All right, so good morning again, like I said, my name is Sarah. I work for the Opioid Response Network, and we are a SAMHSA-funded grant where we provide technical assistance, which just means training and education. And your group reached out to me wanting to get some sort of like some one-on-one education out for you guys. And I have had the honor to reach out to Dr. Andrea Weber, who is going to be here with us today, who's going to do this training for you. So Dr. Weber, would you like to introduce yourself? Of course. Good morning, everyone. It is actually 11 a.m. my time, so slightly later than most of you. So I'm Andrea Weber, I'm a assistant, or sorry, a clinical associate professor at the University of Iowa. I'm the assistant director of our Addiction and Recovery Collaborative, which is kind of our addiction medicine subdivision within the University of Iowa's Department of Psychiatry. I've been working with ORN for a couple years now, I think, and I'm really excited to be here, learn from you, hopefully share some information that will be useful as you guys continue to grow and provide your services. Am I good to go all the way, Sarah? You too. All right, sounds good. So I'm just going to flip through some slides about the Opioid Response Network. Sarah kind of gave the brief overview, which the Opioid Response Network, ORN, is SAMHSA-funded. It's really trying to help provide resources and technical assistance for people. Initially it was kind of created around opioids. It's kind of expanded to both opioids as well as stimulant use. They really do try to localize people to kind of, you know, localize stakeholders, you know, people with experiences in certain areas based on the request, and try to keep it within the same region whenever possible. And they kind of have different specialists throughout the region. If you represent, work with different organizations and you do want to submit a request, feel free to go to the website. It's super easy. If you go to the actual, this webpage, it's like the top right corner, you can just say like click and submit a request. So they make it super easy for you. And then again, all of these materials are vetted through different people who work with ORN, so I'm not necessarily completely spouting off at the mouth and saying stuff that's not true, but there is a disclaimer that, you know, what I'm saying is not necessarily going to be explicitly, you know, representing the federal government, which is pretty standard with a lot of federal state type funding. And then again, overall, the mission of these types of trainings is to provide kind of information about prevention, treatment, and recovery efforts around people with various substance use disorders, especially people with opioid use disorders. All right. So I'm going to get a little bit more into my material. There was a lot of topics and information that was requested for this. So I will do my best to deliver it as high energy as possible, knowing that we're kind of all on Zoom and our computers, and that's kind of been a big transition for a lot of us in our professional and personal worlds with tele-video. But I entitled this kind of inclusive care for people with substance use disorders, and I'm really going to try to span talking a lot about different ways that we care for people who use drugs as well as have substance use disorders. A few kind of formal disclosures, I don't have any like pertinent financial disclosures other than I'm kind of a consultant that works with the Opioid Response Network. I will say that I am a harm reductionist, so in the realm of kind of providing addiction medicine care, I do see the world through a harm reduction lens and really try to prioritize those principles in my practice. And at the end of the day, I really love people who use drugs. I have a lot of friends and family with lived experience. I work with a lot of people with lived experience and various stages of use and recovery, and these are wonderful people, and I'm really passionate about making sure that they get really good care that I would want myself and my family to receive. So this is our roadmap, our path. So we're going to start looking at stigma, we're going to talk a little bit about different types of kind of U.S. drug policies, especially from a health care lens, about maybe how we kind of ended up here that informs some of our legislation. Talk about more of the neurobiology of maybe current models around addiction and substance use disorders. Talk about harm reduction, applying those things. We're going to spend some time talking about opioid overdoses, how to see them, how to intervene on them, utilizing naloxone. Then we're going to transition talking more globally about different types of treatments available for substance use disorders, really focusing on alcohol, nicotine, and opioid, which we have FDA-approved medications for. And then finally, we're going to talk about kind of recovery community organizations, how do we define recovery, what are some key elements of that. So again, we're going to spend some time with each other today. Now it's really important to me, especially when we're talking about policy and stigma, to really make sure you guys know who I am and where I'm coming from, and there's likely lenses to which I see the world that are influenced by my background, and those might be lenses that I don't even acknowledge or am aware of. So I'm 38 years old, I consider myself white, I'm heterosexual, I've been married for the past 10 years. I'm from Iowa originally, born and raised, trained here as far as my medical care. I've got two school-aged daughters. I grew up in a household, I have no lived experience with more problematic substance use. My parents actually never consumed any substances, they still don't consume alcohol. And so from where I grew up, this was not necessarily something that I was exposed to in that way. As far as some of my more professional kind of experiences then, so I went out east to Connecticut for college, came back to Iowa, went to the University of Iowa for both my medical school as well as my residency training. I did residency in both internal medicine and psychiatry, so that's kind of my background. I worked a little bit out in the community for about a year and a half after I graduated from residency, then came back to the University of Iowa, mainly because our department head at that time was really focused on trying to expand addiction medicine care and it sounded like a really awesome opportunity. In Iowa, we don't really have any under, or sorry, all of our kind of syringe service programming and things like that are considered underground because we have a pretty strict paraphernalia law. We have one more statewide harm reduction organization called the Iowa Harm Reduction Coalition. This is our little shield right here. And I currently serve as the board chair for that organization. And then I have this lovely, what's supposed to be a cartoon pictorial of a cannabis plant. Iowa has a medical cannabis program and I, part of that law created a medical advisory board and I represent psychiatry for the medical cannabis board for the state of Iowa. All right. So with that, we're going to transition into stigma and I will say I'm going to, I kind of split this up into segments. I do have the chat open. So if you guys have questions as I go through, feel free to throw them in the chat and I'll try to answer them in real time and or between each section. So really love interaction. Feel free to throw out questions or clarifications as you see. So let's talk about stigma. So stigma has a lot of definitions. There's a lot of, depending on what paper you read, if you're a sociology, anthropology, you know how this gets defined might change a little bit. This is one of, I think a definition that's a little bit concise and to the point that I usually go back to. And so this, this defines stigma as a dynamic process in which individuals and structures continuously engage in exchanges that are mediated by power, control, and domination. So really, you know, and I think stigma is not necessarily this fixed set point that that dynamic process is really important and it's all about power. Who has power? Who are we trying to limit in power and how we apply strategies to do those things, kind of how we utilize stigma. Stigma has a lot of categories. I'm going to talk about three. So we might think of stigma as being internalized, something that's kind of more interpersonal between one or two, sorry, two or three people, and then maybe more globally and institutional type of stigma. So internalized stigma is really the process to which an individual, a person, both cognitively and emotionally absorbs a lot of negative messaging or stereotypes about their actions. And they kind of come to believe that. They see themselves through that lens that maybe it's been applied to them over and over. This tends to cause a lot of anxiety, a lot of isolation. People kind of maybe lose themselves, lose this idea that they're worthy of love. And unfortunately, they kind of allow themselves to experience injustices through that. So an example of internalized stigma, if we think of maybe someone who is pregnant and using drugs or is using drugs and might become pregnant, we might have someone who, because they're using drugs, they find out that they're pregnant. They believe that they are a bad person because they are using substances during pregnancy. And so subsequently they delay or they avoid prenatal care because they kind of feel like they're not worthy of that care or they're going to be treated poorly anyway. So then kind of expanding the bubble a little bit more, if we think of stigma and how that plays out in a more of an interpersonal fashion, this is kind of how stigma gets reenacted and manifested between individuals. And this can change depending on circumstances. So for example, if someone is using substances, maybe they use with their partner or with a family member, if they find out that they are pregnant and they still use substances, they might experience kind of some of this new kind of judgment or response through their partner or their family because they continue to use substances while pregnant. And unfortunately, especially when we talk about interpersonal stigma, we don't necessarily see education as being something that's protective against this type of stigma. So for example, when they've studied and surveyed primary care doctors, potentially people who have learned that substance use disorders are a medical condition, they have treatments, we should see that through that lens, 75% of those physicians said that they would not be willing to have a person with an opioid use disorder mirror into their family. And over 50% of them said that they actually thought that people with opioid use disorder were considered dangerous. So again, these are educated people, people who have maybe seen and kind of experienced the medicalization of a substance use disorder, but still maybe carry some stigma around how it applies to their family. And then again, that kind of third type of stigma, we might think of stigma as being an institutional level. So this is how kind of an organization, a group of people, a system, if you will, how their negative attitudes, beliefs, and then kind of subsequent policies start to negatively affect either how a condition or a group of people is how they're treated. These types of stigma, this type of stigma gets written into laws, into policies, into how we allocate social services, for example. And if we kind of think about substance use in particular, this is really what informs a lot of the underinvestment that we've seen in addiction treatment infrastructure. It leads to a lot of discrimination with insurance benefits, employment, housing around people who use drugs or have a history of a substance use disorder. Here in a lot of the sessions, we've seen a lot of our elected officials say things like we're not going to extend, for example, a child credit to people because their parents are simply going to use it to buy drugs. So a lot of stigma that gets applied in how we allocate social resources to people. Stigma around substance use, I think if we look from a really critical lens at the United States in particular, there's a common theme that has happened where if there has been a group of people that we decide we would do not welcome, we would like to have them leave, we would like to kind of maintain power over, for example, there has been a plan or a way to do it where you take that group of people, you associate them with a substance, and then you criminalize that substance really heavily. And you kind of create almost this propaganda machine around it. This is what happened with cannabis. So cannabis was used medically in the United States up until about the 1930s. Right around the 1910s, we saw Mexican immigrants coming to the United States. There was a huge kind of anti-Mexican immigration sentiment. They found that Mexican immigrants used a lot of marijuana. And so they associated kind of marijuana as being this substance that caused laziness, that made people not helpful in society. And then we passed the Marijuana Tax Act, which basically made cannabis unavailable until it was ultimately replaced by the Controlled Substances Act and remained a Schedule 1. This is also what happened with opium, with heroin, fueled a lot of kind of heroin being associated with the Black community, especially the Black jazz community, and a lot of the heavy criminalization about those groups of people. And you guys may have heard about this or known about this in the past, but Richard Nixon and his administration were kind of felt to be one of the really large amplifiers of some of our war against drugs policies and how they kind of utilized these racist sentiments against substance use and kind of create a policy around it. And this was an interview that was done in 1992. So this is John Ehrlichman. He was the primary counsel to President Nixon. And in this interview, he kind of just came out and said the quiet part out loud. He just said, you know what this was really about? Nixon had two enemies. He had the anti-war left and Black people. We knew we couldn't make it illegal to be either against war or Black. But by getting the public to associate hippies with marijuana and Blacks with heroin and then criminalizing both heavily, we could disrupt those communities. And really that last sentence is, you know, lying in the sense of when we said, you know, all of these substances would make people, you know, really crazy or make people menace to society or violent or those things, kind of, again, lying about some of the exaggerated features of substance use in order to really criminalize those communities. And as we were talking about this, we were also talking about the fact that we were And as policies do, we tend to get the results that policies are created to get. And so if we think of stigma, if we think of that being applied as kind of a structural racism, we know that communities that are historically excluded have had worse substance related outcomes. They tend to have more alcohol related illness, more disability, more premature death, tend to have more involvement with the carceral system, higher rates of overdose, and they're less likely to seek treatment, even if we control for things like the Affordable Care Act and insurance coverage. You know, I was alive, but not necessarily conscious of what was going on in the world during kind of the, you know, crack cocaine epidemic in the 1980s and 1970s, 1980s or so. But if we just compare those two, you know, arenas, we can kind of see how the structural racism and kind of through a stigma lens got applied. So the reaction to when crack cocaine was really negatively impacting a lot of Black communities, especially in more urban areas, was kind of met with this militaristic violence of we need to create this war on drugs. We just need to fight it. We need to criminalize a lot of the behaviors that are going on. And if we contrast that a little bit to what we saw maybe with the opioid epidemic more recently, you know, the opioid epidemic primarily was affecting working class, white communities, much more affluent communities. And we saw that the reaction this time around was, man, this is a public health crisis. We need to we need to increase treatment. We need to kind of view this through a lens of not necessarily fighting it like it's a war, but really trying to help people through a medical lens. Now, is it possible that we just got smarter and better, maybe? But I also think that there was a huge racism lens that got applied when we kind of think about how we responded to crack cocaine versus how we responded to opioids. And a lot of the structural racism just has been perpetuated in the legislature over the course of decades. So, you know, drugs were kind of considered this national security threat. We still see that language. We still see it applied to things like fentanyl nowadays. We talk about things like mandatory minimum sentencing. So nonviolent crimes, if they involve drugs, we see these really elevated sentences for people involved in the carceral system. And then even in policies, in which case, you know, different forms of the same substance carry a higher penalty, even, you know, just because that's the substance that's more commonly found, let's say, in a black community than a white community. And even though like different administrations have lessened that gap, for example, with crack versus powder cocaine, it still exists. There's a big difference between if you're found with powder cocaine versus crack cocaine, realizing that powder cocaine was much more commonly used in white communities versus crack cocaine, which was more commonly found in black communities. And, you know, a lot of these policies, a lot of these laws have created what you'd anticipate. So we kind of see in the 1980s, this huge surge of more of our black community members being involved with the carceral system, much higher drug arrest rates compared to our white communities. And it doesn't really lie up to what we know about who's actually using or selling drugs. So, again, if you look at this table, you'll kind of see in that first bar graph, people who use drugs versus people who sell drugs, pretty even. If anything, you know, people who identify as white tend to use drugs more often than people who identify as black. And yet, if you look at people who have had arrests or carceral involvement, we see much more commonly that black community members are going to be arrested, more likely to be incarcerated, both at a state and a federal level. And at a state level, I want to share some data from Iowa, because we're no different in a lot of these aspects. And so this was a study, they gathered about 180 people who were using drugs in Iowa, people who were active participants of the Iowa Harm Reduction Coalition. And they partnered with the Iowa Department of Public Health and did focus groups with people and asked them a variety of questions. And these were just some of the questions that they asked. And I think especially from a treatment medical lens, you know, this is stuff that really fuels why I do what I do and try to provide kind of different types of care for people. So they asked a lot of the participants, in the past 12 months, was there a time you thought you should go to a health care provider for a medical or physical issue, but you didn't go? Majority of people said yes. And when they asked him, well, like, why didn't you go, the most common reason they didn't go is because they didn't want to be judged, you