Well, hello everyone. Welcome to the CARES July 3rd, Thursday webinar. Really glad to have you here. We're going to have a great training today. My name is Alvin Cotton. I'm the database coordinator for the Georgia Council, but more importantly, I am a person in long-term recovery. What that means to me is I haven't felt the need to take a drink to deal with my anxiety, my depression, my loneliness, my isolation, or my legal problems since September 13, 2001. And I think it's really great to have this number of people who want to be in the peer workforce and who are in the peer workforce. I work for recovery to make sure that every time someone seeks recovery, a peer is across from the table from them because we are the best help. And thank you for coming. Today's webinar comes from the Opioid Response Network. It's entitled, Addiction is a Brain Disease. Science Matters. A medical model of addiction and treatment is crucial to understanding recovery. This presentation will provide a summary of how the brain is impacted by substance use that is rooted in science to reduce stigma surrounding the disease of addiction. A brief overview of the value of medications for treating substance use disorders medically will be offered with a highlight on approved medications for opioid use disorder or mode. We are really glad to have you here. I'm going to ask everybody to mute if they get the chance. And there we go. I think we're good. This will be an interactive webinar, so we're going to ask for your engagement and participation. Housekeeping wise, we're going to remind you to keep your microphone on mute if you're not speaking. I will mute people sometimes if it seems like it's necessary. Everyone who remains until the end of the webinar will receive 1.5 CEUs. You'll receive a certificate from me, Alvin Cotton, to go out probably next week. Anyone who shows up more than 15 minutes later has to step away for that long, may continue to attend the webinar, but you may not receive credit. And you can search for my name in the inbox, Alvin. If you can't find your certificate, that's how you'll find it. The certificates will likely go out, like I said, next week. So make sure the name on the screen matches the name that you want on your certificate if you're using somebody else's Zoom information. And please include your pronouns if you would like us to be able to address you correctly. So I am going to launch a poll today. There we go. Can you all see that? I'm asking you who is here. And I see that you can see it because I see the numbers coming up. There we go. You're unmuted. There we go. We're at 57 people so far, and it looks like about 49 of y'all have responded, 50 so far. So that's good. That's good. I'm going to take a quick picture of this when I end the poll, and I will show you all who's here. There we go. There you go. 84% of us are CARES, 14% are aspiring CARES. We have five clinicians, four recovery allies, and two people listed as other. So thank you all for coming today. Really happy to have you here. So now I'm going to turn this over to our presenter, Dr. Andrea Yatsko from the University of Texas, Houston. Is it University of Texas, Houston? It's University of Texas Health Science Center at Houston. It's a mouthful. Awesome. Thank you, Andrea, for coming. We're excited to have you here. Thanks for having me. I see we accidentally wrote on the slide, do you know how to clear the slide at all, Calvin or Haley? I know with this new whiteboard option, it's been happening in all the meetings. I do not have any experience with that. Okay. And I know it happened in a previous one, and Kat was the saver of me for that. I'll look into it. Y'all keep going. Do a quick Google. I think there's just a quick space where you can clear it, and I can't remember where it's at. But for now, it's the red line there. We're just going to roll with it. And that's what we do. If we don't bend, we break, right? We've got to be flexible. So I am very excited to be here today. I come here through the Opioid Response Network, so they do a variety of different things. Normally, there is an ORN staff member who's also here on these trainings, but the one who has been coordinating with this just welcomed a new grandbaby into the family, and she's doing more important things today than hanging out with us. So I'm going to run through the ORN slides just a little bit in case you're not familiar with the Opioid Response Network so that you are aware of the resource that's out there. So the Opioid Response Network assists states, individuals, and other organizations by providing resources and technical assistance for the things that you may need locally to address the opioid crisis. And technical assistance is available to support evidence-based prevention, treatment, and recovery of opioid use disorder. A lot of the funding that ORN gets is through SAMHSA, which I think we're probably all familiar with, the Substance Abuse Mental Health Services Administration. And so they fund and put on these types of supports and trainings so that all the boots on the ground have the ability to access these types of services. They accept requests for education and training, different types of, you know, broad trainings like this, individualized trainings, one-on-one type of consulting, depending on what's going on. And each state or territory has their own kind of regional group of people. So in this realm, Cat House is the requester that gets all the requests and then works with all the different consultants and puts something together based on the needs of what that request requires. So if you want to submit a request or have other questions or just want to know more, the information is here, the opioidresponsenetwork.org. There's email, there's phone calls, whatever your preference is for reaching out and connecting to people. With that, all of these trainings are provided free of charge to y'all. And so like anything, right, no, if there's nothing free, we want something in return. So ORN would like to get some of your feedback and evaluation at the end of today's training. So there is a QR code up there, there is a link that I know that Alvin I think is going to drop in the chat box here at some point. And then we will put this up again at the end, obviously, right, because you don't know if you liked it or learned anything yet, because we just got started. But if you want to click it, open it, save it, pull it up on your phone, have it however you want to do it. That'll be an option there. So. Hey, Andrea, I just dropped some instructions in the chat to you. Ah, got it. Trying to multitask there. Got it. That was real easy. I have to write that down. So it's going to come up again. Thank you, Hayley. Of course. All right. So Alvin already did a pretty good overview of what we're doing today. I'm learning along with you, no one's got this all figured out, right? Don't drive, mute your line. I love cameras if you got them. I don't like just staring at myself when I talk. I like to look at all the other faces and see how everything's going. Although I did chuckle in cornbread's like, I can't see myself. And I was like, those are even more disorienting. At least, you know, I can always be grounded. I'm like, there I am. That's what I'm doing. But I love it when your camera's on. But I appreciate it. There's things that maybe prevent you from having your camera on. A little bit about me, it's not too much about me. We're not going to spend a lot of time on me, but just my background of who I am and kind of the route that I've taken to come and hang out with you all today. I've got my background in a mix of kind of psychology, criminology, criminal justice. I worked behind the walls for a while in treatment in Massachusetts, both in the male, male jail population, the female prison population. That is really where I kind of got into the realm of substance use and understanding the disease of addiction and all the things that go along with that. So I got my certifications in the addiction field. I've worked in Vermont in the Department of Children and Families. They're doing some really interesting stuff up there with kind of some youthful offender strategies, utilizing family courts up until the age of 22 for a lot of, you know, types of behaviors rather than putting them in the traditional justice pathway, you know, at 18. So they're doing some interesting things up there that I got to be a part of. And most recently, I have been with the UT Health Science Center at Houston working on a variety of different things there, mostly in clinical research, direct patient care, systems of care and kind of generally just creating better education and access for anyone looking for medication based treatment. So that'll come up in the three series of the sessions that I have where I'm scheduled to hang out with you all this month, next month and the month after. Medication based care and science based things are going to be a big chunk of what we're talking about here. I appreciate it, Alvin, that you put the poll out because that gave me a little about who's here and kind of what different, you know, walks of life are hanging out today and learning a lot about Georgia. I've not done a lot of Georgia trainings yet, so definitely still learning about y'all in the landscape. And I've already learned a ton just on the few minutes we hung out together before this training started. So very happy to be here. This is what Alvin read to you all. I'm not going to reread it. We're going to work on really getting some of this introductory science of addiction as a disease, as a medical condition, making sure that we understand what's going on behind the scenes, because it's really easy to look at things kind of from the outside and forget about what's going on on the inside. So we're going to talk about the brain and the body and what happens when we start introducing substances and kind of what goes on behind the scenes. And I do my best to make it simple and relatable and understandable. We don't have to be neuroscientists. We don't have to be fancy, you know, educated, all these degrees and letters. Like, I just want to talk about kind of generally what's happening, because I think it gives a lot of insight and helps us understand what else is going on that we don't see. Right. It's the stuff we don't see that can be very impactful in driving how we work with someone who is in active use and or entering into recovery or managing recovery long term, wherever they're at in their journey. These types of things are really helpful. We're going to just touch on the idea of medications for opioid use disorder today. Session two next month, if you all come and hang out again, we're going to talk a lot more about that component of things. But we'll give a little teaser, see if I can convince you all to come back so that we can hang out and get into that next round. So I like to kick off some of my