Hi everyone, thanks for joining us today. I'd like to welcome you all to today's training, Addiction Treatment and Policy, Part Two. For those of you who joined us last week, welcome back. It's great to see you again. 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. I'm Jenna Fold, Technology Transfer Specialist, working with the New England Region of the ORN. The ORN is funded through a grant by the Substance Abuse and Mental Health Services Administration, and our grant prime is the American Academy of Addiction Psychiatry. Next slide. 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. Also, this is provided at no cost as it's covered through the SAMHSA grant. Next slide. If you wish to submit another request in the future, our contact information can be found in this slide. You can go to our website, email us, or even give us a phone call, whatever works best for you. And we look forward to hearing from you if you have any questions or requests in the future. So for today, we are fortunate to have for a second time around, Dr. John Kelly. Dr. Kelly is the Elizabeth R. Spallin Professor of Psychiatry and Addiction Medicine at Harvard Medical School. He's the founder and director of the Recovery Research Institute at the Massachusetts General Hospital, 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 the 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-led 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 is 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 and your role and what organization you are joining us from. You can also use the chat to discuss any needs for technical support, for any topic-related comments, and to submit questions. I'll be monitoring the chat throughout the presentation for any of your questions, and you can also use the raise hand feature and we'll address all the questions at the end. We are going to record the didactic portion of today's training, and it may be shared to outside sources, so for privacy purposes, if you're not comfortable, you can remove your name and turn off your camera. We will then stop the recording for the Q&A portion. At the conclusion, we will share instructions on how to claim continuing education credit through our learning management system, and I'll be sending a follow-up email on how to claim the CME, as well as how to access the slides and the recording for today. We thank you again for joining us, and I will now turn it over to Dr. Kelly. Hey, John, good morning. Thanks so much. I'm really delighted to be here again. Welcome back, for those of you returning, and for those of you joining, welcome for the first time. Honored to be here with you all. If you have questions from last week that we didn't get to, hopefully we will be able to address those today, if you still can remember them. And so last week, as you may recall, we talked about a lot of the fundamental concepts around addiction, the bandwidth, the broad spectrum of substance involvement and substance impairment, how to think about that, how it affects the brain, the neurocircuitry, how genetics are involved. I'll talk a little bit about that today, just in terms of treatment and recovery, and that's where I'm gonna focus most of my talk today, is what we know about treatment, harm reduction, recovery, and what we're learning about all of these things. Now, of course, when we think about these problems, we understand them to have major impacts in terms of health, wellbeing, functioning, as well as mortality risk. They have a high economic burden, a high social burden, legal consequences. We're all very familiar with these. I think the magnitude of the impact is really quite stark and startling, and it's something that we should not forget and something that we should keep on the front burner, just because of the sheer impact when we compare it to other kinds of diseases and disorders. Substance use disorder and related problems are really the top public health problem in most middle and high-income countries, and the largest preventable cause of death. When we think about zooming out, I mentioned last week about the war on drugs, and that was declared about 50 years ago. Some of you may recall, some of you may have been there, when Nixon famously described, quote-unquote, drug abuse as public enemy number one. That really marked the beginning of a concerted national effort, which occurred in an international context that I mentioned, which involved an update to the Single Convention on Narcotic Drugs, to which 186 countries were signatories. So it was an international effort, really, not just here in the United States, and it wasn't necessarily a harsh, punitive, you know, legalistic stance taken internationally, but certainly that was part of it, to be stricter on enforcement, particularly on supply and interdiction in terms of supply, distribution, sale of illicit drugs. But it also addressed alcohol, the legal drug, the domesticated drug as well. About 50 years, you know, I have been reflecting on what's happened in the last 50 years in terms of where we've come from, what we've learned, and where we are now and where we're going. You know, one of the other things to remember is right around that same time that this war on drugs was declared was also marked the birth of two national institutes of health, the National Institute on Alcohol Abuse and Alcoholism in 1970, and the National Institute on Drug Abuse in 1974. And when we think about what we've learned in the last 50 years, if you zoom out and think about this, it's really, we've learned a lot, courtesy of these two institutes that's funded this research, and 90% of the world's knowledge on addiction has been, in the past 50 years, has been produced by funding from these two agencies, the NIAA and NIDA here in the United States. So we've learned a lot, for example, about the etiology. I mentioned this last week about the multifactorial nature. Now we know that they're, just like other complex illnesses, addiction has a genetic basis. Some of us are protected by virtue of our DNA. Some of us are more vulnerable, just like other complex illnesses. It's not the whole story, of course. You can still have the genetic predisposition, but never contract the illness, as it were. And in contrast, you can not have the genetic predisposition, but still suffer from other kinds of consequences related to drug alcohol and other drug exposure. So it's not the whole story, but it's an important piece that's helped, our understanding has helped to reduce blame, that blaming stigma I was talking about. So we tend to have more compassion for people who succumb to addiction because of this phenomenon. We now know to be a genetic predisposition, just like other complex illnesses. Neurobiology, you mentioned this last week in terms of stigma. This has to do with the controllability aspect, is this notion of impaired control over the ability to regulate the impulse to use substances despite harmful consequences. And, you know, in the prefrontal areas and in the limbic system, deeper in the brain, all these areas associated with that addiction circuit are radically impaired. Decision-making and appraisal, putting the brakes on, when we feel like putting the brakes on to inhibit a response gets diminished over time with chronic exposure to these powerful reinforcers. And we've been privileged now to be able to see these in the living brain through neuroimaging, through functional magnetic resonance imaging and so on, other PET imaging and other new imaging to enable us to see inside the living brain, to understand how the brain is actually affected by exposure to substances, as well as through magnetic resonance imaging, which looks at structural changes in the brain. So we can understand now much more readily how this impairment that we see from a psychiatric standpoint, which of course places it in the psychiatric realm because of the involuntariness of it. In other words, people end up using against their will. They try to stop, but they find themselves unable to do so for very long at all. And it's because of these changes in the brain. And this is why people often refer to it as a medical illness or a disease of the brain because of its effect on the brain's neurocircuitry. And we can see that much more clearly. And we've learned more about the exact nature of that, those changes that affect behavior. Epidemiology, again, we've learned a lot about the risk factors in the general population, haven't we, in terms of things that can increase or decrease risk in the development of the human organism, early childhood status, poverty, impoverished environments, hardship early in life, abuse, trauma. All of these things can have effects on the developing human organism, including the brain and the genetic and the genome. And we call these effects epigenetic effects when they affect the genome because they are stressors. They can be environmental stressors that can affect the human organism, but also exposure, early exposure, as I mentioned last week, to substances which can turn on genes which would not be turned on otherwise. And there's also, we've learned a lot about the multiple pathways into, through, and out the other side of addiction in terms of the clinical course of addiction as well as treatments that have been developed in the last 50 years. And we've developed, of course, pharmacological treatments as well for opioid use disorder, for alcohol use disorder, for nicotine use disorder. We have not developed medications yet for cannabis, cocaine, or methamphetamine or amphetamine, but there are some emerging lines of research in those areas. Mostly we have opioid and alcohol use disorder medications. An important piece of this picture when we look at how best to address these endemic problems has to do with the fact that there's about 90% of this population, there's about 48 million people in the United States who met criteria last year for a substance use disorder, that's for an alcohol or other drug use disorder. 