So thank you so much for joining us. My name is Emily Mossberg, and I am a regional coordinator with the Opioid Response Network. I work in the, it's called Region 10, but basically the Pacific Northwest region, which is Oregon, Washington, Alaska, and Idaho. And before we dive into the training, I'm just going to share a little bit 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 through SAMHSA to provide no-cost training and technical assistance to enhance prevention, treatment, recovery, and harm reduction efforts across the country. To do this work, we use a pool of consultants and multiple partner agencies who are located all over the country. And it is truly our goal to tailor the content, so it's not a one-size-fits-all approach. We try to meet the request or a specific need. We operate on a request basis, so anyone can submit a request for assistance on our website at opioidresponsenetwork.org. Today, we are starting the first in a series of three training sessions with Boston Children's Hospital, who is our partner agency. Today, we will be talking about substance use disorder, kind of an overview introductory session, and then we will follow it up with a training on addiction in the brain and medications for opioid use disorder, specifically for youth and young adults. We will be recording this session, or it is recording currently, so just note that. And it will be available for viewing within about a week or two. If you have questions, we will have time at the end for that. And Rachel, I just wanted to check with you. Is there anything you wanted to say or add before we dive in? No, that's great, Emily. The one thing I'll mention to the Cocoon House team is that if you are watching it with someone else, please message me and let me know so that I can make sure that you get credit for attending the training. So, because only one of your names will show up in the participant list. So, just let me know. And thank you so much, Emily and Carlos, for being here. We're really looking forward to this series and have been wanting this kind of training for a long time. So, thank you. Of course. All right, well, I will go ahead now and introduce our presenter for today, Dr. Carlos Llanes. He is a fellow with, like I said, our ORN partner, Boston Children's Hospital, and he is originally from Laredo, Texas. He earned a degree in biology from Baylor University. He then moved to Lubbock, Texas, where he obtained a medical degree from Texas Tech University Health Sciences Center. He completed his family medicine residency training at Stova Health in Danville, Virginia. In his free time, Dr. Llanes enjoys being active outdoors. He enjoys activities such as hiking, running, and gardening. All right, with gratitude, I will now pass it over to you, Dr. Llanes. Thank you, Emily, for that wonderful introduction, and thank you for hosting us. I mean, it's a pleasure, really. So, with that, you know, feel free to ask questions in the chat, and we'll have time to get to those at the end. Thank you. Let's jump in. Today, we're going to be talking about Substance Use 101. I just want to disclose I have no financial conflicts of interest with any of this material in this presentation. I'm employed by Boston Children's Hospital. So, today, we will define addiction, substance use disorders, go over some of the epidemiology associated with those in adults and adolescents, review some of the short-term and long-term effects, and go over some of the signs and symptoms of intoxication, toxicity, withdrawal of a few different substances, and then highlight the role of prevention in adolescents with substance use or substance use disorders. So, you know, I like to talk about the language, and I know you all acknowledge that as well. So, you know, making sure this is a person-centered language when we talk about this stuff. You know, they are not their disease, and it's not a moral failing. So, just always want to keep that in mind. So, what is a substance use disorder? So, we use the DSM-5, or Diagnostic Statistical Manual of Mental Disorders. It's the fifth edition. It came out in 2013. So, a substance use disorder entails any substance that has to do with four different domains and different symptoms within those domains. So, impaired control, physical dependence, social problems, and risky use. So, you can see there the symptoms associated with each of those domains. So, you know, you're losing time at work, or you're spending a lot of time doing it. Your body can become physically dependent and manifest itself with tolerance and withdrawal, tolerance being you have to use the same amount of the substance to get a similar effect. Social problems, you're neglecting your roles, and risky use, and you're putting your life or others at risk or your mental health at risk while you're using. And really, you know, this is a substance use disorder diagnosis. You know, addiction itself, the hallmark and definition of it is a loss of control over behavior. So, you