trainings with just a little anecdote. There's a philosopher that was named David Foster Wallace, and he actually went to the University of Arizona, my alma mater, and he wrote a bunch of stuff very, I mean, some of that philosophy, right, gets very heavy and, you know, very insightful. And, you know, it can be a tough read. But the favorite thing that he actually put out was a commencement speech at Kenyon College in Ohio. This was probably back in, what, like 2005 and it's on YouTube, the audio is and some people have done some animating things and stuff like that. But it's a great kind of little intro that I've stolen now and I use for mine, but I do my best to give him credit. But he opens up his commencement speech and he talks about, you know, so there's two fish swimming along and a third older fish swims up to him and says, hey, boy, hey, boys, how's the water? And then that third fish swims off and the first fish looks at the second fish and says, well, what the hell is water? And there's kind of this, you know, we're in it, we're living in it, we're existing in it. But there's also this kind of psychology of like we get so used to it that we forget it's there, right, that we're not aware of it unless we're being aware of it. Like we kind of have to toggle that on to pay attention to what's going on around us. And so this idea of, you know, what's water? Water is what we live in, what we exist in, what our experiences, what everything that is going on around us. And it makes so much sense to us, right, that we kind of forget that it's there. But trying to take that step back and be a little more mindful about the landscape, my landscape versus your landscape, all those types of things really come into play here. And he goes on to talk about this idea of and I like that it's kind of ironic, right, it's in a college graduating class and his whole premise is it's not about education and knowledge at all, but really it's about awareness. And the simple awareness is the types of things that he was hoping they would take with them and kind of be more mindful and integrate into their day to day routines and activities. And the idea that, you know, the most obvious, important things may be right in front of us. And sometimes those are the things that we miss the most. Or thinking about, right, if you think something or feel something, you just know that to be real, right? Like I think it, I feel it, like I'm experiencing that. That's 100 percent me right now. But somebody else's thoughts, somebody else's feelings, somebody else's experience, that has to be communicated to us. Right. Like we don't just know it. Like we know the things that we're going through. And so he really kind of drives home this point of individual experience and perspective matters. And I think this really translates well into the recovery field and the treatment field. And it's why I included in a lot of my presentations is because I mean, right there at the bottom, right, individual experience and perspective, like that's the core of what we're doing. That's the core of what peer work is based on. Right. And that even though it's your journey, someone else's journey may be different, but you might be able to learn something from my journey and let's come together. But let's also have that mindfulness to be able to take that step back, to look at that water, to look at what's going on around us, what's going around other people and not just kind of take for granted of like, well, I think and I feel so that's all there is. It's like, well, no, like what else may be going on or what someone else is thinking and feeling maybe entirely different than what you've got that feels so real. Right. And so I think there's just kind of that little just nugget of carrying that around of that awareness, that mindfulness and just that appreciation that we get so kind of just comfortable and routine that taking a step back and really looking at, hey, how is the water and what's going on here is very impactful in both our day to day as well as the work that we're doing in this field. So I want everyone to wake up that little hamster, get them running on the wheel here, stretch out your fingers. I want to do a quick chat box activity, so go ahead and pull up the chat box and when you hear the word addiction, we're just going to do a little of this free word association, right? When you hear the word addiction, what are three words that come to mind and go ahead and drop them in the chat box. And there's no right or wrong. Like I said, it's very kind of free, fluid. When you hear addiction, what comes to mind? Put it in the chat box and we will go from there. We have a lot of people who are putting stuff in there. Thank you, guys. Appreciate it. So those are rolling in. I'll read through some as others are coming in. Bondage, darkness, emptiness, pain, trauma, connection, sad, stigma, brain condition, obsession, compulsion, control, another bondage, darkness, alone, destruction, hopeless, death, power, threat, meaning. I'm driving. Yes, I don't like when people are driving, but if you're driving, please don't put yourself at risk by trying to chat and unmute and do all those other things, of course. Prisoner, bondage, isolation, loss of freedom, no control, hopeless, loss, misery, darkness. Bondage, that's the theme today, desperation, hopeless, stigma, struggling, pain, shame, numbness, judgment, struggle, trustworthy, hopeless, out of control. All right. I appreciate everyone who's put some stuff in the box here. So without fail, every time we do this activity and it's always very interesting to me, and I think it speaks to us kind of generally of what we default to. A lot of that is very, you know, it's the dark side of addiction, right? It's the struggle, it's the pain, it's the trauma, it's the bondage, the darkness, all the things that are out there that are very accurate descriptions of what active addiction is like. And I appreciate that that's kind of where we go, like default, right? I'm like, here's all the dark and here's all the things that go along with it. And especially if you've lived it, been through it, have loved ones close to you, have been through it. I mean, those are the things that jump out at you. Right. And I'm here today to also, you know, remind and highlight that like anything, right, there's the two sides of the same coin. Yes, all the darkness and all the things that go along with the pain and suffering of addiction. And the other side of that coin is the recovery part of it. Right. That recovery is possible. I did see a couple in there like connection and a few things like that, you know, recovery and connection and hope instead of hopeless and and all of the other things that are that other side of the same coin. And so I think it's also very important if we're in this field to make sure that we're the drivers of the positive messages as well, because we know we get the negative messages, right? All the news stories, all the numbers of the people who are out there who are fatally overdosing, all of the dark sides of the things that surface when we're talking about addiction and active use. And that's not where the story has to end. Right. There's good. There's positive. There's the ability to recovery, to have treatment, to find your people, to figure out how to be supported and connected. We know the opposite of addiction is connection. And so I think we're wired to always default. And so, again, that idea of awareness, of being consciously able to choose what perspective you're embracing on a day to day basis, you know, and making sure that we're not adding anything to the dark and hopeless that's already out there. What are we doing to contribute to the other side of things? What are we doing to highlight the great things about recovery and the great stories of people who are in recovery? And and how do we bring light to a topic that really is very dark and depressing sometimes? And so, I mean, think about it, right, like a Yelp review. No one goes on and talks about all the great things that but if you had a bad experience, you hop on and it was the worst burger and the worst waiter and everything was horrible. Like those ones a lot of times get all the attention. And the people who had a good experience, they don't take the time. And so, again, just keeping in mind this idea of when we're in this field, when we're talking to others, when we're out there, let's make sure that we are contributing the other side of that coin, these other positive, hopeful that they're, you know, people do recover types of messages out there so we can balance out some of that darkness. And if we can put enough light out there and get enough people on that side, right, we can start shrinking down all the death and destruction that goes along when we talk about the disease of addiction. So just some little, you know, food for thought of keeping that at the forefront of, again, what are we putting out there? All right, so a little bit about stigma, I'm sure I don't have to highlight that, you know, stigma is something that goes hand in hand, unfortunately, when we're talking about addiction and on some level, right, you can maybe appreciate that the symptoms of addiction can look very kind of careless and thoughtless and reckless, but that's just the observable symptom, like the disease itself, you know, is not just the symptoms that we see in a day to day out there, you know, the things that we see of people who are making unhealthy choices, making bad decisions, finding themselves, you know, with criminal justice charges, all these types of things like but that even though it looks like that, kind of at the very end of that line, at the core of it, right, there's people, there's a person, there's, you know, all the human dignity and compassion and things that are supposed to go along with that. And that the disease of addiction and all of these symptoms that we're seeing isn't a choice. Someone's not in a frame of mind to be able to make good and healthy choices. We're going to talk about some of that today when we get into the brain behind the scenes. And it's unfortunate, though, that that stigma is out there. And I just wanna, again, drop some of those little nuggets of language and stigma go hand in hand, right? The words we use are powerful and they matter. And we need to be very mindful and kind of handle with care of what words we're choosing to put out there. Because not only does it reinforce kind of what broader society hears and repeats about addiction and living with the disease of addiction and being in recovery, but we're also shaping kind of how individuals think and feel about themselves in this process too. We know that labels matter. We know how easy it is to internalize the things that we hear over and over and over. Even if at the forefront, we know it's not true or accurate or fair to have these labels over time, it's going to break down