90% of those, nine zero percent, did not seek any kind of treatment who met criteria. Most of those people don't believe they have a problem. So they're definitely at the milder end of the spectrum. The kinds of folks that we see in specialty care, in outpatient, in inpatient, in intensive outpatient settings, in our recovery support services settings, tend to be that 10% who are on the more severe end of the spectrum. Now, it doesn't mean that those 90% are not on their way to more severe status. That care is true, but some of them not. Some of them will remain of that type, that particular phenotype where they're gonna stay in that mild, they might have a protracted course of the illness at a mild level or a moderate level. Some of them will progress into, that's how we classically think of addiction. It kind of starts somewhere and it gets worse over time. And certainly for a number of people, that is true. For some people, they don't continue to get worse, but rather have this more stable phenotype, a stable expression at a less severe level. A question, of course, is how to reach these folks who don't seek treatment, but still are causing harm to themselves, as well as other people in their environment. How do we reach those people, those 90% who don't wanna go to treatment, they don't see a need for it? This is a big question from a public health standpoint, because the burden of disease actually is much bigger in that large population of 90% than it is in the 10% of much more severe cases, because there's many more of them, nine times as many, but the less severe. But when you do the math, of course, it's the multiplication which leads to that burden of disease. So this can mean more accidents, injuries, domestic violence, car crashes, all the rest of it that we associate with alcohol and other drug exposure, even at the low levels. Another thing is how to reach young people sooner in the course of the illness, right? Because we know that the earlier we can intervene, the earlier to remission, and then how to help more people achieve stable remission sooner. This timeline here highlights what we see in the addicted population, and why, you know, why addiction is often considered to be a chronic illness. And this highlights this. These are, this graphic here is representative of the more severe cases of substance use disorder, what we would call addicted cases. So these are people in specialty care. These are adult cases taken from dozens of study, clinical studies. And you can see here in the middle, on the left-hand side, after people meet criteria for a substance use disorder at the severe end, it takes about four to five years after that before they'll start to seek help. So they meet criteria, and then they're trying to cut down and stop by themselves, oftentimes is what happens first. Part of that is just, you know, just natural attempts to try and stop and cut down. Other barriers are just a stigma and fear of discrimination, which people have that prevents them from seeking help or seeking help sooner. In the middle, you can see after people start help seeking, it takes about eight years and about four to five treatment episodes or mutual help group engagements before people are able to achieve that first year of sustained remission on average. So that's quite a long time, isn't it? Eight years, about four to five treatment episodes on average before people get that first year, full year of sustained remission. That's 12 months with little to no symptoms other than craving. So that's a long period of time. What's also noteworthy on the right-hand side, you can see that even after someone achieves that first year of full sustained remission, that's 12 months without any symptoms of a substance use disorder, it takes another five years before the risk of meeting criteria in the following year for a substance use disorder drops below 15%. Why 15%? Because 15% is the annual risk in the general population of meeting criteria for one of these disorders. So to be no more likely than anybody else in the general population of meeting criteria for one of these disorders in the next year, if you've already had it, takes on average about five years. So risk remains elevated for the first five years after people achieve that sustained remission. The good news is that as you can see on the right-hand side here, even among these severe cases, about 60 to 75% are achieving full remission, getting into recovery. So this is actually a good prognosis disorder when we compare it to other kinds of psychiatric illnesses. Most people who have this disorder in their lifetime will be able to achieve full sustained remission. Now, as you can see though, it takes a long time to do so on average, particularly when we look at these severe cases. Now, an obvious question here when you look at this timeline is can we speed this up? Is this just an inexorable course of the illness? You just have to wait eight years before someone will get their first year and then wait another five years? Or are there things that we can do to speed up the time to initial remission and to stable remission and long-term stable recovery? I alluded to this a little bit earlier. This is a slide from Michael Dennis and Michael Dennis's work, which is very compelling because it really illustrates here the importance of early intervention. I think a lot of clinicians can lose heart when they're dealing with adolescents and young adults because they think that it doesn't make that much difference when they're intervening with an adolescent or emerging adult. They feel like it doesn't change their behavior that much. We can't have much effect. But what this graph shows here is that even though at the time, maybe in the next 90 days or the next six months after an intervention with an adolescent or young adult, you might not see that much change. What you do see here is that young people who get some kind of intervention in the first nine years after they begin their use, right? So sometime between the ages of 10 and 20, typically, if they get some kind of intervention relative to kids who don't, they get into remission seven years earlier than adolescents who don't get some kind of intervention. So that is a huge difference in terms of early remission versus later remission. So just remember that I think it's something, it's a message that we need to communicate is that while it may not have immediate profound effects in the long-term, it does. Just like other kinds of prevention and early intervention, substance use disorder responds to early intervention. And this is where we need to focus much more, I think, our efforts. And this is why I started this new National Center on Youth Prevention, Treatment and Recovery to address this very issue, to place youth right back at the top of the substance use agenda. So we can intervene earlier, begin those conversations earlier, head off deleterious trajectories and premature mortality and help these young people change course. Even though we may not see immediate effects, the long-term effects do have a preventative effect. And this is good news. We have to remember this, that we shouldn't expect maybe immediate short-term effects, even though those can be gained depending on what you do, but having some kind of intervention early can offset this long, prolonged trajectory. Now, how else can we shorten the course to this initial sustained remission and stable recovery? How can, what can we do to speed up the time in general for people, adults who have these disorders? I think there are things that we can do. I think when we look back over the last 50 years, I think arguably if we've done one thing right, and again, I use this burning building metaphor, is that we recognize there is a crisis. The building is on fire and we need to put the fire out. Where we've spent a lot of time is doing exactly that in the last 50 years. We have spent a lot of time on medical withdrawal management, I don't know what, detoxification, medical withdrawal management, stabilization, metabolic stabilization, so that people don't have heart attacks in alcohol withdrawal or have other kinds of seizures or other kinds of adverse events from coming off of different drugs. So that's been critically important, literally critically important in terms of preventing those deaths in withdrawal. And so we focused a lot of efforts on developing those protocols, the medications that can manage those withdrawals and stabilization. We've spent most of our efforts, 90% of the clinical trials conducted in the last 50 years have been 12-week trials. So these are mostly 12-week protocols, whether they are medications or whether they are psychosocial interventions. Typically, they are 12-week trials of administering a medication and or a psychosocial therapy. And then you remove the treatment, and then you follow people up for a year. Now, that's been important because we didn't have those before. We didn't have those evidence-based protocols. So