Before I forget that. So my name is Haley Sherlock, for those of you that do not know, and I'm the CARES program team lead at Georgia Council for Recovery, but most importantly, I am a woman in long-term recovery. And what that means to me is that it's been a little over four and a half years since I had the need to escape my reality using any mood or mind-altering substances. Today because of my recovery, I get to be a present mother for my 16-year-old son, even on the days that he's driving me absolutely wild. I get to be a dependable sister and a reliable daughter. I'm a homeowner, I'm employable, and I get to show up for my community in ways that I never thought that was imaginable. And I choose to speak out about recovery because I remember a time where the shame and stigma had drowned out my own voice, but that is not the case today. It is through my own lived experience that I'm able to bring value to my community. And with that value, I'm able to help educate, advocate, and support those who are seeking recovery services. So again, I am really grateful that you are all here. And if anybody has any accessibility issues, please send me a message in the chat and I'd love to help you out with that. This will be an interactive online webinar, so we do ask for your engagement and participation throughout this webinar. Please raise your virtual hand to be called upon or drop some things in the chat. A few housekeeping rules. So for those who stay for the entirety will earn 1.5 CEUs. It ends today at 1 p.m. Eastern Standard Time. When submitting your CEUs, please keep up with the month topic and panelists. You will receive a certificate for this training no later than the end of next week from Al Cotton. And I say that lightly, that's normally how it goes, but the team is in New Haven, Connecticut right now, so it may be the end of next week or the beginning of the week following. Please make sure that your Zoom name matches your real name so that you can get credit for being here. And remain muted throughout this entire presentation unless called upon. And again, you can put your questions in the chat and we will try our best to answer all these questions. If you are unmuted and we're hearing some background noise, I will mute you. Again, this is interactive, so there will be plenty of opportunities to share your experience. And so like at every one of our other webinars, I'd like to start this off with a poll question. I'm going to go ahead and launch it here. So who is here? Are you a CARES or CPS AD? Are you aspiring to become a CARES? Are you a clinician, a recovery ally, or other? Let us know. About 20 more seconds. We're waiting on about six participants. All right. Thank you. I'm going to end the poll now, and then I will share your results. Please let me know if you're seeing them. Yep. I'm going to take a quick peg. All right. So, as I previously stated, we are collaborating with Opioid Response Network. We started this off last month in July, and this is going to be our second webinar with them, and so I'm grateful to be able to introduce Cat House with the Opioid Response Network. Good morning, everybody, or it's probably good afternoon. It's still morning my time. So, my name is Cat House, and I work with the Opioid Response Network, and just want to go over just a couple of slides about the Opioid Response Network before I turn it over to Andrea. Basically, the mission of the ORN is to provide training and technical assistance through local consultants, and now, Andrea, we have a wide variety of consultants all over the world. We try to use the ones within our region, but Andrea is from Texas, and so we were able to bring her in to do this PowerPoint training with you today. Next slide. We also build on existing efforts, so just like Haley said earlier, they're working on getting all of you trained and up to speed on everything that you wanted to know, and so that was how she reached out to us, and we've started these virtual series trainings, and that's what we do. We fill the gaps where you need some help. The next slide. We provide local experienced consultants in prevention, treatment, and recovery, and we also do education and training anywhere, virtual, face-to-face. We have a territory, and y'all are in Region 4, which is my region. Next slide, and if you have any questions about ORN, you can go visit our website at opioidresponsenetwork.org, or you can email us or call us, or you can reach out to Haley, and she can get you in touch with me, or you can, I'll put my email address in the chat. The next slide. We also are funded by SAMHSA, and everything that we do is free of charge, so if you're looking for any kind of training for any other organization to help us spread the word. Next slide. Important slide, probably the most important slide that I said thus far, and that is every time that we do a training with our grant with SAMHSA, they require us to get evaluations, and so we really need you to take a minute, and you can do the, you can take a picture of the QR code, or I have just dropped the link where you can do it on the website in the chat, but we really need that when it's done. It takes you about five minutes, okay, and so I'm going to turn it