There we go, I'm going to hit record to make sure we have this going forward. And again, we're joined today by Dr. Suzuki. So Dr. Suzuki is the Director of the Division of Addiction Psychiatry in the Department of Psychiatry at Brigham and Women's Hospital and an Associate Professor of Psychiatry at Harvard Medical School. He's been a consultation liaison psychiatrist in the Division of Medical Psychiatry at Brigham and Women's and serves as the Program Director for the Brigham and Women's Addiction Medicine Fellowship Program. Before we hand it over to Dr. Suzuki, I'll hand it over to Jenna for just a moment. Thank you so much. It's so nice to be here. I'm just going to ask Dr. Suzuki to bring up his slides and then I'll jump in and get started. So if you want to just go to the next slide. So an absolute pleasure to be here today. My name is Jenna Fold. I'm on here from the New England Region Opioid Response Network and we're partnering with PARI to provide this presentation today. The ORN is funded through a grant by the Substance Abuse and Mental Health Service Administration and we're led by the American Academy of Addiction Psychiatry. Next slide. So we do provide technical assistance to individuals, groups, and organizations and we cover all areas of opioid and stimulant use disorder. We cover prevention, treatment, recovery, and harm reduction and this is provided at absolutely no cost because it's covered through our SAMHSA grant. Next slide, please. If you have any more questions, I know this is really brief, please reach out to us in the future. You can see this is our contact information and we really just look forward to connecting with anybody. If you have any questions, concerns, we're always here to help. One last thing before I turn it over to Dr. Suzuki is at the end of this presentation, we will have a Q&A session and I will also be sharing a follow-up survey that we really appreciate for you to take part in. We really need everybody's feedback so that we can continue providing this education and training. So I will send those instructions over at the end. I will now turn it over to Dr. Suzuki. Thank you so much. Great. Thank you so much for the kind introductions and really nice to see everybody here. And so I'm just going to jump right in, like was mentioned, I'm a physician at the Brigham Women's Hospital and I'm an addiction psychiatrist. So basically everything I do is related to substance use disorder treatment and research and education. I have no conflicts of interest, financial conflicts of interest to report. So here's our outline. I'm really going to focus on talking about addiction as a chronic disease and some of the neurobiology around it and really cover some of the other relevant topics. I'll do my best to sort of stay on track. However, all the slides can be made available and if there's any questions people have, feel free to interrupt me at any point. And yeah, let's just jump right in. So I think this is no surprise to folks on this call here right now that we're still in the midst of an opioid crisis. This has been ongoing for several decades at this point and it's opioids, but also other drugs and alcohol as well. But even for opioids, we're still looking at over a hundred overdose deaths each day in this country. This crisis initially started with the overprescribing and the overuse of prescription opioids like Percocets and OxyContin that evolved to heroin. And then as people now know, it's now morphed into a fentanyl crisis all across the country. And Northeast actually was the epicenter of the fentanyl crisis and it really spread westward. And of course now people probably know that cocaine, methamphetamine and other things are actually increasing as well as alcohol, benzodiazepines, et cetera. So this drug crisis is a real tragedy that really continues today. And one of the real challenges that we face as treatment providers is this fact. This hasn't changed in about over a decade. And what this really represents is that this is a national survey that SAMHSA conducts each year of the general population. We're talking 40,000 face-to-face interviews that people, the government does each year. They ask a lot of questions, but one of the questions they ask is, do you have a substance use disorder? And if you do, did you get any treatment? And this has been true again for a long time. Of those people who have a substance use disorder, close to 20 million Americans, only about 8%, 7% report receiving any type of treatment in that given year. And there are many reasons for this, lack of access to care, can't afford it, don't know where to go, not interested. I mean, there's all kinds of reasons, but this is a pretty dismal situation because if you compare it to mental health conditions, let's say depression, actually about half of those who have a diagnosis will have received treatment. And if you compare that to physical illness, let's say hypertension, diabetes, the majority of people who have hypertension receive some type of treatment. The majority of people who have diabetes receive some type of treatment, but substance use is this one big exception across many chronic conditions, the majority do not. And there's many, again, many reasons, but the biggest reason is addiction treatment in this country has been largely fragmented away from general medical care. So it's not until recently that it would even occur to a person to seek help from a healthcare provider for their substance use. Not that long ago, that was not the case at all. 20 years ago, if somebody wanted help for their substance use, it would not occur to them to go see a doctor because they would have been told, well, we don't really do that here. We treat everything