can have a substance use disorder without having necessarily addiction, and the other way around as well. So, it's a little nitty-gritty, but in general, you know, we make the diagnosis of a substance use disorder, and diagnosis of addiction is not necessarily used. And so, when we talk about, you know, different substances, there's everything under the sun. There's the big three we talk about in adolescence, which is alcohol, tobacco, slash nicotine, and cannabis. But there are many different substances, and obviously stimulants, and hallucinogens, opioids, sedatives, inhalants. And some of these are the street names for these different substances. And then, you know, with smartphones being a thing, kids are very descriptive with emojis. So, these are different emojis that they use to, you know, signal for different substances. And so, I think it's always smart to keep those in mind, because kids, you know, use all types of words to describe different things. So, keeping up with them, I think, is important. Now, when we talk about, you know, substances, we're really worried about overdose deaths, obviously. And this is the information from 1999 to 2022. And you can see there, you know, the biggest contributor is fentanyl. You know, we talk about, you know, three different waves of the opioid epidemic, with the most recent being about 2017. You can see a big spike there, and then 2019. And that's the largest contributor to the overdose deaths. You also see it pretty largely with cocaine and methamphetamine. And then, whenever you have overdose with opioids, it's commonly mixed in with, you know, benzodiazepines or another non-prescribed medications. So, that's for all ages, by the way, in America. So, who's most affected? You know, you can see here, you know, people of color are most affected in general. And this data has been trended over the years, and this is just the last two years. So, it's important to be mindful of that and, you know, practice, you know, equity when we're seeing people of all ethnicities. Now, getting down to teens or adolescents, you can see in the red is overall, in the blue dotted line is, you know, males or boys, and in the purple dotted line is girls. And this is how they perceive themselves. But you can see the death rate per 100,000 is right around almost two there, when we talk about teens. And this is tracked every quartile. This is from 2015 to 2022. I'm going to talk about substance use disorders. You know, the younger you use, the more likely you are to develop a substance use disorder. So, this is showing on the left, alcohol with people who started at 13 or younger, they were more, they were 47% chance to develop a substance use disorder. Later on in life, as opposed to someone who started using at 20, they're down at 11%. Same thing with cannabis, started at a younger age, you're more likely to develop it. 75% of Americans with a substance use disorder started at the age or younger of 17 years old. So, it really is, you know, an adolescent disease. And, you know, it's really important that we prevent this substance use until, if at all, until a later age, really. So, this is the percentage of 12th graders, and this data is from 2023, monitoring the future study, which has a nationally representative sample. They have about 50,000 students in about 200 schools across the nation. It's conducted every year. So, you can see, again, you know, the big three being alcohol, cannabis, and nicotine. You know, over 50% of seniors have used any alcohol in their lifetime, and about a quarter have used in the past 30 days. When we talk about, you know, being drunk or inebriated, it's about a third, about 12.5%. And, you know, vaping, nicotine, and using cannabis are about a third lifetime use, about 15 to 20% in the past 30 days. And then there are less common substances, you know, hallucinogens, inhalants, amphetamines, other opioid pain medications, cocaine. And those are not nearly as common, but they hold their own risks. So, what is associated with substance use during adolescence? You know, they're most prone to injuries, whether they're intentional or unintentional, you know, with overdoses, car accidents, stuff of that nature, emergency room visits, school, you know, poor academic performance, violence, arrests, incarceration, which, you know, saves a view for life, sexual assaults, unprotected intercourse, and sexually transmitting infections, such as HIV. Linked to many different things, it's important we address them. So, why are adolescents particularly primed to use substances? So, one of my colleagues will get to a lot of those details next week. So, I'm happy you all will be able to hear about that. But it has to do with brain development. And anywhere from 15 to 21 is the final stage of brain development, where the what's called primary executive functioning and inhibition starts to develop. In kids with ADHD, that development can go up until 30, 35. And so, they're really just