over to Andrea. She's going to take some time to talk about herself. I think most of y'all joined us last time, but if not, y'all are in for a treat, so I'm going to turn it over to Andrea. Thanks, Haley. Thanks, Cat. I appreciate you both. I'm happy to be here. How many of you did hang out with me last month when we came and we talked about the brain? Okay, I see a couple hands. All right, okay, so we're building on some of the stuff that we talked about, but we're also kind of in a standalone space as well, you know, so if you didn't get to hang out with me last month, you're not going to be, you know, willfully behind. We're still going to, you know, get in this space today, so last month was a lot about, you know, the brain and addiction and what's going on behind the scenes. Today is really looking at the mood component of things, and if you haven't heard the mood acronym, it's medications for opioid use disorder. There's medications for alcohol use disorder. There's medications, you know, for tobacco use disorder, you know, but we're looking very specifically kind of at the opioid side of things today, and that's going to be our focus of the things that we are discussing. I know the previous acronym is MAT, medication-assisted treatment. That was kind of the big umbrella term that covers all types of medications for all types of substance use disorders, so we're just a more specific niche for today, but there are other medications for other SUDs. There's lots of other trainings and things out there, but today is going to be focused on the opioid realm of things, so we're going to talk about mood. We are going to really emphasize and highlight that it's evidence-based, like we're not just making this up, that there's a lot of science and research and understanding to support how effective and how necessary these medications can be for a lot of people who are stepping into recovery, and of course, though, we're not advocating a one-size-fits-all. We're not mandating. We're not doing any of those things. This is an educational event. We're trying to give you some of the best knowledge and resources that are out there, and then, of course, doing whatever we can to support our patients individually in their choices, their pathways. If you hang out with me next month, we talk a lot about decision making and some other things that'll get really specific into those individual elements, so spoiler alert if you're looking ahead. That's what we're going to do the next time we hang out, but today, it's all about the medications and the mood and a little bit into advocacy and how we can take some of these things and make sure that they get into the hands of the people that can be most impactful within our organizations and in our communities, so I would like to kick off here with a quick poll, and it's a 10-question poll. It's going to be true or false responses, kind of a knee-jerk reaction. Read it. Pick a true-false. It's anonymous, and no one's going to know what you selected, but we will look at kind of the questions and the percentages briefly at the end of it. You do, I believe, have to answer all 10 questions in order to submit it, so I will not talk for about two minutes, so you guys can read through that, do some true or false answers there, and then we'll chat, so thank you for launching the poll. I appreciate it. Half of the people responded give you guys another minute and there's a lot of reading and clicking. Responses have slowed down. Do we have anyone who needs more time? Okay, I'll give you another 30 seconds. Anyone else need more time? All right, let's go ahead and end the poll and share some results. Oops. You guys seeing the results that popping up on your screen. I see some thumbs up. Awesome. Okay. Does anyone have any thoughts, feedback, want to unpack what it was like going through some of those questions? A lot of these things we will kind of get into and address today. So we're not going to go through every single one, but I want to give people some space after going through some of those questions and picking some answers. Does anyone want to reflect on the science and stigma poll? One feeling chatty today. I'm trying to kind of figure out, because you said to answer exactly how your brain is thinking. Yeah, kind of that knee jerk response as opposed to overthinking it, because then you can get in the gray area really easy. Right. And then you're like, what should I say? And then what am I actually thinking? And that'll get a little bit mixed. Gotcha. Anyone have a hard time with just generally some of the questions being, you know, hard of like, I don't know what answer I should be in or I'm not sure where I'm at. Yeah, I had a hard time because if I don't know the answer, so I left some of them blank because I literally did not know the answer. So I'm not going to pick one or the other. Gotcha. All right. But that's OK. Not knowing and acknowledging not knowing is why we're here. Right. To learn some things and maybe to fill in some gaps. Anyone feel very strongly now that you're seeing the results about kind of the divide amongst our group? I think some of the questions, I don't know, I guess from my perspective, it's just such an individualized