and it does frame how people think about themselves. So words are so important. Language is so important. Keeping those types of things in mind, it's really unfortunate that having a substance use disorder is the most stigmatized health condition in the world. And a lot of that is perceived because of this idea of like, oh, there's a control and you're choosing to do this or that there's some type of kind of will involved to being on this pathway of being with someone in active use or in active addiction. And again, I imagine everyone on this calls knows that's not the case, but we need to be the ones that are putting those messages out there to fight back when we do see stigma, to try and educate and appropriately challenge those types of things. Because when someone who's living with a disease of addiction feels stigmatized, right? They're not going to seek treatment. Well, the last time I tried, like they treated me horribly just on the phone call. Like I'm not going to go and show up in person and take that type of abuse. You know, in that sense, they just don't seek out treatment. If they do seek out treatment and they're still feeling stigmatized and they're not going to keep coming, they're not going to engage. They're not going to follow through on that. And then that, right, just cycles back into feeling isolated, alone, and kind of stuck in this healthy pattern. And it's unfortunate out there. I think we're talking about it more. I think we're educating more. I think we're trying to get into other systems of care more so that there is less stigma, but there's still a lot of it out there. And so we've got to be mindful of it. And we've got to be kind of the change agents of what are we not happy with and what can we do to start changing it? Even if it's just a little bit at a time. So the language we use, the interactions we have, all of those things are very crucial in reducing stigma. And some of this, like I said, is a given. There's certain words we don't use anymore. I know some of them are also hard habits to break. You know, maybe there's words we've said for a while in this field that are no longer the norm and having to adjust and update our language on a regular basis. And I'm constantly getting feedback and being reminded, even some things that I've been putting out there, I'm just like, oh, I can't say that anymore. Like I just learned detox can be negative and stigmatizing that they want us to push this idea of medically management withdrawal now. And so I'm trying to remove detox from my lexicon and start using different words, or even saying something like someone who struggles with addiction. We're imposing then kind of our interpretation of what it's like to live with this medical condition. And we want to be more of like someone who's living with the disease of addiction and be more kind of empowering and strength-based. And so there's a lot of stuff and it can feel a little tedious sometimes, but it's so important for us to at least try, right? We might not be perfect, or there may be things that are out there, or we've said for so long that it's hard to kind of rewire and create a new habit. But it really is important to keep person first language, not losing that people are at the heart of this and all the other stuff are the details. Keeping that in mind. The best thing I was taught when I really got into this field from some of my mentors is I think our default sometimes when people are different from us, or they're not thinking like us, or they're not making the choices that we would choose is what's wrong with you. And really we need to flip that and be more mindful about what's happened to you. Because again, think about water, think of those experiences, think of everything that's shaped someone. Like we are a product of our experiences and the things that we've been exposed to and the role models we've been around and whatever behaviors have been put out there. And I like, hey, Libyan, what's right with you, right? Like strength-based stuff, absolutely. We wanna flip the script a little bit. But if we're trying to be mindful with the population that we're working with, we have to appreciate that their journey is their own journey and there's a lot of things that have been a part of that journey that is why they're sitting here in front of us today, why they're seeking services today, why they're trying to do something different today. And if we make sure that we're not, what's wrong with you, but really trying to be empathetic and compassionate about what happened, like what's brought us here because if I understand the journey here, then maybe I can help you with the journey out of here. And so just, again, it's not what's wrong with you, it's what's happened to you or very strength-based, right, of what's right with you. And that's probably one of the questions that the hardest when you ask someone, when you're doing assessments or intakes or things like that, if you ask someone to list their strengths, especially if they're just getting out of active use or an early recovery, that is one of the hardest questions. They just kind of look at you and they're just like, and it's crickets and it's heartbreaking because then you have to kind of work with them and help them figure out, what are their strengths and resilience and ability to keep going and having the motivation to ask for help and be sitting here today and being open-minded about what's next. And you gotta help them find those things. And so I think if we come at it with the compassion of understanding that their journey's brought them here and they may be working with nothing and we have to build that what's right with you and help build some of those strengths and help them see the things that they do have that are valuable if they aren't able to see them themselves. All right, anyone wanna take a gander at the difference between substance use disorder, dependence and addiction? Any thoughts on that? I know sometimes we kind of use them interchangeably. Any brave souls wanna try and break down the differences between that? I think I'm Vanya, addiction is more the disease concept. Dependency, like we're dependent on it, but we don't necessarily use it every day or whatever. We depend on it, but we don't, I don't know. I don't think we really have to be dependent on it. I don't know. I don't think we really are addicted yet. Like that's probably before you get to addiction. Substance use disorder, maybe like you should just start out like I use it and there's some consequences kind of coming with it. It's physical, maybe spiritual, I don't know. Okay, yeah, go ahead, George. You're breaking some stuff down, I like it. Trying to see some of the subtle differences there. Mike, I see your hand, do you wanna jump on that and give a little more clarity from your perspective? What are you thinking? Are you there, Mike? Y'all hear me? Yep, there you go, perfect. All right, hey everybody, I'm Mike. I think it's, obviously it's the wording, but when you're talking about the addiction is the, like Vanya said, the obsession and compulsion, but it has a negative connotation to it. When you talk about dependence, when you shared about, oh, well, it's the moral decision to where like, oh, you're dependent on it. Oh, well, why can't you just stop? As far as that in the substance use disorder is the term that's kind of like what we are trying to change of me working in the hospital and using it every day, the substance use disorder to where, hey, I am, words are powerful. So it's like, I'm not only speaking things into existence and teaching the peers about it, but I'm also teaching the social workers, the case managers, the doctors and the nurses of what we expect. Oh, well, this is the terminology we can use so they can start using it. So it kind of breaks down those barriers of stigma. Okay, all right, and let's do one more. Lisa, build on the two before you narrow in here. I would say the substance use disorder is a diagnosis, the dependencies, the need for the drug and the addiction is the problem. Okay, I like the short and sweet, but I think I like kind of where we're going with that. I also see there's some stuff in the chat here. I like kind of like how we're, who's identifying it types of things does kind of come into play, diagnosy codes. So, okay, so it's subtle, right? And it's kind of hard to, cause we use them all kind of interchangeably, but generally speaking, I do want to highlight that dependence in and of itself, and there's a reason that the DSM did away with dependence as part of their diagnosis, because dependence on something is just a medical biological response to something in your system. I mean, how many of you had coffee this morning or this afternoon or having it right now? You're dependent on that coffee, right? When you don't have it, you feel miserable. You're kind of feeling the withdrawals. You're grumpy, you're unhappy, but like, I'm presuming here, but nobody, you know, has maybe found themselves making bad choices or finding their lives unravel or all of these other things because they had a couple of cups of coffee today, right? Like, so they're dependent on something, but in and of itself, it stops there. There's a biological physical dependence on this substance, but it hasn't gotten to a point where it's kind of problematic, right? And so a substance use disorder is that clinical diagnosis. And at its core, right, is continued use despite harm. So now there's criteria that you measure kind of, well, what kind of things are starting to fall apart and be a little messy? And when it's become unmanageable and that continued use despite harm, well, now we have a clinical diagnosis that drives a lot of, you know, the treatment, of course, you know, payment and insurances and all that other fun stuff, right? But now we're defining kind of that extension of it's gotten to be problematic in somebody's life. So now there's clinical criteria that measures that. And then addiction really is, and you guys definitely kind of nailed this, this idea of like, it is the chronic disease. It's the big picture. It's kind of everything that's going on and all the, you know, biological, physiological, psychological things that go into that. It's like the big umbrella of it all. And so subtle differences, I know we kind of use them all swapping in and out, but I think it is important to kind of tease out a little bit, especially that dependence part of it, because we've tied dependence in so long with addiction, but dependence really is its own thing and doesn't necessarily have anything to do with addiction one way or the other, because there's a lot of things that we can be dependent on that don't clinically or from a medical stance mean anything beyond the fact that we're dependent on it, you know, and coffee's that easy go-to, but we could make a whole list of things that we get dependent on that doesn't cause harm and isn't causing