But hi everyone, my name is Emily Mossberg. I am a technology transfer specialist with the Opioid Response Network. Before we start today's presentation, I'm just going to quickly share some information about the Opioid Response Network and the work that we do. So the Opioid Response Network was initiated back in 2018 in response to the opioid crisis in our country. We are funded by a grant from SAMHSA to provide no-cost training and consultation to enhance prevention, treatment, recovery, and harm reduction efforts across the nation. And to do this work, we utilize a pool of consultants who are located all over the country and who can respond to local needs. We operate on a request basis, which just means that anyone can submit a request for assistance on our website at opioidresponsenetwork.org. Today, our consultant, Paul Hunsicker, will be presenting on opioid use disorder, which will include some information about addiction in the brain and also how opioid use disorder is treated. And we'll also try to get to as many questions as possible. Please note this session is being recorded and will be available for sharing in about two weeks. And I'll pass it over to you, Paul, to introduce yourself. Thank you. So I'm going to try to share my screen. Thank you so much, Emily. Let me pull up here. Hopefully Zoom won't crash on me this time. It looks like it's working. Great. Okay. So, yeah. Hello, everybody. I'm Paul Hunsicker. I'm going to be working with you kind of on opiate use disorder 101 today. Introducing myself a little bit here. So I'm a marriage and family therapist and a substance use disorder professional in Washington State. So I live in Tacoma. I'm currently about 30% of my time I'm in private practice and the other 70% of the time I spend teaching. And I teach a number of different... I teach for the Opioid Response Network. I also teach for the Addiction Technology Transfer Center, which is also SAMHSA funded. I also work with many different agencies. I work with Early Head Start, many different organizations on things like motivational interviewing and clinical supervision, which are counseling related. There was a question about, because in one of the intros, it looks like folks were able to see, I've founded a family therapy-based substance use disorder treatment center. And so kind of looking at what has gotten me into this field. It's a bit of my own history as a teen having some challenges with substance use. Also, I have family members that have had struggles with opioids specifically. And so there's some family piece to that. And then the family component is really... When I started learning about family systems in my bachelor's program, it spoke to me because it spoke to kind of... Because with family systems, the person having the problem isn't necessarily the source of the issue. It's looking at the family as a whole and how the family's functioning. And that worked really well for me, just kind of explaining some of the challenges I was having. So yeah, some personal background on that. So let me move ahead a little bit here. Oh, and Emily ran through all of this while I was crashing out of Zoom and coming back in. So I'm going to move ahead a couple of slides here. So we're going to be talking about addiction and the brain. So addiction. Addiction is a really broad term and it can mean substance use. It can also mean compulsive behaviors like gambling. It can mean a number of different things. And so sometimes we actually even avoid using the term addiction. In the substance use realm, we say something like opioid use disorder because opioid use disorder is much more specific and it's more easily defined. That being said, it is important for us to recognize and step back and look at addiction and the different ways that we've defined addiction. So this definition of addiction that we see up here, it comes from the American Society of Addiction Medicine. It's more commonly called ASAM. And so this ASAM was founded in the 1950s and they really were looking at bringing... It was physicians looking to bring addiction treatment into the realm of regular health care and get it looked at on par or equal to regular health care and bringing up and enhancing treatment so that it was more and more effective and that we knew we were serving people that suffered from addiction well. They've done a number of things. One of the things that ASAM has done is created this definition of addiction here. And so I'll read it out here. Addiction is a primary chronic disease of brain reward, motivation, memory, and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and or relief by substance and other behaviors, substance use and other behaviors. So there's a lot in there. It's a pretty dense definition there. And it looks at talking about chronic brain disease. Some of you may have heard the disease model or the belief that addiction is a disease of the brain. It's a commonly held belief. It's not universal. And they add some other things in here that go to some of the different directions talking about how brain reward, motivation, memory, related circuitry. It talks about how we know from the science that the brain changes through substance use and then subsequently through addiction. And then it goes broader and talks about individual pathologically pursuing reward and relief by substance use and other behaviors, kind of talking about the pattern that falls in place. This is a widely held definition because it's so broad and it really helps just bringing our field into more consensus around an understanding of addiction. So I want to add in here, looking at drug use and addiction. Now, it's really in the last 20 years that we've started getting really good brain imaging and so MRI studies. And these MRI studies really have helped us gain an understanding of how the brain changes or the structures in the brain that change from addiction. And so the areas that tend to be impacted without going into too much detail here, the areas around judgment, decision-making are impacted specifically with substance use. So to give a quick, so there's the very front part of the brain, which is called the prefrontal cortex, which is not fully developed until we're 26 or 20, well, 25, 26 is when we understand that. That is the part of the brain that is really responsible for judgment because it's the part of the brain that lets us think way ahead. And then there's the other parts of the brain, which are more towards the brain stem, which are like the pleasure. Some of you may be familiar with dopamine. Dopamine is a commonly referred to neurotransmitter. And that a lot of those dopamine acting areas tend to be more towards the center of the brain. What we know from this MRI, these MRI studies is the connections between the center of the brain and the front of the brain are impacted or wouldn't fully say severed. They're just impaired. They're made so