thing. Like for some people, it is a really appropriate thing. But for for some people, it's really not. So it is it's kind of hard to generalize these things, you know. I agree. And with that, I think that's a perfect kind of wrap up comment here. Right. Of it's really important to kind of be aware about what hat you're wearing. Is this a personal hat? Is this a professional hat? Is this a peer hat? Is this a loved one hat? Like because sometimes that changes our beliefs and our values. Right. Like what I support when I'm at work versus what I would do in my own life versus, you know, all these different moving pieces. And so I think, you know, the biggest thing is, is being open minded, that there's not a one size fits all. Like that's kind of that first step. And like, it's OK if that's not something that worked for you or works for you or something that you think is appropriate for you. But then being mindful not to kind of overstep with that belief and say everyone needs to believe that everyone needs to agree with me, everyone has to kind of follow suit. And so I think there's always that mindfulness about kind of what hat, what capacity, where are we at? And if we wouldn't want someone telling us what to do, right, making sure that we're not trying to do the same thing to others because there are so many different journeys and pathways and what works and what doesn't. And just, you know, that understanding of to avoid stigma. Right. Like letting our beliefs exist in certain areas and other areas being more open and letting other people and their value and their beliefs dictate kind of what's going on in those situations. So it's always that balancing act of figuring out kind of where we fit in and where, you know, someone else's opinion and wants and needs and desires fit in to what we're doing here. So. OK, so we will talk about a lot of those topics here. Close that out there. All right. So let's get into the good stuff. We talked a lot about last month about addiction being a brain disease. There is a lot of evidence, a lot of understanding, a lot of science, a lot of organizations that specialize in this. Right. So it's a medical condition. And with that, just to highlight a few of the things that we talked about last time with one of the things being right, recurrence rates. And we had this slide come up where we talked about, you know, how stigma and how recurrence rates, which is, you know, what we say now, because relapse can even be stigmatizing and not the greatest language. So recurrence of symptoms, recurrence of use is really the more appropriate scientific language. And we don't treat all chronic illnesses kind of the same sometimes. And I speak, you know, with the royal we like the general broad context of the community and everyone in it, not necessarily everyone just on this call today. But being aware that recurrence rates are similar with the medical condition of having an addiction compared to diabetes, hypertension, asthma, like sometimes we're not great at following doctor's orders or we aren't doing the things we need or despite our best efforts. So, you know, the condition is not responding as well as it used to to certain treatment modalities. And so there's always a lot of things that go into it. And again, just kind of really fighting that mindset of, you know, there's something inherently wrong if somebody has a recurrence of substance use disorder and embracing that's part of this continuum. Right. That it's a long term, you know, chronic condition should be treated and evaluated like any long term medical condition. And of course, when you're evaluating things long term, you have periods where things are going well and you're going to have setbacks or things that aren't going as well. And when we talk about recurrence, like it's not a sign of failure. It's just something that kind of comes with the territory of having a medical condition that is chronic. And so if something's not working right, it doesn't mean that you failed. It means that something's not working. So let's review. Let's adjust. Let's try something different. Let's look at, you know, our medications there. Are they their appropriate medications? Are those medications at the right dosage? Or maybe there's other strategies that need to be incorporated and added to somebody's treatment planning. And so, again, setting all of that out as we get into the space for medication based treatment to just kind of ensure that it's not one size fits all. It's not an easy fix. Right. It's not a one and done. It's managing something long term. And that has, you know, different things that are going to come up. Nothing is, you know, the same today as it was yesterday or will be tomorrow. And so just being mindful about some of that dynamic. So we already talked a little bit at the start. MOOD versus MAT. There's new acronyms out there. There's other acronyms for other medications for other substance use disorders. But MOOD really is that more specific one that we're talking about today. It's evidence based. You know, when medications are used for OUD, it's a very regulated treatment. And there is actually, you know, a lot of science and best practices that are out there supporting what