know, that that interpersonal stigma that they feel, they didn't want to be judged for that. And that was a huge reason why people wouldn't seek appropriate medical care, which is really sad. And so I think we just, you know, could all do a lot better in recognizing how difficult we make it for people when they use drugs or have substance use disorders to kind of present themselves in different institutions. And this is just some of the free responses, especially if you work in health care that I think are worth, you know, worthy of thinking through. So one participant said that, like, I was basically told I wasn't worth treating because I wasn't going to live anyway. I don't want to get care or talk to people about my substance use because all I'm going to be is a drug user. That's kind of my identity. That's all I'm going to be associated with. People didn't think that their health care information would actually be protected. They associated the hospital with the cops. And that was kind of an association that they didn't want to be interacting with. They never had anyone tell them that they could come to them or they could trust them. And they said it was really hard to get mental health treatment because they kind of felt like everyone just saw them through their lens of substance use and no one was really wanting to address maybe the underlying mental health issues. Again, even though we know that those are really concurrent, really commonly comorbid for our patients. I'm going to leave our stigma section with just this slide. I think there's a lot of, you know, we could have an entire discussion about ways to possibly kind of decrease stigma, especially as a barrier in different avenues of our health care system. But I think one of the probably the lowest hanging fruit ways is to try to really pay attention to the types of terminology that we use. I think this is becoming more common. I don't think people, I don't think anyone really likes their language being policed, but I think it can be really helpful just on an individual level to really reflect on the different types of words that not only we say to each other, to ourselves, to patients, but then also types of words we use in our charting. Things that follow people sometimes and now with electronic health records, I kind of follow people for a long period of time and really being conscious about what type of language that we utilize. So just for example, you know, instead of using a term like narcotic, which is a legal term, you know, just using substance, a little bit more benign, a little bit more medicalized in that way. Instead of saying abuse, saying something like use disorder, chaotic use, high-risk substance use. Polysubstance, I usually just train my learners, especially when I'm talking to our addiction medicine trainees of, you know, when someone says they have a polysubstance use disorder, I don't really know how to treat that, right? Like, there's not a medicine that's FDA-approved for polysubstance use disorder. And so I really encourage them, like, you know, like, we really need to tease out, like, what types of substance use disorders does this person have? Because that will help me actually pick appropriate treatment. So just being a little bit more thoughtful, a little bit more purposeful with those diagnoses. Again, using person-first language. So instead of calling someone, you know, alcoholic, addict, junkie, really trying to call, you know, say someone, this is a person with a substance use disorder. We know a lot of people self-identify in different ways. I think sometimes if people self-identify as an alcoholic, people can self-identify how they want to, and I support them in how they want to. But I also feel like sometimes that's internalized stigma that's coming through. We've kind of applied those terms to people, and now they've kind of, like, internalized it and owned it, usually in a positive way, in a kind of redemption way. But I also feel like that's a sign, just more and more, we need to start reflecting on the language that we utilize. And then probably another big one is just kind of clean, dirty. Again, there's a lot of morality tied up into kind of this dichotomy of something being clean versus dirty. And so, especially from a medical perspective, really just trying to focus on things being positive or negative. Someone's history, someone's drug test being positive or negative for a specific substance, even those little things, not only can help us reduce stigma for our patients within other healthcare systems, but I think there's evidence to suggest that it also helps us feel better about our patients, about our populations that we're treating, maybe helps reduce some of our burnout and our emotional burden that we carry for certain patients. Okay. We are transitioning to step two on our roadmap, and we're just going to talk a little bit about some U.S. drug policy. And again, this is a broad category. This could be like an entire college seminar. And so, I'm really going to focus a little bit more on kind of healthcare policy, things that we know both from healthcare and the law that contributed, especially to the rise of opioid use disorders and opioid overdose. So, back in 1980, in the New England Journal of Medicine, pretty prestigious medical journal, there was a letter to the editor that was published by Dr. Jick and Jane Porter, who was kind of a research assistant at that time. And really what they said is, you know, we're just a short paragraph to summarize some information that we got from our medical record. We looked at our files, and we looked at about almost 40,000 hospitalized patients. And of those patients, about 12,000 received, you know, some sort of a narcotic preparation. And there was only about four cases of that group that went on to be diagnosed with an addiction. And again, they kind of said that the drugs that were included were things like meparidine, just two kind of full agonist opioids that people received. And their conclusion was that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction, because that was also a prerequisite. It was not someone who had a history of substance use disorder. Now, from a quality of evidence, right, we don't do anything in medicine based on a letter to the editor. You know, ideally, we have high-quality studies and randomized controlled trials. We have systematic and meta-analyses. And ideally, you have something that's repeated over and over again before we start to include that as kind of a foundational change of practice or something that, as a field, we should be transitioning to thinking about. And so by no means is this kind of a high-quality journal of anything. It was just like a, oh, by the way, we saw this thing in our health, in our single institution health care system. And yet what happened as we started to see kind of opioid, you know, different sort of marketing schemes is, you know, this letter to the editor, the Porter and Jiff article, got used and kind of described in a lot of different ways. So for example, in Purdue Pharma's OxyContin marketing materials, they use this to justify the statement that less than one percent of patients treated with opioids become addicted. That is not what this letter to the editor said. A highly misleading statement. This was called an extensive study by Scientific American, so becoming a little bit more of a popular, you know, slash scientific publication. And this was even referred to as a landmark study, showing that exaggerated fear that patients would become addicted to opioids is basically unwarranted. This was published in Time Magazine in 2001. Okay. So we have this article. This was 1980, about 15 years later. This is when OxyContin was FDA approved. And really when Purdue Pharma started marketing directly to physicians that OxyContin was a safe alternative to what was on the market at that time, which is basically an opioid plus acetaminophen or Tylenol. They said like, oh my gosh, all that Tylenol is so bad for your liver. You should put your patient OxyContin because it's safer because there's no acetaminophen. That was kind of the tagline there. Right around the same time, pain medicine as a specialty was becoming more common. So there was new medical societies, people trying to like kind of increase their influence, increase their memberships, increase their fees that they could kind of utilize to take care of their field. And right around this time is also where this idea of pain as the fifth vital sign came from. And this was coined by James Campbell, who at that time was the president of the American Pain Society. So you kind of have this, we have this article that's kind of being misrepresented. We have a company that's making a new product that's really motivated to kind of increase its market share by increasing how often it's prescribed. Right around the time, you have a pain specialty that's really also trying to increase people wanting to pay attention to pain and trying to treat that more aggressively. In 2000, we had the Drug Addiction Treatment Act of 2000 that was passed. This was the law that allowed us to utilize medications that were FDA approved to treat opioid use disorder that were at least scheduled three in a clinic setting. And right around 2002, we had the only drug that currently falls into that category, which is buprenorphine. So this was kind of the law that created the buprenorphine waiver, the DEA waiver, the X waiver is also what it's called, that allowed doctors to prescribe buprenorphine. Also around this time, we had the Joint Commission, which is a group that kind of monitors the quality of a lot of hospitals in the country, especially ones that accept Medicare, Medicaid. They started to kind of jump on the bandwagon and said, yes, we need to pay more attention to pain, in which case they started to enforce that you had to have pain assessments for all of your patients. And if you didn't, you weren't going to be accredited. And it had to be well-documented. You had to address what you were doing to assess or to react to those pain assessments of note that subsequently being eliminated. But again, kind of adds to this people really wanting us to treat pain more aggressively. Now, between 1995, 2010, you've got this direct to physician marketing. You've got more prescriptions for chronic opioids or people with chronic non-cancer-like pain. And a lot of people on boots on the ground were saying, hey, FDA, we've got some concerns. This medicine does not seem to be as safe as it was marketed to me. I have a lot of patients who are having developing use disorders related to this medicine. Something needs to change. And so under a lot of pressure in 2010, the FDA really kind of tried to force Purdue Pharma to create an oxycontin that was abuse deterrent. And they really just reformulated it. So it was a little bit harder. If you tried to dissolve the oxycontin tablets, it would kind of create this gel-like substance versus the previous tablets where you could kind of just remove the outer film in order to kind of dissolve or crush up the medication. And then right around this time, we also just see that globally, a lot of prescription rates start to decline. Again, I think people's boots on the ground were like, yeah, we want to treat pain, but this does not seem to be this like magic bullet that you guys all made it out to be. So then we start to have more guidance, more desire, more laws to really try to increase access to substance use treatment, especially office-based substance use treatment. So in 2016, we had the CDC put out their first kind of set of guidelines around prescribing opioids for chronic non-cancer, non-sickle cell pain. So really trying to say like, hey, this is how you should be doing this. We haven't really had to do this before, but since so many people are prescribing opioids, we probably should try to provide some guidance. This is also when the CARE Act was passed, which just increased the ability of our kind of nurse practitioner, our PAs to also prescribe buprenorphine, basically non-physicians who could also prescribe. We ultimately had the U.S. government saying, hey, this opioid epidemic is being identified. This is a public health emergency, again, viewing it in more of a public health light rather than that criminalization that we talked about before. Shortly after, again, we have more funding available. They start to remove this X waiver that got created with the DATA Act in 2000 because they felt like that was limiting people's ability or desire to utilize buprenorphine or to get buprenorphine in the office-based setting. Further laws to kind of make it easier. Ultimately, we have that waiver requirement being removed completely back in 2022 in December. That was with the MATE Act. And then we have another set of updated CDC guidelines that were, if anything, they were almost more gray because they felt like a lot of doctors were kind of getting lost in some of the numbers. And so they wanted to give a little bit more of grayness to say like, hey, just, you know, between the patient and physician, you guys need to work it out. Here's some guidelines, but we're not going to say like you must or you should to keep things below, like, for example, a certain amount of morphine mill equivalents if you're using that for chronic pain. Now, if we think about that timeline, right, so 1990, the Porter-Jic article, 1995, we have the FDA approval of OxyContin. We see prescribing rates start to go down in 2010. And then we kind of start to have this desire to increase access to buprenorphine in the office-based setting for treatment for opioid use disorder. And so we've kind of superimposed that. We kind of see what this looks like. So we start to see a rise of prescription opioid deaths, you know, starting around 1999. Makes sense. This is when we started to have OxyContin, more prescriptions of chronic opioids in the community. Right around when OxyContin was being reformalized, we started to see that heroin as the cause of opioid-related deaths starts to rise, just as basically as OxyContin becomes more difficult for people to access, they start transitioning to the different market that's cheaper, easier to get in the form of heroin, which unfortunately is, you know, unregulated. People weren't really sure what was in their product, but at that point, it pretty much was heroin. And then in 2013, that's really when we started to see this surge of opioid-related deaths, more consistently related to our synthetic opioids. These are our fentanyls, our carfentanils, basically non-methadone type of opioids. And unfortunately, there hasn't really been much significant decrease. We've seen some plateauing a little bit, but if anything, we're just seeing surges of different, you know, overdose deaths related to things like stimulants, for example. So again, increase of prescription opioids. When OxyContin became difficult to get, people switched to heroin. And then as the market does what it does, as we start to criminalize things heavily, the market's going to shift to a product that's more potent, easier to transport because of lower weight. And that's how, you know, we started to see a lot of fentanyl being involved in a lot of our different drug supplies. And then, you know, I think it's always good from, you know, when we think about policies in our population level, just kind of putting a pulse on the matter, right? So the Substance Abuse and Mental Health Services Administration does this national survey on drug use and health every year. And they send people out into the community, they ask them about what's your substance use like, do you qualify for a use disorder based on our criteria, mental health services, things like that. And they extrapolate that data to the entire population, really focusing on people who are in non-institutionalized settings. And what we know from that data, at least in 2022, that about 25% of people during the course of the past 12 months said that they had used some form of an illicit substance, most commonly being cannabis. And then if we look at people who then met criteria for a substance use disorder, of people, kind of, you could think of about 17% of people said that they met some sort of criteria for a substance use disorder. And then again, it's not really fair to compare the top to the bottom, because the bottom would also include alcohol. But you kind of see the drug use disorder being 27.2 million people relative to maybe the 70.3 million people who said that over the past 12 months they had used drugs. And so, when I take these numbers, if I take, okay, if I divide 27.3 million people with a drug use disorder, divide that by 70.3 of people who have used some sort of illicit substance, that equals out to about 38.6% of people who have ever used a substance going on to develop some sort of substance use disorder. And then depending on what substance you're talking about, most of those people might be a mild use disorder versus more moderate to severe. And so, although we talk a lot about substance use disorders, you know, I think there's also a lot of intervention to do for people to actually just maintain safety and maintain around, you know, substance use that isn't necessarily a use disorder, just because most people who use drugs actually don't develop a substance use disorder. So, if we want to think about prevention, we might think of people who have a history of trauma, and really, you know, especially kind of pervasive trauma, people during key developmental periods, you know, during childhood, for example, people who are genetically predisposed, try to do prevention efforts to make sure people aren't using early in life. We know that earlier you use a substance, the more likely you're developing use disorder. Really focus on good mental health care, making sure people have access to good physical health care, because untreated, those two things increase the risk of a substance use disorder. And if we think of our chronic pain populations, really trying to facilitate better access reimbursement for really high quality pain management, because if people just have chronic unspecified pain, they're also more likely to develop a use disorder, especially if we talk about opioids. And then again, if we think about US policies, and kind of where we are now, Richard Cohen, in 1986, kind of describes what he was kind of been termed the iron law of prohibition. And this is really the idea that as law enforcement and criminalization becomes more intense, that the potency of a substance that's available tends to increase. And he's kind of quoted as saying that like, if the demand is not satisfied through legal means, it will inevitably be satisfied by the legal market. We've kind of seen this throughout history, right? We saw this during prohibition with alcohol, where we're starting to have alcohol products kind of moonshine that was extremely potent, if not laced with alcohols that were not really made for human consumption, it could cause things like blindness. We saw this with cannabis, we see and then you know, if we think about opioids, we see you know, we had opium initially that was kind of freely available at dispensaries at stores. We saw that kind of transition with criminalization to heroin, and then more recently into more of the synthetic opioids that are really driving a lot of our opioid overdose deaths. So I give a talk to our students and our residents. And you know, part of the talk is we talk a little bit about, you know, drug decriminalization and what that means. And I always like threw up prop 110 of like, this is kind of what Oregon was hoping and kind of thinking about when they really were the first