that there can't be a connection between pleasure and judgment. And so what we end up seeing is folks that have problems with behavior control, because they can't think ahead through the consequence of, they're not able to actually think ahead all the way through and see how something's going to negatively impact them or others. And that, yeah, it really, and what's also unusual with this is it doesn't mean that judgment in every area of their life is off, though it can impact other areas. It's really specifically around the substance use itself. What also gets impacted is learning and memory. Sometimes the substance itself affects memory, like alcohol actually decreases your ability to code memory. But there's also some impact on the areas of coding memory of remembering the bad experiences. And so folks will just stay with what they thought was good, and that causes them to then want and anticipate continuing to use more. And so, yeah, this is a really quick overview of how that works. It really, these changes do alter the way the brain works and helps explain the compulsion that folks experience in trying, in usings. And compulsion means a desire to use and inability to avoid it. So specifically, we're talking about opioids today. So opioids are natural or synthetic substances that act on the brain's opioid receptors. So a little bit more detail on this. So opioids, there are natural ones, which are derivatives from the poppy plant. And so you've got morphine, codeine, well, even heroin technically, which is a slightly modified version of morphine. Those are all natural and come and directly from the poppy plant. And they were the original, they're what made opium and some of the original opioids. But then over time, we've developed ways to synthetically recreate these substances and make them more intense. Like many of you probably have heard of fentanyl. It's one of the more recent, more potent versions of an opioid. That's a completely synthetic opioid. There's nothing in that that ever came from the poppy plant. So as for the brain's opioid receptors, these are actually what we call endorphins. So our body releases endorphins. You may be familiar with them. They're our natural painkiller, if you will. If you've ever gotten a runner's high, it's a way to experience a little bit of what an opioid response would be. It's much, much lighter. That's not, but it is essentially, there's a very similar experience there because it is a natural endorphin release. So in working on those endorphin receptors or the opioid receptors, what opioids do is they dull pain. They don't relieve it. They dull it. And more importantly, they relieve the anxiety that comes from thinking about pain. So things like aspirin or ibuprofen, like things you would take over the counter, actually work at the pain site and can actually relieve the pain itself. Opioids work in a different way. They work more in the brain and on the nervous system to get the nervous system to have less perception of the pain. And then more importantly, it gets folks to, people to not care that it hurts so much. What, it's not as much, I mean, there is some of the pain relief aspect that people are going after. The piece that most are going for is the rush or feeling of euphoria that can come from opioid use. And because of this rush, it can be extremely habit forming. So any drug that causes a rush comes on really quickly. And the quicker something comes on, the more likely we're going to want to keep doing it, especially if it feels good, like opioids do with a sense of euphoria. So side effects. So things, if you ever see someone under the influence of opioids, they might be very drowsy or sedated. In fact, they tend to kind of nod out. And in fact, that's what an overdose from opioids is, is someone falling asleep. However, they're nodding out way before that, before it's a risk. So what will happen is someone will be kind of nodding out. They're kind of paying attention, but they can get a little bit confused. They're not wildly out of it like they would be with alcohol, which can make people pass out, or even amphetamines, which can agitate folks in a certain way. They're pretty chill, but they might be a little bit confused. There's some nausea and vomiting that can happen, both from the high and from withdrawal, which we'll talk about in a moment. Constipation. Yeah, opioids do cause the gastrointestinal system to slow down or possibly stop. In fact, Imodium is technically, it's an opiate. It's just, it's too large of an opioid, I'm sorry, to cross the blood brain barrier. And so you can't get high from Imodium. And it doesn't work as a way to alleviate withdrawals, because it doesn't bind to things the way that it would need to, to do that. However, Imodium even without those does actually impact the gastrointestinal system and it causes it to slow down and stop. So opioids have been used for this reason as well. So these next slides are actually all referring to pupil size. So when someone is under the influence, their pupils are tiny. When they're not, they're in withdrawal, their pupils become really large, like dinner plates. And so that's one thing, it does affect the pupil size based on where they're at with their high. And then the last part, slowed or depressed vital signs. In fact, someone ODing from opioids basically falls asleep. And someone asked in one of the questions, whether you could sense that someone could sense that an OD was happening. Unfortunately, no. Someone going into an opioid overdose isn't aware that they're experiencing an overdose. What's happening for them is they feel like they're experiencing the best high they've ever had. And then they just don't wake up. And you can see this in, we don't talk as much about Narcan here, we might mention a little bit. Someone who is given Narcan or Naloxone, when they wake up, they wake up and they usually have a really gnarly headache. It's because their brain has been deprived of oxygen because of their low respiration rate. So someone ODing from opioids basically stops breathing. So opioids here that are out there that are common, codeine is still prescribed. It's from the poppy plant. It's given in cough syrup. It's legal in Canada. You've got the Tylenol 3s that have codeine in them. It's a pretty mild acting opioid, but it still can be addictive. Oxycodone, so Oxycontin, Percodan, Percocet. So Oxycodone, it's a stronger, it's a fully synthetic, or actually is it? Yeah, it might be semi-synthetic, but it's an opioid. It was really in its highest levels of use in the mid 2010s. We saw Oxycontin was known and folks were, it was a sought after substance. It's fallen off a bit as more intense versions such as fentanyl have taken hold, but it's still out there. Now, it's important to note with Oxycontin, Percodan, Percocet, and even Vicodin, which is hydrocodone, all of those have either ibuprofen or acetaminophen, which