things should look like. And, yeah, so MOOD is the new term. If you're not using it, you're going to see it more and more. So does anyone feel comfortable sharing what they've heard about medications? Or maybe they don't know a lot about and, you know, what some of their assumptions or some of their, you know, just perspectives on these things. Does anyone want to open up and talk about what's the landscape out there? What are we seeing? What's happening? I have a couple of people in my program who are on methadone and methadone. And they both want to change to a different medication. And the place where they're going doesn't seem to be doesn't want to cooperate. But we did recently in Cobb, we have a medical detox and just for detox around here. And then they can help you get on an MAT. So I'm excited. I really am. I asked them because this actually says that they can medically support stimulants and waiting on that forever. But she said he said that's not really a medication for that, that they do comfort meds and help people get detoxed. So you bring up an interesting component, though, right? Like, you know, there's providers and health care and clinics and systems and things that play a big role in what we're doing. And unfortunately, that means it complicates the space as well, too. Right. Because sometimes things have to go through multiple people or multiple organizations to be able to get to the end result that we're trying to get to. And so it's a messy landscape. Right. There's a lot going on out there. Any other thoughts, comments, things we want to put out there before we jump in? I just want to say that I believe that there is a difference. I'm thinking about old school and those people who have been in treatment for a long time. I believe that they are very cut and dry, no gray area, as opposed to people who and that's anything like even in, you know, just how we live our lives today that if you're not doing it completely abstinent from any minor mood altering substances that you're just not doing it. So I think that's why I really appreciate and respect the fact that there's different ways for you to get to the same end goal, which is I'm assuming that's why I'm here because I'm trying to learn about it. But I'm assuming that at some point in time that that that that medication is removed from your life, you know, at some given time at some end point. Right. We're going to talk about that, but you definitely highlight that idea of kind of that old black and white thinking there's this way and then that's the only way we get settled and comfortable. Right. We don't like change. We don't like doing things differently. And unfortunately, we still see a lot of that out there. There's very much, you know, one way to do things and not being open to other ways or, you know, other research or, you know, evidence that may support other ways. It's hard for us to change our minds. So when we wrap up today, we definitely put on that advocacy hat a little bit of like trying to create space for those types of conversations and discussions and things like that. So what are the goals of medication treatment? Right. Like they do a couple of different things. So first and foremost, you know, at least two of the big three that we'll talk about today are going to help with those withdrawal symptoms. So it's a very important in that transitionary stage of getting out of active use and getting into recovery. Withdrawal is not fun. If you've been through it or you've heard from someone who's been through it, like it's very uncomfortable. It's very long drawn out. It's, you know, sometimes days and weeks to get through this process. Medications are going to be able to make that transition a lot smoother and a lot more comfortable for people. So it's not the old school, you know, cold turkey, just quit and be miserable and get through that. Right. There's more options now. So medication treatment can fill that space, but it does more than just fill that space of withdrawal. Right. Because it is a long term treatment therapy. It's meant to be long term. The evidence support that it does more than just get through withdrawal and just help with that detox process. But by creating stability and consistency in the brain, which we'll talk about today, it's going to help with cravings. So by creating that balance back and creating some of that stability behind the scenes, then the brain's not seeking that substance that, you know, that opioid as much anymore. It may not eliminate it completely, but it absolutely reduces cravings. And that's based on a lot of patients and self-report. And again, a lot of data and evidence over the years of speaking with people who are in a position to be in recovery, be on medication treatment and to report that, hey, it helps with these things. Right. So, you know, the science makes sense and the self-report matches up and validates the science, which is nice. And that all works out like that. And if the brain's stable and settled and not craving right, then we're reducing the recurrence of use. Then we don't have that drug seeking, that craving, you know, that wanting to go back out because you're feeling, you know, out of sorts and imbalanced. And so there