in the nation to decriminalize, you know, personal possession of different drugs with this idea that they were going to save money to reduce kind of prison jail costs, they were going to hopefully free up law enforcement to do other things that were probably more important for public safety at the time. Try to prioritize treatment over punishment for people with substance use disorders, hopefully reduce stigma, hopefully reduce barriers to get kind of good harm reduction services in that way. I acknowledge that as recently as like last week, you know, the prop 110 measure kind of got reversed. I think if we have time, I would love to hear people's thoughts, just as people who are living in this environment in the state and how it's been going. I've read a lot of articles about kind of what fueled it, you know, a lot of what the pros and cons of people have said about this, you know, kind of this feeling that we felt like there was issues, maybe those issues were being misapplied to what prop 110 was meant to do, but then also some criticism that prop 110 wasn't carried through the way it was hoped for, that a lot of those cost savings were not being trickled down quick enough to the services that I think, you know, clinics like you guys are trying to provide. So, but again, I think decriminalization is still something to think about and how our aspects of criminalization have led, especially to things like overdose deaths and, you know, ways to mitigate that. And I still think I'm still really jealous, if anything, of people who have practiced in a state where even just the idea that we're going to try this, you know, decriminalization for a period of time. And again, hope to talk to more of you about this going forward. Okay. Step three, this is kind of, we're going to almost, it's really a huge jump. We're going to talk about, you know, transition from stigma and policy and really talk about hopefully in the brain, kind of what we understand about what's going on. Full disclosure, I am not a neuroscientist. So if you are, if you have more in-depth understanding of things in the brain, I apologize if I say anything wrong. I'm usually, I'm talking to groups of people who actually do like brain research and stuff. So I just try to put a disclaimer, if anything, just to lower your expectations a little bit. If I start to try to talk about brain circuitry and I say the wrong things. Now, when we talk about, especially the development of a substance use disorder, if we think of risk factors, again, some of those risk factors I brought up before, there's always this discussion of, well, how much of those risk factors are the fish, the person, things that are inherently part of them versus the bull, the environment that they're either raised in or living in at the moment. So if you think of things that might be the fish, we might think of, well, what's their family history? Are they genetically predisposed? What are their underlying mental health or physical health conditions? But then if you think of they're in bull, right, of their environment, were they exposed to trauma? Are they still exposed to trauma? How old were they when they were first exposed to a drug? That might play a lot into their environment of just accessibility. Did they grow up in poverty? Are they still in poverty? Different types of abuse experienced. Did they grow up in kind of neglecting areas? And then did they experience kind of chronic stress? Are they still experiencing that? And are there ways to intervene in that way that might meaningfully change what happens to a use disorder? And I think these are still important things to think about because we had a lot of people who would have met criteria, let's say, in the Vietnam War for an opioid use disorder while they were in Vietnam, but we know a lot of those people came back to the United States. They were out of that environment, out of war, back with their support systems. And a lot of those people never used opioids again, and they didn't require treatment for it. They just stopped. And so there's a lot of things that just inherently about our environments that play a role into both our predisposition but our development of a use disorder. And thinking specifically then about age of exposure, right? We know that our gray matter tends to mature as we age. It tends to mature first in some of our impulsivity things, but last in some of the parts of our brain that help us weigh kind of more abstract long-term risks with short-term gains. And so the matters in development through substance use disorder is that if you expose a 12-year-old brain to a substance, that's going to be very different than exposing a 30-year-old brain when we talk about things like their ability to use executive functioning and higher level reasoning. Whereas if I'm young, I probably just have a lot of impulse, a lot of emotion, and that's going to drive a lot of my decision-making and potentially increase my susceptibility to a use disorder. All right. So I'm going to look in the chat. Target more. Yeah. Yeah. That all sounds not surprising. Yeah. Just about some of the factors as well as the timeline that maybe got delayed. Yeah. Gosh, yeah. I'm sure everyone agrees with me that I feel like we lost time between 2019 and 2022. I just feel like there was a black box of everything. Yeah, that's great. Yeah, hopefully we have time to talk more about this. Thank you for the chat. So I'm gonna, this is a model that's been kind of developing with Nora Volkow and Dr. Kube, and so they've published a different, a few kind of growing series about it as we maybe flesh it out, understand it better. And so the idea that they have is that basically all substances that can predispose or kind of create an addiction tend to either directly or indirectly increase the amount of dopamine that's released from our ventral tegmental area. And that's a part of the brain that kind of interplays with things like mood regulation and mainly our reward pathway in particular. There's a lot of different systems that interplay. So the cannabis, the endocannabinoid system plays into that. Our endogenous opioid system plays into that. But really we think of dopamine as this primary reinforcer of behavior and kind of seeking out something as a priority. And so I'm gonna go through each of these stages. We're gonna start with the blue stage. So this is kind of the binge intoxication phase. The primary part of the brain that's involved is what's called the basal ganglia. This includes a few different places. This includes the nucleus accumbens, the dorsal striatum. Those are parts of the brain that are involved in motivation, reward, and habit formation. So really if you think of activating that part, this is gonna make, if you do something and dopamine reinforces like, hey, that's a good activity. We should keep doing that. That part of the brain is gonna say, hey, this is really important. We need to keep doing this. And so it's this part of the brain that we think leads to this incentive salience. So this idea that we need, we start to prioritize this as being really important, really salient for us to continue doing. And it's this part of the brain, again, I think it's important to, more and more research is being done to kind of distinguish this idea of liking a behavior versus wanting a behavior. And so what we think is happening, right, is that dopamine tends to be more a part of reinforced learning and motivated goal seeking. So kind of this wanting effect, like I need this, regardless if I like it, I need this. Dopamine tends to play much more in that learned behavior versus liking something tends to actually not engage dopamine that much. It tends to engage more of our endogenous cannabinoid system, as well as our opioid system. And this makes sense because one of the treatments we're gonna talk about later is something called naltrexone, which blocks some of our opioid receptors. And this is kind of explains if we block the liking effect of, let's say, drinking alcohol, people just don't enjoy it maybe as much. They don't crave it nearly as much. It's not really something that they would continue doing because it's just not providing them the same reinforcement as it used to. So again, just this idea of liking something, which is maybe more the opioid cannabis system, our cannabinoid system in our brains versus wanting something, that reinforcement that this is a necessary thing for us, which is much more reinforced by dopamine. And if we look about different substances, things that we associate with use disorders on a more prevalent basis, we kind of see that if we look at how it affects that VTA, that ventral tegmental area, as well as the nucleus accumbens, we kind of see that they all either directly or indirectly increase dopamine activity. So stimulants do it directly. They just kind of sit there and flush dopamine into the system. Opioids do it kind of both ways. So if we look at the use of opioids, so not only do they kind of indirectly increase dopamine, but they also, again, activate that opioid system. Alcohol kind of does similarly to opioids, except the increase of opioids more kind of indirect because it's not a primary activator at the opiate receptor. Nicotine itself is going to activate dopamine. It does so very well. Nicotine is a very well-designed drug to get our brains to continue wanting to do it. Activates those same dopamine neurons in that VTA, and then also acts directly on our nucleus accumbens through the endocannabinoid system itself. And I've seen at least two iterations over the past two years of this process. And so there's just a lot of research going in, which is awesome. Super exciting. Hopefully it leads to some translational treatment options. So let's, you know, we're still in that blue area, that binge intoxication phase. And so this kind of looks a little bit about what's happening about when someone is naive to a drug, so has never used it, versus someone who's being exposed to a drug. And so drugs that interact with kind of our nucleus accumbens, our ventral tegmental area, they can change both kind of this phasic increase of dopamine, so episodic kind of increase, decrease, as well as this tonic. So almost like the baseline changes for how much dopamine is being transmitted from the nucleus accumbens. So you kind of see, if you take someone who's just kind of the general population, not someone who uses drugs consistently, they might have this phasic release of dopamine, but their baseline's kind of at the same baseline for most people, versus someone who's actively using a drug, you might say that their baseline's elevated. So they kind of have a lot more dopamine activity from the nucleus accumbens, at least maybe in the acute time. When they use drugs, that black filled circle, or that black filled triangle, the dopamine increases phasically. And then this white triangle is actually just trying to show, like, even if they think about drugs, if they have a cue in their environment that reminds them of drug use, even that cue enough is usually enough to give people a phasic increase of dopamine in their brains. And if they use the substance immediately or like kind of time-wise following that cue, then the phasic increase of dopamine is even higher. And so we see the brain responding, you know, very aggressively for people who are using certain substances, and probably for people who develop substance use disorders, this leads them to a lot of changes of behavior that really start to prioritize utilizing that substance. All right, now walking this path of this circle away from our binge intoxication phase, we go to this red area. This is the withdrawal negative affective phase. So this is a part of the brain or the stage of the cycle of addiction in which someone starts to experience a really negative emotional state in the absence of a substance. It's usually involving like a lot of stress hormones and especially this extended amygdala, which is a part of our brain that's kind of our emotional stress center. And then it's connected to our memory portion of our brain, our hippocampus. And so, you know, we don't remember anything as well as we remember sometimes kind of this desire to not experience negative stuff. And so this really big connection in the addiction cycle starts to facilitate people having this really strong negative experience after they've been using drugs and then kind of tapping into their memory bank to try to relieve themselves from that. So if you think of this stage, people are going to have increased sensitivity to negative experience. So the bad is going to feel even worse. Pain is going to feel more heightened. Distress is going to feel more heightened. What would maybe make someone sad a little bit is going to make them extremely dysphoric, for example. And this is going to be enhanced not only by kind of the lack of dopamine activity, but from like stress hormones, our norepinephrine, that fight or flight part of our brain. And it causes someone such significant distress that they're going to seek out something that's going to give them relief from that. And they might tap in to their memory bank, that hippocampus, to say, hey, brain, what did we do? What did we do to get to not feel like this? And our hippocampus might say, oh, hey, we used to use this substance. And so this will kind of get into our green area. We're going to stay in the red area for now. And so again, this extended amygdala part of our brain tends to make us kind of not feel the reward that we usually feel, and also make us feel negative stuff really strongly. So the good stuff isn't as good, and the bad stuff's really, really bad. And if we look a little bit again at kind of our dopamine as kind of a driver for this need, this wanting effect that tends to play a huge role in people having a substance use disorder, we know that dopamine concentrations can return to basal levels, or they can kind of be above with drug use. So again, we kind of have this baseline. We kind of talked about this person who's maybe drug naive, never been exposed, having phasic increases of dopamine. Then we talked about during their drug use, they have this baseline increase, and then they can have some phasic increases and decreases. Then if we go to this red stage, this withdrawal phase, when someone is without their substance, especially after they've been using for a while, their tone, their baseline of dopamine activity actually goes down. In which case, if they have a non-drug cue, they might have a little bit of an increase, but not enough maybe to even get them significantly above baseline. If they have a drug-related cue, they might get more above baseline, interestingly enough. So if a non-drug cue is something like good food, for example, maybe they don't enjoy that as much. But if I give them a drug cue, they're going to have much more of a phasic increase of dopamine. Subsequently then, if they use the drug or return to their drug use, very quickly their dopamine levels are going to return to that elevated baseline, and they're still going to get those elevations with the phasic type of use. So again, a model of what's going on in the brain as far as dopamine really driving both people craving a substance, but also maybe why they feel so poorly in that early recovery stage. Some psychotropic medications, prescribably can increase dopamine. Yeah, I think these models were not necessarily applied to people who were on chronic antipsychotics or even things like aripiprazole, which increase certain types of dopamine in certain receptors. It's also unsure if those medications actually affect dopamine levels, or they just affect how much dopamine or how much activity is happening at the dopamine receptor, if that makes sense. And so I can't really say intelligently how those medications might affect some of these graphs. It's a great question, though, kind of thinking of especially a lot of our concurrent patients with severe mental illnesses and substance use disorders. So again, if we translate that, so this is a graph that I sometimes talk through with my patients when we talk about opioid agonist treatment for opioid use disorder, so primarily things like buprenorphine or methadone. I'll kind of say like, hey, you got exposed to this substance, and you were having really positive benefits for a while, or these kind of positive experiences. And at a certain point, your body got used to it. And now you're in this chronic phase where when you don't have it, you feel really bad. And it's beyond sometimes a physical bad. Like sometimes people psychologically feel really bad in withdrawal phases. And we see that especially in substances that don't really have a huge physical withdrawal. So for example, methamphetamine. Methamphetamine physically doesn't necessarily cause a lot of the symptoms that we associate compared to like alcohol or opioids. But psychologically, people feel bad. Like they feel real bad. Mood is low. They're not sleeping. They're anxious. And that can be a huge burden for them to carry. And that's also what's happening during this chronic use phase. And so often what we're doing with our medications is to not only physically get them back to that kind of normal physiological state in the maintenance phase, but also try to give their brain some relief so that they're not trying to fight against maybe that lower amount of dopamine activity that they're experiencing in that early withdrawal phase. All right. And then finally, again, we're kind of moving ourselves around this circle and we get to this green area. So this has been called the preoccupation anticipation phase. And this is a stage in which someone seeks a substance again after a period of abstinence. And that tends to be mediated by this interaction, both with our prefrontal cortex, which is kind of the part of our brain that helps us make decisions in kind of ways, risks, benefits, things like that. Also tapping into our extended amygdala, so our stress mood center, and then also our basal ganglia. So this idea of how important is this activity based on maybe how we're feeling emotionally, for example. And really what's happening, it's kind of interaction between dopamine and glutamate. And a lot of people have referred to this stage as kind of the stop-go system or this imbalance of stopping and going. So this idea that there's this over-activation of the go system, in which case, if you think of that basal ganglia area, that wanting phase, they're going to say like, oh yeah, we got to do it. We got to go get it. We got to use the substance. Let's go. Let's go. It'll be fine. It'll be fine. And the part of our, if you think of our devil and angels on our shoulders, the stop part of our brain is just weak. It hasn't been built up that often, especially if we think about early recovery. And so that's kind of the squeaky voice that's like, hey, we probably shouldn't. Do you remember how badly we felt? Think of all these things that are really important to us that we know kind of get diminished. But unfortunately, that go side is still really over-activated relative to our ability to kind of weigh some of those negative effects, or if anything, inhibit some of that stuff. And so as people progress into recovery, and this is kind of beyond treatment, right? We know that with time, but especially if we think of a lot of our interventions, is to really help people stabilize their stop system, to really help people say, hey, you're going to have cravings. You might have impulses. You might see something that's going to cue you to your substance use. And our goal is to really allow time, but then also some skills training to really strengthen that inhibitory response, that stop