else, but that's for the AA meeting down the road or the detox center down the road, not us. We've come a long way from that, but we still have a long way to go. And one of the reasons why we feel very strongly that addiction should be treated within the healthcare system is that there's a clear recognition now that substance use disorders represent chronic illnesses. Up until very recently, it was conceptualized as an acute illness, like a pneumonia that you treat with antibiotics and you're cured. So people would go to a detox unit, get detoxed, and then you're cured. Why would you pick up drinking or use drugs again? You just went through detox. Why would you use it again? But we now understand, and I'll go through the neurobiology of this, but now we understand that it's a chronic illness, like obesity, diabetes, hypertension, where those illnesses cannot be cured. I try to exercise, eat well, and stay active, but if I lose weight, I'm not done, unfortunately. I wish I were done. I wish I never had to eat right and exercise again, but if I don't maintain that, I will gain weight or have the risk of becoming obese again. And so that's the hallmark of chronic illnesses is that you actually can't treat it, cure it. You can treat it, but you have to treat it over many years, oftentimes many, many years, because relapses are common, and oftentimes they're heavily influenced by our behaviors. And diet and exercise remain the two most important contributors to chronic illnesses. And for substance use, obviously, it's the ingestion of substances that contribute to that, and the risks never go away. I used to be a former smoker. I can never pick up a cigarette again like a non-smoker could, because my brain is different. And so for the rest of my life, I have to always be mindful that I can't just pick up a cigarette and expect that I can just put it down easily. As a former smoker, I know what would happen if I smoked again. It could easily lead to smoking a pack a day like I did at some point. Now compared to other common chronic illnesses, relapse rates are similar enough, meaning that if you look at things like diabetes or hypertension or asthma that require a chronic sort of effort to manage and maintain, addiction is sort of similar in that regard. It's not particularly that different. And so when we think about substance use disorders today, we think of the DSM, diagnostic criteria. And this is consistent across all the substances. So it could be opioids, alcohol, cocaine. They're actually the same. And there are four categories. Physical dependence, characterized by tolerance and withdrawal. But the other three actually are the most important ones. And what will be actually easier to remember is called the three Cs of addiction. Loss of control, cravings, and accumulating negative consequences. So just taking a substance does not mean you're addicted. It's when you begin to manifest these different elements is when we think of it as a behavioral syndrome that we call addiction. And what that also means is that if you're taking a Percocet because you had surgery, simply taking it doesn't mean you're addicted. I think that makes sense. But let's say you're taking it for chronic pain, you have to take it for a longer period of time, and you start to have withdrawal when you stop taking it. Again, the emergence of withdrawal or tolerance alone does not actually mean you're addicted. It's when you begin to manifest these other symptoms is when we start to call it addiction or a substance use disorder. And the way we think about this in terms of the neurobiology is that whenever you consume something pleasurable, there's a part of the brain that actually gets activated. And it's part of the brain that's deep inside. And it's actually called the ventral tegmental area or the VTA, which is in the deep brainstem. And neurons that project dopaminergic neurons, meaning that they release dopamine into what's called the nucleus accumbens. And it's when you consume, let's say, a piece of cake or have sex or eat something, you know, yummy, that's part of the brain gets activated and you experience pleasure. This is normal. This is how our brains were designed. This is how our species continue. This is how we survive. This is perfectly normal. If you, however, continue to engage in this very heavily in a sort of a more binge pattern, a normal reaction of the brain is to actually begin adapting to it, to begin tolerating to it. And so if you would eat the entire cake every single day, maybe, actually it would become less pleasurable over time because your brain is saying this is too much. That's actually a normal part of how your brain reacts to sort of keep things in balance. So what that means actually is that over time, let's say you use cocaine. Over time, if you keep using it, you actually experience less pleasure each time. And again, this is a normal part of the brain's response. If that's all that happened, addiction would never occur because after a period of time, it's just not that enjoyable anymore. You just stop using it. The behavior would extinguish. Unfortunately, that's not what happens. I mentioned dopamine earlier. The release of dopamine in the brain is a signal that something important is happening. It's giving a clue to the brain that this particular behavior, this particular reward must be important. So it's teaching the brain to pay attention. And so as you progress with, let's keep using the cocaine as the example, if you keep using it over time, it becomes less pleasurable. Because each time you use, dopamine is being released. It's teaching the brain that this particular drug or substance is important. And why this is a central part of addiction is