problems. And so that's where, you know, it starts to kind of then tease out in this clinical and into these medical things that we discuss. So with that, let's get into some of the science stuff here. So addiction is a chronic relapsing disease that affects the brain, causes compulsive drug seeking and use despite harmful consequences. And the reason it is a disease is because it absolutely changes the brain structure and function. So it's not just something that kind of sits on the surface and causes problems like our brains and our bodies react, respond and change when we started introducing things in there. And because of this, that's where it really puts it into this disease category, because the brain and the body are adapting and responding to a substance being introduced. I also think it's important to highlight again, to make sure that that idea of like control is not something that we get caught up on. Let's play devil's advocate, right? Maybe that initial decision to use a substance for the first time was a voluntary choice. Choosing to use this, I want to see what it's like. I'm curious, all my friends are doing it, whatever it is. Maybe there's something in there that's a little bit voluntary. I should put a big asterisk next to that because we also know that substance use often starts when you're very young, right? We know the brain's not developed yet. We know our brain's not capable of understanding the costs and benefits and consequences and pros and cons and all that kind of stuff. So even that voluntary isn't a very well-informed voluntary, even if it is a little bit voluntary. So even, it's hard to stretch it, but if you do say maybe that first time was a choice, once we've introduced something, it kind of kicks everything off to the races. We're going to talk about the brain and how it's impacted and what that looks like. And repeated use affects a person's ability to control behaviors, make decisions, and do a lot of other things in that kind of normal routine. And so once we start changing and messing with things, any voluntary of that first choice, if there's any there at all, is gone. And now there's like a whole new kind of system that's rocking and rolling that has become reliant on these substances that are being put in there. So we're going to talk a little bit about that. So at its core, right, and this is just me drawn on the psychology of things, right, in early use, it may be that it's pleasurable, right? Positive reinforcement. I enjoy this. It feels good. I have fun. You know, I feel great feelings. Those are, you know, a little carrot on a stick there, right? He's chasing that. Okay, this is a good thing. But then continued use may be that you're avoiding negative effects. We call that negative reinforcement. Well, if I stop using, I feel like garbage and I don't like that. So how about I keep using and now I'm avoiding the negative outcome of feeling withdrawal and pain and discomfort. And so now that becomes kind of the driving. It's not that maybe it's not as fun or as enjoyable as it was, but it's better than not using because that feels really miserable. So you get kind of stuck in this loop here. And then really as this progresses, you know, into this, you know, clinical or medical addiction realm that you're using despite of the effects, you know, the pain, the discomfort, the pain that you're feeling. They're not enjoyable anymore. A lot of people say it stopped being fun a long time ago, right? Like we're now past that point, like the drug less, but now I need it more because of the things that are being changed behind the scenes that even though, you know, on some level I understand this isn't good and healthy and something I should be doing, like that's not a possible response anymore because the brain function and structure has changed and I think I heard that term right. The disease of addiction like hijacks the brain. So it's going to take the things that generally help us and help us survive and move forward and all those types of things. And it kind of flips it and uses it against us in a way. And we're going to talk about that. So this is our brain. What's going on behind the scenes, right? If you kind of sliced in the middle and we're looking at it from the side and you got a lot going on up here, you've got movement sensation in the back. You've got kind of vision and coordination. Judgment is the prefrontal cortex. This is what I call the smart part of our brain. It's the things that we have that other mammals don't have. All of our ability to make decisions, problem solve, logically think about things. Those types of things are up there. When we're talking about addiction, we're really going to talk about the core of what's in the middle of the brain. So you'll see there's kind of a reward pathway that's there in the middle and maybe not, you know, surprising the pain, the pink part that's going up and down that's tied very closely into the center of our brains. This is where like fight and flight is wired into us. So it makes sense that pain's tied very closely into that. And then keep in mind, there's that kind of green circle that goes around, which is the memory part of the brain that encompasses this reward pathway and this pain part of our brain. And that's going to come into play as we get a little further into what happens when we start experiencing things and how our brain responds to that. So without getting too technical, generally speaking, there are receptors in our brain and receptors are just a chemical that's on the membrane of a brain cell or a neuron. And I think of the receptors as like little buckets. And so there's little buckets kind of scattered all over. And when there's other chemicals in there, chemicals and buckets like to connect to each other. I think of it like the kid's toy, right? The square block goes in the square hole and the circle block goes in the circle hole. Our receptors are that same way. Like they're kind of wired to be attracted to different types of chemicals. And so you have chemicals and receptors that have a higher affinity or like a magnetizing effect or a bonding effect that comes into play. So we've got receptors, we've got different types of receptors, we've got lots of different chemicals. And there's kind of this, you know, method to the madness behind the scenes of receptors and chemicals and things that keep us, you know, kind of in this homeostasis state of mind. So we have opioid receptors, these little buckets kind of all over the brain, but also all over the body. So it's not just a brain disease. I know we talk a lot about that, but these receptors and chemicals and neurons and everything, they're all kind of interwired and connected. So we have receptors throughout our spinal cord, our digestive tract, and then our peripheral neurons, which are kind of like the things that just sit on top of everything in there. And you've probably heard of Hebb's rule. You might not know that it's called Hebb's rule, but that idea that neurons that fire together, wire together. And so when these neurons and receptors and chemicals kind of start hanging out together, those bonds get stronger, they get more efficient and effective, and you kind of get these like super pathways, super highways of these things that are happening behind the scenes and the stuff that's not being utilized, you know, isn't as strong or isn't as efficient behind the scenes. So generally speaking, how do drugs work to produce pleasure in the brain? So the pharmacological mechanisms for all of the drugs are a little different, right? Opioids being pain relief and stimulants and, you know, uppers, downers, all the different things. They're all gonna be slightly different when you're looking at the impact of what's going on behind the scenes. But generally speaking, that middle part of our brain, that reward system, the activation, what happens here is very similar regardless of what substance you're putting in. So we're gonna make some kind of generalizations here because the pattern is the same regardless of what substance gets introduced. And you're probably familiar with the term dopamine. Dopamine's a neurotransmitter. It's what I call one of our feel-good chemicals. When we do certain things, we get a release of dopamine. And these types of things are important for us because dopamine's a feel-good chemical and we're kind of wired to seek pleasure and avoid pain. When we do things that release dopamine and feel good, then we kind of create a, oh, okay, I'm gonna remember that and then I'm going to do it again. And so when dopamine and, you know, this whole system is activated at, you know, what we call normal levels or kind of common baseline levels, the system rewards our natural behaviors. So if I'm hungry, then my body starts to tell me I'm hungry, right? My stomach's growling, I'm uncomfortable, maybe I'm all lightheaded, I'm weak, I'm tired. And what do I do? I'm like, oh, I know if I eat a sandwich. I eat a sandwich, what happens? I actually get a boost of dopamine when I eat that sandwich. And that's my brain telling me that, hey, that felt good. You were miserable, you ate a sandwich, you now feel better. That's good for your survival. Remember that little memory pathway around it all? Let's do that again. Next time you're hungry, eat a sandwich, yay. Next time you're thirsty, drink some water. Gonna give you some dopamine. Brain's gonna reward you, give you some of that, you know, feel good chemical and remind yourself when I'm thirsty, I drink some water and I feel better and that helps me survive, right? So at normal levels, this kind of is reinforced and this all happens behind the scenes, right? Like we're just wired this way. Like we don't have to know how to do it. It's just hardwired back there. The problem being that when we start to mess with this natural system and we put things in there that aren't supposed to be there or aren't there naturally speaking, as far as, you know, it's a well-oiled machine, it kind of is doing what it's supposed to do. When we mess with that, then it produces effects which are stronger than our natural rewards. And that's where now we start to kind of mess with the machine and the homeostasis and the baseline of it's rocking and rolling, it's doing what it's supposed to do. You put something in the structure and the function of the brain are going to adjust. And since these are much stronger and motivating releases of larger amounts of dopamine. Now we've hijacked the part of the brain that was once good for our survival and now it's off to the races only really existing in this place of seeking the substance and eating the substance more and more. So quick overview of dopamine releasing behaviors, right? Food, sex, relationships, other people can release dopamine. You know, other types of behaviors listed here are standard types of behaviors that'll release dopamine when we engage in them. And then of