response to say like, yeah, I could, but no, I'm good. I'm going to go do something else. I'm going to go kind of distract myself in some other way. So really trying to suppress some of that drive from the extended amygdala and really trying to bolster that prefrontal cortex to really remember our value system, what's important to us, and how we achieve those goals, even if it means kind of suppressing some of that stress-related response. All right. You guys now know as much as I do about the neurobiology of addiction, maybe more at this point, but we're going to transition now to talking more about harm reduction. And again, I think between Washington State and Oregon, you guys are a lot further ahead in harm reduction policies and principles than we are in Iowa, which again, makes me a little bit jealous. So you guys might know the stuff a lot better than I do, just kind of being raised and allowed to practice in some of these cultural ways. So just as a reminder, kind of what is harm reduction? And I think to answer this question is going to depend on who you're talking to, what field you're talking about, and maybe what stance you have and what community you're a member of, for example. So if we think of capital HR harm reduction, that's really defined as the social justice movement that was created primarily during the HIV AIDS epidemic area, where they were really demanding just kind of basic things like dignity, respect, and human rights for people who were using drugs, as well as people who were doing sex work, and kind of different populations at that time. If you think of lowercase HR, you might think of that as more just a philosophical approach, kind of a way to understand and approach different human interactions, especially for the idea of people using drugs. You might see that as harm reduction as kind of just some practical tools or skills that are primarily supposed to be led by people who use drugs. So a way to empower a community to take care of itself. And then you might see it if you're in public health as kind of a framework towards public health interventions, and we'll talk about some examples of that in a few slides. Ultimately, depending on how you define it, especially if we apply it more from like just a practical principled matter, how we apply this to different areas of medicine in particular, treatment in particular, harm reduction is really focused on the idea that we're trying to help people just make more informed decisions regarding their substance use and empower them to reduce potential harm for their ongoing use. So the idea that we're going to prioritize people and safety in their lives over this idea that everyone just has to, you know, you just have to stop using drugs. We're just going to, you know, this kind of dichotomous approach and really trying to empower people to take better care of themselves. And this is really important because, you know, depending on what substance you're talking about, there's a huge continuum of how people utilize substances. And this might vary on which type of substance people utilize. This might vary on their community, where they are in their life. And so, you know, sometimes people don't use any substances or they definitely don't use a certain substance. Sometimes people use it, you know, socially, recreationally, all the way to people who are, you know, developing really severe use disorders, in which case we're really trying to throw a lot of intervention to help them stay safe and get into recovery. And, you know, a good reminder for all of us is that, you know, we all practice harm reduction. So maybe you're someone who tries to eat a salad, you know, maybe I try to focus on more like vegetables than meat these days. So, you know, that's kind of a form of harm reduction for my health and for the environment to a certain way. We wear seat belts, you know, we don't say, hey, sorry, you can't drive because there's a risk of a car accident. We say, hey, buckle your seat belt so if you get into an accident, you're less likely to, you know, be dead or get kind of thrown from the vehicle. We encourage people harm reduction around alcohol. So instead of, you know, we might say, hey, drink a glass of water in between your alcoholic beverages just to pace yourself. That's a form of harm reduction. We have people who take self-defense classes, especially maybe for women, excuse me, as a way to, you know, reduce harm for themselves and be able to protect themselves in certain areas. We put warnings on things to, you know, inform consumers to not, you know, be surprised when their hot coffee is hot. We wear bicycle helmets. We put life jackets on everyone, including our beloved dogs. And we, you know, more informed practices around sex education encourage, you know, more harm reduction practices. So not necessarily just don't have sex, but hey, if you're going to have sex, which is, you know, relatively a normal human behavior, if you don't want to, you know, be at risk for things like a sexually transmitted infection, we should wear things like condoms. So we think about harm reduction strategies. These are just some of them that I'm going to talk about. But again, I think there's a lot of different areas where this plays out. So we're going to kind of go through these one by one with some slides and examples. So we talk about education around education as a form of harm reduction. Sometimes we can just have a discussion about people about their continuum of drug use. So, hey, you're not ready to stop using cannabis, but you're using a lot. And so is there a way that we can kind of move you down closer to the blue green part of the spectrum where maybe you're using less frequently, you're pacing yourself, it's only once a week, for example, rather than every day, if anything, just to maybe reduce the risk of your body becoming tolerant to it. We tend to do education a lot in harm reduction around how we utilize drugs. So the route of use, people can use drugs in a variety of ways. So they might ingest them orally, they might insert them, you know, either vaginally or rectally, they might snort them, smoke them, vape them, inject them directly into their bloodstream. And some of the effects are kind of, you know, one of the things that people might inform how they're utilizing a drug is maybe how quickly they want to feel the effect or how strongly they want to feel the effect. So, for example, if someone smokes a substance, that's gonna be the quickest way to get into the bloodstream. If you're looking for the highest amount of concentration over a short period of time, usually intravenous use or injection is the way that people achieve that, versus a kind of a slower onset, longer acting effect might be better achieved by someone ingesting the substance. And then if we think of, you know, harm reduction is, you know, how do we change route of use as a way to minimize harmful effects, especially from a medical perspective, we can have a conversation with someone and say, hey, probably the lowest risk way to use a drug, if you're going to use a drug, is to try to ingest it if that's available. So probably the biggest risk with that is people might consume it too quickly because they don't feel the effect quick enough, in which case they might unintentionally just take more than they need to. If we think of just inserting things, we worry most about maybe irritation of the, you know, mucosal membrane, maybe increased risk of infections. Snorting, kind of same thing, we just think of that with a nasal cavity of kind of wearing down that mucous membrane and increasing risk of things like infections. Smoking, kind of the same things we worry about a lot with smoking anything, is just risk of injury both to our airway, maybe to our mouth, as well as to our lung tissue. And then if we think of maybe the most concerning way that people utilize a substance would be things like intravenous use. And outside of maybe just the risk that someone's going to have an increased risk of overdose with IV use, we also think from a medical perspective that that's much more likely to potentially, you know, cause a bloodborne infection. People are much more likely to have a health compromise of their veins. They're going to start injecting in places that are less safe on their bodies because they might lose access to veins that would be safer for them to inject. Infections can happen locally at certain veins. And then, you know, regardless of that, all types of use obviously have the risk of an unintentional death potentially by kind of poisoning or contamination of the drug supply. And so, again, one of the ways that we might provide harm reduction to people is just to say, hey, like, you know, your vasculature has taken a hit right now. You know, you're talking about potentially injecting into places of your body that are more risky, maybe your groin, maybe your neck, for example. Have you ever thought about just changing how you use your substance? So have you thought about maybe just, you know, swallowing it, inserting it, smoking it rather than using it intravenously? And just, like, allowing people to move down that spectrum can be a way to really reduce harm and provide harm reduction principles. Other ways that we do education around harm reduction is just to do kind of safer use practices for people. So if people are going to use drugs, especially if they're going to inject drugs, you know, we really do recommend that people don't use by themselves. Unfortunately, you know, you want someone there who could go get help and provide assistance or really trying to employ a buddy system when possible. We try to encourage people to use in an area that's kind of hopefully safe, you know, clean, well-lit. For a lot of our people, especially if we continue to criminalize substance use, it makes it hard for people to access areas that they can do kind of their drug use safer. Clean water, soap and water can also be difficult depending on your access to clean water. Make sure, especially in a buddy system, that someone has naloxone available. Again, just in case someone needs it. And then just touching base with yourself to say, you know, where am I? Where am I in my physical headspace, my emotional headspace? One of the higher risk times for people to utilize a drug is when they're going through withdrawal because they tend to, you know, they're kind of desperate, right? They feel really bad. And so they might use more than they can tolerate. They might skip some steps around their sterile supplies or skip some steps around using with someone else. And so that's kind of a high risk time for people to utilize a substance. So it can just be a reminder for people to try to plan ahead and try to just tap in like, hey, if I can't, you know, if I can't wait any longer, if I can't use with someone, the least I can do is maybe just take a half of a dose knowing that I don't feel good. And I can always use more, but I can't necessarily always use less if this ends up being too much for me. We also talk about things like having sterile supplies. We think of things like a tourniquet to isolate a good vein so we're not scarring over our vasculature, having sterile water, sterile syringes, hopefully a new sterile syringe every time, alcohol swabs, you know, a metal cooker if you need to, especially one that has maybe a rubber handle so you're less likely to get burns on your fingers. We talk about vitamin C sometimes to reduce, yep, never use enough. Perfect. Love that resource. A really great one. And then, you know, even giving people sterile filters that they can kind of put into their dissolved drug, pull up into their needle through the filter so they can kind of remove some of just those irritants and preservatives that not only affect the vascular health, but then also can increase the risk of people having inflammatory responses throughout their body. And then we talk about things like where do we inject? So, you know, ideally you inject in places that are not next to really big, important veins or arteries. So we think of hands. We try to avoid the wrists because that's where our radial artery is. It's pretty close to the surface of your skin, really easy to unintentionally inject there. We maintain, you know, try to avoid the neck, hard to see it, but then also there's a lot of important arteries pretty close to the surface of the skin and try to avoid the groin area because there's a lot of bacteria there, increase the risk of infection from kind of soft tissue infections if we inject there. And then, you know, we also talk about harm reduction principles like if they're going to inject to make sure that they kind of have the bevel up so they can get, they can kind of see the kind of the depth to which their needle is going in so they don't go too superficially, but not also too deep. We talk about doing kind of registering their shot. So if they kind of see blood come back, ideally it's a low pressure, really dark blood that usually means that it's more in the vascular, sorry, in the vein versus an artery. We try not to inject drugs into arteries. And then again, doing test doses, so not necessarily using the whole thing, but using a little bit, making sure it's not stronger than we anticipate, and then we can always utilize more if we want to. Another part about education that kind of falls within a lot of harm reduction groups and principles is the idea of trying to test drugs with whatever possible. There's been a lot of growth in this area, both from, you know, different local areas, but then also within science and what we have available, but then even national groups to try to give maps to different parts of the country to say, hey, your drug supply, this is being sold as heroin, but what's actually being, what we're actually finding is something different. So we think of things like fentanyl test strips, xylosine test strips are becoming more available in states like Iowa. Unfortunately, fentanyl test strips have been considered part of our paraphernalia law, so they are not available. They would be illegally disseminated in Iowa. Unfortunately, we're trying to pass laws to get that changed, but it's still kind of been a big issue, even though fentanyl test strips are becoming more available. You'll also see areas that are actually having kind of mobile services where they've got a van that actually has a gas chromatography mass spectrometry machine where they can take a substance and tell you exactly what's in it. The University of North Carolina has a group where if you mail your drugs to them, they'll test them, they'll give you a printout, they'll send it back to you, and they're kind of creating a database. Interestingly enough, if you have a drug and you don't know what's in your drug, you can actually legally send it through the mail. They cannot send you the drug back because once they've tested it and they know what's in it, if it's an illegal substance, they can't legally send it back to you because they know what's in it now. But you can send drugs to that group if you wanted to do drug testing. Another kind of category of harm reduction outside of education is naloxone. Naloxone is the opioid antagonist medication. It's primarily utilized intranasally or intramuscularly and out in the communities. And kind of the big principle around naloxone is that like everyone should have it and really trying to prioritize making sure that people who are using drugs have it. For a while, when naloxone distribution became more common, we seemed to prioritize emergency medical services, police officers, and didn't necessarily prioritize making sure that people who were using drugs had it, even though in theory, especially if people are employing the buddy system, they might be the first person available on scene to provide naloxone to someone. I think that's getting better as we just have more community-based distribution, but also a form of harm reduction that, to be honest, a lot of groups throughout the country have fought really long and hard to make sure that there's more naloxone distribution. We're going to talk about medications later, but medications to treat opioid use disorders in themselves are a form of harm reduction. They reduce HIV hepatitis transmission. They increase the rate of recovery for people and then also decrease mortality. That's awesome. Yes. Yeah, we have a hard time in Iowa. I mean, we distribute them underground through our services, but they're expensive relative to a lot of stuff. They're about a dollar a strip for us, and so we have them, but they go fast, and they kind of eat up our budget pretty quickly, and so if anything, we just tell people to assume that their drug is contaminated, especially if it's a powder-based drug, and then they're like, okay, I don't know if their drug is contaminated, especially if it's a powder-based, and try to just plan accordingly, make sure they have naloxone probably more than anything, but I'm happy you guys have some great people making sure that people have access to that. And then I think when you think of harm reduction, oftentimes people only think of syringe service programs, which is a key part, but not necessarily all of harm reduction, but syringe service programs are also really wonderful, have been shown in many different countries over decades to reduce overdose death rates, increase actually treatment entry. It's actually estimated that people are five times more likely to enter into treatment or recovery through a syringe service program than through other routes of linkage to care, and so I think that just goes to show how if you have a group of people who are trauma-informed, who help to reduce stigma around substance use, you're actually going to pull people in and help them achieve different recovery goals than maybe some of the systems that we have in place now that might be kind of entrenched in some of that stigma. They reduce substance use, help prevent different types of diseases, because if you think of maybe a more inclusive syringe service program, oftentimes they can have vaccination groups, they can have wound infection treatments on site, and so there's a lot of great programs who have a lot of access to different types of harm reduction, a lot of different treatment. And then unfortunately, and I put this in because this makes me sad, syringe service programs are not necessarily always available, so this was data from January 2023. You guys are doing awesome. Go Oregon. Love that. Iowa, unfortunately, is still in that blue category, which just means that technically by our laws, syringe service programs are not allowed in our state, primarily because our paraphernalia law is extremely restrictive. But Calvin had a question in the chat about kind of information about mandatory treatment versus voluntary treatment, and I think this is, it's kind of a confusing literature base because, you know, so for example, in Iowa, we have civil commitment law that is specific to substance use, so I can file for a civil commitment for someone to complete substance use treatment, but there's only maybe like 33 states in the country that have those, so a lot of people, a lot of places don't. I'd say there's more literature about involuntary treatment in the form of like criminal court, so instead, you know, the drug court, so instead of going to jail or prison, I'm kind of court mandated to complete treatment. That's kind of my sentence, kind of my diversion pathway. Drug court data is pretty positive. It kind of says that a lot of people do well, people do just as well as people who enter into voluntary treatment. Drug court data is probably a little bit skewed because they tend to choose people who are