is absolutely kind of a long term purpose beyond just that withdrawal and detoxification period. But the cravings and the recurrence of use is where the long term medication component really helps to come and settle, settle things in. It's also just not fixing the chemistry, right, because if it was as easy as detox, right, detox and abstinence would work. And unfortunately, it doesn't work. The numbers don't show that if you've been, you know, in active use and through recovery, it may have taken a handful of detoxes before you figured out what worked for you and how to fully make that transition. By and far, every study out there of detox and abstinence within a year, most have fallen back into a recurrence of their symptoms. And so there's just nothing to support that that's effective broadly and for a lot of people. Now, of course, you're going to know someone or maybe you or that someone like everyone's got someone who like, oh, well, they just decided not to use again. They never picked up again for the rest of their life. Like, OK, there's always an outlier. There's always something. But like the researcher in me is like, let's look at the broader numbers. If for most and a majority of people, detox and abstinence doesn't work, like that's not a fluke. The numbers are showing that there must be a better method or treatment or alternative that can help increase positive outcomes in the long run. If we hung out last month, you saw this slide, I just wanted to kind of mention it here again, because it does give us a little more insight behind literally behind the scenes, because these are MRI scans of composites of a variety of brains in each of these categories. And when we talked about it last month, we acknowledged that there was more of red all the way to the right in the opioid sustained abstinence. And so that's someone who has a history of opioid history is in recovery and is not doing any type of medication based treatment. You've got the composite of brain scans in the middle that show people who have that opioid dependence history, but they're on a mood based treatment plan. In this case, they were on methadone. And then you've got the control brain. There's no active history of addiction. There's no medication. You know, it's just that kind of, you know, average comparison to the other two categories. And all of that red was an indicator of glucose metabolism. Right. And glucose metabolism, we learned, was an indicator of kind of how much stress the brain is under. So if there's a lot of glucose metabolism and a lot of this chemical happening behind the scenes, when we measure and see it here on this scan, it's an indicator that there's a lot going on in the brain, that it is stressed, that there is a lot of kind of pressure on what's going on behind the scenes. But you wouldn't notice this. Right. If you were just standing and talking to someone, we don't realize maybe what is happening, you know, biologically, chemically, you know, all of these things behind the scene. And so we see that the mood brain has a lot less red compared to the abstinence only brain. And being mindful that that means, you know, on a very scientific level, right, that there's less physical, biological stress behind the scenes. So if we're creating stability and consistency, we're reducing some of the stress that the brain and the body goes through when you're transitioning from active use and into recovery and trying to figure out what recovery is now. And then the brain and body are trying to figure out, you know, how to settle back to their, you know, kind of pre-using baselines of things. Anything that we can do to eliminate some of that stress and pressure and, you know, all of these things behind the scenes is going to be very beneficial in so many ways for the person who's actually in recovery to have some stability and consistency. You know, I kind of tongue in cheek ask, like, who wants the brain that's got all the red? Like, I don't think any of us are raising our hands and saying, like, I want the stressed out brain. I want to feel just, you know, depleted and maxed out all the time. Like, but when we are in this field sometimes or people who don't understand addiction, like sometimes we're making those demands of other people, of other patients, of other, you know, saying it should be this way. And being more mindful that we may be asking a lot of somebody in that space. Haley, I saw you on mute. What do you got? Yeah, you got a few good questions in the chat that are pertaining to this particular slide. Okay. Oh, I love the good lava question. How many years after opioid abstinence was this picture of the brain taken? So both of the scans for the opioid dependent and mood population in the middle and the opioid sustained abstinence on the end. These are people that, and it's an average, right, because it's a group of brain scans. It's not just one person. But it's between four and a half and five years into their recovery journey. So one had a medication pathway and one had an abstinence only pathway. And so this idea, right, you know, you're cured or things are magically fixed or you've been through detox, like the brain and the body are slower to respond and catch up and