that's been important to develop and test and implement. But I just showed you that it takes not 90 days or six months or one year, but five years before the risk is at the same level as the general population. So this risk remains elevated, and the fire can restart. So I think where we have dropped the ball is in providing access to the scaffolding and the building materials that people need to access when the fire is out. Not only that, but also the building permit that people need to be able to start building, gain access to these materials. Most people, many people with prior drug addiction have felony convictions related to sometimes just simple drug possession. This can prevent them from gaining access to that building permit that allows them to get a job, to get a bank account, to get a loan, to get access to educational resources. So denying access to that building permit because of prior felony convictions is a big challenge that we're faced with legislatively. Something we need to address because, and again, this is part of the push to decriminalize, is that we should not criminalize possession of drugs because it can prevent people. It can be a deterrent maybe, but it can criminalize people on the other side so that when people get into recovery, they can't get the kinds of traction that they need. And it takes away people's hope and optimism that they can move forwards in their life if they cannot get access to these materials that they need in the scaffolding because they're denied a building permit to rebuild their life. So nothing will take the wind out of the sails like the doors closing on them after they're ready to go and ready to really move forwards. And they're told they cannot gain access. So this is a major problem that we need to address. We often think about these building materials and scaffolding and the building permit as recovery capital these days. This is kind of the newer catchphrase, which captures all of these different elements. You can think of recovery capital as the entire set of internal and external resources that people can draw upon in their kind of recovery bank account, if you will. Their motivation, their skills, their capacity, their self-efficacy, their confidence, their coping skills, their relapse prevention coping skills, their social environment, who's in their corner, who's supporting them, who are they hanging out with, where are they living, do they have a home? All of these things are important to address from a socioecological standpoint when we understand how the human organism recovers from these disorders. Now, why is it so difficult to recover? Why is it so difficult? Why do people often begin, but then relapse, have a reinstatement and recurrence of the disorder? We now know also from a lot of the neuroscience research that's been conducted in the last 50 years, particularly in the last 30 years, that there are two major vulnerabilities, biobehavioral vulnerabilities, which trip people up. And these occur as a result of this chronic exposure, as I mentioned, in the brain that affects the neurocircuitry of the brain and the neuroendocrine system. And the aftermath, what we call the post-acute withdrawal, after people are medically withdrawn from a substance, they're not magically out of the woods. They don't suddenly bounce back after 10 or 20 years of exposure to the drug and chronic poisoning from the drug, as it were. They don't suddenly bounce back in the next week or month. There is a period of reparation. Mother nature has to do all that recalibration. There is new neuronal connections that occur and things change a lot in the brain and endocrine system. But early on in the first few months, and sometimes for some people in the first year or two, they have these two vulnerabilities, this hypersensitivity distress, which manifests as anxiety, sleep problems, appetite problems, sex problems, kind of what we call neurovegetative signs. But also coupled with that is this decreased capacity to experience normal levels of reward. Now, as I mentioned, alluded to last week, is that the brain, as the brain is exposed to these abnormally high levels of reward and reinforcement, these chemical cascades, which are abnormally high, the brain adapts. We call this neuroplasticity or neuroadaptation. It's maladaptation, actually, but we call it neuroadaptation. It's the brain adapting. You can think of it as getting a really loud signal. If you hear a really loud noise, you sometimes put your fingers in your ear. You can think of your ears as receptors and the noise as the signal. And when we put our fingers in our ears, it dampens the response, right? We don't hear it as loudly. What happens in the brain is exactly that at the neuronal level when it comes to these abnormally high signals from drugs. Mother nature says that's way too loud. It metaphorically sticks its fingers in its ears. It closes those receptors, in other words. And so what do we do? We turn it up. We have to take more drug to get the same effect as we used to, to hear it, that kind of hedonic deafness that occurs over time in addiction as the brain adapts. But when you take away the signal, when you remove the drug, what happens? It takes a while for mother nature, in other words, to remove her fingers from her ears, as it were, for you to be able to hear. We call this hedonic deafness, anhedonia dysphoria. It's the blah-ness that occurs in early recovery. A sunny day just isn't as sunny as it once was. You know, a good movie just doesn't cut it the way it used to. Hanging out with friends is still okay, but it's just nothing like it used to be. There's this kind of dysphoria that can last for weeks and months and can trip people up. You think about that coupled with this hypersensitivity distress, which is partly neurophysiological and neuroendocrinological, but also manifests because of the lack of coping skills that people often have in terms of dealing with just normal day-to-day things, social anxiety, other kinds of life skills that people have not developed. Why? Because the predominant coping response has been turning, using the substance to cope with all kinds of things. So it has become this predominant coping response. So when you remove that, there is both psychological and biobehavioral and physiological aftermath that has to be dealt with. And again, these are the post-acute withdrawal or protracted withdrawal symptoms that we often think about when we, and have measured when people are coming out of addiction. And you can think of addiction as a form of chronic poisoning in the central nervous system that the central nervous system tries to adapt to. It does its best, but it can't keep up. It just cannot keep up. And so it becomes dysregulated and affected negatively in an attempt to try and cope. Another model that's helpful, I think, to think about the notion of recovery and behavior change in addiction, why it's so hard without the access to these building materials and the building permits and scaffolding. Is because people become exhausted. And I like this model. This is a model that wasn't specific to addiction, but I like it because it does pertain, I think fits pretty well with addiction or any kind of behavior change maintenance, which is very difficult to do. And you can see here, this is the general adaptation syndrome developed by Hans Seely in the 1950s. And what he was describing here was how organisms get stressed. They get stressed out. And when you stress out a rat, and he was studying animals, when you stress out a rat or an organism, it start to get sick. If you chronically stress a rat, it'll get sick and it will eventually die. Now, what happens as the organism is stressed, you can see here, there's an initial alarm reaction followed by resistance. So the organism will try to resist the stress as best it can. But what happens? You can see on the right, eventually it'll get exhausted. It just can't keep up with the chronic stress. And I think when we think about addiction, what happens? There is often when people try to stop or cut down, there is an alarm reaction. There's some kind of incident or accident. Maybe there's an overdose. Maybe there's a fight with a spouse. Maybe there's a DUI. Maybe there's an arrest. Maybe there's an accident, an illness, which will get people's attention. This is it. I mean business. This is the last time. I'm not gonna do this anymore. I promise this is the last time. And they mean it. They mean it. But what happens? They're holding on in that resistance phase, but eventually they get exhausted. And so they lose that motivation. They become exhausted and they can have a recurrence of the disorder. So it's not just about this model at the top here, which is motivation ability. What we normally think of as ready, willing, and able. Is the person ready, willing, and able to make these changes? Can we equip them? Can we use motivational interviewing, harm reduction, coping skills to help them move in a more healthy direction? And do they have the capacity, ability to be able to do that? And can we equip them with the skills through CBT, for example? Yes, all those things are good. But the other thing to remember is what I've mentioned is the environment. Is what kind of environment are they living in? Do they have a job? Do they have housing? Do they have education? Do they have the capacity to earn an income or do they have other resources that can help them get their needs met? So it's the difficulty of the environment