that then when you take the cocaine away, the brain starts to say, well, wait a second, you've been teaching me this the whole time that this particular powder you've been storing in your nose is really important. Where is it? And the brain starts to crave it. And this craving for the drug becomes extremely powerful. And it's actually no different than when you're hungry. The whole point of the subjective experience of hunger is so that you know when to get up and go get food. Now, of course, it doesn't work perfectly there either. But at least theoretically, the idea is that if the brain is supposed to, you know, want, you know, is telling you, you need to go eat. And that is signaled by the hunger. And it's the same part of the brain that evokes this feeling, the brainstem, the deep part of the brain. So it's the same part of the brain that's telling the person, you should go get the stuff that you've been teaching me that is so important, whether that's cocaine, alcohol, opioids, sex, games, there could be a number of different behaviors for which the brain begins to, you know, want and crave and seek. And this craving can be so powerful that it's hard to resist. And in fact, that's by design. You know, at some point, when you're hungry, that hunger will actually, you know, get you to go look for food or thirst, right? It's no different that our brains were designed that way. But in a way, drugs can activate that part in a very powerful way, much more than the natural rewards, like, you know, like a lunch. That's pretty rewarding, but maybe not as powerful as methamphetamine or fentanyl. The other part, so what I've been talking about is, scientifically, it's called incentive salience. It's this idea that we're teaching the brain to want something, to seek it out, you know, when you're craving it, this is what you want. But there's also a flip side to addiction. When I talk about this, you know, wanting, generally, the brain is remembering, oh, yeah, that felt good. I really enjoyed that. And in fact, for all, you know, drugs, alcohol, people use because it made them feel good in some way, right? I liked how alcohol made me feel. I liked how fentanyl made me feel. There's actually a flip side to this, and it's this idea that people may choose to use drugs or continue to use drugs or alcohol, because not that it makes them feel good, but it takes away something bad. And so within the AA world, for example, hungry, angry, lonely, tired, or felt is actually a commonly sort of described term, because whenever you feel that, that's when your brain may choose the overlorn behavior to cope with it. So there are many ways you can cope with hunger, like have lunch. You know, if you're angry, you might go for a run or, you know, have a nice time with your family, right? So there are many ways in which we cope with stressors, with difficult emotions. But unfortunately, as, you know, as the brain starts to sort of seek out this reward that I've been talking about, under stress, the brain is much more likely to want that particular reward for behavior and not the natural rewards. Because again, the dopamine signal has taught the brain that this particular reward is really important. And that becomes a go-to target when somebody is under stress. In fact, the stress can be both positive or negative. You know, a positive stress could be, you know, a wedding, you know, or going to a New Year's party. That's stress in a different way than a negative stress. But any kind of stress can actually trigger this craving for the substance. And in fact, any kind of reminders, the brain is really, really good at connecting dots between the particular reward and triggers, you know. And so, and again, in the AA world, they talk about people, places, and things. Any body or any thing or anywhere that reminds you of that particular drug or alcohol or fentanyl, et cetera, is also going to trigger your brain to want it. I'm sure you know this with, that's why advertisements work, you know. You see a commercial for McDonald's, there's a part of your brain that's wanting it. And so, basically, the neurobiological addiction is this sort of push and pull of this wanting something that feels good and going towards that, and also moving away from something that we don't like. And both of them combined really perpetuate this particular behavior. And this actually, it can be demonstrated in neuroimaging and other images of the brain where these changes can persist for a long time. In fact, we believe that these changes may be somewhat permanent, meaning this is actually drug memories we're talking about, and the brain never forgets. Our brains actually were designed to generally not forget things, right? So traumatic memories, you can't just erase them. And that's true for drug memories as well. And so, again, the moving towards something we want and moving away from something we don't want, this is called the positive reinforcement and negative reinforcement. And addiction generally starts off initially with positive reinforcement. That tends to be the reason why we move towards a particular substance. And it can also be because, you know, it took away anxieties, or it took away depression, it took away stressors. Those could be a driver as well, but oftentimes for most people, it's the positive reinforcement that drives it. Over time, there's a tendency for the negative reinforcement to take over. And if you see on this graph, on the left side is early days of addiction or early days of substance use, it may be driven more by the fact that, ooh, you know, I drink because it makes me feel good. But over time, there's a tendency to end up in a place where drinking or using drugs, yes, it is pleasurable, but