figure out some things, as well as, you know, how much damage and stuff was done that may hang out for a lot longer or may sometimes be permanent. And so having some understanding that this isn't like a couple of weeks after detox. These are long term scans that show us what's going on behind the scenes. And so, again, the science of seeing it through a different lens versus sometimes what we think, like, oh, well, that's so far old news, old school, like you've been sober for so long. It doesn't mean that the brain and body have figured it all out yet or have fully healed yet. And just some mindfulness, right, that there is some stuff that does hang out a lot longer and it could take years or it could be things that are permanent. All right, let's see, other question. What other outside factors were taken into consideration? So the study itself doesn't go too far in there. They did look at like who was attending 12-step groups. That was an element that they looked at. So those that were in recovery were working some other treatment things as well, but it doesn't get super detailed of like, what else is stressful? What else is going on? It is still a snapshot of things. So like anything, there's a thousand variables that may play into things, but I would say generally what we do in research is we do look at kind of the composites here of like a group of people in these brain scan categories are showing these things. So it's not like one person is just really, struggling with stuff at home or whatever. Like when you have a lot of people that are showing these same patterns, while we're not testing for everything, you do kind of start to see, is there a trend here? And they did find that there's a trend in this amount of glucose metabolism between the groups as opposed to being very specific individually. So of course there is stuff that we don't know, but that's kind of where there's always room for more research and more understanding, but group trends do matter. If the trend is showing something, like maybe it's not by chance, right? That maybe it's not explained away easily with one or two other variables. So, you know, it's not a perfect system, but it does give us a little more insight in there. Okay. Oh, I see some feedback. The slide has been effective, I like that. So that means you hung out with us last month when we had this slide and talked about it. Awesome. And it's a short article. If you look it up, it's not that long if you're interested to get in there and see kind of what they were doing, but it's a good one. So just some of that food for thought and this idea of, you know, what it really means to be in recovery and what the brain and body are going through is always important to kind of keep in mind. So as we talk about the medications here, right? We've got the big three, methadone, buprenorphine, which a lot of us know is like suboxone. They also have the sublocade, which is kind of that extended release version. And then you've got naltrexone, which most of us probably know it as the brain named Vivitrol, which is the shot that's an extended release version of that. They actually also use naltrexone as a pill form and they also use that in alcohol use disorder. So this was one of those that kind of, you know, shares its space with alcohol use and opioid use. It's been effective in both of those populations. So those are the big three. The biggest takeaway, and if you go down the rabbit hole of medical research and different groups and studies and meta-analyses and all this kind of stuff, like it becomes very undeniable that it's been very much replicated and shown over and over and over that mood treatment is at least twice as effective as abstinence only. And a lot of studies find that it's even higher than that, kind of depending on specifics of what they're looking at. But we know that all three medications reduce opioid use and opioid use disorder-related symptoms. It increases time in treatment. If you're on a medication-based therapy, you're more likely to be engaging in other types of, you know, clinical and behavioral services, which we know is great for someone in recovery. Biggest thing, right, lowers risk of overdose mortality. So getting people connected to mood reduces fatal overdoses. So like, that's a huge one. It also has kind of that ripple effect of reducing the risk of infectious diseases because we're reducing kind of other high-risk behaviors indirectly. By treating the substance use disorder, we eliminate some of those confounding variables, so other positives that come out of this. And there's been a correlation with criminal behavior and medication-based. So if you're in a medication-based treatment, you're finding yourself less likely and less frequently being involved in the criminal justice system. So there's a lot of stuff kind of over and over and over and like citations just like crazy of just research after research that really supports that these work more effectively for a lot of people than the abstinence-only model of things. Again, are there outliers? It's not 100%, right? It's not a perfect system, but to double the chances at a minimum of increasing a positive outcome and reducing some of these negative outcomes is