primed, because they don't have that inhibitory controlled development quite yet. So, we're going to talk about the big three, first of all, and then we'll get into some of the less common substances and opioids as well. So, we talk about alcohol, you know, we have beer, wine, liquor, you know, seltzers. And some, you know, a lot of these seltzers nowadays are marketed, I think, towards younger people and kids. They're very colorful, they look like energy drinks. And so, it's, it can be very persuading. And so, we look at, again, like the past month use in the new 23, 2023 Modern Future Study, we see that over the past five years, it's actually decreased steadily, but still remaining about 25% in the past month, and then they've been drunk in their lifetime, you know, also steadily decreasing, but still a considerable amount of 12th graders, 10th graders, and eighth graders. In particular, the, you know, binge drinking from 2000, 2024 has fallen from 30% to 9% in seniors, binge drinking episode being more than five drinks in one session. So, it continues to fall, but it's still fairly prevalent. So, this is, again, showing that trend, it's been falling for a while. But, you know, anyone who uses is in themselves at a higher disposition, you know, predisposition for developing alcohol use disorder. You know, I think we, a lot of us know the signs and symptoms of, you know, alcohol intoxication. Adolescents are less, one of the difference being adolescents are less sensitive to sedative effects of alcohol. And they saw this in a rat study, after the same amount of alcohol, instead of being sedated, they were more activated. So, over time, you know, with mild impairment, you get this learning speech, impaired coordination. As you increasingly become more impaired, you have more increased aggression, poor memory, and as it continues, you have judgment decision-making, are just impaired, you can have vomiting, your memory can black out because it affects the hippocampus, and then you can eventually have loss of consciousness and be at risk of, you know, life-threatening alcohol overdose, actually. So this is a progressive, and this diagram here shows it as a BAC percentage, with the legal limit being, you know, a legal limit for driving being 0.08. So you can still have some mild impairment before that, even. And I mean, so that's pretty much alcohol. I wanted to get really into the other two of the big three. So cannabis, you know, now comes in many forms and has very many names. You know, there's obviously the bud or the flower, there's edibles, gummies, chocolates. You have your concentrates or vapes or cartridges or pens, which comes in all shapes and sizes. Again, you have your pre-rolls, your sheesh, which is a powder on the bottom left, and again, the concentrate on the bottom right, which is sometimes called wax. And then all your historic names. You know, the way cannabis can be consumed, there is many different methods. So you have ingestion, oral consumption, you have inhalation, you have the vaporization, and then you have the dabbing. With the concentrates, you do have a higher potency and concentration of THC. So you tend to have more psychoactive properties and signs and symptoms. So again, similar to alcohol, cannabis has taken this further and, you know, really markets to children. You know, these look like candies, you know, Pop-Tart chocolates, like fountain drinks. And so these are like, it's not like nicotine where it's, you know, multi-billion dollar industries, but it's a growing industry and they have a very targeted audience. So when we look at the daily cannabis use in 8th, 10th, and 12th graders, you see in 12th graders, it's almost 7%, but you also see that past month use has decreased over time. But in past month, it's almost 20% in 2023. So the, you know, effects reported and that we've seen with cannabis, you have euphoria, decreased anxiety, increased sociability, increased appetite, and decreased pain in some cases. And this is why you will see a lot of adolescents say, when I turn 18, I'm going to get my medical marijuana card and tell the doctor I have chronic pain. But some of the negative effects you can have increased anxiety, actually paranoia, this impaired short-term memory, which makes it difficult to learn or retain information, which can last for up to three days for short-term new users. You have that poor attention, distorted spatial perception, which can have an effect on driving. And it's been studied that cannabis use affects driving, like spatial perception and reaction times up to three days later as well. And many of these other effects also have a hangover effect that leak into the next day. So when we talk about the physiological signs and symptoms of cannabis use, they vary. So in inhalation, it presents about, you know, after a few minutes, about 30 minutes, and after ingestion of an edible or a concentrate, you'll see it a little bit later, one to six hours. But you see this bilateral