course, that means that there's chemicals. When we introduce chemicals into our brain, we trigger a release of dopamine. Kind of, and again, that non-natural pathway, we're creating an environment by putting something in and forcing this release of dopamine. So again, even though all the substances are different, they all operate in the same sense of getting into the system and producing this dopamine burst. So just a visual chart here of kind of where we're at. And so there's a baseline there at like the 200 mark. I don't know if you see, it's kind of a little more blue across than the others. So this is kind of like where our natural threshold is. This is how much dopamine our brain can release depending on what's going on, you know? So you get a promotion, you win the lottery, you have something going on, you're gonna get a boost of dopamine from those types of things. And there's only so much that our brain can do on its own. And through the course of a day, a week, a month, our lifetime, right, there's ups and downs. Like sometimes things are going good and we're feeling great and we're getting those dopamine boosts. And other times it's a hot mess and we're struggling and we're not getting any of those feel-good chemicals and we're, you know, dealing with other types of things. So it's a roller coaster, right? Up, down, all around. Generally speaking, if we're eating that sandwich, right? Or we're drinking that water, we're getting an okay amount of dopamine. That sandwich tasted good, I'm gonna go back there. I'm gonna give them a good Yelp review and not just put the bad ones out there. So we're getting some to reinforce that. All right, felt good. I'll remember when I'm hungry to eat because it generally makes me feel good for a little bit. Sex releases a little bit more of this dopamine. Again, not all the way up to the threshold but a little more enjoyable than that sandwich. And now if we get into some of the other substances, right? Alcohol. Okay, we're kind of getting to this threshold of like how much our brain can produce on its own. Nicotine, cocaine, opioids, methamphetamines. So what happened to our baseline? I mean, we're gone, right? We're off the charts. The amount of dopamine now that we are, you know, creating artificially by putting substances into the body is well above any threshold that our brain can do on its own from all the general day-to-day things like, you know, being rewarded for eating a sandwich or having sex to procreate or all these other things that are kind of hardwired. Now we've really superseded that line and we're way up there with the amount of dopamine that gets released. And keeping in mind how kind of starkly different it is. It's not like just a little more than what our brain can do. It's a lot more than what our brain does on kind of that normal baseline of things. And so with this in mind, our body likes equilibrium. A little scale there, right? It likes to be in balance. It likes to know kind of everything's there and everything's got the right proportion of what's supposed to be there. So remember you got those receptor buckets and you've got chemicals. Every receptor likes a bucket to be full. So the receptor and a chemical like to always be kind of balanced out. And our brain's pretty good at trying to find this balance on its own. And so it just does that. Again, we don't have to tell it to do it. It just knows that this is how it's supposed to be. When we flood the brain with an exogenous substance, something from the outside, it's going to mimic those natural endorphins, right? So that square block in a square hole. Well, this substance I put in also looks like a square block and it actually has a very strong bond to that same receptor. And so now all of a sudden we're getting this strong connection. We're getting that big boost of dopamine, right? Like some of those off the chart levels of dopamine. And so now the system is like, whoa, what's going on here? I've got all this dopamine going on. The brain responds and reacts and basically decides that, hey, if there's a flood of dopamine, like we must've done something wrong. We're producing too much on our own. So they shut the factory down. They stopped making dopamine. They stopped making these natural feel good chemicals because the brain is registering that there's way too much in the system. And therefore you've got this response of, okay, that's too much. That's not what it's supposed to be. Let's stop the factory and then we got to clean up this mess, right? So we're no longer going to be producing things naturally to put into the system, but we will now have to clean up the mess, right? So I've got all this extra dopamine that's just floating around up there. I need more receptors. I need more buckets to clean this up. So my body and brain create more receptors and more buckets so that every chemical has a bucket and it all balances back out again. So now we've changed exactly what's going on behind the scenes, right? And so we've shut the factory down. We've created all these extra buckets. And now we're in this space that this is the new norm, right? Now I have more buckets and I don't like when these buckets are empty. It's uncomfortable. We're out of balance, right? So when that drug wears off, I've got more empty buckets that need to be filled. That's drug seeking, that's drug craving, right? I need to fill those buckets. I need to get my balance back. And then you kind of start to see how this cycle happens. And so when you take that substance away, you've got a lot of extra buckets and everything's very angry and uncomfortable. And so this is where kind of tolerance comes into play. But what's also happening alongside tolerance is this idea that we kind of, because we flooded the system and we've kind of put more strain on it than like generally naturally occurs, it's almost like we've overworked the system. So everything gets desensitized in the process too. So we're putting stuff in and that same amount of chemical doesn't fill the bucket all the way like it used to. So it needs more of that chemical to fill the bucket, to create that balance of equilibrium and to make that discomfort go away. And let me give you an example here. If you're a football fan and your team's in the Super Bowl and it's down to the last couple seconds, the last play of the game, your team's losing, your quarterback throws the ball, you're like, oh, it's gonna happen. Your receiver jumps up, kind of grabs it, pulls it in, gets the points, the clock expires, your team wins the Super Bowl. And what do you do? You're jumping off the couch, you're high-fiving your buddies. You're like, this is the coolest thing ever, right? And that's because you just got a huge burst of dopamine. It was new, it was unexpected, it was surprising, it was fun. And so you got that whole experience of that big boost of dopamine. And then like two minutes will go by, they're gonna show the replay and you're still kind of amped up and you're like, oh, oh, look at how nice that grab was. One-handed, pulled it in, like still pretty amped, still kind of riding that dopamine. And then the night goes on before all your friends go home and you're still talking about it, you're still kind of amped, you're still feeling the response of that event that happened. The next morning, right, you turn on SportsCenter and you're watching the replay and you're just like, oh, that was really cool. Like you're still feeling a response to it, right? You go to work, still a little amped up. And then a week goes by, maybe a year goes by, maybe we're now like a 30 for 30 episode that you're watching. It's still cool, right? Like it's still neat. Like you know what's happening, but you don't, when you're watching the 30 for 30, you're not jumping off the couch, high-fiving your buddies. Like that ship has sailed, right? That experience happened once. It can only happen once. That newness, that novelty, that kind of something that it's never experienced before is off the charts. And our brain responds again with those dopamine levels that are off the charts. The next time it happens, remember that memory pathway that's tucked around the reward pathway? The brain remembers it. It recognizes it. It knows it. It knows what it's all about. And so the response is muted and you don't get the same off the chart response as you got from that first time. And so that applies to everything. Again, the first time it happens is off the charts. The second time, the review of it, the revisiting of it will never be the same as that first experience. So you've probably heard that phrase of like someone's chasing their first high. There's so much science to that because when the brain experienced that first big boost release of dopamine, it was much higher than any other use that came after that. And in fact, again, that desensitization happens. And now for my visual learners here, right? The big boost is high. Remember we shut the factory down so we don't go back to our baseline. We actually go to a low. That's the discomfort. That's the withdrawal. That's the whole uncomfortable part of being in a detox state. So then you're like, oh, I don't like feeling down here. Let me use again, right? So now I use, I'm not nearly as high as that first use, but I'm back above the baseline. So I'm feeling good. I'm feeling all right. Oh, and I know that if I wait too long, I feel miserable. So I'm going to use it quicker this time to avoid that down feeling. But now the desensitization, the tolerance, everything's building up. So now I'm using to kind of sort of feel normal. Now I'm using just to function or barely function and get through the day. And I think that there's a real progression of by the time we're meeting and connecting with someone, they're well on this journey, right? They're all the way down on this right side of the chart. They're trying to figure out how to create that balance and routine in their brain again, but they're so far gone that the brain can't do what it was doing before substances were introduced. And so like we know, right, the system is reliant on these outside substances. The body needs more. If you take it away, it's going to be withdrawal. So your body's kind of like the guy with all the plates at the circus of trying to spin them all and keep them all going and just find a way to manage. But we know those plates are going to come crashing down. And when the system is removed, you got all those empty buckets. And remember where we said the buckets were, they're not just in the brain, they're in your spinal cord, they're in your digestive tract, they're in your peripheral neurons. And so this is where you're feeling the withdrawal. Your whole body is in withdrawal, not just your brain. So you get a lot of people who are like, oh, my back is killing me. It's because all the empty opioid receptors in your back are very unhappy that they don't have a substance attached to them right