is Tylenol, mixed in with them. And so it's really important if someone is taking those, they're also taking another medication. And if they take more than prescribed, they're taking more ibuprofen or acetaminophen, which can increase the danger related with it. There's also Demerol and Dilaudid, which are used heavily in surgery. They're powerful synthetic opioids. They are fast acting. And there's some different that I know Dilaudid is used quite a bit as a really heavy duty painkiller in a hospital setting and sometimes for cancer patients. Fentanyl is another one. Some differences with fentanyl are that it's even more potent and some versions of fentanyl are the most potent out there. There's carfentanil, which is used for large animals. One of the other things with fentanyl is it tends to be the one of the longer lasting opioids. And so it's sought after for those reasons. And then we end with morphine, which is one of the original derivatives from the poppy plant. So there have been four waves, and these waves can be referred to in a different book. For this slide here, we're looking at, and I know it only goes to 2021, but the tracks continue, and we can discuss that in a moment. So with wave one, it was rise in prescription opioids in the early 2000s. So these were deaths in the 100,000s on the left axis, and then on the bottom is the year. And you can see that green line, it went up right around 2010, 11, 12. And then as of 2015, 16, when we really started honing in on the opioid crisis, those opioid overdoses decreased back, not quite to the level that they were in 1999, but not too far. And then we see rise in heroin without stimulants in 2010. And then that is the purple line. It really peaked. You can see that it peaked a little bit later than the prescription opioids. And this was because prescriptions around the opioid, we started becoming aware of the opioid crisis, and doctors started changing their prescription habits. And once they started changing their prescription habits, we saw an increase in heroin use. But that also tailed off, and you can actually see deaths per heroin overdose have dropped really close to what they were back in 1999. But then we get to fentanyl, and with the fentanyl rise without stimulants. So this is starting in 2013 is really when this rose. So fentanyl, you'll see, has been around for a while. It's been there. What we saw with, you'll see, it starts in 2013, starts to increase. What's happening here is a couple of factors. The opioid crisis was starting to become more obvious, and we started taking actions to interrupt it. This caused folks to try to find sources they would switch to heroin. Heroin, of course, needs to be grown and cultivated and used, so it's a little bit difficult to move around. What we started to see is cartels and other folks being able to produce fentanyl illicitly, and they started creating a steady flow of fentanyl coming into the country. And really, where it really took off was in 2019, and that's when the cartels really fully came into full production, and we saw the amount of fentanyl out on the streets go through the roof. It was easy to get, and it was cheap. You'll notice there's a fourth wave, and the fourth wave is fentanyl with stimulants. This is important because this is the number that we're seeing increase, and you see it getting very close at the very end there in 2021 to fentanyl alone. It looks like it's surpassed since that time. What's happened here, and the reason why stimulant use is specifically methamphetamine, because what's now happening is dealers will carry both fentanyl and methamphetamine. Because if folks are maybe not familiar, back in the early 2000s, there was the problem we had with homegrown meth labs. And what people were doing was getting pseudoephedra from a pharmacy or from the grocery store, and then they could take that and then go through a process in a home lab and produce methamphetamine. There was the law that was passed that made it so now you have to go behind the counter to get things like pseudofed or things that carry pseudofedra in them. That law worked really well at shutting down the home labs. What it did though was it caused the market to then shift again and the cartels figured out and how to produce and create their actually a stronger, more pure version of methamphetamine. And that took over in the mid 2010s. What's now happened is dealers will have either meth or fentanyl on them and folks will go. And sometimes if they're out of fentanyl, they'll get meth instead because meth can be a substitute in some ways because it can make it so that the withdrawals don't aren't as rough. And what some folks will also do is they'll purposely switch over from fentanyl to meth to bring their tolerance down so that they don't need as much fentanyl. And then they can go back to using fentanyl at the lower tolerance so they can use it to kind of take breaks. What's also happening to now, and this is where we see the most overdoses is people combining meth and fentanyl together on purpose usually, but sometimes not unintentionally. And what that does, it can enhance the high. But what it does in the background is it makes it so that you're numbed out to, now I mentioned with an opioid overdose, someone is not gonna be able to feel that coming on. They're not aware. With meth, you can be aware that there's an overdose happening because it's a heart attack. You're very awake. It can either be a heart attack or stroke or it's some kind of cardiovascular event. The problem is the fentanyl will make it so that they're not feeling that anymore and it increases the risk of overdose. So that's why those two drugs are melded together so often and we're seeing this fourth wave of fentanyl and methamphetamine. So talking about opioids and tolerance. So higher and higher doses are required to achieve the effects. This is called tolerance. And eventually the drug is taken mainly to prevent withdrawal and not to get high. And this is specifically with opioids. So what happens is every time you take opioid, really any time you take any substance in your body, your body, even though you may enjoy it, your body is not having a good time because it's throwing things out of whack. And so your body then needs to figure out how to kind of balance, rebalance itself. And one of the things it does is it increases your tolerance. It can make it so that your liver is better at processing the substance. It can make it so that there are fewer receptors in your brain for the substance to work on. There's a many different things that your body can do to increase tolerance. And that's fine to a point, but after it makes enough changes, you start to feel really badly when you're not using the substance. In fact, you only feel normal when you're using the substance. And so this last part here, talking about how they're using it not to get high, they're