conjunctival injection or red eyes, you have a dry mouth or dry throat. So you can see them drinking a lot more water. And you can have increased heart rate and blood pressure. So like I was saying before, you know, potency of cannabis has grown over time. And with these concentrates, you have more adverse effects. So you can have more paranoia, anxiety, panic attacks, hallucinations, agitation. And as you see on the right, the number of young people showing up to the emergency room for cannabis-related reasons has sharply risen in the recent years. With, you know, 2006, about 20 years ago, that 12 and a half percent, and now we're about 50, or not 12 and a half percent, 12 out of every 100,000, every 10,000, about 50 now, every 10,000. So you're really putting these kids in danger when they use more concentrated versions. And it can go as far as, when you have toxicity, you can go into coma, respiratory depression, and require intubations, end up in ICU, and possibly even seizures as well. We can talk about the long-term effects. Like I've been harping on the much higher risk of a substance use disorder or addiction. When you use any substance during adolescence, it affects your brain development. So we talked about that primary executive functioning inhibitory control with people from 15 to 21, up to 30, alters that brain development for the rest of their lives. And you'll learn a little bit more about that later. They have poor academic outcomes, and it's been studied with people who are chronic users that even have a lower IQ average. It's about two to five points. It's, not huge, but it is significant. People who use cannabis regularly during their adolescence have been found to have an increased risk of psychosis, schizophrenia, anxiety, and depression in adulthood, anywhere from two to five times greater. And so these are all the neurological long-term effects. You also have the respiratory effects of chronic bronchitis. So that's what kids think of when they smoke cannabis or smoke anything. And so people who are chronic users, like we said, we can develop this physical dependence, and it presents itself as withdrawal. So cannabis withdrawal is kind of the opposite of intoxication. So instead of having that euphoric or decreased anxiety, you can have the restlessness and anxiety, increased irritability and agitation, difficulty sleeping, decreased appetite, and subsequently weight loss and night sweats. And, you know, cannabis withdrawal can be, I think, a little insidious. It can last up to a month in some cases, and it can really present itself delayed as well. So, you know, stop one day. Sometimes withdrawal symptoms don't really present until, you know, second or third week. So it can be difficult for kids to link those symptoms to the, you know, cessation of cannabis use. And so this is a graph that shows the use over the years, the availability of cannabis, and the perceived risk. So I think, you know, largely in media, cannabis is perceived as, you know, a natural, you know, plant. It's not as addictive. It's not as harmful. And you can see that in that blue line in the middle where that perceived risk has decreased significantly over the years. This perceived availability has remained, you know, pretty steadily high. And then you saw a big drop in 2018. And since legalization in many states, it's become more widely available. You can see that little increase there as well. As far as use, you know, back in the 70s and 80s, it was much higher at, you know, 38%. And has since leveled off in the early 2000s to about 26%, 27%. So it's become more widely available. It's perceived to be not as harmful. And the use has been, you know, steady over the past 20 years. The next of the big three we talked about is nicotine. You know, it used to be we only talked about, you know, tobacco being cigarettes, cigars, hookah, shisha, which is that third from the left on the bottom. But now we have oral formulations being brand names like Zins, or you also have chewing tobacco. Obviously, it's been around for a while. But you have vapes as well, which can come in any shape or form. When they first came out, they looked like a cigarette, you know, on the very left. And since then, they've changed their shape a lot looking like pens, looking boxes. This one here on the top right, looks like an inhaler. On the bottom right, looks like ChapStick. So it can be very deceiving. And, you know, nicotine has been around for ages. And so the funding around nicotine, you know, although vapes have been popularized, a lot of those companies are being bought out by older tobacco companies. So their marketing has also obviously been tailored to young people. I mean, all these colors, all these, you know, cool young people using, smiling, looking energetic. So it's like, how do kids stand a chance, you know, against all of this? It's pretty remarkable. So we use, we talk about daily nicotine vaping, 12th graders about 6%. And when we look at the past