now. You've got all the nausea, vomiting, diarrhea, right? That's all the ones that are in your digestive tract. They're in dysregulation and in disarray. Those peripheral neurons, that's your goose bumps. That's all the other kinds of neurons that are disrupted and uncomfortable in this process. So keeping in mind, again, it's not just one part of the body going through this, it's the entire body going through this dysregulation. And so remember we did that first chart, right? I said at that 200 level was like our general threshold of like, here's how much dopamine we need for our brain to recognize that, hey, this feels good and I'm happy and it's enjoyable. Well, that's the old line. And so things like going on vacation, getting a job promotion, winning your fantasy football team, those types of things reach that threshold and your brain's like, that's fun, that's enjoyable, that's awesome. You do it again. Now we've introduced one of these many substances into the mix, right? And we told the brain, no, you were wrong. You can actually have this much dopamine that's released behind the scenes. So the brain's like, my bad, I was wrong. So what it does is it raises the threshold and says, ah, this is how much dopamine I need to feel joy and pleasure and not feel pain. So you've changed this response behind the scenes and you've adjusted this upwards, right? And so now there's even a term for it, this inability to feel pleasure. Because when you look at these two kind of curves here, right, hanging out with your kids, going to the park to play basketball with your friends, any of these things that used to hit the threshold of pleasure, they don't even come close. So this gap is called anhedonia, inability to feel pleasure. So the natural, normal, day-to-day, routine, enjoyable human activities that used to bring joy don't register scientifically behind the scenes anymore because we told the brain, I can actually feel more joy. I can get more dopamine from the drug. And so these things don't even, they're a blip on the radar, if anything, at this point. The good news is, is if you take the substance away, right, eventually the brain will figure it out. It'll adjust, it'll adapt. It'll find its way back to kind of the wired threshold that we have naturally in there. The factory will start back up again. The extra receptors will get absorbed and you kind of get back to this new routine of things. And therefore the old stuff that used to bring pleasure will now eventually register as pleasurable again because the brain will get back to this old threshold. The thing there is, is it's not like flipping a switch, right? So the amount of time it takes for dopamine receptors, all those extra buckets to regenerate or regulate with just abstinence at a minimum up to a year. And that's a long time of not feeling normal, enjoying anything, all of that type of stuff, right? Being in that anhedonia of like, I'm sober and I'm miserable. Like that's a very hard period to be in. And so there's also longer timeframes, right? Post-acute withdrawal syndrome, where acute withdrawal is that physical detox, like 10, 12, 14 days or whatever it takes depending on the substance and the history and all that, takes 18 to 24 months for post-acute withdrawal. And that has its own host of symptoms and dysregulations and things that are going on while your brain and your body try and figure things out and catch up. And this is why even though someone's been sober for a short time, it's really hard to maintain, especially in those first couple of years because you may have that exogenous substance out, but everything is still a mess. The function and the structure and the way your brain is operating has been entirely changed. And so to make a change back doesn't happen overnight. Good news is when we get into medications and stuff, that's going to come into play because that's gonna provide a lot of support there. And it's gonna start to kind of make sense how we're tying these together, right? There's a lot of dysregulations and medications can create that stability and consistency. That's something to be mindful of. How are we doing? Quick check-in. It is six o'clock right now. So we have about 30 minutes. Awesome. And it looks like you have some pretty good questions in the chat too. All right, I'm just going to check in here. So let's go back here. So the question from George is, why do many folks not like or enjoy the initial effects of alcohol and nicotine? So that's kind of the million dollar question, right? Because some people, same with opioids, some people have a very visceral effect and response to opioids. They feel nauseous, they're uncomfortable, they don't have a joyful experience. And these are kind of some of the things that science is still trying to tease out. It goes into some of the genetic components and things that are happening behind the scenes, trying to figure out why we are different. And not everyone has the kind of same response to things. It's also, again, all the other stuff that's going to come into play of when it was introduced, what was modeled, what types of things, you know, have played out for one individual. It could be very different for the other individual, but at its core, right, I've disrupted something and that can be very unpleasurable. So even though that there's a dopamine boost of things, there's still a lot of this isn't what I'm used to and that unfamiliar, uncomfortable feeling is across the board, where you're still going to have some of that, this isn't my baseline and our body doesn't like change or things to be different. And so anytime we mess with that, it can be a very disruptive experience. And again, getting why some people enjoy things and some don't, like that is kind of the million dollar question that we're still chipping away at to try and figure out what is going on, where it isn't a universal experience for everyone. So Andrea, here's a question from Sonora Rudolph. She wants to know why certain drugs get involved with eating up bones or the physical consequences of using some drugs. So I guess keeping in mind there, right, when we're putting things in there that aren't supposed to be there, we're disrupting and dysregulating the whole system. We're also reprioritizing the whole system. And so things like our immune function, our ability to heal from things like pain and inflammation, the ability to prioritize the amount of resources to keep us healthy and moving forward, that takes a lot. I mean, that's a day-to-day thing. Our body's doing a ton of things behind the scenes. If I've hijacked and taken that away and now my system is, nope, I need a substance. If I don't have it, I feel miserable. I'm gonna seek it. I'm gonna get it. It stopped doing all the stuff that it was supposed to be doing. And so that's why immune systems are impacted. It's why general health is impacted. It's why we're not able to regulate all those other maybe stressful chemicals like cortisol and adrenaline and other things that wear and tear on our body over time. Our body doesn't have the resources to clean up any of that and function because it's prioritizing the substance use over everything else. And so bones, I mean, that's just one of many things that happened to our bodies. They become very unhealthy and they can't maintain and do the things that it's supposed to do. And so we really are deteriorating kind of from the inside out because the substance use is the only thing that our brain and our body is focused on. It stopped doing all the other stuff that it's supposed to be doing to keep us healthy and functioning. Our muscles, our bones, everything is going to have an impact of this. Do we have time for another question, Andrea? Can we park until the end and circle back? Because I do want to make sure we have a few and then if there's other things, I will definitely create some space there for us to unpack. So, all right. So a few things, and this builds back into some of the stigma stuff that we talked about, right? This idea of recurrence. I was talking about recurrence. It feels like we left everything. Oops, I got open mic there. So recurrence rates for chronic illnesses, right? And recurrence rates, we used to call it relapse. Relapse is a dirty word now. It has too much negative connotation. We're not talking about it. So it's a return to use, a recurrence of use. Those types of languages are much more appropriate here. When you talk about the recurrence rates for someone with the condition of addiction, it's 40 to 60%, right? Like two thirds of people are having setbacks, are going to have recurrence, are going to kind of be in and out of their recovery management. And think about how we respond to that, of like, you've been through medically managed withdrawal. You're no longer dependent on the heroin or the fentanyl or whatever you're putting in. Like, how come you're going back to it? This idea that there's a disconnect, that we're not understanding the whole body and the bigger picture of things about, having a chronic condition means that there are things that need to be managed long-term. And it also means that we're not perfect in recurrence rates long-term, right? And you have stigma, right? You know, for substance use, but we don't have that same conversation with someone who's managing asthma over their life course. We don't have the same frustrations with someone who's not doing the things or taking their meds or whatever is needed to manage their hypertension over their life course. And even diabetes, right? If you don't follow the regimen or your medications or the things that you're supposed to do, you're gonna find yourself back in that doctor's office dealing with the consequences of those things. And we just don't respond in the same kind of visceral, you know, response of like, you've relapsed again, right? You're doing this again. You're making all these bad choices. What's wrong with you goes back to that, right? And so there's a kind of knee-jerk reaction for us to stigmatize someone who's dealing with learning how to manage a long-term chronic medical condition where none of these are 100% or none of these are 0%, right? Like none of these are like, we're just not perfect. It's hard to manage something long-term. Sometimes we do what we're supposed to. Sometimes we follow doctor's orders. Sometimes we don't. Sometimes even when we do what we're supposed to, our bodies aren't responding the way that we want. So maybe we gotta adjust our meds or our routine or things like that. And so I think it's important to keep in mind that substance use disorder, right? Addiction is a chronic disease. It's no, there's no cure, but people who comply with their treatment regimens have more favorable outcomes. And we really need to make sure that the norm is to evaluate this type of condition long-term just like we evaluate anything else long-term. And when we get into the medications piece, really