and also the difficulty by time when it comes to exhaustion, right? So it's not just a temporary environment, where are they living now? But where are they gonna be living for the next year, the next several years? What's their situation like? Do they have hope? Do they have optimism that can sustain them? Do they have the social support needed to be able to sustain them? So this is where access to these building materials I was talking about, the recovery capital can come in because when people have access, when they have the building permit, when they have the scaffolding and the building material, that can instill hope and optimism that can prevent exhaustion and can help people to continue up that slope of resistance and build capacity and resilience. Another way to think about it is just in this reciprocal way, as I mentioned, that remission, early remission results in greater recovery capital, but recovery capital can also result in greater chances of remission because it reduces that allostatic load. It reduces that stress that I was talking about through the access to these building materials and scaffolding and building permits. It builds hope and optimism that can sustain people, help build their confidence that they can move forwards, get well, and stay well if they continue to move in the right direction. Now, I mentioned the treatments. One of the other things we've learned is, very importantly, is the process of change when we're talking about addictive behavior. And this highlights this model of the trans-theoretical model of change, which is old now. It began in the 1980s. It's still very useful. And it's been very helpful in terms of understanding the process of change because it's helped us to map on different kinds of interventions that can be helpful. For example, when people are in the pre-contemplative and contemplative phase, when they don't want to change, they don't see a need to change, but they can easily overdose and die, for example, in the current opioid epidemic with these high-potency synthetic opioids like fentanyl around. It's very easy before people are ready to change to overdose and die. So harm reduction has been a very important piece of this. You can see on the bottom left when it comes to people in the pre-contemplative and contemplative stage. Also, motivational interviewing has been very important as a piece of this because we know that roughly 60% of cases that we see in the outpatient world are in this ambivalent stage where they kind of want to stop, but they kind of don't. And so how do we help people resolve that ambivalence? That's been a very important piece of mapping on, again, mapping on interventions which can address different stages when people are at different stages. And as I mentioned, harm reduction piece has been critically important in the current, it's always been important, but it's been even more important in the current opioid poisoning crisis that we've seen grow in the last 25 years. And so again, Narcan, I love that. There was a, I forget where it was now. I saw it, it was one of the groups around the country. I forget now. And it was a lovely statement that says, I can, we can, Narcan. I thought that was a very nifty, public health messaging. I can, we can, Narcan. Or I can, you can, Narcan. And it was a way to kind of help people understand that you can administer Narcan, it's easy to do. You need to have it available because it can save a life. I like that, that I can, we can, Narcan. And I think it was on some SAMHSA thing I was doing recently. Someone had brought that up. I just thought it was a lovely way of communicating that from a public health messaging standpoint. Anyway, these other aspects here, of course, in harm reduction services have been very important and an important piece. I mentioned this. This was very important because it really, you know, tipped the balance or turned the tables on this notion of people being ready. Back in the 1960s and 70s and even early 80s, it was, there was a case of, you know, if you're not ready, go away and come back when you're ready, when you're motivated, right? And that notion of, you know, and people need a good talking to. And motivational interviewing came along. And what it really said was people, what people really need is a good listening to rather than a good talking to. So it really kind of upended the notion of this psychoanalytic stance that people needed to have those psychological defenses of denial. Remember, there was a lot of talk about denial and you're in denial and you're minimizing, rationalizing all these psychological defenses which came from the psychoanalytic world was really upended in the sense that it was more of a Rogerian psychotherapeutic stance, which became popular, a client-centered, you know, this unconditional positive regard that Carl Rogers used to talk about to build trust and trust builds openness and openness can catalyze this willingness to be open and honest can catalyze people's coping skills. And what, you know, the progenitors of this model would say is that when people are in the right conditions, the right therapeutic conditions, they know what to do. They already know what skills they need to implement. They often have the skills. And this is the supposition, the theory behind this approach is that when you create the right kinds of warm, empathic conditions, people can feel free to be themselves, open up, and you can resolve ambivalence and help people change. This was another big innovation, of course, was relapse prevention. Alan Marlatt and colleagues from the academic side, from the cognitive behavioral research side, as well as Terry Gorski and Merlene Miller on the kind of community-based relapse prevention side, both had very important models. Some of you may remember Terry Gorski's models of these relapse warning signs, kind of these early warning signs before people have a recurrence of the disorder, what he called the abstinence-based warning signs of relapse. In other words, the things that were precursors, the craving, the mismanagement, what he would call kind of not addressing, avoiding things that you need to address in your life. So that kind of avoidant coping style was predictive of relapse. And he would look at these warning signs of relapse. Alan Marlatt was looking at it slightly differently and looking at high-risk situations which could trigger relapse. So more on the front end of the cue reactivity, the people, places, and things which become conditioned cues for triggering substance use. So a slightly different model, but very important in terms of helping us move forwards and develop therapies that were based on skills building, avoiding high-risk situations, identification of high-risk situations, using functional analyses and so on. Contingency management, 150 clinical trials showing the potency of contingency management, one of the biggest effect sizes. In other words, shaping the environment to produce positive consequences that can help people stay engaged in treatment and improve in substance use, very important development, as well as I mentioned, the medications that have been developed that have been life-saving, particularly buprenorphine, suboxone, commonly known as suboxone, buprenorphine, naloxone, as well as methadone, which has been around since the 1950s, as well as naltrexone for alcohol use disorder, of course, injectable naltrexone vivitrol for both alcohol and opioid use disorder, the mu-opioid antagonist, which can block the effects of opioids, so it can prevent overdose. This is, of course, the way Narcan works, but it can also prevent onset of use as an injectable formulation for people with opioid use disorder, shown to be as effective as, or as or more effective as methadone and buprenorphine for people who are detoxified, medically managed withdrawal first, and then engage in the injectable naltrexone for opioids. So we've got some medications. Some of these are quite effective. The problem is, is helping people sustain them. We know that 50 to 65% of patients who start buprenorphine will stop within six months. So it's a barrier that we have to overcome in terms of helping people, not just with medications, of course, but medications can save lives, but helping people to sustain some kind of intervention and treatment that can help them sustain change over time. Again, conceptually, you know, when we think about how we can accelerate the time to initial and sustained remission, another way to think about it is from the environmental perspective. I alluded to this already in terms of how difficult, remember I said that, you know, motivation, ability, that ready, willing, and able, but then the difficulty of the environment and the difficulty by time. So these environments are very important when we think about healing, how organisms heal. I often use this metaphor here. When you have a diseased plant, a plant that's sick, that's withering, that's dying, when you create the right conditions, there's very little we can do with a plant on any given day, what you have to do to get that plant to recover is you place it in the right light with the right moisture and the right nutrients and the right soil at the right temperature. And that plant that was withering and dying will actually start to photosynthesize and begin to recover. But it takes time for that organism to recover, not only to recover, but to survive and thrive and flourish. I think of addiction recovery, not as a photosynthesis, but