month, use has been decreasing steadily from 2019, with 12th graders being about 17%. You know, when we talk about nicotine, and, you know, we used to say cannabis, you know, was a gateway drug. We know that any use of any substance leads to an increased risk of using another substance. So adolescents who do use a nicotine vape, in particular, are almost six times more likely to use alcohol, more than six times more likely to use cannabis, and three times more likely to use, you know, other illicit substances. So nicotine in the short term versus withdrawal, when we think of intoxication, substance has, it presents with symptoms and withdrawal is usually the opposite. So with intoxication of nicotine, you can have alertness, so increased focus. And that's the reason a lot of kids say they use now the reduced appetite, we can have the increased heart rate, palpitations being feel your heart rate. And these, you know, occur within seconds. When someone develops a physical dependency, they can have nicotine withdrawal. So withdrawal can occur, you know, here it says four to 24 hours. As vapes have become more concentrated, nicotine become more concentrated, this withdrawal manifests much quicker, and be anywhere from an hour as soon as last use. This is why kids use so frequently a lot of the times. So nicotine withdrawal symptoms include headaches, anxiety, difficulty concentrating, restlessness, hunger, sweating, the tremulousness. And these also, you know, last up to a month as well. But they peak early in the first week. When we talk about nicotine vaping, you know, we have the acute harms, you know, associated with inhalation, the increased temperature to vaporize a liquid into a gas, or not a gas, a particulate. So you can have burn injuries around the mouth. You know, some kids have had burn injuries while they have a vape in their pocket. And so then, you know, heats up and explodes and you can have burns on your thighs or hands. The long-term effects of nicotine vaping, again, has a long-term effect on brain development, just like any other substance, has those pulmonary and cardiovascular risks. So you're increased risk of asthma, COPD, cardiovascular disease, atherosclerosis, and also puts you at higher risk of cancers, lung cancer being the main one. So it's acute and long-term. But we also have a subacute effect as well. I don't know if you've heard of EVALI. It's an e-cigarette or vaping-associated lung injury. So this happens when not just adolescents, but anyone who previously healthy uses a concentrate that needs to be heated up in the past 90 days. And these vapors, they settle in your lungs and they can cause, you know, opacities or infiltrates that just sit there and they disrupt the lung function. So people will have, you know, cough, exercise intolerance, shortness of breath. And they, you know, someone might think they're infectious, you know, have, you know, COVID or the flu. And really, it's this vaping-associated lung injury. And almost all the time, 85% of the time, about respiratory symptoms, about three-fourths times those constitutional symptoms of fever, weight loss, chills, just not feeling good. And about almost two-thirds of the time you have these GI side effects, abdominal pain, nausea, vomiting, and diarrhea. So when we talk about toxicity with nicotine, you know, most kids describe it on, you know, initiation of use or, you know, taking what's called a tea break or a tolerance break and returning to it. But these nicotine toxicity symptoms can manifest as abdominal pain, dizziness, headaches, and decreased concentration. So, and different nicotine vapes and different brands have different concentrations of nicotine, so it's hard to pin down, you know, how much nicotine is in a concentrate sometimes. I'm going to lightly touch on stimulants and the effects that they have, being cocaine, methamphetamine, other amphetamines, like non-prescribed medications, Adderall, Ritalin. And these, you know, really, they're stimulants, so they stimulate your body. You have that euphoric feeling, your pupils become dilated, you can have increased heart rate, increased blood pressure, which can lead to anxiety, panic attacks, and tremor. You have this diaphoresis as well. And, you know, cocaine can come into powder, methamphetamine can be powder as well when it's broken down. You know, another stimulant we see is MDMA, which can look like a sticker, pretty much, or a tab, can look like a piece of plastic, and look like pressed pills, tablets. So, you know, stimulants and hallucinogens, which I'll hit on next, can really present in many ways. So, hallucinogens being LSD or acid, psilocybin, magic mushrooms, DMT is an older formulation, not as common these days, but psilocybin and LSD definitely being more prominent these days. So, very similar signs of intoxication, with the exception of additional psychoactive effects, so hallucinations, disorientation, you know, GI side effects as well, nausea, vomiting, and hyperthermia