'm just mimicking that by making a point here. The point is, if you were to tell me, I'm sure you could pick out and guess which ones are the addiction treatment facilities and which ones treat other health conditions. Now, why is it that we can tell the difference? Because typically, the kinds of structures and environments that are devoted towards mental health care, and addiction care in particular, tend to be more dilapidated, more impoverished, have left fewer resources than buildings and infrastructure for cancer or diabetes or heart disease. Why is that? It's because of stigma. This is a clear structural discrimination against these disorders. What does that do? People with SUD often get treated in second-rate dilapidated buildings. It gives them the impression they have a second-class illness. Not only do they worry about getting poor quality care, but they also get the message that they're not worthy of high-quality care environments where people with, quote, real diseases get treated. The common phrase, it's good enough for them, it's good enough for addicts, is good enough, quote, unquote. So there's things that we can do. I remember when I worked at a VA in Palo Alto, California, and they have a domiciliary unit there at Menlo Park, and I went in there to meet with the director, and I was completely struck by just how beautiful the environment was at the Menlo Park campus for the homeless veterans with mental illness and addiction. And I said, this environment, I said, it's absolutely fantastic, it's beautiful. And he said, thank you for noticing. He said, that's what we try and do because we want to reflect. People have lost their dignity and respect. We want to reflect that back to them. We want to give them the impression that they have. They have intrinsic worth, and you have an environment which respects that humanity. And I love that, I just love that. It always stuck with me that it was such a beautiful environment. That's the kind of thing I think we need to pay attention to in addition to all the other things I'm going to talk about. But that structural discrimination is visible. It's visceral, and it can affect people's perceptions, the self stigma, as well as the public stigma that drives it. Around the world, we also see these conditions stigmatized, not just in the United States, but this was a study done by the World Health Organization. 14 countries, 18 of the most stigmatized conditions. This included being HIV positive, being gay, being a criminal, as well as being addicted to heroin or alcohol addiction. And across these different societies and conditions, guess what? Number one, illicit drug addiction was the most stigmatized. Number four in the list of 18, alcohol addiction. So two of the top four, including the top, universally across these 14 different countries, those were the top in the top four. We also know that substance use disorder is more stigmatized than other kinds of psychiatric illnesses. Why? Because people are viewed more to blame for having these disorders than people with schizophrenia or major depressive disorder, for example. And again, we can talk about why, but part of that, of course, is that it involves initial choice. People have to decide, oh yeah, I'm gonna take a drink. I'm gonna take a drug. But again, it's that interaction with the exposure. And again, people not knowing what they're getting into. And the train leaves the station, picks up speed. Before they know it, they can't get off the train. Now, treating, describing substance use disorder as treatable and that people can recover does help to reduce stigma. People who have these disorders who have more stigmatizing beliefs about it actually are more likely to discontinue treatment, drop out of treatment, independent of how severe they are. So if people believe, patients believe that these are, I'm to blame for my disorder, I have this disorder, then they're more likely to drop out of treatment irrespective of how addicted they are and how severe they are. Also importantly, clinicians and physicians and healthcare workers and other people who are not in recovery themselves often hold the same prejudices and stigmatizing beliefs, but education does seem to help. Why are we all talking about this? Well, of course, it has public implications, both in terms of public opinion, but public policy. Where should we devote dollars to address these problems? Should we build more prisons or build more treatment facilities, build more harm reduction services, build more recovery support services? What should we do? How should we address this problem? This is what's changed, of course, in the last 50 years, but also stigma affects people. It affects people and their families. It leads to more, less self-disclosure, less self-acknowledgement, more hiding, more secrecy, more shame, less likely to seek treatment, more likely to drop out. As I mentioned, I alluded to this fact that addiction stigma is not just one thing, but has multiple dimensions. And these are four of the biggest ones that we often look at when we think about stigma related to these disorders. Blame, for example, is one that I think our default, our cultural default goes to blame. Are they to blame? Is it their fault or not? That's the kind of major piece of stigma that we often think about. But there are other ones too. Can people get well who have these disorders? And this was something that came up recently when I was talking to NPR the other day was this notion of a chronically relapsing brain disease. Is that helpful in turn? In fact, it's helpful reducing blame, but it's not helpful for giving the impression that people actually can get and stay well, which