a kind of psychosynthesis in the sense that when we create, again, the right conditions for the human organism, that the human organism can begin to heal and flourish and grow and thrive. What are those conditions? Broadly speaking, they make up this acronym, the S.A.N.E.R acronym, the social, the activity, the nutrition and the emotion regulation. If you think of the social environment in behavior change, when people are addicted, when they're moving in the direction of behavior change and recovery, the social environment is, you can think of that as like the soil. It's like the soil through which all the other nutrients and ingredients are absorbed in the human organism as it recovers. That's where the exchange happens largely, is through that social network. Clinicians, recovery support, service workers, family, other people in the network that can support that individual. So that social environment is like the soil that can really help the person recover and heal. Activity is very important. Physical resilience is associated with brain health. People oftentimes are undernourished, underweight when they're stopping an addiction pattern and building physical resilience through physical activity as well as working, working occupation, some kind of occupation to prevent preoccupation, to prevent the preoccupation with substances. Having occupation can really help. So those kinds of activities are key. Nutrition, just eating regularly early on really helps to stabilize individuals, making sure that they eat three meals a day. For example, any kind of food is good early, and then hopefully balancing nutrition to include more antioxidants and other valuable nutritional elements that can aid in brain health and functioning. Arguably the last one on the left here, the emotion, the ER in the SANER acronym, the emotion regulation is a function of the other three. People will begin to regulate emotion and feel better as a function of the right social environment, activity, and nutrition. But also we can address and affect emotion regulation directly with things like cognitive interventions and behavioral interventions. So we can address that piece directly as well as indirectly through addressing these other three components. And again, all of these components make up this notion of the right conditions that can help the human organism heal over time. And again, it's not a case of withdrawal management. That's where it begins, putting the fire out, but how do we create the right conditions, access to the right building materials and scaffolding building permits that people need? So you can think of, there's a neuroscience to recovery capital. The recovery capital, as I mentioned, is kind of a total sum of all these internal external resources that people can draw upon to move forwards towards health and wellbeing and remission and recovery from these disorders. And you can see here the different pathways in the brain that are affected by chronic exposures to substances, reward memory, motivation, impulse control, and judgment shown here. Now we often think about medications, of course, when we think about biological interventions, yes, medications can affect from the inside out. Of course, we can give someone a medication into their body and that can interact with brain neurocircuits and cells. It can help reduce craving. It can help stabilize people very well. But we also know that other things can also affect the neurological system in our brain, as well as the neuroendocrine system throughout our body. It turns out that we've learned a lot about social relationships. Now as primates, we are very social creatures. We are really interdependent and our happiness depends on other people. Have you ever tried tickling yourself, for example? You can't tickle yourself, right? If you try to tickle yourself, but someone else can tickle you. It's a very strange phenomenon that only somebody else can tickle us. We can't tickle us. And that's just an example of how other people are needed for our own happiness and wellbeing. And it turns out that social isolation has been a lot, I talked about this recently, the surgeon general has said this is one of the major facets undermining health is social isolation, as well as loneliness. So that lonely feeling, as well as actual social isolation, both of those things independently are predictive of not only ill health, but premature mortality. If you look at this, this was a large meta-analysis that was conducted by Julianne Holt-Lunstad, which showed this, that if you were socially isolated or felt lonely, independent of other factors, you were more likely, much more likely to die prematurely at the same rate as someone who was a cigarette smoker. So that's quite profound when you think about how social isolation that we would not ordinarily think of just purely social isolation can affect health and wellbeing. And again, when we think about these two facets that underlie vulnerability to addiction, to relapse, to recurrence, and how these social factors, as I mentioned, social factors being the soil through which all these other nutrients are absorbed in the human organism as it recovers, we've learned a lot about social buffering and psychobiological mechanisms underlying social buffering. So there's a neuroscience and a neuroendocrine science to understanding, you can see here, this has been explicated now, we're understanding much more about why is it in addiction, particularly in addiction and not in other psychiatric illnesses, that people are drawn together in groups. We see this naturally occurring when people are recovering from addiction. They tend to congregate around, seek out other people, and they find great success when they're around in groups, mutual help groups, recovery support services. They tend to congregate and aggregate in these areas, in social groups. You don't see this anywhere near as much in other kinds of psychiatric illnesses. And again, why? Because the nature of the impact in the brain that has occurred as a result of exposure. And you can see here how social support can mitigate this stress, this chronic stress I mentioned earlier, as a vulnerability to reinstatement of this disorder. It's getting offset here by this social support through the vasopressin, through oxytocin, other endogenous opioids in the human body and brain. You can see here it offsets the impact of stresses in the hypothalamic pituitary axis, which is the stress access in the body. The other pathway I mentioned, how do social factors affect this reward downregulation? Look at the impact here of social factors impacting reward capacity. So I mentioned that as a function of people's chronic exposure to substances and the upregulation of the dose to get the same effect as we used to at a smaller dose, the brain is constantly downregulating those receptors. It's sticking its fingers in its ears. And then when you stop the signal, the loud drug signal, you remove the drug, the mother nature can take her fingers out of her ear. You can actually upregulate. It turns out social factors will upregulate these downregulated receptor systems in the dopamine pathway much quicker. You can see the correlation here on the left and right related to social status and social support. What is social status? Access to resources and autonomy. That's what social status translates as. So the more access to the building materials, the scaffolding, the building permits, and having greater self-determination on autonomy, when you manipulate that, give people more of that, it actually upregulates their dopamine pathway, as well as social support independently. Look on the right hand side, same thing. More social support, more upregulation. You can manipulate that. Greater social support leads to greater upregulation of these dopamine pathways. And that upregulation is protective against relapse. So the more of these receptors that people have in the brain available, the less likely they will be to use. And this has been shown now in several studies. Now, all this to say, very importantly, this is why we have seen this growth from a treatment and recovery perspective of so-called recovery support services and peer recovery support services that are run by peers. And you can see some of the different flavors here, the different models of peer support and recovery support services that have been around for a while, and some of them are new kids on the block. Mutual help organizations, and we'll take a break in a minute, but mutual help organizations like Alcoholics Anonymous, Narcotics Anonymous, the 12 Step Fellowships, as well as newer kids on the block there, Smart Recovery, Life Ring, Women for Sobriety, Dharma Recovery, there's myriad now other kinds of mutual help organizations that's come, manifested to help people, provide choices for people. Peer-based recovery support services, these are things like recovery coaching, recovery coaches, recovery coaching that are operating now widely across the country in emergency rooms, as well as mental health settings, addiction clinics. These provide peer support, flexible peer support. They're often employed by clinical agencies or recovery support services to provide that flexible lived experience, experiential support. These peers often have training as well, in addition to their lived experience that can really be helpful. We've just conducted another systematic review of the literature there and finding good effects now, and a maturing literature