having that understanding that medications for substance use should be thought of in the same fashion as any other maintenance medication. Maybe it's an inhaler for someone with asthma or corticosteroids, or maybe it's insulin for someone who's diabetic. Keeping in mind that long-term medications are often paired with long-term medical conditions and that's okay. And if things don't go well with the idea of relapse and failure and all that, that's not what's going on. It means your treatment needs to be adjusted. We need to find a different game plan and it should be the same across all medical conditions, but we still have a tendency and we still see that substance use is treated differently when it comes to these things. So a few notes about medications and M.O.O.D., MAT, all the fun acronyms that are out there. The term for a while was MAT, Medication Assisted Treatment. They've become a little more refined and now we call it M.O.O.D. It's Medications for Opioid Use Disorder. So that's kind of the new terminology. Medication Assisted Treatment, it's still out there, but it's less favorable. It also seems to suggest that medications alone can't be helpful because they have to assist other treatment and there's some research that suggests that's not the case for everyone. So you're really seeing like Medications for OUD, Medications for AUD, Alcohol Use Disorder, like it being a little more, you know, appropriately titled, but it's alphabet soup out there, right? We got a lot of acronyms. Generally, we're still talking about the same thing. If you're still used to the MAT acronym, it's now a M.O.O.D. acronym. Medication Treatment then is looking to kind of do a couple of different things. First and foremost, it helps with that withdrawal. We talked about the dysregulation and everything kind of being a mess behind the scenes. Medications are going to fill some of that space and help create stability and consistency. If the brain is in balance, guess what? It doesn't need anything. So the cravings get reduced because it has that kind of homeostasis, right? That little scale. And if everything's rocking and rolling and we're not having this craving to go back out, then we're lowering the chance that a recurrence of use is going to occur because we've created a healthy system that's moving forward and it's rocking and rolling. And so these other things then don't become the focus anymore for someone who's on a medication plan. It's important to understand it's not just fixing the chemistry, and we all know that, right? Medication is one tool in this. It has a very important and helpful and useful purpose. But there are other things that go into that approach, that whole body, that person-centered approach, this concept of being very mindful about if you're not changing anything else, when that medication goes away, you might find that you're back in and not knowing how to manage and you're struggling in that day-to-day because you didn't build anything else around that medication. So keeping some of that stuff in mind. For the skeptics out there, I want to throw up this slide. I like it because it's visual. It's good to look at here. But these are composites of brain scans, meaning that they have a bunch of people in each category and they did brain scans and they kind of compiled them all on top of each other and made like an average of what these groups' brain scans look like. So you've got your control brain, which is just your average Joe, no history of substance use disorder or addiction. And then in the middle, you've got someone who does have an extensive history of opioid dependence for a long period of time. I think on average, it was like six to eight years of active use for this group. And this group is on medications for OUD. So this group's actually on methadone. And then you've got your brain composites all the way to the right, which is someone who has that history of opioid active use addiction, but they're in sustained abstinence. And so they're not doing any medication. They're obviously sober. They're not taking any other types of substances. So what's the first thing that stands out that's different between these three kind of groups of brains here? Any guesses? The amount of redness? Red, yes. You get the scratch and sniff sticker today. So the red is starkly obvious, right? Like it's very different that the control brain on the left has very little red and then the brains all the way on the right have a lot more red. And then of course the one in the middle, a little of both there. So red in these brain scans is actually measuring glucose metabolism. And glucose metabolism is really just a proxy for how much stress is going on in the brain. So if you have a lot of glucose metabolism, then you've got a lot of stressful chemicals and things kind of happening behind the scenes. So you've got elevated levels of this means that the brain is in a stressed state. So now that we know red is an indicator of these kind of glucose metabolites that are being measured by the scan and are telling you which brain is the most stressed out. The last one. The last one, right? So that's sustained abstinence. Someone who had a history, someone who is no longer in active use is no longer using any type of medication. And so very different from the control brain, but also very different from someone who's on a medication-based treatment, right? And so when you start looking at these brains, first off, which brain do you want? If you get to choose, does anyone want the red brain? I'd like the control brain. I like them, right? And I like to make note, right? They're still red on the control brain because life is still hard and stuff's still stressful. Like no one's immune from it, right? But as far as the chemicals and what's going on behind the scenes, the abstinence-only brain is going through a lot more than the brain that's in the middle, which is a little, I mean, really a lot closer to the control brain. It's not identical, right? But of the two, it's much closer to the control brain than the abstinence-only set of brains. And so I like this slide, and I know it's a little dated, but science doesn't expire, right? So I like it because it helps remind us that this idea of like, oh, again, I've gone through the detoxification process. I'm no longer in acute withdrawal, and I'm maybe 90 days in, maybe a year in, like, I'm good. Or even the mindset that often goes along with like, how long you should be on medication-based treatments. This idea of, oh, get on it for a little bit and then get off of it. So it might be shocking to know that these brains, on average, are almost five years out from their last use. So five years of abstinence-only, that brain is still pretty stressed out, right? And this idea of like, there's a quick fix, or be on meds for a couple of weeks, or after six months, you need to get off them, or we have all this other stigma, right, that goes along with it. But the reality is, is this isn't a quick fix. And it takes our brains and our bodies a long time to catch up. And some may catch up a little quicker than others. Some may never catch up to the extent that we would want it to. And medications help create stability and consistency, which is helpful in a lot of ways in our day-to-day. And think about what someone in recovery is dealing with, right? They've maybe got their PO, they've got to figure out how to get CPS out of their lives, they don't have a place to live, they don't have a job, they've got all these classes they got to take, you've got all this stuff piling up. And if we're already in a brain that's kind of overworked and overwhelmed, and got all this stress going on, and we pile on top of that, and then we're surprised at six months when that, you know, card tower just comes crumbling down. And we're like, I don't understand what's wrong with you. Again, we default back to that when if we be more mindful about what's happening behind the scenes, then we have a lot more insight into what's going on with someone that we can't see, right? Like, we can see all the observable behaviors, but we can't see what's happening behind the scenes unless you have this really expensive, fancy equipment that will scan your brain and show you what's going on, right? And so I think I like this slide because it does show that medications for OUD are very impactful, very helpful, very useful. And hopefully to challenge this idea of like, it is a long term, it's a chronic condition, right? So why would the medication be a short term response, like a long term medication plan pairs well with a long term medical condition. And if we're forcing people or insisting that people go the abstinence only route, we're asking a lot sometimes. And I think this right here, again, no one wants that very stressed out red brain. So I think that idea of, you know, being mindful that there's a lot going on behind the scenes. And I do see one of the questions in there, right? You know, like what happens after a decade or two decades or some that that's where I imagine there is going to be some individualizing of things there. Some people may find that they've built a new way to live and a different thing of recovery, and they're able to figure out their brain, their body can kind of catch up, they can heal, it can fix some of the damage, right. But for some people, maybe that use was more extensive, some of that damage is a little more extensive. Some things may not go back fully 100% to that pre using state. And so there may be in there are some people that find that long term, and maybe the rest of their life, medications is the only way that creates enough stability and consistencies behind the scenes. And so I think, you know, this one size fits all mentality, we want to challenge and get rid of, and say, it depends, right. And there's a lot of different journeys. And there's a lot of different things. And some people do get off medications for OUD. And they find themselves being able to have created and restabilized and healed and found a new way to move forward. I translate to like diabetes again, right? Like, so, of course, I'm told to lose weight, eat healthy, manage my diet and exercise and all these types of things. And for some people, that's enough to get them out of that diabetic range or out of that pre diabetic range, and their brains and their bodies and everything kind of figured it out, and you're good to go. Other people, despite being healthy and active and doing everything they're supposed to, their body isn't doing what it's supposed to, so they still need to take insulin or some of the other medications or things like that. So it's different for everyone, right? Like and lifestyle matters, but it might not be the same for everyone, you may be doing everything right. But if your brain and your body aren't able to get back to a state that is able to be stable and consistent and healthy, medications might need to