not that much more pleasurable than, you know, not a whole lot more than what it used to be, in fact, it's a lot less. But what it does more is it helps us to not feel awful. It helps us not to feel so depressed or anxious or stressed out. So the negative reinforcement can be the greater, you know, motivator over time. And it can get to a point where, pretty extreme where, people will say, you know, I shoot up heroin, but it doesn't really make me feel any good. I don't really feel any high from it, unless I use a lot of it. I just used to just feel normal. And it just seems from the outside, almost irrational. Why would you keep doing this thing that's destroying your life that you don't even benefit from much? You're telling me you don't even enjoy it that much. But again, it's really this taking away something bad and just feeling normal, because even a stronger driver and actually removing the cravings can actually become its own negative reinforcement. So over time, people report that the cravings can be so powerful, even though they don't like it, even if they don't enjoy it anymore, the desire for it, the wanting, the seeking, the craving can be so all-consuming, right? And this is the paradox of addiction in a way. Even beyond in the drug use phases, people can actually stop using, because this push towards it may not be as strong. So in a way, in the early course of this progression, people may feel like they can take it or leave it. So they don't feel the need to stop. And the negative consequence that I talked about earlier may not be as severe. But over time, the wanting of it is so powerful, and they're not able to stop it even if they wanted to, and their lives are sort of getting worsened by it. And that's the irony of addiction, is that early on, they could have stopped if they tried. But they may not have felt the need to do so, and the negative consequences weren't as bad. All right. So that's, of course, I'm simplifying things in a way. So this is actually how we conceptualize substance use disorders today and it's a chronic brain condition that does not go away just because you stop using. This you know the wanting and the craving can be all extremely powerful years if not decades later after you stop because the brain doesn't change automatically just because you stop using. All right so I'm going to pivot now to talking a little bit more about some of the specifics around treatment harm reduction and other things. For all substance use if there's if it's possible we conceptualize as a biopsychosocial you know illness and the treatment therefore you know targets all three levels in a way and if it's available you know medications are really effective in quieting down the cravings that I mentioned earlier. They're also really important in taking away withdrawal for opioids and alcohol for example if they can be really dangerous and particularly for alcohol can be life-threatening and so medications can be very helpful in that but also cravings. As I mentioned the cravings can often never completely go away but medications can really do a nice job of quieting that down and for we have really good medications to do that for opioids, tobacco, and alcohol. Unfortunately we don't have any good craving reduction medications for stimulants or cocaine for example. Counseling remains very very important. Recovery is distinguished from abstinence and recovery is something that people have to learn and understand how to avoid risky situations. How do I manage cravings when they do emerge? That's one of the things that people have to learn you know just because you stopped using doesn't mean your brain is back to where it was before you started using. The brain is going to crave for that if it's triggered or if it's stressed if it's hungry, angry, lonely, you know tired and it's learning how to manage that so you don't relapse every time you're triggered. That would be a you know that would be a difficult way to live and so learning how to manage risky situations and preventing relapse and then also you know treating any concurrent comorbid mental illness. And then finally creating this sort of recovery supportive environment is really important and it can be a challenge for a lot of patients to create a whole new network of people who are sober oriented or you know more supportive of their recovery. You know good example is you know you can't hang out at the bar if you're trying to be sober that's it that's a no-brainer but it's this idea that you have to create a social and physical environment that's conducive to recovery and all these things are really important and it really depends on each person you know which one to prioritize or which one to focus on but that's what we target during treatment. For opioid use disorder specifically we have three FDA approved medications currently available. Suboxone is your go-to that's the most widely available. It is a first line medication that we offer to patients and it has some of the most robust evidence base in reducing overdose mortality, all cause of mortality, reduces cravings, reduces withdrawal, it helps people function better. It's one of the most effective medications that we have available. It doesn't solve everything but just the fact that it can quiet down the cravings can be really really powerful. Methadone also is actually a very effective treatment but less accessible, more onerous regulations that govern it. It is more risky so that's the reason why there are greater restrictions around it but it's still a very very robust medication that reduces overdose and improves outcomes. And finally Vivitrol which is an antagonist. It's an opioid antagonist so it's a blocker. For opioid use disorder it's