most people do actually who have these disorders. The other two elements are dangerousness and social distance. So are they dangerous? Are people who've had these disorders, are they dangerous and unpredictable? And should I therefore keep my distance from them? Would I have them as a babysitter? Would I have someone in recovery as a babysitter? Would I have someone in recovery as a roommate or as a coworker? So why are these things so stigmatized in relation to other disorders and problems as well as other kinds of psychiatric illness? I think there are two dimensions, particularly to the blaming type of stigma. And I've alluded to these already a little bit. If we can say, for example, it's not their fault and they cannot help it, compassion tends to increase, stigma tends to decrease. On the other hand, if we say it is their fault and really they can help it, they're just engaging in selfish, willful misconduct at the expense of other people, then stigma tends to increase. And as I mentioned, we now know, and this has helped our knowledge, and this is where education can be important in reducing stigma, particularly the blaming type of stigma. We now know that certain people by virtue of their DNA are just more susceptible than others. Some people are protected, some people are more vulnerable by virtue of their genetics. This has helped to diminish that blaming type of stigma regarding personal blame and fault. In terms of cause, can they help it? Again, our understanding of the neurobiology of addiction has helped us understand how changes in the brain's neurocircuitry of reward, memory, motivation, impulse control, and judgment shown here, how these changes, radical changes with chronic exposure reduces, it produces this impairment in the ability to regulate the impulse to use despite humble consequences, what we now know as addiction, what we understand. I mentioned this earlier, is processes of neuroadaptation, but also neurotoxicity. And you can see here on the bottom right, you don't have to look long or hard to see the difference between someone with chronic alcohol exposure versus someone who's limited alcohol exposure in terms of its effects on the human brain. So what can we do about it? Again, education, personal witness, and changes in our language and terminology. Think about language, why it's so important. You know, people often say words matter. Of course words matter. If words didn't matter, wouldn't matter what I said right now or what I've been saying for the last hour. Words is exactly how we communicate, how we elicit attitudes and action patterns in human behavior. It's through our language. We think in our language, we dream in our language. It is how we act and navigate the world. So it's critically important when we think about our human behavior. And language is the key to all of this. You know, the words that we use and the meaning derived from those words. It evolves over time as well. Of course, we don't use language such as dypsomania or inebriates or lunatic asylums. We talk about alcohol use disorder and mental health facilities these days. So language does evolve and change over time. Why does it do that? Well, in part, because things are always changing. Our language, our precision, our fashions change. But also when language is known to be stigmatizing and we want to proactively change that. So let me ask you, you know, if we were to, when discussing the disorder itself, we were to emphasize the biological causes, what happens. As I mentioned, this has been one of the underlying factors of why NIDA and NIAAA and government levels have been talking about addiction as a brain disease, a disease of the brain, because why do they do that? They want to reduce stigma. They want to take it out of the criminal justice camp and put it in the medical camp. Instead of peering through key holes into prison cells, we're looking through microscopes into brain cells to understand more about the medical phenomena. But what happens when we do that, when we emphasize the biogenetic aspects? Well, this is a study of 28 studies, what they call a meta-analysis of 28 studies looking at the biogenetic emphasis in mental health. These are mental illnesses. So people were suffering from a variety of mental illnesses. What do you think happens when, to stigma, these dimensions of stigma, when people talk about the fact that mental illness has a genetic foundation, is genetically influenced? Well, this is what they did in these studies. And when they grouped them together and looked at the outcome of all these studies together, they found that, yes, actually, when you emphasize the biogenetic aspects, the fact that mental illness has a genetic component, it reduces blame. So people feel more compassion in terms of it's not their fault. But look what happens to the other things. It increased social distance, dangerousness, and prognostic pessimism. So people feel if it's a genetic disorder, you can't get well. You cannot get well. What about in terms of controllability, this other dimension, as I mentioned? They looked at this as well in mental health. What did they find? Again, they found that actually had no effect on blame. So when you emphasize the neurobiological aspects of addiction, or in this case, it was mental health. In other words, this kind of chemical imbalance, when you emphasize this chemical imbalance in the brain as a way to de-stigmatize, it actually didn't do anything. It didn't affect social distance or dangerousness or people's perceptions of the likelihood that somebody could get well, and it had no effect on blame. What about addiction? Well, we did this study. There's been fewer studies