nonviolent offenders, weren't, you know, they tend to remove people who were maybe large quantities, trafficker, you know, like kind of different sentencing, so it tends to kind of isolate people who are probably lower risk and potentially more likely to benefit from a substance use treatment program. Sometimes the data from drug court gets extrapolated and applied to civil commitment, but I don't think that that's, I don't think you can do that just because in civil law, right, like if we civilly commit someone to substance use treatment and they decide they are not going to follow through with that, I will tell you realistically what happens is the commitment just gets dropped because the treatment center will say you're not going to benefit, you don't want to be here, we've got a group dynamic to maintain, we're not going to like involve police to force you to be here from a civil perspective, and so I think the fact that, you know, civil commitments just kind of don't have teeth, that it's kind of hard to like extrapolate that. I also just feel like, you know, people have to at least have some desire to want to make kind of these big behavioral changes, and again, at least in Iowa, access to treatment is so hard, even for people who want to be there, that I think there's a big equity issue of over-utilizing involuntary treatment for people in kind of a civil way when we don't even have enough treatment for people who voluntarily are, you know, kind of seeking that and really do want to be there. So I see that the data is skewed, and it kind of depends if you're talking about civil involuntary treatment versus kind of more the more legal-based involuntary treatment. And yeah, I think, you know, I think a lot of people, yeah, I think it's skewed in the literature at best, and I think part of that is just because there's no like uniformity of practice from region to region or state to state. Okay, I was using Nirvana as my break song because Kurt Cobain, you know, had a history of opioid use disorder, actually had really great success with buprenorphine when he was over in France, kind of lost access to it. There was a lot of stigma around buprenorphine at that point in the United States, and, you know, unfortunately, he died a drug-related death. So I kind of used him, and I think his music was really powerful, especially in kind of accepting people and kind of meeting people where they are. All right, so we're going to transition to our next topic, which is opioid overdose naloxone administration. So this is a little bit of a training type of mindset. It sounds like some of you have already gone through opioid overdose naloxone trainings, which is awesome. Thank you so much for doing that. You know, increasing access to naloxone is really important, but if you don't know how to recognize an opioid overdose, you're not going to be very effective with your Narcan, so I think both of them have to go hand in hand. So just kind of taking it back to the basics, what is an overdose, especially an opioid overdose? So these overdoses tend to occur when there's unopposed stimulation of the opioid pathway, which, especially in the brain, if we look at those pons in the medulla area, decrease the respiratory rate, which subsequently leads to death. So it's overactivation of the opioid receptors, specifically in the medulla pons, which control our respiratory centers. How do you recognize it? How do we train people who are not medical professionals to recognize this, right? So here are some things that tend to get utilized to help people identify when it's happening. So if someone can't move, isn't moving, or they can't be woken up, if their breathing is either really slow or even just inconsistent, sometimes we call it agonal breathing. So kind of a, you know, just this really inconsistent breathing. If they're making choking, gurgling signs, it's probably a sign that they're not clearing their airway very well. They're not breathing effectively. Do they have really pinpoint pupils, really tiny pupils? That's one of the effects of opioids is it makes our pupils really small. Is their skin cold and clammy? And have they lost access to oxygen to the point that maybe their nail beds and their lips are blue in color? For IHRC, when we do our overdose identification and naloxone administration trainings, we tend to kind of talk about the CPR mnemonic mainly because it's kind of also associated with lifesaving measures. But in the setting of opioid overdose, we think of C as being kind of level of consciousness, you know, can't wake up, can't stimulate, P being pupils, especially pinpoint pupils, and then R being really focusing on that respiration. So their breathing, is it slow? Is it random? Is it agonal? Are they making some of those weird sounds? And if you kind of identify those key points, that that might be someone who needs to be administered naloxone. And so how does naloxone work? So naloxone is a mu-opioid receptor antagonist, which just means that it blocks the receptor. And the nice thing about naloxone is it's a really good competitor against other opioids. And so if an opioid is occupying a receptor, naloxone's pretty powerful and can kick that opioid off the receptor and attach itself, which is really important because that's what we need to happen. We need to have something that can kind of say, hey, get out of here, heroin or fentanyl. I'm going to take over this receptor. And then once it takes over the receptor, all of a sudden that excessive opioid stimulation goes away. And so people will hopefully start breathing more regularly and even kind of maybe wake up if they're being hard to stimulate. A mnemonic that we incorporate, it's probably incorporated into various naloxone trainings in particular is I-CARE. And so we're going to walk through this. So I stands for identify the overdose, C stands for call 911, A stands for administer naloxone, R is rescue breathing, and E is to ensure safety while you're waiting for the emergency medical services to arrive. All right. So starting with I, identification. Again, similar things that we talked about, the CPR, those kind of six quadrants of how to identify if someone might be having an overdose. So you can verbally try to stimulate them. Hey, are you okay? Kind of touch them. Maybe you kind of rub your knuckles over their sternal bone, which is super annoying. So if someone's going to respond to a painful stimulus, they're going to respond to a sternal rub. If they don't respond to that, that's just more of a signal that their consciousness level is really low. Again, breathing changes, blue pinpoint pupils. So identifying that this might be an opioid overdose. And we really try to encourage people, you don't have to be right. They might be overdosing from something, or they might be in need of medical attention, but maybe it's not an opioid. But if you think it might be that giving naloxone is still going to be important, it's still going to be indicated, and you're not going to hurt them by doing that. So you don't have to be right, but if you see it, it's a possibility, and you have Narcan, try Narcan. Once you identify that this person might be having an overdose, you're going to try to call 911. Ideally, if you have two or more people at the site, one person can call 911, the other person can start to administer naloxone, which is that next step. Again, naloxone might not work, primarily because they might not be overdosing on an opioid. They might be having a similar presentation, but it's not from an opioid. And then also just a reminder, the naloxone might work, but it might not work for as long as you need it to until an EMS person can arrive. And so if you have multiple doses, you might have to administer multiple doses in kind of a steady frame until you get someone there who can provide different medical attention. Third step, A, is to administer naloxone. Depending on what version you have is going to vary on how you administer it. Again, this is kind of a pathway as far as the nasal spray naloxone. Usually people are going to respond to that dose. They're going to respond within two to three minutes. The appropriate response, the main thing that we're looking for is for their breathing to normalize. That is what's needed. That's the life-saving measure. It's okay if they're still sleepy. It's okay if they're still kind of difficult to arouse, but as long as their breathing is normal and no longer that inconsistent pattern, that means that their body's getting enough oxygen and they're safe at that period of time. And again, you can continue to give doses as you need to, especially to maintain that effect to make sure their breathing stays normal. Breathing is the most important thing. If we give someone who's opioid dependent too much naloxone, we are going to put them into opioid withdrawal, and it's going to be terrible and miserable. They're going to get really upset. They're going to feel terrible when they wake up, and they're going to be at risk of actually leaving the scene and potentially going to get other substances because they feel so badly. The next step, fourth step, is rescue breathing. This is someone who maybe you give naloxone, maybe it works, maybe it doesn't, but their breathing is still not looking like it's being very effective, in which case you're going to make sure that their airway is clear. You're going to kind of tip up their chin, which allows their trachea, their breathing tube, to be really straight to kind of allow maximal movement of air. You're going to tilt their head back, pinch their nose so that all that air goes down into their lungs. You're going to give slow rescue breaths, ideally about one every five seconds. You're going to give enough air until their chest starts to rise. It doesn't have to rise all the way, just starts to rise, and then you're going to put it back down again. Just keep doing that until either the person kind of starts to have breathing on their own or until other emergency medical services come. Then the last step is just to ensure their safety. You gave naloxone, their breathing normalizes, maybe they're not fully awake, in which case we try to get people into a safety position. You make sure the area is clean. Maybe you roll someone onto their side, they kind of protect their head with one of their hands. You bring their knee over their body so that if they were to wake up or if they were to start to vomit, for example, they're not going to fall back on their back and maybe start to breathe in some of that vomit, which can cause problems for people. Then again, just this eye care mnemonic. Can you give too much Narcan? Outside of putting someone into opioid withdrawal, no. That's going to be the most severe thing that happens to someone. With Loxado, with some of these higher strength naloxone products. You know, a lot of harm reduction groups have been pretty antagonistic about some of these companies coming out with, you know, higher than four milligram doses, basically because they said, we don't need it. And honestly, all you're gonna do is put people into withdrawal. And then there was recently a study in New York where they actually kind of monitored like outcomes of people who received the four milligram versus the eight milligram. And it kind of played out exactly as harm reduction groups have talked about, which is we don't need to give people more Narcan. We just need to make sure that people get enough of it and that kind of community members have enough doses. So if people need to be bridged, you know, let's say for 30 minutes until people can get there, that we have enough doses to make sure the breathing stay as normal for an extended period of time. But outside withdrawal, that's kind of the biggest concern. Seizures induced with withdrawal with opioids is really, really rare, arguably really like uncommon in adults and kids that can happen, but not really with adults. All right, moving on, we're gonna talk a little bit more about substance use treatment. I throw this up just again, just to remind us that we have a lot of people who use drugs, in which case I think prevention, education, harm reduction is really important. And then we have a smaller set of population that have use disorders, whether we're talking about alcohol or other things, in which case it's really important that we're constantly trying to increase access, reduce barrier to treatment, and really try to make sure that we're providing people with evidence-based treatments when they're ready for them. So there's been different definitions, right? So maybe a kind of a more one sentence summary of a substance use disorder. This is from NIDA. So they kind of give a definition of a substance use disorder as a chronic relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. So this idea that this is a medical condition, it's chronic, people can kind of be in and out of their substance use disorder. And it's really characterized by people compulsively using a drug despite having problems from it. Another way that we sometimes define a substance use disorder is based on the DSM-5 criteria. This was last updated in 2013. This is kind of when we got rid of abuse and dependence and we kind of consolidated all substance use disorders as you need to have at least two of these over the past 12 month period. And the more symptoms you have on this list, the more severe your use disorder. And when you read through these criteria, I think it's really important just to remember that you don't really see anything that talks about like a specific quantity, right? You know, people can, you know, just because you use a lot of alcohol doesn't necessarily mean you have a substance use disorder, for example, right? You know, a substance use disorder is really characterized by this like inability to stop, this compulsion like behavior around your substance use, things like cravings or complications from them. And then really like how much is it impacting your day-to-day life, especially in kind of key areas like social, employment, schooling, for example. And they make a specific note in the DSM that especially for people who might be diagnosed with an opioid use disorder that if you only have tolerance and withdrawal, so number 10 and 11 on this list, you cannot be diagnosed with an opioid use disorder. If you, you know, you need to have something else basically. And they're really trying to tease out, we don't want people who are opioid dependent because they've had long-term opioid prescriptions for chronic pain, for example, to be diagnosed with a substance use disorder. So really trying to tease that out. One of the ways and probably a big way that as a, I'd say as treatment institutions, we try to conceptualize what type of treatment might be indicated once we've diagnosed someone with a substance use disorder is based on kind of utilizing what are called the ASAM criteria. So ASAM being the American Society of Addiction Medicine, they've kind of put out different reiterations of these criteria. And really it's a formalized way of doing a biopsychosocial evaluation. And it's really meant to kind of, I think, give a uniformed language and criteria that insurance companies can follow non kind of hospital-based substance use treatment programs can follow, but then also medical providers can also follow. I think that's the spirit of the ASAM. And more recently, they kind of create, they came out with their fourth edition. I'm sure some of you who do this as part of your job day-to-day are very familiar with this and potentially more familiar with the changes than I am. But the big things that kind of came out of this fourth edition is they removed the readiness to change category. And the primary reason that they did this is because they felt like that category was sometimes stigmatizing. And it sometimes kind of got applied as if people weren't ready to change that we actually needed to put them in more intensive treatment versus if they weren't ready to change, but maybe we're willing to do some outpatient treatment, maybe to reduce their use. We maybe didn't utilize that correctly. They also were worried that there was some stigma built into that category. And so they opted just to remove it and they added this new category, which is called person-centered considerations. And that tends to be a category that lumps in a lot of the stuff that just like day-to-day practical stuff make it hard for people to do treatment. So maybe I really want to do intensive outpatient treatment, but I don't have a car. Maybe I really want to do residential treatment, but I'm the only caretaker for a child and I have no childcare. So I can't just go someplace for 14 to 28 days to stay all day, even if residential treatment is maybe what's best indicated for me. So really trying to inform how we make treatment decisions and kind of those just person-by-person things that interfere with different or inform different treatment pathways. And then they changed some of the wording again, I think hopefully to do more person-first language, reduce some of the stigmatizing terms and kind of make it more streamlined. And these criteria, kind of this format of how we talk about this biopsychosocial evaluation for someone who has a substance use disorder, then hopefully gets kind of translated into a level of care. And there's level of care is based on numbers. We kind of start with maybe the lowest intensity, which is outpatient treatment. We kind of then go up to more intensive outpatient treatment even things like partial hospitalization services. Although it sounds like partial hospitalization is actually going to be removed as a criteria. It's going to kind of get re-imagined a little bit with the fourth edition. Then we go up to residential treatment programs and then even higher than that, people who maybe require hospitalization, they need to be medically managed in some sort of facility maybe before they would transition into a residential inpatient service. And ideally throughout these levels of care, we would employ harm reduction principles, especially trauma informed care principles. There's more and more literature to support probably what all of us who have been boots on the ground doing this is that a lot of people with substance use disorders have been exposed to various types of trauma, whether it was childhood trauma or trauma they incurred over the course of their substance use and really trying to provide a lens of, providing our services through a trauma informed way. Another portion of treatment is to provide medications. This is a table that summarizes medications that have been studied, if not FDA approved for various types of substance use disorders. I put an asterisk next to everything that's not FDA approved. So you kind of see obviously for stimulant use disorders, cannabis use disorders, we don't have any FDA approved treatments. These are just all things that have been studied and maybe have some amount of positive literature around them. Sometimes things that we can utilize even as non FDA approved treatments. And then we're gonna transition now into talking specifically about the FDA approved treatments for alcohol, opioid and nicotine use disorders. Again, trying to apply that as a substance use disorder treatment. So we talk about alcohol. So transitioning to alcohol use disorder treatments, FDA approved treatments. We have disulfiram. Disulfiram blocks the metabolism of acetaldehyde into acetone. Acetaldehyde is a pretty nasty chemical. It's the chemical part of alcohol metabolism that provides most of the carcinogenic effect of alcohol. It also makes us feel really badly. It's the hangover chemical if you wanna call it that. And so the idea with