actually not as effective. It can be an option but we use it far more for alcohol. For opioid use disorder really buprenorphine or Suboxone, methadone are going to be your first line choices. And very quickly talking about how buprenorphine works is that buprenorphine and methadone are both opioids. So chemically they're similar to oxycodone you know which is Percocet or heroin or fentanyl. And so we think about what happens in the brain itself, we actually have our own naturally occurring opioids. They're called endorphins and the brain's own morphine in a way. And so when the brain is activated to release the endorphin it attaches to the opioid receptors and that leads to predictable responses. And this is true whatever the you know the chemical is endorphin, morphine, buprenorphine, it's actually the same but the difference in different in degrees but the effects are very much the same. And so same thing in heroin. If you take heroin it'll actually cause these things and of course the most concerning thing is going to be the slow breathing part. That's how people overdose from opioids. If you take enough of it it'll slow the breathing down sufficiently that you don't get enough oxygen to your brain and then you die. Now buprenorphine or suboxone actually does the same. However it's called a partial agonist. So it activates the opioid receptors only partially. So you could pile on the buprenorphine or suboxone in the brain receptors it's not going to slow the breathing to the point where you stop breathing. It may slow it down a little bit but only does partially. So actually you can't overdose just on buprenorphine. Typically you have to add it with something you know like a benzodiazepine or alcohol but unlike heroin or fentanyl it can easily overdose on its own. You really can't with buprenorphine. Now the other really important thing about buprenorphine, this is true for methadone, it's true for Vivitrol as well. If you're taking buprenorphine, buprenorphine attaches to the receptor very very very tightly. And what that means is heroin cannot attach to that receptor. Buprenorphine acts as a blocker. So if somebody's taking buprenorphine and they use heroin or fentanyl they're not going to feel the high. Now this depends on how much buprenorphine you're taking. You have to take enough. In the early days of buprenorphine I remember patients would would be skeptical of this but then of course they try. They come back and say you were right I just wasted 40 dollars I'm not going to do that again because I didn't get high from it at all. So these two reasons, it really takes away the cravings because it provides some of the opioid effects but it also acts as a blocker. That's why buprenorphine is extremely helpful. Now a common sort of complaint or concern is that buprenorphine is just replacing one addiction for the other. And I can understand that concern because it is an opioid. It's a super methadone as well. It's replacing one addiction for the other. However if you look at the three C's that I talked about earlier you see that the situation is very different. If somebody is using heroin or fentanyl they can't control it. That's the whole reason why they come to treatment or they seek some help for it because they're not able to control it. They have strong cravings like I mentioned earlier and their lives are getting worse. So they meet the criteria for substance use disorder if you look at the three C's. On buprenorphine or methadone or other treatment options that we provide patients actually can control their buprenorphine use. Now not every single patient can but the vast majority do. We provide a prescription. We say take two pills a day. They take two pills a day. I mentioned earlier the partial agonist effect. It actually because you know I said that that limits how much it slows down the breathing. It actually same thing applies to how much it affects how much euphoria you feel from it. In fact it's very limited. And so patients you know there's no reason to take more than two or three. For example unlike heroin or fentanyl you can keep taking more and more and more. So for the most part and this is the vast majority of patients they're able to take buprenorphine the way it's prescribed and they can control it. And studies after studies have demonstrated that when you're on treatment your cravings go down. Unlike when people are using heroin or fentanyl their cravings go up. People generally don't crave for buprenorphine the way they do for heroin or fentanyl. And then finally when people are in treatment their lives get better. They're just there's simply no you know there's there's no comparison. So is it an opioid? Buprenorphine or methadone? Yeah absolutely. But when you apply the three C's you begin to see pretty clearly that it's not replacing one addiction for the other. It's replacing one opioid for another. But the pharmacology is completely different and this is why these treatments do work. Now as I mentioned earlier counseling is an important part of this treatment as well. We don't ignore it. Although the way we conceptualize it today is that we offer it for anybody who's willing to take it you know to to accept it to engage in it. We think it's great but we don't withhold medications for those who don't want counseling. We used to. There was a time that that's how we operated. But we've come to realize that that actually doesn't work. Because if you force counseling on people they'll actually forego medication treatment. Which is the exact opposite of what we do. So we offer counseling wherever possible. We think it's important. But we don't make it a mandatory part of buprenorphine treatment because buprenorphine alone has a huge impact on