using it just to sustain or get by. And they'll take a hit in order to be able to eat or go out and function. They really, it changes. And in many ways, it's not enjoyable anymore for them at that point. Some people will still use to get high, but it's more just to get by. So withdrawal occurring when someone who is, or dependent or addicted stops taking their opioids suddenly. So once you stop taking within a few hours, sometimes longer, because fentanyl remember stays in the system longer, you'll start to feel withdrawals. So withdrawals are described as this severe flu. It's can be muscle aches, pain, trouble sleeping, diarrhea, vomiting, hot flashes. The pain is really down to the bone. And the, well, the trouble sleeping, cold and hot, I'm sorry, cold and hot flashes. It feels almost like they're feverish. In other words, like there'll be shivering and then they'll get a blanket over them and then they'll be sweating. The diarrhea is a rebound from the constipation that's caused by the opioids. It's a pretty miserable experience. And folks that describe this say it is, you want to do everything in your power to possibly avoid this. And that's why it becomes impossible for folks to stop using because to stop using means they have to go through this and experience this. So looking at athletes, and there was a question in how often this is the case of how often someone gets, starts using after a prescription from the doctor. I think it was brought up that it's common TV and you're right, it is a common TV thing. But it is actually, it is a thing, unfortunately. And I know I've worked with many people that have started this way. And so it, yeah, it is common. And the gateway for athletes tends to be getting an injury. So, or having a surgery of some kind. And the data on this is looking at, and it says high impact sports such as football and hockey tend to have the highest opioid use rate amongst athletes. And you think about that, those are really the sports where you're most likely to be injured and likely to encounter the need for opioids. Now, athletes can tend to be high alcohol users or cannabis users, and that might be a way to get in. And then other things that can put athletes at risk are being under pressure to play through the pain, especially, and this is mentioning elite athletes. So these are folks that are really trying to pull to the next level. There really is a culture around this of just keep going, play at all costs. And there's a good reason for it. You might have scouts out that are gonna come out to see you. You are needing to make a certain select team or get to a certain level. The pressure is real. And then this last part, use of opioids during someone's athletic career puts them at greater risk for use in retirement. And this is what we see. There are athletes that can use and become dependent on opioids while they're actively playing. But most often it's actually a rebound effect that happens later on after they retire. So they might've been introduced to the opioids and that sensation when they were playing, but they knew that they didn't want it to interfere with their playing. So they figured out how to stop. But then later on in life, after retirement, and they don't have those concerns, it can come back and they can start up again. And unfortunately it can become a problem. Something to note with this too of someone getting a prescription for opioids. In fact, there are people that will take opioids either after a surgery or an injury. And they can use to a point that they have some mild withdrawals, but most folks will just stop still and realize, oh, wait, it's just the med. The beginning of the body becoming dependent that's the beginning of the body becoming dependent on it, but it doesn't necessarily mean that they're addicted. And the difference is the addiction would then lead to someone going out and seeking out more opiate or opioid and then starting to do things that they wouldn't do before and getting into trouble, having all these problems related to their opioid use and continuing to use. Most won't go down that road. The difference does seem to be risk factors such as challenges in childhood, difficulties they might have with mental health. There's some complicating factor that makes it so that once they use and get that feeling from the opioid, that they're more likely to be drawn to trying to continue that feeling and get more and more of that effect. So we're gonna shift here and talk about medications. And so these are classification of medications, medicated opiate use disorder. So there are three and these medications are all used to help people come off of opioids or a better way is to help them not have the problems that are brought on from their opioid addiction anymore. And you'll see why in a moment why I'm saying it this way, because it's looking at opiate use disorder as something that a condition that can be medicated so that you're not experiencing the problems caused by it. So the three types of medication, we've got methadone, buprenorphine and naltrexone. So methadone has been around a long time. Talk about it in more detail in a moment. But what methadone does is it's called a full agonist that generates the effect. It's an opioid. It's a synthetic opioid. And so you can get high from methadone. It has advantages that we'll talk about in a moment, but it basically, it's an opioid that you're taking so that you don't have any cravings or withdrawal or effect. Buprenorphine, buprenorphine is in many medications, but one you might be familiar with is suboxone, which is actually buprenorphine combined with naloxone. But buprenorphine itself is what we call a partial agonist. It generates a limited effect. So that's why it's got those dots there because it's connecting. So the blue part is the receptor and the green dots are the buprenorphine molecule. And it's partial agonist. So it actually binds to the receptor and partially generates an effect. And why this is nice is that it means you can get an effect. You can get relief from cravings, relief from withdrawal, hopefully not too much of a high, but there's kind of a ceiling effect. You can't keep going. You can't keep taking more buprenorphine and feeling more and more high, which is nice because it means that it kind of caps itself. You're not going to abuse it or makes it not worth necessarily abusing. And so that is another class of medication. And then we have naltrexone. So naltrexone is what's called an antagonist. It blocks the effect. So that's why it's a bar there. And so it prevents opioids from binding to the receptor. And so what's nice with this is then there's no opioid in it. And so, and it prevents the person from using opioids because if they take any other opioid into the system, it won't have an effect. It blocks the impact. Methadone a little bit more further, going into some more detail here. So methadone is