in addiction. We did one, a national study a couple of years ago. Very interestingly, we were comparing, again, these more biomedical terminology, including chronically relapsing brain disease, up through less medical terminology. So I was interested in what difference does it make if we describe these disorders or somebody who has them, if they have a chronically relapsing brain disease, or call it a brain disease, or if we call it a disease or an illness or a disorder or a problem, does it make any difference to the general public's perceptions of these elements of blame and prognostic optimism and dangerousness and social distance? Well, very interestingly, we found results very similar to the mental health field. If you look on the top here, you can see in terms of blaming stigma, this is blaming stigma at the top. When people were assigned a description of somebody who is getting treatment for opioid impairment, when that person was described as having a chronically relapsing brain disease, blame went down. When they were described as having a problem, an opioid problem, blame was up. But the complete opposite was true when you talk about the likelihood of recovery. When you describe the disease as a disorder or the opioid impairment as a chronically relapsing brain disease compared to having an opioid problem history, look what happens. People think that you can get well if you had an opioid problem history. You cannot get well, or you're less likely to get well if you've had a chronically relapsing brain disease or brain disease or disease. Different effects in the same vignette, depending on how the opioid impairment is described, it has the intended effect on reducing stigma, the blaming stigma, when we talk about it in more biomedical terms. But people are less likely to view that person as being able to get well if they have a disease, a brain disease versus an opioid problem history. And you're less likely to want to have them as a babysitter or as a coworker if they have had, if you describe them, a history as having a brain disease or a disease, for example. So what are the implications? I think really interestingly is that it depends on the focus in the public health communication, what we're trying to do. Are we trying to get more people into treatment to de-stigmatize the blame and the shame? Then we want to use biomedical terminology. If we wanted people to reintegrate back into society, to get jobs, housing, to be perceived as people who can act normally and function normally and be good citizens, then we want to use less biomedical terminology. So it's interesting. It means that we want to be careful and selective about the kind of language that we use depending on the purpose. I think what's also interesting in the study was that for women, women were found when, because we crossed this study with the person described was either a man or a woman. When the person in the vignette was a woman, the public's perception, again, this was a nationally representative sample of the US adult population in this study. The public out there thought that women were more to blame than men. But men were viewed as more dangerous and should be more likely to be socially excluded in recovery than a woman. So it may mean that because women are held to a higher standard who have opioid related, perhaps other drug impairment, I think we can generalize as well to other drugs, including alcohol, that women are just judged more harshly for becoming addicted than are men. It may be this kind of cultural boys will be boys kind of phenomenon. Whereas women, on the other hand, may be more frowned upon for getting opioid impairment, becoming impaired through opioids. What about the person? Again, we've got this different terminology, as I mentioned, mixed terminology, all kinds of terms that we have in our field. This is a question I often pose to audiences is people with eating related problems are always referred to as having an eating disorder, never as food abusers. So why are people with substance related conditions referred to as substance abusers or drug abusers and not as having a substance use disorder? Interesting that I've never heard anybody talk about people with eating problems as being food abusers or suffering from food abuse. But somehow we've used in a similar way, have just adopted this abuse terminology and abuser. And I hear it still, even though we've come a long way in changing the language around this. In fact, in DSM, which is one of the reasons why they changed the terminology was because of this fact and what we have found. But is it all semantics and is it all political correctness as some people might say? Is it much to do about nothing? Is it just semantics? So we did a couple of studies. One study was a randomized study where we actually had expert clinicians. So these were roughly 600 expert, these were MDs and PhDs. So expert, well-trained clinicians in mental health and addiction. And we randomly assigned the 600 clinicians to receive a description of somebody who was in trouble with alcohol and drugs. And in half the vignettes, the person was described as having a substance use disorder. In the other half, they were described as being a substance abuser. Otherwise they were identical. And we randomly assigned them to these experts in addiction and mental health. And what happened, very interestingly, the people who were assigned the description of the same person, but just swapping out the term substance use disorder for substance abuser were more likely to view that person as more to blame, less in need of treatment, more in need of punishment than the same person described as having a substance