disulfiram is people take the medicine, if they drink on top of it, acetaldehyde levels go high and they feel badly. And so hopefully if people take that medicine, they're less likely to drink because they don't wanna feel badly. It's much more of a behavioral intervention more so than having any direct effects on some of that neurobiology of addiction we talked about before. We also have naltrexone. Naltrexone blocks that opioid receptor system. Again, if we think of the opioid system as being involved in the liking effect of a substance, we think that by blocking the opioid system with alcohol use people just don't necessarily enjoy alcohol as much, they don't drink as much, they don't crave it as much, and that can reduce their use and give them more time away from alcohol if that's their goal. And then acamprosate is the other FDA approved medication. Early in recovery from alcohol use, there tends to be this overactivity of glutamate, which is this excitatory chemical compared to GABA. And so the idea of acamprosate is it tries to kind of knock down some of that excessive excitatory activity, which can help people feel less anxious, sleep better, maybe have less tremors, things like that, which can subsequently then reduce their craving experience. So if I'm stopping alcohol use, and if I don't have as much anxiety, shakiness, inability to sleep, I'm gonna be less likely to crave alcohol and hopefully more likely to achieve abstinence. So a few studies about these medications. Disulfiram is a medication that's purely based on adherence, which completely makes sense based on how it works, right? So this was a study in a VA population where it was a blinded study. They gave basically one group disulfiram, 250 milligrams, and one group of placebo. And as you can imagine, that if the group was adherent to the medication, even if they got placebo, they did well, because again, they thought they were getting the medication. So the idea that they were gonna get sick was enough to have them not drink alcohol, versus if people weren't adherent to the medication, there was really no significant benefit to the medication. So disulfiram is not used as often anymore. It's much more likely to be helpful in kind of a controlled direct observation dosing type of environment. So even if it's just like a partner who's really supportive, if they're there to make sure someone takes their medication every morning, it's much more likely to be beneficial for that person than someone who self administers the medication. Acamprosate is another FDA approved medicine. It's been shown to be effective versus placebo interventions. You kind of see an increased rate of abstinence for patients compared to placebo in this trial, and that maintained even during the follow-up period. So even after the 48 week mark when people stopped the medication, the most common reason why people stop acamprosate is because of GI side effects. So Anabuse is the brand name for disulfiram. It's still used, but much less often. It's kind of considered a second or third line agent, especially it's definitely second line relative to FDA approved medications. I can probably count two people I've ever given it to, and they were both people who were very adamant. It's like the only thing that's worked for me. I really want it. I've got a partner who would give it to me. This is kind of the best option for me. It's not really something that I readily go to, because I just think we have better options that work better now. Hey, Dr. Weber. Yeah. Can you speak a little bit louder? Some people are having some difficulties hearing. Oh, I'm sorry. Okay, I'm going to move closer to my microphone, and then I will try to talk louder as well. Thank you for pointing that out. No worries. Okay. Now, naltrexone. So we have naltrexone in both a pill form as well as a long acting once a month injection. Naltrexone especially as a once a month injection has been shown pretty effective in a dose dependent manner. So the dose is 380 milligrams once a month. This was actually the study or one of the studies that got its FDA approval for alcohol use disorder. And primarily what they found was naltrexone was really good at reducing heavy drinking days. Acamprosate seemed to be a medication, sorry, moving on, before this next thing that I'm about to say, there was a meta-analysis that looked at these two medications and they're both effective. What they kind of globally came down to was based on the available literature that it seemed that Acamprosate did a better job at promoting abstinence, whereas naltrexone did better than Acamprosate at just reducing heavy drinking days. So for example, if someone said, I'm not really interested in stopping my alcohol use, but man, if I could like drink two instead of six, or if I could drink two days a week instead of seven days a week, naltrexone might be a good option for them because they can drink on top of it. And the evidence would say that it just allows people to drink less relative to other treatments. And so again, and this is like a gross thing. At the end of the day, if someone wants to take a medication for alcohol use disorder, I'll offer them every treatment I have and kind of have a discussion about what best lines with their treatment recovery goals. Another thing I want to point out with alcohol use disorder with these medications is that sometimes we don't offer them to people who have some medical complications related to drinking, primarily being things like liver disease or cirrhosis. There's a lot of evidence now to say that these medications, even naltrexone is safe in people with liver disease. And if anything, we probably should be offering more to these people because they tend to still benefit from the medication. So for example, this was a study from 2023. They took a cohort of veterans and they looked at people who had alcohol-related cirrhosis as well as were meeting criteria for hazardous drinking on the audit seat. They actually then compared people who got medications for alcohol use disorder, primarily naltrexone and acamprosate, compared to people who didn't get medications. And what they found is people who got medications had reductions of their all-cause mortality at follow-up. So again, there's no increase of risk really that comes out with the literature in that if these medications might be helpful for someone to reduce their alcohol use, reducing their alcohol is probably going to be the best intervention for their liver disease and much more likely to provide benefit than any harm that some of these medications are going to do in liver disease. So primary summary is that even if someone has cirrhosis or liver disease, we should still be offering them these evidence-based medications for alcohol use disorder, especially if they have alcohol-related liver disease because we can have really prominent benefits for them. I want to also talk about pregnant populations. I wasn't sure with some of your treatment environments how often you encounter people who are pregnant or even people who are at risk for being pregnant, to be honest, at their trial-bearing age. This is stuff that we should be thinking about in substance use treatment. So we know that alcohol exposure in pregnancy increases the risk of miscarriage and stillbirth. It increases the risk of fetal alcohol spectrum disorders, but we don't really know if there's a safe amount of alcohol in pregnancy. There's a lot of cultures throughout the world where alcohol consumption is just part of their culture and that persists during pregnancy. We might've all had parents who had a glass of wine when they were pregnant, potentially. There's been a shift, I think, a lot during, depending on what part of the globe that you've been in. And yet, despite that, we don't necessarily know that people in France, for example, have a higher risk of fetal alcohol spectrum disorder compared to people in the United States. And so because of this, because we just don't know is there a safe amount of alcohol? Does that vary with individuals? For example, the recommendation is that there's no alcohol consumption in pregnancy. We also worry about the risk of severe alcohol withdrawal syndrome. So if I'm physically tolerant on alcohol and I become pregnant, we need to make sure that I don't go into a severe alcohol withdrawal, which can be life-threatening for both myself as well as my pregnancy. When we think about people who have severe alcohol use disorder or binge drinking, that's been associated with more kind of cognitive behavioral disorders when our children grow up, if they were exposed. Again, if we talk about more low to moderate levels of drinking, there's no consistent evidence to know what that does to the development of the child after exposure. Treatment-wise, a lot of the same treatments that we talk about in pregnancy with the general population. Again, a lot of our data, a lot of our medications that we use in pregnancy have not been studied very well in that population. So we tend to use lower quality research. So maybe retrospective studies, cohort studies, which unfortunately just have a lot of confounders. So it's hard for us to make big conclusions about those. Of the medications that are FDA approved, acamprosate and naltrexone can be utilized in pregnancy. We have, again, at least retrospective cohort studies to say that they're safe. And again, definitely probably safer than ongoing alcohol exposure in pregnancy. Disulfiram is the big one that we don't recommend in pregnancy. The risk of hepatotoxicity or toxicity to the liver is higher in that medication, as well as if a pregnant person were to drink on top of their disulfiram and get physically ill with their blood pressure skyrocketing and their pulse going really high, that can also be dangerous for the patient as well as the pregnancy. And so because it's just not as helpful, it's harder to tolerate. And because of that additional risk, it's just not something that we recommend utilizing in pregnancy. And then obviously all the other things that we do in treatment, we would also incorporate into our treatment of pregnant population. So group therapy, individual counseling, and then other types of recovery supports again, which we'll talk about later. Transitioning now to talk about medication, FDA approved medications for opioid use disorder. We have methadone, buprenorphine and naltrexone. So naltrexone I talk about first because it's kind of the slightly different mechanism of action. So naltrexone as far as what it does to the body is actually very similar to naloxone or Narcan. So it blocks that opioid receptor system. The way it gets packaged, it gets packaged either as a pill or as a once a month injection. For opioid use disorder, the long acting injection, that once a month injection, otherwise known as Vivitrol, is the only version that's actually been FDA approved for opioid use disorder. So the pill is not FDA approved for opioid use disorder, it's just the once a month injection. It's got some benefits to it. So it's not a controlled substance, which is nice. People don't get physically dependent on Vivitrol or the long acting naltrexone, which is also helpful. So if people want to stop it, they don't necessarily have to worry about withdrawal. The biggest difficulty with naltrexone in the treatment of opioid use disorder is people have to have time away from opioids before they can start that medicine. And so if you think of an office-based treatment, that can be really hard for people just to walk into clinic and say, hey, we can do naltrexone, but you have to just not use heroin for seven to 10 days. Most of the time people are gonna look at you like you have three heads and say like, well, yeah, if I could do that, I wouldn't necessarily be here talking to you about treatments for my opioid use disorder. And so naltrexone, as far as initiating the treatment, might be more beneficial for people who have already, or more likely or successful for people who have already potentially involuntarily gone through the withdrawal process. Maybe they were incarcerated, maybe they were institutionalized, maybe they were in treatment programs and they kind of just opted to go through a medical withdrawal phase. But it's a little bit less likely to be the first option that people go to in an office-based treatment setting. The other two FDA approved treatments are considered more opioid agonist treatments. This is the same graph that I had showed earlier, kind of talking about some of that neurobiology and translating that into treatment. So oftentimes early on in acute phase of opioid use, people are feeling kind of positive benefits from the substance. We kind of see that positive benefit start to go down as their body gets used to it. Most of the time when people start to see me, they have kind of been in chronic use phase where they're kind of just using to feel normal or to function, because if they don't use, they're going to be into that withdrawal phase and feel pretty poor and not be able to do the things that they need to do. And so the goal then with buprenorphine and methadone is to help them kind of stay in that normal physiological range. So I kind of described to people that they can just like pivot. So they can kind of take some of that mental emotional energy that they're using to utilize their substance and to maintain their substance use disorder and just apply it to things that they also really care about that maybe have had to take a backseat for a while because their substance use was so heavy. So methadone, methadone is an FDA approved treatment. It's kind of the oldie but goodie as far as treatment for opioid use disorder. It's a synthetic full opioid agonist. So it interacts with that receptor and turns it on all the way. I use the term synthetic because it's completely manmade which means that it follows a very different metabolism pathway. So if you've got a standard urine drug screen on someone and they're on methadone, it'll still be negative for opioids or opiates. You'd have to test separately for methadone because of its purely synthetic development. It's long acting, it's been shown to reduce opioid cravings. It blunts the effect of other opioids if used on top of it, so people just aren't reinforced to continue utilizing or to return to opioid use if they're on methadone. Typical maintenance doses can be anywhere between 80 to 120 milligrams a day. It can have some side effects, especially maybe in older populations, people who have more complex medical needs. It can prolong the QTC, which is a measure of how the electricity is going through the heart. If that gets too long, people can go into this fatal arrhythmia called torsades, and so sometimes we'll get EKG monitoring to make sure people are safe with methadone, especially if they're on a lot of other medications or if they have a heart condition. People can overdose on methadone, so we pay attention to how we titrate and make sure we don't over titrate someone, especially in an outpatient setting. Probably the biggest issues with methadone, honestly, is not necessarily the medication. The medication's very effective and lifesaving, but it can be hard for people to get. There's stigma, there's transportation issues. In a state like Iowa, we have like eight opioid treatment programs throughout the entire state. They all run east to west along I-80, so if you live in the northern central part of Iowa, you're probably driving two, two and a half hours one way every single day just to get your methadone dosing, so it's really hard for people to access in states like that. We also have buprenorphine, which is, in contrast to methadone, only activates that opioid receptor partially, which is nice that you have eight methadone clients in Portland. That's awesome. That's awesome. Dr. Weber, also FYI, two hours. Thank you. Appreciate you. So again, in contrast to methadone, buprenorphine activates the same receptor, but it only activates it maybe like partially, so maybe 50 to 60%. Fortunately, that's usually enough activation to get people out of opioid withdrawal and to kind of shut down a lot of those cravings. Not everyone, but a lot of people. It also has really high affinity for the opioid receptor, so kind of similar to naloxone. It can kind of out-compete with other opioids, and it attaches pretty, it's pretty sticky at the receptor, and so it can stay there, it can do its job, and it's really hard to kind of override buprenorphine once people are on a good dose, so it's protective in that way. Back in the good old days of just heroin, 16 milligrams was a pretty common treatment dose. Now with fentanyl being more widely available, at least in Iowa, we're seeing more commonly needing like 24 milligram doses for people to be stable. A lot of different formulations, some with just buprenorphine, some buprenorphine combined with naloxone. It can also be given as like a once a month subcutaneous injection. There's tablets, there's films. Probably the only way you can't, the big way you can't take buprenorphine is by kind of swallowing it, just because there's only about, there's less than 1% of the medication that is ultimately effective if people swallow the medicine, so it still has to be kind of taken under the tongue for opioid use disorder. All right, and then I'm gonna briefly go, I don't know how many like clinicians or prescribers we have on the call, but I'm just gonna go through some of the ways that, the three main ways that we might start someone on buprenorphine. If you don't prescribe, you might just have a sense of how we might do this and help to guide your clients or talk to people about what the options are, or at least be able to participate in a conversation of someone talking about their experiences. So we kind of have the traditional model of starting buprenorphine. Traditional is just because it's like the one that we started with. It was the first one I learned and what we typically did until about a couple of years ago, but it was basically just this idea that people stop their opioid. We wait until they get into about a moderate amount of opioid withdrawal, depending on what opioid they were taking, that might be 12 hours, that might be 72 hours. We might, if we were like in a structured setting, we might do like a clinical opioid withdrawal scale to kind of get a sense of where they were on that severity. Once they were in enough withdrawal, we would give them two to four milligrams of buprenorphine, kind of like a test dose. We would wait an hour. Hopefully after an hour, they either feel better, ideally, or not worse. Because what we don't want to do is we don't want to put them into what's called precipitated withdrawal, where the buprenorphine came in too early and knocked out all those opioids. Instead of that person having this amount of opioid activity, all of a sudden they got dropped to this amount of opioid activity, which puts them into withdrawal. At one hour, if they're still having withdrawal symptoms, we'll give them another dose, potentially up to four milligrams. And then usually in that first 24 hours, our goal is to get someone out of opioid withdrawal. We can usually do that with eight to 12 milligrams of buprenorphine that first day. Whatever dose they took that first day, you give it to them the next day. You might, you know, they might need to take an additional few tablets later on in the day, just to bridge to make sure that the effect stays. Then usually by day three, we would try to get someone to at least 16 milligrams a day, if not push up to 24 milligrams a day, if we anticipate they're going to need more buprenorphine. So that's kind of traditional. The biggest downside of traditional