a full opioid receptor activator. So it binds to the receptor and fully activates. And the goal with methadone is to get it so that the person is in that sweet spot between not experiencing withdrawals and not experiencing a high. It takes a little bit of threading the needle to get there, but that's the goal is to get someone there. Now, an advantage to methadone is that it lasts for one to two days. So it's a super long acting opioid, which is really helpful for making it so that people don't have cravings or withdrawals for a long period of time. And it makes it so that there isn't this up and down in their bloodstream, it's very even over time. Now, that's mainly given in liquid. It's also only distributed by opioid treatment centers or methadone clinics. And the reason for that is that it prevents, those things prevent it from being diverted. And diversion means that it being taken and then given to someone else. Like pills, someone could take like cheek a pill and then spit it out later and technically give it to someone else. You can't really do that easily with liquid. And plus, when you go to these opioid treatment centers, they watch you take it. And so it makes it really hard for folks to divert it or give it to other people. So something to know about methadone that's important is it's been around for a really long time. Been around, it really helped after the Vietnam War with soldiers coming home that had been using heroin and it really helped them get through that process and get stabilized. So people that tend to be really good candidates for this, folks that have used a lot of opioid historically, tend to do better with methadone. Anyone that's had a hard time connecting with treatment and then if anyone's tried suboxone or other approaches and it didn't work, methadone tends to be a good fallback. In fact, in my own practice, when I'm talking to folks regularly, especially if they're having a hard time with something like buprenorphine or suboxone, I'm like, hey, let's think about methadone for a moment, which can be challenging because folks usually push back right away when I bring up methadone because there's a lot of stigma around it. But once we are able to work there and if they do try it out frequently, they are grateful that they had that opportunity to look at it because it can be a really great medication for folks. Personal preference for the medication is that it needs to be taken into consideration. So what someone wants, it should be taken into consideration and ideally what's given to them medication-wise. Buprenorphine. So this is what's in suboxone. It's similar to methadone, but the nice part is it can be given by any doctor. And as opposed to methadone, which needs to be given at a clinic, this can be given to by a doctor. It's pretty similar in ways. The differences are it has to be started in withdrawal, which can be a little bit rough starting out. And the reason for that is because buprenorphine is that partial agonist. And so they don't want to accidentally kick someone into withdrawal. They want most of the opioid to be out of the system. Whereas methadone can be used on top of an opioid, buprenorphine really is best done alone. Dosing tends to be anywhere from four to 16 milligrams, but it goes all the way up to 32. Now, it tends to be another long-acting substance. It stays in the body for at least a day. Here's the piece that's there. Folks on treatment with both methadone and buprenorphine, it's a minimum of 12 months. Though what we're finding is people really do better the longer they're on these. And so minimum of 12 months, but many times longer than that. And what this is saying here is continued reassessment, continued titrate for cravings. If someone starts to have cravings or they start to titrate down, their treatment is adjusted. And for many being on methadone or buprenorphine for life is the best option. And it's one of the things we have to move past the stigma around of recognizing that people, there are for many people staying on it for life is going to give them their best quality life. That being said, folks can decide on their own. And there are many that do decide to come off on their own and it is possible. Though I've seen this in my own practice, folks coming off of buprenorphine, what will happen is they'll come down and say they're at eight milligrams. They'll go to four, a couple of weeks, two, and then going from two to zero tends to be the most difficult step for them. So oftentimes buprenorphine is combined with naloxone. So naloxone is the active drug in Narcan. So it's the thing you see that the nasal spray that will be given that brings someone out of withdrawal or yeah, brings them out of overdose, I'm sorry. The reason why it's nice to combine naloxone here is that it prevents people from using more opioid on top of the buprenorphine. Because if they use an opioid on top of it, the naloxone will come in and block that opioid and actually flush the whole system of opioids, period, and cause the person to go into withdrawal. So there's a built-in protector. If they use more opioid, they will be an unpleasant experience. So common forms we see are subutex, which is just straight buprenorphine. This is a sublingual tablet. There's also suboxone, which I've mentioned that comes in a sublingual film. It's the most common. And what they do with that is they'll cut the strip. It comes in eight, I believe, like four section strips. Each one is two milligrams. They'll cut how many sections they need. They put it under their tongue. It dissolves within just a few minutes, but they really need to be careful to make sure that they don't eat or drink anything for at least 15 minutes after they've done it. Because you want it to give time enough to absorb through the skin under the tongue. Subsolve is just a tablet form of that film. And then sublicate is the new market. It's a longer acting buprenorphine. So someone will only need one injection per month. And it tends to be really nice because you can't forget it. Well, it's harder to forget. You just have the monthly appointment and folks have reported some good findings with it. And then this last part here, because many times, and I know when I work with folks, families and even folks that are using will be like, I want to be on the lowest possible dose of suboxone or methadone. And I'll have to say, hold on. It really is, the higher the dose tends to be more effective, it's frequently higher than people expect. And the reason for that is this picture on the right that you see here of these brain scans. And what you've got is BUP on the left, the zero, two, 16, 32. It's showing, and then the MRI pictures of the brain. And the green in the MRI pictures is, and green and red is where someone's experiencing severe withdrawal. And you can see that the 16 and the 32, really the 32 is where they're not experiencing, it's all at