as well. This particular with, you know, hallucinogens, people talk about having a bad trip, where the anxiety increases, they have fearful hallucinations, visual hallucinations, auditory hallucinations, leading to panic attacks, which a lot of times lead to more emergency department visits. You know, one that we don't see too often are inhalants, but because we don't see it too often, I don't think it's taught very often either. I just wanted to hit on this briefly. So, inhalants are anything that can be inhaled, it's everyday household items. So, air fresheners, spray deodorant, cleaning sprays, you can hear the term whippets sometimes, a whipped cream, when they inhale those, fast drying glue, paint thinner, nail polish. And inhalants, they take an effect within seconds, and their effects last minutes. And so, you know, they can have a euphoric feeling, they have some dizziness, loss of consciousness, slurred speech, loss of coordination, and because of the effect only lasting a few minutes, a lot of adolescents use repeatedly within a few minutes, and inhalants can cause increased heart rate or irregular heart rates, arrhythmias, to the point where it can cause a syndrome called sudden sniffing death syndrome, which is a toxicity of inhalants. So, inhalants can be very deadly very quickly. I'm getting to, you know, the opioid epidemic and, you know, most, you know, one of the most lethal substances, opioids, and talking about opioids, this is a total number of deaths from 1999 to 2022, being at 81,000 now, and continues to climb, and to just, you know, it's not decreasing by any means. Now, where do people get opioids from? You know, the large majority is from a friend or relative, and it's usually given. And so, these can be leftover medications, you know, from a grandmother who had chronic pain, or leftover medications from a prior surgery, so it's more than half of the time. A little bit more than a third of the time, it's a prescription from a doctor, from one doctor, and, you know, that percentage used to be a lot higher when pharmaceutical companies used to push these and minimize the addictive effect of opioids in the early 2000s, so that percentage has slowly decreased, fortunately. We can talk about opioid intoxication, you know, as opposed to stimulants where you got to dilated pupils in opioids, it's pinpoint pupils. It also causes, you know, snoring, you can have what's called head bobbing or head nodding, so when someone just bent over like that man in that picture, they could be sitting or standing, but they're not necessarily falling a lot of the time. They become very somnolent, shallow breathing, decreased respiratory rate. You can have what's called cyanosis, which is just decreased oxygenation in the mouth, you usually see it around the lips and in fingertips as well. This is intoxication. When we talk about opioid withdrawal, it's gonna be the opposite, so you see a dilated pupil, you see more yawning, you see nausea, vomiting, you can see what's called pyloreaction or goose flesh skin, so the hairs on their skin will, you know, be erected. You can have hyperreflexia and many like vital signs changes as well, with high blood pressure, high heart rate, and higher temperature as well. So, you know, we talk about opioids a lot and, you know, the use of heroin has decreased over time, but, you know, fentanyl has picked up dramatically and it's the reason it matters is because it's a lot more potent than anything we've had before and it's a lot cheaper than anything we have before. It's also contaminated a lot of other supplies. It's been found in, nowadays it's about a quarter to a third of cocaine has been contaminated with fentanyl. It's much cheaper to make, so you can have a very low dose and overdose very quickly because of the respiratory depression and death, eventually. So, fentanyl, you know, when we talk about opioids, yeah, there's heroin which can be used IV. There's also like fake or reproduced pills which are pressed and they're made to look like real pills. So, oxycodone here and they also call them 30s or oxys. You see the one on the left and it's printed with the M and the 30 and then the one on the right, which is fake. It's not oxycodone or it might have a little bit, but mostly fentanyl. And then they come in many shapes and colors, so it can look like art candy. Very appetizing to kids. So, again, always marketing to a certain demographic, you know, population. So, like I was saying, it's very lethal. Any, you know, substance that has been found has been almost a lethal dose of fentanyl. It's been confirmed in cannabis in Connecticut. It's been confirmed in cocaine as well. When we talk about adolescence, we saw again at the very beginning with adults, it's the same thing with adolescence. Fentanyl is responsible for, you know, almost 85% of deaths in adolescence and these deaths nearly tripled in two years. Nearly a quarter of these deaths were counterfeit pills that maybe the kids thought