is number one, people had to go into opioid withdrawal, which a lot of people don't want to do. They avoid it pretty heavily because it's a pretty miserable experience. And so there's a lot of trust factor that went into starting people in this way. It's also becoming really difficult to utilize this with fentanyl. Fentanyl is, we call it lipophilic. So it stays in the fat cells really heavily. And so people can hold on to fentanyl for really long periods of time, which makes the traditional pattern a little bit more difficult because the metabolism of fentanyl is a lot slower and a lot different than things like heroin. So it just makes it more complicated. The second way, the next way that got published to do buprenorphine is kind of what we maybe call a low-dose initiation. Sometimes we call a micro-induction, but we try to not use micro just because it gets confounding with people utilizing hallucinogens. So a low-dose initiation, basically the idea of this is we slowly introduce buprenorphine, potentially over the course of a week, with increasing doses and increasing frequency while they continue to utilize their other opioid. And then hopefully by day eight, for example, they've already titrated themselves up to maybe 12 milligrams a day of buprenorphine such that when they stop their other opioid, they don't have withdrawal. Really, this is the best way to transition someone to buprenorphine if they've been using fentanyl and it's either likely or confirmed, or if they're even transitioning from things like methadone. This is probably the route that can be most successful for people. And then third, sometimes we're using more and more, especially in ER settings or in hospital settings, what's being called a high-dose initiation. This was developed out in San Francisco in some of their healthcare systems to really try to override the fentanyl issue while also trying to get people on buprenorphine as quickly as possible before transitioning them back out into the community. And so they kind of consider this if people have really high opioid tolerance, especially if they've been exposed to, again, things like fentanyl or synthetic opioids. If they have high withdrawal severity, if someone's already precipitated their withdrawal, so again, maybe they started buprenorphine too quickly and all of a sudden now they're in precipitated withdrawal and you need to stabilize them really quickly. The whole idea of it is that you wait for someone to get into that moderate amount of withdrawal. You would give them a test dose of buprenorphine and then basically every 30 to 60 minutes, you just repeatedly dose them. And you would dose them anywhere between eight to 24 milligrams of buprenorphine at any given time. It's like a water hose to the system. And you're really just trying to quickly saturate the system with buprenorphine and not let anything else attach to those receptors because you're just giving buprenorphine on this kind of repetitive pattern until after a 60-minute evaluation, they're no longer in opioid withdrawal, in which case you might discharge them, let's say from an emergency room with a more standard dose of buprenorphine. So again, anything between 16 to 24 milligrams and then hopefully transition them into a clinic setting. I think at our institution, the most we've given someone utilizing this method in our ER was like 96 milligrams over the course of a few hours to stabilize their precipitated withdrawal. So it works. I think it's kind of a, it's definitely meant for, I think, more acute, higher acuity settings, especially if someone's already put themselves into precipitated withdrawal. And then does buprenorphine also help with pain? Buprenorphine can help with pain. Buprenorphine has FDA-approved vergence for chronic pain. They tend to be dosed as micrograms instead of milligrams, so kind of smaller doses. In my experience, I've transitioned a lot of people from full agonist opioids that were being used for chronic pain to buprenorphine. And in some ways, they actually end up having better pain management. I'm not sure if that's because they have less anxiety about their opioid constantly being removed from them or if because they're kind of resetting some of that opioid-induced hyperalgesia experience. But yes, buprenorphine can be utilized for pain. Just a few studies. We know that methadone and buprenorphine, especially if they're appropriately dosed, can be equally effective for opioid use disorder. And so this is a relatively older study, but it was from a Cochrane review that just kind of put to rest this idea that buprenorphine is not inferior to methadone and they're both considered really helpful for people with opioid use disorder, assuming that they're at treatment doses and they're both more beneficial to people than not offering medication treatment. This was a study that compared buprenorphine to naltrexone, especially the long-acting once-a-month version. Again, this kind of plays out what we talked about, the biggest difficulty with naltrexone is, which is successfully getting people started on it. When they did their first analysis, they included everyone, and you see this big drop-off for the red line group, the Vivitrol group. That's because a lot of people dropped out because they couldn't wait the seven to 10 days they needed to in order to successfully start naltrexone. In the second analysis that they removed people that didn't get on naltrexone, they only compared people who were successfully transitioned to naltrexone and to buprenorphine. They tended to do equally well in this study. So again, it kind of just plays out. It can be hard in outpatient settings to get people directly transitioned from their opioid use to long-acting naltrexone because people tend to drop out. And then one of the questions that comes up a lot is, you know, especially from patients, from families, even from other doctors is like, well, how long do we need to do this? Like, how long is long enough? Can't we just taper, you know, can't we just detox people with these medicines versus providing them more maintenance medications? This is an old study, but I still think it's a great study. And it's got like the best graph ever to put on a PowerPoint slide. So this has been played out a lot in newer literature, but I think this is a study where they took a small group of people. It was a Swedish population. They followed them for the course of the year, people using heroin. One group basically got stabilized on buprenorphine and kind of detoxed from it in the control group. The other group went through kind of a year-long maintenance therapy. The people who were in maintenance were much more likely to remain in treatment, much more likely to be opioid-free. And then the probably more concerning thing is that 20% of the people who were tapered off in the control group actually died within the follow-up year. And these were people that from their, like in the Sweden population, they received like awesome services. Like they got mental health care, vocational rehab, connection to housing services. Like they got like Cadillac level services that I would probably have to like sell my firstborn to get for most of my patients in Iowa. So it just kind of plays out to the importance of this medication, especially if we kind of conceptualize these as maintenance medications can be. Adolescents, I don't know how many people here treat adolescent populations, but buprenorphine is FDA approved for ages 16 and older. I'm not sure what Oregon state laws are, but state law kind of varies based on who needs to consent versus what can be shared with a parent or a guardian when it comes to treating adolescent substance use. So for example, in Iowa, parents do not need to be informed. They do not need to provide consent or even assent to treat adolescents for substance use disorders. As far as how long to keep adolescents on these treatments, we don't really know. We don't really know with adults either. And then as far as like starting and dosing buprenorphine, the treatment principles are the same for adolescent populations. Also want to talk about our pregnant populations. Again, similar to when we talked about alcohol. So buprenorphine and methadone are both considered evidence-based treatment for opioid use disorder. These can be initiated in various treatment settings. Sometimes as the pregnancy progresses, you need to adjust the dose. Although there's not great literature about naltrexone, we do think it's safe. And current guidelines for obstetrics and gynecology say that if someone's stable on long-acting naltrexone and they get pregnant, after you have kind of a shared decision-making conversation, it is considered guideline-based care that you can offer to continue them on naltrexone during their pregnancy, assuming they were already stable on it before. And again, buprenorphine and methadone save lives. They've been shown to greatly reduce mortality compared to not offering these medication treatments closer to what's considered the death rate of the general population. And again, treatment duration, we don't really know how long is long enough. I'm guessing from a broad perspective, we're never gonna know this just because everyone's so unique and what people have access to as far as their recovery capital is gonna change or be different. And so ideally, we just continue these maintenance medications for opioid use disorder as long as basically the benefits are outweighing the risk. So if they're meeting their treatment goals, whether that's kind of decreased substance use, employment goals, education, relationship, for example, as long as people aren't having side effects and they wanna continue, then continuing the medication long-term is currently considered standard of care. There's a lot of ways to improve how many people have access to these medications, especially if we talk about buprenorphine. And so if you wanna check in with yourself to say, hey, are we providing low-barrier care, especially low-barrier buprenorphine care? Some of the things you wanna ask yourself is are you providing same-day treatment? So are you giving people medications the first day that you meet them after evaluation? Are you offering them to start the medication kind of in their home by themselves or kind of in an unobserved way? Are you using harm reduction principles? So are you allowing just the reduction of opioid use to be an acceptable goal of treatment? Are you allowing people to kind of use other substances if that's not really part of their treatment goal, but still providing them with buprenorphine for their opioid use disorder? So if someone doesn't wanna stop using cannabis, but we say, oh, well, you have to stop using cannabis for us to be able to use it, then you have to stop using cannabis for us to be able to stop using cannabis for us to give you buprenorphine. That's not applying harm reduction principles and that kind of conflicts with low-barrier care. And then just providing flexibility in treatment. So frequency follow-ups and kind of other things that's gonna change based on their clinical stability. So not just kind of cookie cutter, one size fits all. And then offering counseling, but not necessarily making it a requirement for people to access medications. Medications are first-line standard of care, should be offered to everyone. We definitely should promote and encourage people to do counseling and get appropriate other care, but we shouldn't make that a necessary thing for people to access medicine. And I think there's good models of care to say that we can do this anywhere, provide this low-barrier care. There's groups doing it out of community organizations that have different types of crisis units, out of different treatment facilities, and even jails and prisons across the country have some pretty novel ways to make sure people have access to opioid use disorder treatments going forward. All right, last week within the treatment category, we're gonna talk about nicotine use disorders. Again, overarching theme, if you're treating someone who wants to stop smoking or using nicotine products, medications plus counseling are gonna be the most effective strategy. We've got nine FDA approved treatments to help people stop smoking in particular. Nicotine replacement treatments, which are things like patches, gum, lozenges. We've got Welbutrin, which is FDA approved for that. And then Vereniclin, which is also called Chantix. Nicotine replacement therapy, yeah, yes. A lot of humility to nicotine. It's a very well-designed drug and very difficult to stop, especially in kind of how accessible it is culturally. So nicotine replacement therapy, a lot of different options. Sometimes you pick something, usually we combine different types of nicotine replacement therapies together to try to optimize and kind of mimic how people utilize nicotine. So we might utilize a patch, which kind of provides a low level of nicotine activity, but then also give people, let's say a gum or a lozenge, so they can have a little bit more of an acute, basic, medication to take when they have a craving. A lot of different types of nicotine varieties that kind of have advantages and disadvantages. Most commonly in our practice, we have access because of our Medicaid formulary to patches plus gum or lozenges. Patches, you can't really titrate that in real time, so that's a little bit less flexible, but it provides a really nice kind of low level activity. Gum and lozenges are kind of nice for high risk situations. You know, if I always smoke in my car, it's really nice to have maybe a nicotine lozenge in my car, so I can just pop that in instead of lighting up a cigarette, for example. They can be kind of hard in the teeth, especially the gum. It's a pretty hard gum, and so if people sit there and chew it, they can get jaw pain, for example. Nasal spray and inhalers are less commonly used, but are also technically available on formularies. And then if you're a prescriber, or maybe you just want to guide someone on how to utilize these products, there is this great resource. It's called the Mayo Dosing Resource, but it has a, it's like a whole long guideline about how to kind of pick different products, pros and cons, and you know what doses to start based on how much someone is smoking. So I always throw this up because it's really nice for nicotine replacement guidance. Bupropion, again, the SR stands for sustained release. It's just the version of the bupropion that got FDA approved for nicotine use disorders. It tends to block the nicotine receptor while also increasing some of that dopamine activity. So again, if you think back to that neurobiology, we're kind of blocking the effect of nicotine at the receptor, but also giving back some of that dopamine level that might be deficient for a while in people with early recovery. What is done to help the person work on different, oh good, okay, I'm gonna come back to those, sorry. And then as far as bupropion, there are kind of pros and cons of this medicine. It's easy to use. You can combine it with other, you know, for example, nicotine replacement treatments. It's been shown to lower cravings and withdrawal. It's technically considered contraindicated if someone already has like a seizure disorder or maybe another condition that's gonna make it more likely for them to have a seizure and can just have some various side effects as far as dry mouth, irritability, insomnia, anxiety. Varenicline is the third FDA approved treatment. Arguably one of the more effective treatments that we have as far as research goes. A lot of my patients are on buprenorphine because of the nature of my practice. And so I usually introduce varenicline as far as how it works is, it basically just does to your nicotine receptor what buprenorphine does to your opioid receptor. So it partially activates that nicotine receptor. So it helps to minimize withdrawal, then reduce cravings so that people can not smoke and kind of make some of those behavioral changes while they're not feeling like they're having nicotine withdrawal basically. People start nicotine the week before their quit date. And then hopefully by the time they reach their quit date, they're up to their maintenance medication or maintenance dose, which is one milligram twice daily. Most of the studies would study this for about three months. So it's kind of considered a treatment course. As far as disadvantages, it has side effects. Probably the most common thing that people stop varenicline for is they either get irritable, they can have some GI upset, or sometimes people get really vivid dreams, not necessarily nightmares, just vivid dreams, which unfortunately for some people can have negative themes, which fall more into the nightmare category. Of note, there used to be an FDA black box warning against using varenicline for people who had a history of psychiatric condition that has been removed. So if that's like part of how you learned varenicline, that has been removed, it's been shown that to be not an issue, those neuropsychiatric side effects are no more common in people with psychiatric conditions than in the general population. And people with mental health conditions are just as likely to benefit from varenicline as the general population. So don't withhold this medication just because someone has a mental health condition. And at the end of the day, all of these treatments are better than nothing. So really trying to improve access and offering nicotine cessation medications whenever possible. This is what I was referencing. So when the black box warning was out, knowing that people with severe mental illness were actually dying young and oftentimes they were smoking or dying from tobacco related illnesses. The government reissued a group to try to study this to say like, well, what does, you know, varenicline do to this population or basically all the smoking cessation treatments. And this was just the study that was published in the Lancet in 2016 that basically said, hey, people with psychiatric conditions are no more likely to have these side effects. They're just as likely to benefit. We shouldn't be withholding these medications. And this was the study that ultimately removed the FDA black box warning. All right. And then again, if you have someone who's pregnant or maybe is trying to become pregnant and they're using tobacco, similar to a lot of our medications for alcohol use disorder, we don't really have as much research, high quality research as we would like, but most of the guidelines and studies would say that these medications are likely safer for pregnancy than ongoing tobacco use, especially if it's combustible tobacco use. So for nicotine replacement treatment, again, we don't really have great data, but a lot of the data actually says that the efficacy might be worse in pregnant populations just because maybe they chew up more of the medication, which makes it less effective. But again, it's low quality evidence. Varenicline and bupropion, there's no known birth defects, strata genetic concern with these medications. And some of the systematic reviews of smaller studies say that it's likely safe in pregnancy and again, likely safer than ongoing tobacco use. So even if people are pregnant, we should be offering them medications to help with tobacco use disorders. And just in summary with nicotine use disorder in particular for our medications, we should offer medications. If I had to kind of do the big equation of how to prioritize the treatment options for medicines at least, Varenicline works equally as well as a combination of nicotine replacement treatment. So let's say a patch plus a gum, equally effective. Both of those options