one. Their withdrawal level is completely flat. And this is that just recognizing that it is really important to get the right dose and not try to, and because unfortunately what's behind some of that is a stigma of, okay, I want to be a little less addicted. And we need to move away from looking at buprenorphine uses just using a different opiate or opioid. We want to look at it as a medication because if it's a medication, you want to take the dose that's going to be most effective and it tends to be the one that's a little higher than you might think. Some more technical stuff here. We mentioned it's a partial receptor activator, same goal as methadone, getting them to the point of not experiencing withdrawal, not experiencing craving. The duration is about 24 hours. So it's a little shorter than methadone, but it's still up there. The sublingual tablet already mentioned or film. So it actually has the receptor sites, the buprenorphine, the receptor sites like it better than other opioids. And so it can kick off other opioids, sometimes precipitating withdrawal. And then because it's a partial agonist, I mentioned this earlier that it can't, it doesn't fully activate the receptor. So there's a sealing effect. Whereas on this graph on the right here, you'll see morphine. Someone will come up and use some morphine and then they can use some more morphine and get even higher. Whereas with buprenorphine, you would, once you hit that ceiling, that red line there, it tails off. You could use more suboxone on top of it, but you're not going to get any effect. And so that's the difference here. So results here for, and this is the differential access to medicated opiate use disorder is the MOUD treatment. So this is to show some disparity that's been occurring and how, because it's historically, and it's still sometimes stated out there that the most common profile for our cultural identity of someone that uses as an older white person, in fact, older white male, that's not the case anymore. That's changed drastically. And this is coming out in the overdose rates. And you can see this is looking at since 2013, how you've got the line for overdoses amongst white individuals. And let me, I gotta move my gallery here. You see how it was white and Native American and Alaska natives were up and down. And it's actually one of the silent ones. It was interesting when we would say it was mainly white individuals. It was actually, let me come back. Native Americans were on par. And at many points exceeded the number of overdose deaths of white individuals. But then you see black or African-American deaths were pretty flat. And into the 2010s, it didn't really rise until we got into the middle. And like this is saying in 2013, where it really skyrocketed. All the numbers are continuing to go up as of 2020. And I know some data was released last week talking about we finally seen a little bit of a drop in overdose rates nationally, which we still don't know exactly why yet. And we don't know whether that's sustainable. But you can see up until last year, there been this constant increase in the amount of deaths per 100,000 of people dying from opioid overdose. And so you can see where, yeah, everybody's still increasing, but African-American black is shooting up some of the fastest as well as Native American and Alaska Native. So those numbers are really, really coming in here, unfortunately. And we're talking what 40,000, 400, I'm sorry, 400,000. Or, yeah, I'm sorry, 40 per 100,000. There we go, that's the way to read that, yeah. So looking at overdose and this is data that came out, was released in 2023, it's for 2020 through 2022. And this is looking at specific overdose deaths in Oregon alone. Now this is overdose rate, overdose death rate per 100,000. So you've got on the left axis here, you've got the 10, 20, 30, this is the number per 100,000. And then you've got, yeah, the cultural group on the bottom here. And it's showing similar data. It's exactly on par as the chart I was showing before. The chart I was showing before is nationally. This is Oregon specifically. Oregon pretty much tracks with the rest of the country. So you've got the massive increase in 2022 across the board. The largest jumps in African-American, black, also American Indian, Alaska native had a jump, not quite as high, but it's growing really fast within the black community. Still growing in white community, but not at such an exponential rate. And then also Asian Pacific Islander. And some questions for reflection here, and we're going to do question and answer in just a moment here. What extent, in kind of thinking of these questions, and these are just things you can hold on to here, so to what extent are problems with opioids explained by the effects of the drug itself? And this is really asking, like, when we look at opioids themselves, how much do, does the drug contribute to the problem? It's a bit. It's not, it's not the entire picture, but there is going to definitely be some impact there, because the substance is, the way it impacts the brain causes us to want to use it more. It's mimicking a natural response within us that is there for protection, but it's putting it on overdrive. And then that gets to how much responsibility for dependence is on opioids is due to the drugs themselves. Same idea there. So I want to open it up to questions, and I'm going to see, I've got a, I don't have access to those other questions. You have that whole long list of questions. Does anybody have questions now? I've hopefully answered a bunch through the process, but I'll open it up to folks. I'm going to actually come out of the presentation and look also at my because I can pull up that list that y'all that y'all made for me, which is great. But go ahead and if you want to ask questions go for it. You feel free to unmute and ask away or if you're more comfortable just typing it in the chat box. I'll go ahead and do that. I'm going to share my screen. Okay, so there's a bunch coming in now. There we go. Great. So Sophia, that question of the area of the field I'm most interested in going into the future. I mean, I like where I'm at and just definitely learning more and staying on top of what's kind of happening with treatment. I am fascinated in there's contingency management, which is becoming more and more of an evidence-based practice for amphetamine use, because we don't have that many things that are very good at working on methamphetamine. And that's one of the things that's promising. And then Ash asks, is there development for more medications to help with withdrawal? There's research going into medications all the time and Sublicate is one of the more recent ones that came out. And so that's promising. It's following, there's a trend of a number of different medications being given in an injectable form that can stay in the body for at least a month, which is a huge game changer