use disorder. We did another study, a follow-up study. That was with clinicians. This was with the general public. Look at the magnitude of the difference here when we use the abuse terminology compared to describing the person as having a substance use disorder. When we use the abuse terminology, much less, the general public thought that the person was much less in need of treatment, much more in need of punishment, more of a social threat, more to blame, less likely to be exonerated and more likely to be in control of their substance use. In other words, they're engaging in willful misconduct at the expense of other people. So it matters. It matters even when we don't think it matters. This is the interesting thing. Even when we don't mean any harm by it, even experts are susceptible to differential judgments, more punitive, more harsh judgments for the same person when we use that term describing them as a drug abuser or a heroin abuser or an alcohol abuser or that abuse terminology. This is why, of course, now we've moved away from that terminology towards this hopefully universal application of disorder terminology and person-first language. Other language too in our field, talking about clean and dirty urine results, we don't use that kind of language in any other area of psychiatry or medicine the way that we have adopted this street language into our clinical and public health infrastructures in terms of describing people's results as clean or dirty, a dirty urine or a clean urine. Now, we should not be using that kind of language in our clinical and public health settings. And I don't think we need to study to reach consensus, hopefully, on describing someone's test results as dirty. So again, there's this movement away from this kind of language and terminology towards more person-centered, more holistic person-first language. This has been adopted really from the mental health field more broadly where for a long time, people have been described not as schizophrenics, but as people with schizophrenia or people suffering from schizophrenia. Schizophrenia is an illness that they may suffer from, but that does not describe the whole person in the same way that somebody's substance use disorder does not describe the whole person. They may suffer from it, may they may have it, but that does not consume them, that is not the whole person. And so there's been advocation for these changes. We developed a dictionary at recoveryanswers.org, that is the Recovery Research Institute website where you can view different glossary of terminology in our field, and hopefully we can reach consensus. Why is this important? I think if we want addiction destigmatized, we need a language that's unified and that accurately reflects the true nature of these disorders. You can check out the dictionary at recoveryanswers.org. And again, as I mentioned, we still got work to do in changing these institutes. There have been new names offered for the National Institutes of Health and the SAMHSA, which keep the acronyms the same, which is handy. So we don't have to change the acronyms, but we can change the language. And as you can see, for example, NIDA has been proposed to be renamed as the National Institute on Drugs and Addiction. That way it removes that abuse terminology, which we now know to be stigmatizing. And you can see the others are also following suit in removing the abuse language and yet keeping the acronyms the same. So what can we do in our clinical and public health settings and community settings to destigmatize? Well, one of the things in terms of language is we can prescribe, model, and reinforce universal use of appropriate language, as I mentioned, removing abuse and abuser from our websites, from our published literature, and refrain from using it in our discourse and communication. Again, it doesn't have any utility. And if anything, it will only induce more stigmatizing attitudes. Education, again, is important, but making sure that we talk about the fact, not just that these are biomedical disorders and diseases that affects the brain's neurocircuitry. That's a fact. That is true. The question is relative emphasis of how do we frame it? How do we talk about it? We need to talk about that to reduce shame and blame, but we do want to talk about the less biomedical language when we're talking about reintegration and recovery and support in the community. And again, providing opportunity for interaction, exposure to peers in recovery, people who've had that lived experience, living experience, so we can dismantle, deconstruct these stereotypes and hopefully remove and dismantle prejudices that people have around these disorders and create recovery-friendly education and workplaces. We know that there's a massive, the biggest of the economic burden, roughly $700 billion a year attributable to alcohol and other drug disorders in terms of lost productivity, healthcare and criminal justice. 80% of that is lost productivity, people not going to work. 80% of people with SUD actually are going to work. They're employed, but they're calling in sick. And so employers and companies are losing a lot of money because of people not showing up because of unaddressed substance use disorder. So ensuring that there is a culture, a culture of promoting and helping people who have these disorders to get the help that they need. It's going to make economic sense, if nothing else.

Addiction Treatment

Addiction Policy

Dr. John Kelly

New England Region Opioid Response Network

SAMHSA

Opioid Use Disorders

Stimulant Use Disorders

Addiction Stigma

Substance Use Disorders

Public Health Approach

Addiction Recovery

Neurobiology of Addiction