are more effective than Welbutrin or just using kind of one type of nicotine replacement therapy. So maybe just doing a patch or just doing gum by itself and all of it is better than placebo. So all of it does better than nothing. So if someone's only interested in one type of medication, we should still be offering it to them if they're interested. And then there are opportunities to combine these medications, but that's a little outside of the scope of this talk. Okay, guys, we're at our last topic. So we've made it, we're going through our path here. And we're gonna kind of come to talking about recovery. And I have a sense that a lot of what I know about people who are joining this talk is a lot of you have been a part of recovery communities to kind of focus on this a lot in your practice. And so a lot of what I might talk about might be stuff that you know much better. But recovery, one of the definition that SAMHSA gives is that recovery is a process of change through which individuals improve their health and wellness and live a self-directed life and strive to reach their full potential. And this definition of recovery was meant to apply very broadly. So not necessarily just to people with substance use disorders but also people with chronic mental illness, people with severe mental illness. One of the physicians who taught me who's now an emeritus professor, he used to say like, you know, recovery is just someone having something that they love and something to do on a Saturday night. No more or less complicated than that. The big dimensions, when I talk about what should we focus on to really like intervene with recovery status is things like what's their health? What's their home environment? What is their purpose? The purpose to which they kind of go day-to-day throughout their life. And what's their community? What is the community they identify with? What's their community setting surrounding themselves? When you talk about recovery communities and I think, you know, there's, I'm fairly young in my professional career, I would say. And so, but I get the sense from reading about, you know, the transition of policy and substance use treatment that especially as we have more like medicalized viewpoints of substance use disorders and medications, for example, we talk about recovery communities. A lot of 12-step programming, for example, has kind of been shifted and maybe not necessarily thinking about it as an intervention or a treatment, but really as kind of a form of a recovery community for people. I think there's pros and cons to that when we kind of think of 12-step and how it was created and how it gets implemented. But I include 12-step programming. So like Narcotics Anonymous, Alcoholics Anonymous as part of recovery communities as a little bit more of how it's conceptualized more recently. And then we have SMART Recovery. So again, this is the idea that we have communities of people who are all focused on the same goal, who provide people with purpose, provide people with that community sense who are all there kind of seeking, you know, similar goals potentially at different pathways. For SMART Recovery, you know, the SMART stands for Self-Management and Recovery Training. Similar to 12-step programming, they tend to be abstinence oriented, tend to be peer-led. Outside of, what makes them a little different is they identify as more being kind of secular and science-based, maybe rather than a spiritual-based sense of community and recovery. And it was developed kind of in combination with people who were in recovery as well as kind of addiction psychologists. And so slightly newer than some of our 12-step, 12-step recovery communities. There's also other types of recovery communities that are based in different spiritual backgrounds, you know, different. I think, I would say, I think the biggest thing is this, you have a community of people who are there to support each other, make people feel belonging. And then usually within those communities, people can derive a sense of purpose and they can apply that into other places, even outside of their recovery communities. We also talk about recovery as having kind of dedicated peer recovery specialists, which we have started to integrate more into our more formalized treatment settings. The use of a peer recovery specialist, you know, a lot of that came from work historically, where you had really communities that had been disenfranchised and they were really trying to help each other and turn to each other for help. It was kind of considered, it started as this mutual aid mentality and kind of closer to the 19th century. And then it was informed as we transitioned into more as the 12-step program and became kind of developed and more available in the 20th century. The idea is that we kind of provide people with recovery coaches, people who have kind of gone through this process to overcome some of the despair and shame and hopelessness, and let's be honest, stigma, that hinders people's ability to successfully either seek care or maintain themselves in care. And then again, we try to kind of utilize this kind of like all-spectrum involvement. So we want to have peer specialists at all steps. SAMHSA fairly recently put out what they're trying to kind of consider this national model for standardization for providing peer recovery specialists. I'd really encourage you if you're interested in this space or kind of planning programming to read their principles. I thought they were really well done. And as someone who kind of does harm reduction and work in community-based organizations, I thought it was really nicely well-informed by a lot of those principles as well. So some of their models is they want people to be authentic and have lived experience. So kind of a prerequisite for people, again, putting the peer in that peer specialist role. They want to make sure that people are adequately trained. So we don't want to equate lived experience to appropriate training. We don't want to put people into a workforce where they're going to be at risk for both themselves and their recovery, but then also participants. And so making sure we're trying to standardize training and kind of a global scale, trying to create some sort of formal examination process where people can be certified, that's kind of focused on the tools and the skills that we want people to have. Again, formal education, part of that kind of formalized training. So not just assuming that because people have lived experience that that's all they need, really equipping them with tools about boundary setting, communication styles, trauma-informed care, things that will allow them to perform in their role much more safely and effectively. Some things that I thought were interesting, they talked about background checks. And I was kind of taken aback by this when I read the standards, but really what they were emphasizing is we want people to be certified and we don't want certification organizations to worry about background checks. We should let organizations who are going to hire peer recovery specialists to worry about what they want to do with background checks, but we shouldn't limit someone having appropriate training and certification as a peer recovery specialist. If it's, we shouldn't limit them purely based on a background check, knowing that how often a lot of our patients who have used drugs or had use disorders get involved with the legal system. Recovery was another kind of similar goal. They obviously want people to feel safe and steady in recovery, but they don't necessarily want to give a timeline from a national model standard. They want to kind of allow that to be part of the employer's role. So I can be certified if maybe I've only been a year into recovery, but maybe there's an organization that will only hire me if I have four years of recovery, for example. And so just kind of trying to allow employers to kind of take over that, but really allow the standard of model to be more kind of vague and open. Prioritizing diversity, equity, inclusion, accessibility, so important, especially knowing how racism has impacted kind of how people have been involved with some of our treatment settings and carceral settings around substance use. Having good ethical codes, again, both for our participants as well as our workers. Making sure our people are adequately compensated who are doing peer recovery support. Let's not take advantage of them. Let's pay them for their expertise and trying to figure out models of care that allow us to reimburse people appropriately is going to kind of be a future thing that we'll all encounter. And then making sure people have adequate supervision. I think supervision is really important. It's both, again, for the safety and wellbeing of our workers, of our peer recovery specialists. And I think that provides people with a lot of support while they're doing the hard work of day-to-day recovery coaching. Okay, I'm gonna take a look at the chat real quick because I've got a few more slides, but we're practically done. Okay, you guys are all talking amongst each other about awesome stuff, which is great. I thought there was a question. Let me, I'm gonna start here. I'm gonna go through my slides quick and I think there's, oh goodness. What is it to help the person work on different pleasure, on the different pleasures of smoking? Oh, yeah, I've had a lot of patients do different things. Sometimes this is where like short-acting nicotine replacement therapies can be helpful. So if you drink with your coffee, if popping a nicotine laws and while you have your coffee instead. I've also had patients be really creative. So I've had patients take straws, cut them into the length of a cigarette, put an unused cigarette filter in the straw and they honestly breathe through it, which almost sounds silly, but it allowed them kind of the feeling of breathing in and out hand and mouth as a cigarette, but obviously there's no fire, there's no nicotine, there's no smoke. And so that kind of allowed them to create some of the behavioral stuff without the nicotine exposure. That's probably one of the more creative methods that someone has communicated with me. Yeah, and I think, Nicholas, I think your comment is well taken. It's really actually hard to diagnose someone with a nicotine use disorder in some ways just because like legally, there's not necessarily that many interactions that contribute to maybe some of the negative consequences relative to something like methamphetamine or some of our schedule one medications that are restricted or some of the schedule one substances that are restricted. I have never heard of low-level laser therapy, so I'm gonna have to look that up now. Thank you for sharing that. Yeah, I think, Ellen, I think your point about, social acceptability of behaviors, I think influences us. It's kind of the long path, but I think that's where a lot of our public health measures can have these really huge impacts if we utilize them correctly. So just not allowing people to smoke in certain places or just not allowing people to smoke in certain places. I also think it's interesting if you read SAMHSA's national survey, they always ask people like how dangerous or how negative do you think it is to smoke five cigarettes a day versus to smoke cannabis once a week versus to use heroin once a week? And it's always interesting to watch that trend because inevitably you'll watch that trend and that will inform how people are gonna utilize certain substances or the incidence and prevalence of substance use. We've seen that the, basically the acceptability of cannabis is starting to change dramatically, especially with younger populations, which kind of lines up with, I think of how kind of culturally cannabis is becoming kind of less stigmatized, less seen as kind of through a predominantly negative lens. I'm glad gum worked for you. That's great. All right. Do you think the changes in ASAM will change? I don't know, to be honest. It's a great question. SAMHSA put out a bunch of grant funding for the past five years around trying to develop different recovery community organizations as well as peer recovery programs. And they tend to do that to gather data to inform national standard. And my guess is once they start to implement national standard as maybe a requirement, they'll have to start figuring out how that interplays with the ASAM criteria, especially the fourth edition. All right, sorry. Okay, back to my slides. I have a few more slides left. So again, if you like drugs or if you like to read books about drugs, these are just ones that I've read all of these. I think they're all great in their own way. Dope Sick by Beth Macy. The book is better than the show for what it's worth. Kind of tells the impacts of the opioid epidemic, especially around Appalachia. Chasing the Screen by Johan Hari is more of an anthropological piece about talking about the different ways to which the opioid kind of epidemic impacted different people, whether it was people selling the drugs, using the drugs, families, friends. It's a really well-done book. Gabor Mate has In the Realm of Hungry Ghosts. He kind of tells about his experience as being a general practitioner at a housing first model in the Lower East Side of Vancouver and really kind of emphasizes just how much trauma impacted a lot of people that he saw and how that kind of influenced their substance use and vice versa. The Urge, which is a book by Carl Eric Fisher. He's a addiction psychiatrist out in Columbia. He tells, he kind of mixes in a, just kind of this like human history of using substances to change our headspace. And he kind of mixes in his own personal experience. He has a, he had a pretty significant use disorder during a lot of his medical training in particular. And so he kind of mixes in personal memoir with our history of substance use as a species. The Many Lives a Mama Loved is awesome. The author is someone who had a substance use disorder. She spent time incarcerated. So, and she kind of talks about how she, her experience was probably different than a lot of people's because she was white. She had, she was well-educated, had a lot of opportunities when she was kind of getting into recovery, but it was, it's a really, it's a really well-done book. And so I'd recommend it. Undoing Drugs is a great book about harm reduction, especially the history of harm reduction as a social justice movement. So I recommend you read that if you want to learn more about harm reduction or if you love harm reduction and just want to like consume everything that you love. The Weight of Air is a book by David Pocis. It's a personal memoir of kind of his experience with an opioid use disorder as well as really significant depression. He writes really beautifully about just how impactful his mental health was to his substance use disorder. He did find success for a while on buprenorphine. Unfortunately, he died a few years ago, pretty young. I can't remember if they actually declared if it was an overdose versus a suicide, but there was some thought that maybe that was it, but beautiful book. He tells his story very well. All right, so just to review, right? We talked about stigma. We talked about US drug policy. We talked about kind of understanding the neurobiology of addiction as we understand it and maybe about how that's so far informed some of our medication treatments. Harm reduction, we talked about opioid overdoses utilizing naloxone, talked about different treatments, especially our FDA approved medications for different substance use disorders. Talked briefly about recovery, kind of where we are, how we might define those communities. And I leave this last slide, just my director, who's someone that I admire greatly. She always has this saying that, rising tides lift all boats. It's probably, I've heard it in some variation, but we are forms of tides and providing experiences and education, whether through trainings like this or by talking to our peers or our family or our friends and really trying to humanize people who use drugs or have substance use disorder just allows us all to kind of lift those boats. And so just encourage you guys to keep doing your awesome work and hopefully this information has been helpful to you. I always forget to, Oren really enjoys having your feedback, helpful, not helpful, constructive, anything that they can do to make their service better. So if you have time or the inclination, feel free to utilize a survey link. And I'm happy to stop talking for a minute. If anyone has questions, comments, yes, Dreamland is also a wonderful book. Very, reminds me a lot of Beth Macy's as far as, and he kind of tells a little bit more about the impacts or kind of the economic, I guess, market involving Mexico, for example, and how their communities were impacted when heroin became a kind of an export with our opioid increases. I haven't read The Least of Us, so I'll have to look into that. Thank you. Is it okay just to talk? Yeah, please. Okay, thank you. I was typing this and trying to get this out. You had mentioned the Measure 110, and I really would like to talk about it. This is genuinely the best presentation I've ever seen. It was so informative and complete, and it really was balanced on just the reality of some people are going to reduce and some people are going to stop, and some people are not, and this is how we can keep them safe. With Measure 110 being overturned, the governor is assigning to the counties, at least from what I've understood, the resources, and they were supposed to figure out a plan. Are you working with elected officials to kind of train them on, give them this education so that they know how to utilize those funds? Because it sounds like it didn't work because money didn't get it out, Well, now we have this moment, and counties are scrambling. Are you reaching out to do that by some miracle? So I'm located in Iowa, so just full disclosure there. That's a Sarah question, and that Sarah question is- Oh, thank you. Yes, don't worry, don't worry. That's a, yeah. If you have local governments who are interested in learning more, we are happy to set up trainings for them. I just don't know all of your local governments, but if there's anybody that you want to get in contact, I'm happy to talk to them about our services and talk to them about the education that we can provide. We have done this training for other people and other local governments, specifically in Washington, so happy to do it for Oregon. Honestly, you just got to let me know how to help. I think somebody asked for my email. I will put it in the chat. Thank you. Yes, because like I said, right now is the time that they are literally getting the money issued and have to develop plans. So having this type of presentation where they could actually learn about, what's the reality could help guide that. This is like critical timing. So thank you. And thank you so much for the information. Yeah, and I know that like the opioid settlement funding money is also being distributed right now. And we also have people at ORN like consultants who know how to do that and like how to write the proposals and stuff that can help you walk through how to write that. So again, we've got a lot of people. I used to just say it has to do with opioids. ORN usually has somebody as a consultant who can help. Okay, thank you so much. And thank you again for this training.

addiction cycle

preoccupation anticipation phase

habitual compulsive phase

heightened attention

cravings

prefrontal cortex

insula

automatic behavior

reduced control

dorsal striatum

reward circuitry

dopamine

basal ganglia

extended amygdala

harm reduction strategies