from a scientific standpoint on utility of these models. Recovery residences is another one that's been around for quite a long time. This is, again, providing the right housing, a safe and secure house for somebody to live in, so that they have that fundamental, from a hierarchy of needs standpoint, they have a safe place to live that is low risk for relapse, where they can get support from other people who are ideally doing the same kinds of thing, i.e., trying to live a recovery lifestyle. There are some long clinical models of recovery management, but surprisingly few. There's one I'll mention later by Michael Dennis called recovery management checkups, which is really treating addiction like a chronic illness and showing very good effects recovery community centers. On the left-hand side here, you can see these are literally the new kids on the block. These are bricks and mortar. These are not residences. These are places where people can go during the day to gain access to the building materials that they need, to get a job, to learn how to put a CV together, to learn how to write a cover letter, to get in contact with employers who are willing to take people who have prior criminal records. Very important linkages going on in these recovery community centers to accessing the kinds of resources that people often need early in recovery to get traction and move forwards. They're populated with peers with lived experience. The final one I'll mention, and I'll go into detail after the break, is recovery supports in education and work settings. These are recovery-ready workplaces, employee assistance programs, which are tailored to addressing people with substance use disorders, as well as people after treatment going back into educational settings or starting an educational setting in a college setting, for example, where they can get support to stay in remission. The same with kids, adolescents, instead of going back to the regular high school, going into a recovery high school where they get explicit support, as well as therapies in a therapeutic environment that can help them graduate high school in a safe manner, stay in remission, and move forwards and gain traction in their life. Okay, folks. Ready for the grand finale here, and then you can get rid of me. Thanks for hanging in there. We're almost done. We're down to the last hour, and I want to say plenty of time for questions and discussion, but the second part, again, just before the break, we were just kind of reviewing, going over kind of the rationale and background for why we've seen this growth in kind of more chronic disease management or recovery management models. Again, because of this, I think, increased recognition, that's really what I've been talking about this morning, is this increased recognition of the vulnerability, the long-term vulnerability to relapse. So we've got the clinical pathology going on, but also the environmental conditions, the long-term environmental conditions in which people live and work are so key for human healing, in the same way as any other organism would need the right kinds of conditions to be able to heal and stay alive and thrive and flourish. And this is what we're finding also with this particular set of disorders vis-a-vis substance use disorders. And so we've recognized now these vulnerabilities in the neurological vulnerabilities, the neuroendocrinological vulnerabilities, and what can we do? We know that social networks and social factors are very important features in the landscape of recovery. As I mentioned, they're kind of the soil through which other nutrients are exchanged and absorbed. And there's been this growth, really stimulated largely by people who have suffered from these conditions themselves, who have started, they have begun these entities, largely because they recognized they needed something more than just acute care stabilization in order to get and stay well. And so they have developed, these are largely developed and implemented and run by peers themselves. And now science is coming along and actually evaluating the clinical and public health utility of these largely peer-generated resources. Most notably, of course, is the research that we've seen on mutual help, particularly 12-step, because that's by far the oldest and largest form of recovery support in the world. Alcoholics Anonymous is probably 50 times larger than any other recovery support service in the world. And it's the oldest. The advantage of these mutual help resources, of course, is that they are available and accessible for free over the long-term in the communities in which people live. And they can also, people can also access them now in the modern age online. And we saw this really growth spurt during COVID where people couldn't go to their regular groups, regular meetings, social entities that they got online. So now this whole new birth of the whole online, it was present before, but it just got amplified and extended during COVID and it's persistent. And they are enduring. They're a good match for the undulating risk trajectory, as I mentioned, that first five years of where risk remains elevated for reinstatement of the disorder. Because they are available, accessible for free, they're a good match for the kind of vulnerability over time that people can suffer. And we conducted a systematic review published in the Cochran Library back in 2020 of all the most rigorous studies that have been conducted on Alcoholics Anonymous and 12-step treatments designed to link patients to Alcoholics Anonymous. So these are patients largely with primary alcohol use disorder, mostly at the severe end. So people who are addicted to alcohol, many of whom also have other kinds of drug problems. There were 27 trials in this study. Most of them were randomized controlled trials. So this is where a 12-step treatment, so it'd be a clinical treatment where patients with alcohol addiction were randomly assigned to receive either a treatment which prepared them for AA and link them to AA meetings versus something like cognitive behavioral therapy or motivational interviewing. And so these were the kinds of trials that were included here. They were all randomized. So there was no self-selection here. These were all randomized trials. And patients were followed up for three years in these, up to three years in these studies. So what did we find when linking to these free ubiquitous community-based resources, in this case, AA for people with severe alcohol use disorder? What we found was quite surprising is that on every single outcome measure that was included in these studies, patients receiving a linkage to AA did as well as any other active intervention on every single outcome, except continuous abstinence and remission. So you can see here in the yellow bars, these were patients who were randomly assigned to AA, to the AA linkage. And those patients had 20 to 60% higher rates of remission across three years relative to patients who were not assigned. They were assigned to CVT or MET or some other kind of intervention. Not only did they have better outcomes in terms of higher remission rates and continuous sobriety, but at a substantially reduced healthcare cost. When we looked at the cost savings back in 2018 dollars that will be saved by linking patients with severe alcohol use disorder to AA, not only are producing 20 to 60% higher remission rates, but we're also saving the healthcare system 10 to $15 billion a year in healthcare costs by doing so. So the kind of double whammy we're looking for, better outcomes, lower costs. That's the promise of these kinds of free ubiquitous indigenous recovery support services we're finding. So that's good news. We're also finding that much more about how groups like AA confer a benefit. Why is it that AA is able to sustain and amplify remission rates over time? The answer is beginning to be uncovered. We are finding that groups like AA are able to produce these higher rates of remission by mobilizing this exact same kinds of therapeutic mechanisms that are mobilized by formal treatment, but they're able, these groups are able to do so over the longterm in the communities in which people live and work. And you can see here, these are the empirically supported, the science-based mechanisms through which AA has been shown to reduce relapse risk. Number one, the biggest one is by changing people's social network. I mentioned that already. The social network is the soil through which all the other recovery ingredients are absorbed, exchanged and absorbed. So the social network is key. Changing your social network, just like your mother told you when you were a kid, don't hang around with those bad people, hang around with the good guys, because they will influence you in a positive way. But you can see here that when you're in the right environment, all the other ingredients are mobilized, increases in cognitive behavioral coping skills through AA, increases in self-efficacy, decreases in compulsivity and craving, increases in spirituality, which help people to cope with stress and reframe stress in a different way, and increases in maintenance of motivation over time. So these are the set of things that are getting mobilized as people access these AA meetings. Now, this is all good. AA works. We now know and have clarified that AA is an effective clinical and public health ally. And that's why I often refer to AA as the closest thing public health has to a free lunch when you think