reducing overdose mortality. There are all kinds of evidence-based you know therapies currently available. And you know hopefully you know most of our patients have access to them. As I mentioned earlier creating a recovery-oriented you know environment is critically important. And so creating a sober network is also really important. AA and other peer support services as a good example of that to really promote you know abstinence-based treatment or you know promoting the recovery-oriented activities you know etc. All right I just want to pivot now to talking briefly about harm reduction. Sometimes harm reduction is sort of seen as a sort of bad word or that it's in you know in contrast to the abstinence-only model. I really find that to be problematic. Harm reduction is part of everything that we do in healthcare. It's not unique to substance use. But when it comes to substance use it's often conceptualized as a way to understand that you know it would be nice to remove drug use and alcohol use altogether for patients who want help. Yeah that would be nice. But the reality is many many patients may not want to stop completely or they can't even if they try. So this is our understanding that for those individuals we should try our best to reduce the harm associated with that particular behavior. And this is many many examples in public health. Seatbelts when driving. You could argue that why do we need seatbelts? If you just drive carefully you don't need seatbelts. But we know accidents can happen. The fact that you're driving means you're putting yourself at risk for accidents. Therefore seatbelts mitigate those risks. You could eliminate the risks of car accidents if you never drove. But that is not realistic. Helmets when riding a bicycle. The same idea. Bars for alcohol. I think this is a good example of a public health initiative where we understood that people are going to drink alcohol. You know we can try to eliminate it. We tried as we all know. There are certain countries that try still to this day. But people are still going to consume alcohol. If that's the case wouldn't it be nice to offer a place where you get a safe supply? Where it's not some random moonshine? You know in somebody's backyard? Regulated places and price control and there's some oversight and accountability. People don't drink alcohol because there are bars. There are bars because people drink. And again this applies to so many other behaviors. Insulin for diabetes. Insulin does not treat the underlying cause of diabetes. You could argue insulin is colluding with people who engage in poor lifestyle choices. If they just lost weight, ate better, stopped smoking, you don't need insulin. But the reality is despite trying, despite being motivated, people still will be harmed from their high blood sugars and the effects of diabetes. Therefore insulin reduces harm. Same thing about medications for you know blood pressure. You could just exercise, eat better, stop smoking. You don't need to be on these medications. We're just you know colluding with your poor behavior. But I think we could all agree that despite trying it's actually hard to control blood sugar and blood pressure because it's hard to eliminate all the risk factors related to those conditions. Same thing can be said about buprenorphine. Buprenorphine has its own risks on its own. I could mention earlier it is an opioid. It can cause physical dependence and rarely but it does happen. Some patients will misuse them and people divert them and that there's a thriving black market for it. There are harms associated with it. There's no question about it. But the benefits that people gain from it just simply outweigh the risks by far. It really really reduces overdose mortality by a lot. In fact if you look at all the individuals who overdose from opioids, very few are found with buprenorphine in their system. And that's another confirmation that buprenorphine itself is very very protective. And in a way you know we've come a long way in thinking about the way we treat addiction is that there was a time where we understood that if they didn't stop drinking, treatment failed. And up until recently many of us sort of had that conceptualization. If somebody came to treatment for alcohol let's say and they continue to drink, we might say they failed treatment. But let's say they went from 12 beers a day down to two. That's a huge success. Same thing. Somebody you know hemoglobin A1c of 12% now it's down to eight. It's not perfect but they're doing a whole lot better. Somebody who's you know BMI of 40 now with treatment it's down to 30. They're doing a whole lot better. We should celebrate that. And for some reason for substance use we've had a harder time accepting that concept. Of course you know if somebody wants to be sober we should support that and encourage that and you know help them do that. But we all know like because of the neurobiology I talked about despite being motivated it's actually not that easy. All right. And harm reduction includes abstinence too. So this idea that it's either or is a sort of a you know I think a misguided conceptualization. We should always you know strive for harm reduction and support abstinence where appropriate. All right. So in a few minutes I just want to cover these other topics very quickly. The idea of trauma-informed care it comes from the recognition that so many individuals in our society have experienced early childhood you know adversities whether it's physical assault, sexual assault, neglect or other sort of stressors that are occurring at home. It's fairly well documented at this point. The more sort of ACE or adverse childhood experiences that you have in early childhood it dramatically