be there for a longer term. So keeping those types of things in mind, right? It's not a one size fits all. There's a lot of things that go into it. It's a very individual experience with that. I do just like to highlight, right? It's more effective than abstinence only. The numbers don't lie. There's a lot of evidence out there, a lot of studies, a lot of research. We're seeing that these medications reduce use, increase time in treatment, lowers fatal mortality for overdose. They reduce other things that go along with it. Infectious disease transmission reduces criminal behavior, right? You fix one, the other problem sometimes goes away too. Things like that. I like to throw in a good naloxone here, approved by the FDA to reverse an overdose. So it is a quick fix. It's a temporary fix though. Those little buckets that are full of all the opioids, the naloxone comes in, kicks them off. And that's why breathing can resume and heart rate and blood flow and oxygen and all that kind of stuff allows the body to kind of resume normal functioning. It's an acute intervention. It is not treatment. It is just an opportunity to save a life, give somebody an opportunity to get better treatment and to go on and make some of these changes, whether it's medication based, whether it's other lifestyle based. So I like to highlight this idea of different pathways. It sounds like y'all had a really cool fitness pathway recently. I wish I had known about. I would have loved to have sat in on that training, but there's so many different ways to recover, to get to what your recovery looks like. It's different for everyone. There's clinical, there's non-clinical, there's self-managed, there's something for everyone out there, right? Like faith-based or natural based, equine therapies, music stuff is real big, art therapies. There's so many different ways that you can find your own journey. And just again, keeping that open mind of if you're in one of these boxes for your own journey, doesn't mean everyone has to be in that box either, right? It worked for you. Great. Awesome. Might not be the box for someone else. Or maybe I need three or four boxes to really get what I'm trying to do or where I'm going. Kind of keeping that type of stuff in mind. We highlighted a little bit earlier, and I liked when Haley put in that thing about, you know, what's right with you. At its core, I hope that you're in pathways that are focusing on strength building, you know, coping skills, resources, you know, all this type of stuff is really going to be important. But there's just so many opportunities and things to find what will work for each person. It's going to be different. Now we have some space for some questions. What else we got going on? You have had a very active chat going on here. I know, I got to catch up a little bit here. I love the engagement. Until someone raises their hand, can MOUD prevent people from picking up other addictions like shopping or gambling? So there's, again, the pathways in your brain, right? Whether it's a behavioral addiction, like gambling, or even unhealthy relationships, right? It mirrors the same disruption. We're seeking that dopamine from a person, maybe even at our own demise, right? It's an unhealthy connection, but we're now caught in this cycle of, I get this rush from being with this person, and I'm stuck, and I don't know how to separate out from that. You know, so shopping, gambling, video games, like all these other things are going to have a similar response behind the scenes. As of now, the focus has been really targeted on, you know, like medications for opioid use disorder impact opioid use, right? So you have a very direct connection. There's some cursory and other things going on out there that when you start to kind of balance and reset things behind the scenes, that there may be like a ripple effect to other types of things. They're actually using like Suboxone and paired with a couple of other medications to try and see where and how it might be helpful for methamphetamine use disorder. Even though it's opioid receptors and pathways, like is there a way to kind of find a balance with other types of things out there? And so there's a lot of still newness to that of like how far can things react. You know, yes, medications for OUD are really only impacting the opioid part on the surface, but we know that there's some residual effects like pain, right? So the pain disruption and the pain pathways and everything, if I'm now on Suboxone or methadones prescribed for pain management. And so it has the ability to kind of fill into these other spaces. And so I think there's still a lot to be learned, but if you're creating a healthier, you know, happy, focused, motivated, successful person, you will see an impact on other things that may be going on, but it might not be like a one for one. So I think we're still trying to tease out what the reach. So this question goes back. Loretta Billingsley wants to know if DNRIs help with dopamine disparity. I do not know what a DNRI is. Is that the norepinephrine dopamine reuptake inhibitors? Is that the acronym? I don't know. That sounds like a very... Does that sound like we're... Okay. So I'm in the right... We're getting the, you know, the alphabet soup here. So I don't know that it's going to like directly in itself like help or hurt really, but you do have something else then that's playing in the mix, right? So when you're putting something in that is trying to create its own stability and consistency in there, like there is going to be an impact on that. Now, is it going to be to the same extent that, you know, other things are? Probably not, but in the same realm, like it's not going to hurt to have something in there that's trying to create stability and consistency in the brain because ultimately all your mental health medications and things like that, they're doing the same thing, right? They're trying to create this homeostasis, recorrect imbalances and find this, you know, kind of stable, consistent environment so that it can be effective and responsive and healthy and all those types of things. So there's of course kind of going to be a magic number, a perfect storm of things. If I am taking other medications, what else is going on? What impact does that have? And that's where it also gets a little messy with trying to figure out what is this perfect place for everyone in their own recovery because other medications will play a role because they are affecting the chemistry. Maybe not to the extent that something for OUD is targeting OUD, right? That's a stronger response, but of course it's going to have an impact on there. So Andrea, Haley had a question a while back about is using MOUD, is that an inclusive term for people with alcohol use disorder who take Vivitrol? So Vivitrol is interesting. If you hang out with me next month, we're going to talk more about it. Vivitrol in and of itself, naltrexone is the drug or the medication behind Vivitrol. Vivitrol is the extended release shot that's generally been used for opioid use disorder. They also have naltrexone oral pills that have traditionally been used for alcohol use disorder. You're seeing a lot of overlap between the two. There's also some crazy things of like alcohol and opioids share a lot of space in the brain, right? If these medications are targeting some of these same areas. So we can chat more next month about those types of things. So come back and see me because we're going to talk about the big three medications and some of the nuances and things with that for sure. And Shelly Sitters had her hand up. Shelly, did you have a quick question? I did kind of, it was more of a comment, but you kind of covered it, but you were talking about the medications and kind of those how the medications can't really, they'll stop wanting to use more of the opioids or alcohol. But I guess it was just more of a comment on the behaviors that most people pick up while in an active addiction state, whether it be an opioid use disorder, alcohol use disorder. So wouldn't it be important for other things to address those behaviors? Because those aren't going to go away just because you take an STD or MOUD, sorry. What do we tell people in early recovery, right? Forget everything that you know, and we got to start over. And that's a frustrating thing to tell someone. Everything you're doing is wrong. Stop doing everything. We're going to replace everything. Like that's intimidating to be told, like, you know, something like that. So there's a tactful way to help prepare people for that, of course. But absolutely. I think I'd like to highlight that medication's right. For some people, medications alone are successful and they don't do all the other things that go along with it. But I'd say for most people, you've got to change everything and you've got to, you know, a lot of things need to be adjusted. And that's why treatment, that's why counseling, that's why working with peers, that's why because everything that comes up, you know how to deal with it when you're in active use. How do you deal with it when you're in recovery? How do you manage this? How do you make choices? How do you do all that? Like, and we'll chip away at some of those things in our next two sessions. So please come back and hang out next month in September because we're going to build on this stuff. So Andrea, if you could put the QR code in. I've had some people who are asking about it. I'm so sorry. Yes, the link's in the chat if that's your style. If you'd like to hold up your phone, scan the QR code. Again, ORN puts on these trainings free of charge because SAMHSA is giving them money to do so. The only way that ORN can prove that they're, you know, getting their money's worth, right, for what they're paying for is for y'all's feedback to be put out there. And with that, if there's stuff you didn't like, it's okay to put that in there too because we refine and adapt and we want to make sure these trainings are helpful and useful. So everything, feedback's just information. Good, bad, the ugly. Put it all out there. But please take five minutes to do that survey. Give some feedback so that these types of trainings can continue to happen. And if your question didn't get answered this time, come back next month. We're going to build on this. This is very exciting. Andrea, this was a great presentation. I've seen so much good comment in the chat. I know. I appreciate everyone who participated, chatted. Thank you so much. And I hope to spend more time with y'all next month. All right, everybody, look for your certificate sometime early next week. And make sure you save it to submit at the end of the year for your CEUs. Thank you. Thank you all. Yeah.

CARES webinar

Alvin Cotton

Georgia Council

peer workforce

addiction science

Dr. Andrea Yatsko

Opioid Response Network

SAMHSA

brain disease

medications for opioid use disorder

stigma reduction

CEUs