were real because they look so similar. And these are some of the other percentages responsible for overdose deaths. So, you see the fentanyl being the largest contributor besides, you know, any opioids, counterfeit pills, and then methamphetamine, cocaine, and benzodiazepines, all of which can be counterfeited, pressed, powdered, and can contain fentanyl as well. So, when we talk about harm reduction strategies, with a lot of our patients, we talk about fentanyl test strips. It's very low cost and, you know, if they're going to continue using, and that is their choice, their decision, we give them fentanyl test strips just to see if their supply is contaminated. When talking about opioid overdose, we do have a rescue medication, Narcan or naloxone. And so, the signs of opioid overdose are very similar to intoxication, just being the extreme version. So, it might be head bobbing, to head nodding, to somnolence, to shallow breathing, to not breathing. You become unconscious, not responsible, or not responsive. You have those pinpoint pupils. You have cyanotic lips or hands. So, we have... So, common risks for opioid overdose, again, mixing of substances, which is very common, using multiple non-prescribed medications. So, it's almost any benzo overdose or benzodiazepine overdose is in combination with an opioid. Other things that can be a common risk is isolation. So, almost three-fourths of overdoses in kids happen when they're at home alone. So, we want to make sure everyone has Narcan and is widely available. It's available over-the-counter, can be prescribed, and that any other chronic medical illness, mental illness, can be very dangerous with opioid overdose. So, Narcan's FDA-approved. It does come in injectable form. The intranasal form is more popular, and it works within minutes. So, if a person's not responding, you administer the second dose, and it might take multiple administrations, and it's not always just one or two. And naloxone is a opioid reversal agent. So, being someone that's going to be an opioid overdose or toxicity, and you use an opioid reversal agent, it will kick that opioid off that receptor and can cause withdrawal symptoms. You know, if someone's found unconscious and naloxone is used, and it is not an opioid overdose, it has no effect on someone who hasn't used an opioid overdose, you know, opioids. So, it's a very safe medication. So, you know, where do we go from here with opioids? You know, it's not taught enough, so I'm glad, you know, your organization is doing some teaching on this. You know, most adolescents learn from it about school, but a great majority learn about it through the internet, friends, and even less so through parents or other media. And when we talk about, you know, drugs in general, we talk about the more lethal ones, opioids and heroin, also meth, ecstasy, LSD, but we don't teach a lot about, you know, cannabis being a substance of misuse or nicotine being a substance of misuse. So, again, this drug education, you know, 35% of these students think evidence-based education on substance use is more effective than a, you know, say no campaign. So, presenting kids with valid evidence-based information is always the best approach and, I mean, that's what they need is just education. It really starts in schools. When we talk about treatment, again, this is a lot of prevention work most of the time, but we also have what, you know, here the tip of the iceberg is a brief intervention. So, we have a lot of screening tools and when someone pops either for one of the screening tools, the most common being S2BI is for a question questionnaire, which has like a 95% sensitivity. And when someone has positive, you can use a brief intervention, which is taught to many PCPs. You also have the rest of the treatment regimen. It's the reason why we don't use the term medication-assisted treatment anymore, or therapy, because you can have effective treatment without cognitive behavioral therapy and things of that nature. And this is just a summary from Reddit. You know, the ones highlighted are many of the drugs we talked about today. And this is just a little chart. When you think someone may be intoxicated and you don't know what substance, you know, always look in their eyes, see if they're sweating, see if they feel hot, and they can kind of clue you in to what they might have used. But either way, when someone, you know, is unconscious, you're always going to call 9-1-1. So, and that's the end of my presentation. So, thank you guys. Do you all have any questions or comments? And like I said, you'll have another couple of presentations, particularly on the neurobiology of addiction next week. And then on more in depth on opioid use disorder, medications for opioid use disorder as well in this series. It looks like Wendy has a question. Go ahead, Wendy. Oh, didn't see that. Thank you. Yeah, I was wondering, I'm kind of involved in my son's middle school and I've seen a lot of like, it's called