increases later life health conditions. Diabetes, hypertension, even cancer, depression, obviously PTSD, substance use, they all increase with more adversity people experience. And so this is an understanding that you know many of us you know have this you know in us that we're you know traumatic you know experiences in the past. And people who are traumatized whether it's in childhood or in adulthood there's a tendency to react to stressors in a fight-or-flight response and it's activating sort of the adrenaline system and people can tend to overreact. But because people overreact and they people tend to shut down because they don't want to overreact and so create this really you know challenging situation. The point here just to say is that we want to we want to do our best to be aware of it and to avoid unintentionally re-traumatizing our patients because if we're not aware the people come with this you know this background. And medical treatment oftentimes can actually be traumatic in that way. I work a lot in the hospital system patients with severe you know medical illnesses and severe medical illnesses can be traumatic on its own. If you have a heart attack that can be a traumatic experience and so severe medical illnesses also can contribute to that. So in the hospital setting we try to be very very aware and try to incorporate trauma-informed approaches and the core principles really is to assure safety of our patients being transparent and building trust. Peer support is a big part of this effort being collaborative and mutual empowering people's voice and then being aware of individuals or cultural and gender and other historical issues that contribute to their treatment. Stigma is another important part that actually contributes to this issue. Substance use disorders are the most stigmatized diagnoses in health care globally. So of all the illnesses this is the one that people are most of you know sort of stigmatized or accepted that it's stigmatized in a way because still too many places you know addiction is seen as a moral failure or a criminal justice problem not a health care issue. And that alone the stigmatization itself can worsen outcomes. People are less likely to seek care. They're less likely to be offered treatment etc. So stigma reduction is something that we focus a lot on and one of them is language. Substance abuser was a commonly used term but when people use that actually there are studies to demonstrate that when that term is used healthier providers are less likely to offer treatment or think that this person deserves help etc. So substance use disorder is a preferred terminology today. So addict junkie you know those things are preferred you know not preferred terminology. Now an exception is when individuals in recovery may choose to use those terms you know that's okay for themselves but as for the health care provider side we try to avoid some of these terms. One of them is like you know clean urine. It sort of implies that if it's positive it's dirty and so we try to avoid those terms. And then finally behavior change you know so much of addiction and other chronic conditions are related to lifestyle choices, diet, exercise, you know using or not certain substances and changing them is difficult. I mean I think we can all you know appreciate that and just by knowing that you shouldn't do it doesn't mean you change. We all know we shouldn't like overeat. We all know probably that we probably shouldn't be snorting cocaine all the time and you know we know that but knowing that alone doesn't necessarily lead to behavior change. We all know how much we weigh. You can just easily get on the scale of knowing you know but that information alone doesn't mean you're going to change. So there has to be something more and so we've come a long way sort of trying to understand how we can support behavior change and people can go through phases and sort of cycles of you know being motivated and not and so sometimes it's called the stage of change model where people may go from not being interested in change to being much more interested but the issue here is that it can actually fluctuate over time. It can be a much more of a dynamic process influenced by internal and external factors. Okay I know I covered a lot and so I also want to make sure that I give plenty of time for any kind of discussion but I hope I was able to convey this idea that substance use disorder is really the current conceptualization is really rooted and grounded into understanding that this is a chronic brain illness and once you kind of get to that point even if you want to it's really really hard to change and yeah and the other message is that treatment does work. You know when I talk to some of my colleagues in primary care I'll ask how many of your patients who are being treated for diabetes now have perfect blood sugars and don't need to be on insulin and they're doing great and have to kind of think about it because you know they have some patients but not that many. Same thing with obesity. How many patients you know that primary care docs treat who have who are obese initially who are now you know ideal body weight doing great. Yeah they exist and now the glp1s much more common but it's still hard you know and addiction is the same but I would argue that the the proportion of patients who are able to achieve you know good outcomes with addiction treatment it's actually might be even be better than some of the other chronic conditions so I'll leave it at that and I'll take any questions and thank you for your attention.

opioid crisis

substance use disorders

neurobiology

addiction treatment

harm reduction

stigma reduction

trauma-informed care

dopamine