about it. It is ubiquitous, it's effective, it's cost-effective. But not everybody wants to go to AA, right? So I mentioned this earlier. What do you do? The good news is is that we have now a growing evidence base on other kinds of recovery support groups beyond AA, non-12, step ones and other ones. Now, the metaphor I like to use here is one of a fitness center. The question I pose to audiences is, do fitness centers keep people physically fit? Well, the answer is, well, yeah, they do. If you have to go to the fitness and you have to work out, right? You have to go and do something at the fitness and you have to go regularly to do so. Now, fitness centers know this. Now, when you walk into a fitness center, do you just see 40 treadmills and that's it? Now, it's true. It's a fact that if you work out on the treadmill, you will increase your physical fitness. If you do that for an hour, three to five times a week, you are going to improve your physical fitness. So scientifically, yeah, you can say that those treadmills will get you if you go back and use those treadmills. Now, what do you do, though, if you don't want to work out on the treadmill? So fitness centers know this. So what do they do? They don't just have 40 treadmills. They've got 40 different classes. They've got pools, they've got courts, they've got weight rooms, they've got free weights, they've got machine weights, they've got all kinds of racquetball and other stuff. Why? Because they want to attract and engage more people into that paradigm of physical fitness. They want to get more people attracted and engaged into something that's their speed, that's their flavor. What we're doing in the recovery support services world is very similar, I would argue, is that we are creating a broader array of flavors, of different things that are different people's speed. Not everybody wants to work out on the Crosstrainer. Maybe AA is the Crosstrainer of recovery. It gets people fitter for recovery better than anything else. But if you don't want to work out on the Crosstrainer, what are you going to do? We need other things that people need to work out to find that they can get attracted by and engaged by. And that's why now there's been this, I think, recognition of a wider doorway. We need a bigger doorway. We need more options for people, more flavors, more types of recovery support services that people can get attracted to and engaged by. And the good news is, is that it's less about relative efficacy. When we think about, yes, we're interested in what works best, we are interested in that, of course. But again, if nobody works out on that piece of equipment, it's useless. We need to find some way to engage in people. So it's less from a broad public health standpoint, less about relative efficacy than getting someone in the door. Right. This is where harm reduction is so important and other kinds of lower threshold services that we can attract and engage. Come on in. We'll talk to you. We're not going to have you, you know, say you've got to work out on this for five times a week for an hour. You choose something that maybe or nothing. You can just sit there for now and watch. And, you know, but we're here to talk to you. We're here to when you're ready to try something. But we've got a lot of different options for you to try. This is where we are going. This is where we have gone. And now we've got many different options that people can start to be engaged by. And this is good news because I think we can reach more people, get something that's their speed, that's their flavor. They can get in the door and try and do something. They may end up on the cross-trainer later on. Who knows? They may end up in AA or other kinds of interventions that may be really strongly associated with long term remission. But getting them in the door is key. Recovery residences. We're seeing a similar picture here with recovery residences. This is a randomized controlled trial randomizing patients from intensive outpatient care and residential care to either go home and receive services as usual or go to recovery residence. This was an Oxford group, Oxford House. So these appear peer run recovery sober homes. And look at the magnitude of the differences here over two years. So substance use was basically the remission rate was double. The employment rate was 50 percent more. The reincarceration rate was two thirds less for patients randomly assigned to live in a sober home and then find a job and get support from the other residents in the sober home relative to going home and getting outpatient services as usual. And again, not only that, but when you look at the cost effectiveness, just like with the AA research, what we found here, what's been found here is that that results not just in better outcomes, but associated with a thirty thousand dollar reduction per person over that two year period in criminal justice, health care costs and lost productivity costs. So, again, not only effective, but cost effective as well. Recovery community centers. These are the new kids on the block, as I mentioned. These are kind of the one stop shop for recovery capital. And these are growing all over the country. You have them in Connecticut. In fact, Connecticut was one of the first states that really adopted this model. Phil Valentine, CCAR, the model you have there was it was a model for the rest of the country in many ways, and it was developed and developed further there than probably anywhere else. And when I many years ago, probably 12, 12 or 13 years ago, I went to visit Phil down in Hartford, Phil Valentine, who is running some of you may know Phil in Connecticut. And I was totally inspired by the model there in Connecticut. We didn't have any here in Massachusetts at the time, but now we have 40 of these around the state. So they've really grown a lot. But you can see here, these are the the elements of recovery capital. These are the building materials, the scaffolding that people get gain access to, the recovery capital that's available at these recovery support services. This is from a study we did in New York state, New England and all across the New England including Connecticut, Vermont, Maine, Massachusetts, etc., New Hampshire, Rhode Island. And you can see here the vast array of recovery support services, access to all kinds of things, linkages to things, information that people can gain access to, including recovery coaching. So and there's tons of groups going on. There's all kinds of support services available, accessible, and they're populated by peers with lived experience. So that helps to diminish the shame and the isolation, the feeling of differentness that people often feel early in recovery. We're also learning how these work as well. We're finding out that yes, these recovery community centers, the RCC, the longer you go, the more recovery capital you gain, and the greater amounts of this stuff, self esteem, quality of life, and decreases in psychological distress. And those in turn are associated with longer recovery duration. The good news is these recovery community centers are providing something that is novel, that's unique, that is not provided by treatment or mutual help groups. So it's something very unique, that array of recovery capital is some, it tends to be something very unique to these recovery support centers that are provided through CCAR in your state, as well as in Massachusetts here through BCESS. And again, all this to say is that we need to do a better job if we're serious about really effectively addressing the opioid and broader substance use disorder, epidemic and endemic problems that we have related to these disorders. We need to create a system, a much better system of linkage of fluid linkage and networking between our more expensive medically managed services and our community-based services, which can help sustain change over time. We need to create the right kinds of environments that are conducive and supportive to long-term stability and change. That's really what we're learning about how to best address these chronic illnesses or illnesses which are susceptible to recurrence over that first five years beyond initial stabilization. And again, when we think about the complexity of these disorders, it's important to know who needs what when for what duration at what intensity, who needs what kind of service when for what duration at what intensity in this timeline through that first five years in particular. There's been this focus on recovery milestones. What are the recovery milestones? Why are they important? Again, because we need to know who needs what when for what duration at what intensity. We have done studies. There have been studies done. We did a national recovery study a few years ago now where we sampled the general population to estimate recovery prevalence in the United States. We found in that study that there were 9.1% of the US adult population had successfully resolved a significant drug or alcohol problem. That's about 23 million people. And this is what the trajectory looks like for these people in this sample. There were 2,000 people in this sample, just over 2,000 with different amounts of recovery, time in recovery. You can see that along the bottom axis, anywhere from a few weeks in recovery up to 40 years in recovery. You can see across those many decades of recovery. Up the vertical axis on the left here, you can see different indices. These are levels of different indices of functioning