galaxy gas. It's nitrous oxide. Can you OD on that? What are like, is it addicting? What are the like the long term effects of galaxy gas? Yeah, so galaxy gas would be an inhalant. And you can definitely overdose from that, yes. Like I said, kids can get this euphoric feeling, this dizziness that they find pleasurable. And because this effect lasts only a few short minutes, they use repeatedly. And this repeated use can cause arrhythmias, so your heart will beat regularly and it can eventually stop. So this is a very lethal, galaxy gas is very lethal, yeah. Is it addicting like opioids and other drugs or like you use it a couple of times and it can be habit forming or like once you stop using it, like, I mean, obviously you crave the effects of it, but like, can you get addicted to it? You can, yeah. With repeated use? Yes, you can. The addictive potential is not as high, you know, the dopamine response or the dopamine response to a particular substance is varying with methamphetamine being the highest, with the highest addictive potential. But there is still a response with inhalants, yeah. So you can definitely still be addicted. We also have a question in the chat from Kate who asks, can you explain again why the term medically assisted treatment is not correct anymore? Yeah, so I'm just going to go back to the very beginning with language. The reason is because you can have, it's not medicines assisting the treatment, medicines can be the treatment as well, because not everyone who uses has, you know, a psychiatric disorder. Not everyone that uses needs therapy. So you can have effective therapy and reach absence just with medications. And so it would be incorrect to use the term medication assisted treatment. But it's used all the time. Yeah, it's used everywhere. And our third, Kate, the third of these trainings is specifically around that, and so I think we'll probably dive into that a little bit more during that training. Yeah, yeah, one of them is be exactly on medications for opioid use disorder, which is where that term is used. Any other questions from the Cocoon House folks on the call? This was a really good overview of what we're seeing. Are folks seeing things that weren't part of this that you have any questions about? Any use? Any other substances that I may have not mentioned? I know one we were seeing for a long time was triple C. Where does that fall in? I actually don't know what triple C is. Oh, and that might just be a local term. It was the cold congestion medication. Yeah, and blues are one that gets brought up a lot. Yeah, like cough medications, antihistamines, things like that. So those would be considered sedatives. So I have heard of Benadryl challenges on TikTok, and that can be addictive as well. And can possibly lead to psychosis and restore depression, leading to intubation as well. And so that can be very lethal as well. It's not as common either. We'll say it's usually used in combination with other things like benzodiazepines and inhalants. But good question. They're still around, and it's over-the-counter medications a lot of the time that kids can just take very easily. So if you find a kid with a box of Benadryl and they're not sick, I would probably confiscate that or ask a question. Because it can be very dangerous. I learned something. Thank you, triple C. In my understanding, Khalil, I see your comment about blues or blueys. Kate, is your comment to that that that's codeine? My understanding is that it's an opioid. It's just one of those three terms here. Yeah, no. Fentanyl is the primary component of blues to my understanding. It's another name for those pressed pills. Any last questions? I mean, if you have any and you don't remember them right now or can't think of any, you have two more lectures coming. Great. And if folks have any things that come up before the next one, it's helpful maybe to send Dr. Carlos that information ahead of time before the next training. So please send me any questions that come up, any areas you want more information on. And thank you so much. Really appreciate it. Of course. Thank you for having me. Have a good day, y'all. Dr. Yannis, are you able to send me the PowerPoint? Yes, I can. Yeah. OK, I don't know. Or you can send it to Kayla to send to me. I'm not sure if I have your email. OK. Yeah, I'll send it to Kayla and let her know to send it to you. Great. Thank you, everyone, so much for your time. I think we got done a bit early. So hopefully that's helpful to have an extra hour in your day. And like I said, the recording will be available in about a week or two. And you can along with the PowerPoint so you can look closely at that. But thank you so much for your time. And thank you, Dr. Yannis, for your time and the overview. We greatly appreciate it. I'll see you all soon. Take care.

Opioid Response Network

substance use disorders

Emily Mossberg

SAMHSA

Dr. Carlos Llanes

fentanyl

harm reduction

youth interventions

substance use prevention