for folks because it means that you don't have to stay on top of taking the medications all the time. Yeah, there's just less to manage. It's less of a headache. Let me share my screen here. So I've got some of the other questions here and if more come through, oh, I can see my chat. So these were the questions I had and it's not pulling that up. I hope my, oh no, I'm about to crash out of the meeting. How can you tell? Cause it's Zoom is freaking out and keeps telling me that I quit. Unintentionally. Oh, okay. Yeah, is it sharing my screen? Yes, we can see the document. That looks like we lost him. Oh, there he is. Oh, there you go. How was that? There is one more question in the chat now. Okay. Yeah, it's a glitch in my Zoom on this computer and it's happened to me too many times. There is the, oh, my chat got blanked out. Could someone read it out to me? Yes, what do you think is the best way to get someone to think about taking withdrawal medication? Oh, that's a great question. And it's something that I work with a lot. So, and it really depends on what their goal is. Is their goal to stop completely? Is their goal to feel less sick or to not feel sick in the morning? And so it's gonna depend, cause it's gonna, the medication they want or they might wanna try is gonna depend on that. And so I'm really trying to gauge what their motivation is. And then from there, it's kind of presenting them like, well, would it make more sense to go to the doctor? Every so often get a prescription. Does that still work for you? Or is it better for you to have a place to go and get it and they take care of it for you? It's a really hard one to answer in any one good way. Everyone is a little bit different. It's kind of figuring out what would motivate them, yeah. So for MRI scans about buprenorphine, can it relate to having similar scans when someone takes medication for mental illness? Yes and no. It depends on the medication. Cause some of the like amphetamines, someone can become addicted to amphetamines and amphetamines is something that's commonly prescribed for ADHD. However, the way that they're prescribed, people don't tend to become addicted to them unless they misuse them. If they use them as prescribed, they don't become addicted. And why that is, is because they're using at a dose that's not gonna get them particularly high and it won't cause the brain to not be able to have the judgment anymore. It's an interesting question. There's gonna be some crossover, but largely no, yeah. Yeah. So if something pops up in chat, let me know, Emily. So I've got, I can't, I'm not gonna share my screen here cause I don't wanna crash out of the meeting, but I've got the question list here. So there's a question about when diagnosing with patients with opioid use, do they, and they get into treatment, is there an immediate effect or can it take a longer time? So with medications, it's a really quick effect cause they're not feeling withdrawal. And so they're feeling, once it starts working, they're doing well. Some of the other stuff, if you're thinking treatment-wise for counseling and other things like that, that can take a longer time. Someone for opioid use disorder tends to be in counseling for at least a year or so. And it can take months to kind of start feeling, seeing some of the improvements. So there's another question here is, someone who's been in the field for many years, seen an increase in mental health crisis, and how have we responded? By far there, especially since the pandemic, the pandemic we saw, there was way too much, way more demand for mental health services than there were providers. And we unfortunately are still in that, in that mode. My center really just responded by being able to treat as many people as we could. I know the field is changing some of our, they're reducing some of the barriers to people getting into the field of mental health to try to make it so that there are more providers out there. So next one here, oh, it's a question about marijuana. And do you believe that by educating others about marijuana and turning its use into a more accepted practice, both medical and recreational, that there can be a decline in opioid abuse? I don't think that that's panned out. I know there was hopes that that would, and we need more science on, and more accurate science on marijuana's effect with pain because there's some conflicting data coming out around it. And I know it's hard, and hopefully they do finish the decriminalization so that we can get better and more accurate unbiased research or less biased research. So we can really get to the bottom of what are the pain relieving factors of marijuana if there are, because I'm not totally sure that it's there. So unfortunately we haven't seen that pan out. Does opioid abuse affect its pricing or impact others correctly when prescribed? Oh, I think what the person's asking here is essentially, does the amount of people abusing opioids cause the cost of the medication to go up? I don't believe it has. And in fact, we've seen just the market flooded with opioids and the Sacra family recently with being sued for their involvement. They really flooded the market with opioids. So I don't believe so. Oh, there's one more question in the chat. How has telehealth implementation affected diagnosis? Huh, great question, Ash. I would say it's increased access to services quite a bit. The only thing that's a little challenging diagnostically as someone who diagnoses substance use disorders, we can't, it's harder to get urine testing so to verify things. And this is a common practice in someone comes in, we ask them a bunch of questions. We also give them a urine test and then see what's in their system. It's just harder to get ahold of that. It's not impossible. At the same time though, the increased access is super helpful. We're able to see so many more folks, it's easier for them to come in. It's so much more convenient. And so telehealth, both for substance use disorder and mental health has really made access, increased access. Yeah. All right. Oh, question about opioid use in settings like retirement homes. Opioids, unfortunately in retirement, opioid use in retirement homes is, cause they're prescribed commonly to folks in retirement homes. And it's mostly around prescriptions. It's just common practice. It's just part of that setting. I don't see any specific pieces that would be added to that. Cause yeah, they're not necessarily, most retirement homes, you're not gonna have as much drug seeking behavior cause it's gonna be just based on what they're being prescribed. Root cause of opioid addiction. And then there's a great follow-up question. Is there a specific cause? There are so many different reasons for this. And in fact, with something I didn't say before of, our understanding of addiction is really in its infancy. And so my answer is we have no clue what the root cause