and well-being. You can see psychological distress coming down from the top early in recovery. That's good news. You can see it coming to sweeping down and staying low down and getting very low up through 40 years. Then similarly, you see these positive indices of functioning, quality of life and functioning, recovery capital, happiness, self-esteem, these are all going up. What you might also notice here is that yes, they go up year over year. That's good news. By the way, this is independent of age. As we get older, we tend to get a little bit happier apparently. Even when you control for age, you still see these increases in well-being and functioning independent of age for people in recovery. What you also notice here is right around the five-year mark is when the slope changes. You see it's steeper in that first five years, and then it shallows off here later after that first five years. Sorry. I mentioned earlier, right around that five-year mark, that's where the risk of reinstatement is about the same level as the general population. We see the same thing reflected here. Early on in that first five years, you see that people are really climbing up. They're climbing up that hill. They're climbing up. You think of it as climbing up that mountain of recovery. It's a lot steeper early on. There's more challenges earlier on, but then it starts to shallow out and people start to feel better and do better as well. In terms of who, again, not everybody recovers at the same rate or achieves these same levels of indices of functioning well-being at the same rate. This highlights here on this graph, in terms of quality of life and recovery capital, different primary drugs. If you, for example, are addicted to heroin or methamphetamine or cocaine, you're going to have a much more difficult time early on than if you're addicted to alcohol or cannabis on average. You can see here on the left and right-hand side, those individuals with an opioid or stimulant use disorder in yellow, start off at a much lower quality of life and much lower recovery capital. It takes them roughly two to three years to reach the same level of quality of life and recovery capital as their counterparts who have alcohol or cannabis use disorder in recovery from those. Now, these people with cannabis and alcohol are not doing well either. They're doing very poorly, but relatively speaking, the opioid and the stimulant use groups are doing much worse. Again, they're more marginalized, more stigmatized. It's more difficult for these individuals to shed that cloak of stigma and to gain access to these kinds of services that they need. We're seeing differences in racial ethnic groups, as well as sexual minorities. You can see here sexual minorities relative to heterosexual status. Huge differences over 40 years in terms of quality of life, functioning, psychological distress. Look at self-esteem in the sexual minority group, tends to rise a little bit, but then drop off as people are getting into recovery over in the last 25 years plus, tends to diminish. Whereas the other group, the heterosexual group, rising in self-esteem. Again, this helps us to identify who may need what, when, for what duration and what intensity. How can we best address the needs? Now, we still need to do a lot of work to understand, well, what is going on here? What's going on with this particular population that we need to address more sensitively and more effectively? The same with the racial ethnic groups. We find that largely racial ethnic groups do as well, except for the American Indian Alaska Native group. They tend to struggle continually over time, despite the fact that they have resolved a significant drug or alcohol problem. I mentioned this earlier, this inflection point around five years. What happens when we look at the question of when, who needs what, when? Now, if you look on the right-hand side here, we're putting the first couple of years under the microscope. I showed you that 40-year graph with a nice curve going up, steady curve going up steeper earlier on, and the psychological distress coming down. That's all good news. That's something that we want to tell people about, that this is what you've got to look forward to. Here's the thing, when you put it under the microscope in the first couple of years, look what's happening here in the first couple of years. Again, this is helping us to understand the timeline, the milestones of recovery. If you look in the first, on the right-hand side here, the circles graph, you see there's initial stability in the first half of the first year, that 0.5 is the first half of the first year across the bottom. You see people are stable, and then they drop. They're dropping in quality of life and self-esteem right after around about that half-year mark, six-month mark. What's going on there, do you think? Well, I think what might be happening, I'm surmising, is that after the fire is out, if you could return to that burning building metaphor, after the crisis is out, the fire is out, and there's a bit of convalescence going on, people are maybe in treatment, maybe they're stabilized, medically managed withdrawal, maybe they're taking a medication, maybe they're in a sober home. What happens metaphorically is the smoke is clearing out of the building. Their mind is getting clearer, now they're able to start to appraise the damage. They look around, they say, oh my God, look what I've got to clear up. They look forwards, perhaps in their life, and they say, look what I've got to make up. Those two thoughts that can occur right after that initial period of stabilization can be very daunting prospects. What have I got to, look what I've got to clear up, look what I've got to make up. This is a daunting prospect. This is where the rubber hits the road, maybe. You can see here, they drop in their self-esteem and quality of life and functioning before the end of that first year beginning to go up again. Now, this is a conceptual model I've drawn here on this graph, really highlighting what's happening, what we think may be happening here in this recovery, the recovery, the dynamic course of recovery. There may be going on here in the left-hand side, this convalescence period where the fire is out. There's that initial calm followed by what I call the dawning of reality. This is that rude awakening that people suddenly say, oh my God, look what I've got to clear up, look what I've got to make up. Now, if people have access to the building materials and scaffolding and the building permit, very importantly, then they can start to what I call engage in the industrial resolution. They resolve to get busy. They can resolve to get busy, provided they get access to these building materials. If they do, then they can start to climb again up this hill and hopefully reach this process of conservation and growth and maintenance over time. We're beginning to understand exactly who needs what, when, for what duration, at what intensity. The kinds of things that maybe people may need is that installation of hope, particularly after that initial stabilisation period where people need a little bit of hand-holding, maybe they need some role models. Say, hang in there, it's going to get better. Let me show you how you can get access to the things that you need. That's what these recovery community centres are for, that they can instil hope and help people really get access to the building materials, the scaffolding and building permits that people need. Again, just summarising here, what I've said is that we've learned a lot in the last 50 years about these problems. That's what I began this morning in terms of how best to address these problems. I think the two institutes of health, NIDA and NAAA, have been catalysts in being able to change public opinion and public policy in moving away from crime to clinic to community. They have helped us move away from squinting through keyholes into prison cells, through looking through microscopes into brain cells to help understand more about the phenomenon that we've seen and address it from a broader clinical and public health standpoint. We've learned a lot, as I mentioned, about the etiology and epidemiology, typology, neurobiology of these disorders. We understand much more clearly about the fact that they tend to have an undulating chronic course before stable remission. This is very important information because we need to think about it not just as an acute care stabilisation, putting the fire out, but how do we keep the fire from restarting? How do we build resilient buildings as it were that are fireproof, that are weatherproof, that are protected in the future against recurrence? Again, we are learning a lot about the kinds of infrastructure that is growing and needed that provide an array of options. I think this is very important. It's not, as we often are fond of saying, one size fits all. It's true that AA works. It's true that 12-step works. It's true that cross trainers help people keep fit. Again, that fitness centre analogy, the more options we have, the more likely we're going to engage more people in that recovery fitness paradigm, just the same way as fitness centres attract more people in the physical fitness paradigm. With that, I'll say thank you.

Addiction Treatment

Policy

Opioid Response Network

Substance Use Disorders

Harm Reduction

Recovery

Dr. John Kelly

Harvard Medical School

Mutual Help Groups

Alcoholics Anonymous

Recovery Ecosystem

Youth Intervention