is. We have some ideas of what it might be and some paths that we're following. And I would say anyone who tries to tell you that they have the full answer of what causes addiction is probably trying to sell you something. Cause we, the research is just not there. We cannot definitively say we know. Answered that question already. How many college students use opioids in Oregon? I don't know the answer to that, unfortunately. And this connects to one of the other questions too, of tracking. So there's tracking use rates. And one of the tools that we use is the National Survey of Drug Use and Health. NSDUH. The NSDUH is a study that we, it's a survey that's done every year and we gather information on mental health, all kinds of health, including substance use. It's, the NSDUH is playing a game of catch-up cause fentanyl is still classified under the larger group of opioids. And it needs, we need to split the opioids out a little bit more to capture better, more accurate data. The other problem we're seeing is we're not capturing data on 12 and up. We only started 18 and up. And so I don't have the rates. There's another study monitoring the future. And I know it wasn't that long ago that I looked at it. Also, that might have better data, but it's harder to get a picture of exactly what's going on with that. In fact, when we look at medications for opioid use disorder, they're just now starting to get approved for people in their teens. They historically have not been allowed to do that. And even that, with that, some of that, it's rare that folks are authorized to do it. And so we're missing, it's a gap. We're missing the fact that a lot of teens are using opioids. Oh, it looks like a question came in. Is there a certain age group that is targeted for misusing opioids? Historically, it's been like middle age. It's folks in their, in later life, but it's pretty broad. The reasoning for the middle age to older is, again, that's when folks tend to have surgeries and injuries that add up and they're having more pain. And so they tend to be more likely to be a group that's prescribed opioids. But yeah, it's not necessarily just that group. We're seeing a pretty broad range, yeah. Yeah. Great question I've got here. What can bystanders, families, and friends do to help support someone struggling with opioid abuse? First and foremost, there can be this idea that tough love is what's helpful. It's generally not. When folks talk about, and when folks are asked the most helpful thing, it's most, their most often thing people say is a supportive, close, someone who was there for them, even in their most difficult times. It's rarely someone that was shut the door or kicked me out. So really being able to stay in close as hard as that might be, to be there as be a support, because folks that are going through this really do need the supports, even though that might be difficult, because there are behaviors and things that they're doing that make it challenging. Such as stealing, if they're needing to get money for use, what can feel like lying. Even though that might be happening, if you can still stay in close and support. The idea here is that someone's desire to change or desire to go to treatment or do something to help themselves, can change by the minute. And so if you're in and close by, you're there and be able to provide support. There's another one out there. There's a hotline for Never Use Alone. It's a national hotline. And that's actually for folks that use opioids to be able to use and have someone there while they're high so that just in case they do overdose and stop talking, that they can call emergency care to them so that they reduce the chances of emergency. Have Narcan on hand and know how to administer it. And yeah, so those would be the things that come off the top of mind. And let me see here, I've got some. Oh, question about measure 110. So that's an interesting one. So I'm not aware of any data that showed that there was an increase in use after measure 110. What folks are responding to is the fact that it was the measure 110 where it was the decriminalization. Folks were seeing that it was harder for people to be arrested for small offenses. And so we were seeing a lot more things that would normally be put out of our view by police, by law enforcement, not put out of our view by law enforcement. So it didn't really increase what was happening. It just made us more aware of what was happening. And so there isn't really data that use rates increased that I'm aware of, again, that I'm aware of. And so it's interesting that the reaction to 110 and trying to kind of shut that down, it doesn't seem like from where I'm sitting, it doesn't look like that's being based on data. That's being based on a reaction. And so it's unfortunate that it's being approached that way. Because again, I don't know data that supports what they're doing right now. Oh, there's a last question here of what dose would be fatal. That is really hard to say because it's going to be based on someone's tolerance, their body weight, body mass. It's going to be dependent on the opioid itself. Now when we're talking something like fentanyl, and you probably heard this, we're talking about micrograms of fentanyl. It's very potent. And so the dose of fentanyl would be, or the amount of fentanyl needed to be fatal would be far less than there would be for, say, heroin. And so it's really hard to answer. And I don't unfortunately know all the numbers on that, but yeah. Looks like that was all the questions I could have. Any others? Well, thank you for having me. Yep. We've got a slide there, and I'm, oh wait, yeah, if you can just follow the link that Emily put in there because I don't want to crash out of Zoom again. Yeah, so this link just takes you to a quick evaluation survey for today's presentation, and we would greatly appreciate your taking a couple minutes to fill that out and your feedback is really important to us. I think that's all we have for you though, Jackie. Is there anything you wanted to say or add? Folks, just don't forget that you have the midterm on Wednesday, you'll have 24 hours to do it. So open up around 9 in the morning and you'll have until 11.59, so a little over 24 hours. You'll have until Thursday 11.59 to complete it. If you have any questions or concerns about any assignments that are due, please check the announcements in Blackboard. I did send out one this morning with some upcoming things that are due in the next few weeks. Otherwise, feel free to email me or stop by and chat. All right. Thank you all for joining and for your engagement in today's presentation, and thank you, Paul, and also thank you, Emily, for your time today. Thank you. Thank you all. Bye, everybody.

Opioid Response Network

ORN

opioid crisis

SAMHSA

opioid prevention

opioid treatment

opioid recovery

Paul Hunsicker

opioid use disorder

addiction treatment