a pretty good space to be in. So that's a sizable amount. So let's talk a little bit about the types of medications. We're not going to get too sciency here, but I do want to kind of at least give some understanding of what's going on. So you've got agonist, which is a full activator of a receptor. So an agonist medication is going to activate those opioid receptors in our brain. And when those receptors are activated, it's going to cause an action. So there's a pharmacological effect. It's going to cause an action in this case, right? Opioids would fill the receptor. One of the actions it's going to cause is pain relief. It's going to have that quality because of the nature of the medications and the receptors and all that stuff going on. But the broader term, right? An agonist is going to fully fill that receptor. It's going to create an action. And some of the things that are full agonists include heroin, oxycodone, methadone is a full activator, hydrocodone, morphine, opioid, opium, fentanyl is on this list too. So those are full activators of the opioid receptors in the brain. Then you've got the other end of the spectrum. An antagonist is the opposite of the full activator. It's a blocker. So it's going to block those receptors in the brain. So it's going to kind of put a lid on that bucket and it's going to close the door. So there's not going to be an effect from that, but it also prevents other things from going in and activating that receptor. So it really is a closed door. So naloxone, which is our Narcan that we know of, and naltrexone, which is your Vivitrol, fall into this category. And so thinking about the importance of being able to block that receptor, but what it also does is if there's anything on that receptor, it empties it out before it closes the door. So that receptor needs to be empty before the door is closed. And so thinking about naloxone, right? If you're putting it in there, it's because there's too much overloading the system. There's too many receptors that are bogged down with opioids. We need to reverse that. It kicks everything out and then it closes the door. And so that's why it's effective in reversing an overdose because it cleans it out and shuts the door. With that, if somebody obviously has a substance in them and we kicked everything off and closed the door, it can precipitate withdrawal, meaning that you kind of go instantly into withdrawal. With naloxone, we take that cost, right, into consideration of saving the life. So yes, you may be uncomfortable, but we're going to give you another shot at trying to figure some stuff out. So we kind of weigh the pros and cons there. Naltrexone, which we'll talk a little bit about, right? Then there's a detox period that has to happen before we put it in so that we don't kick somebody into precipitated withdrawal. It's a little more mindful when it's being prescribed as a medication for long-term use. And then you've got the partial agonist. Sometimes it's called agonist antagonist. It's basically one that's a little of both worlds and it's going to activate the opioid receptors a little bit, but not fully. It also has what we call a sealing effect, meaning that it's not going to ever fully activate the receptor. No matter how much you put in, it's only going to activate that receptor so much. But then it also acts a little bit as an antagonist because it blocks those receptors from other stuff getting in. So it's allowed to be there, but no other opioids are allowed to be there. So it kind of has a mixed bag of things. And most common one we talk about in this realm is buprenorphine. Your suboxone is going to be in this partial agonist category. And for my visual learners, here's a little more of what we've been talking about, right? So you've got all the way to the left, your methadone, full agonist, is going to fully fill that receptor and cause an action and cause a pharmacological effect. Your buprenorphine is going to partially activate that receptor, partially block that receptor. And then your naltrexone is going to kick everything out and close the door, right? So it's an antagonist and is going to block that. Some of the things we're going to talk about here, and I'll talk about, oh, on the next slide. How convenient. Perfect. So this is where I really want to break down this idea of like, I understand that if somebody's telling you, like, I have a narcotic-based problem and a provider tells you, great, I'm going to prescribe you a narcotic to fix this problem. Like, that sounds a little weird, right? Like, that's kind of this mindset of like fighting fire with fire, or this is where some of the stigma comes in of replacing one thing with another. Like, you're just swapping out to something else and it's doing the same exact thing. And I think it's really important to understand that while they're both narcotic, you know, categories, the medications that we're using to treat opioid use disorder are very much inherently different. So even though they're activating or working on the same receptors, it's not exactly the same thing behind the scenes. And so I like this slide because you'll see that they have the example of heroin as this red, right? So heroin is a short-acting opioid. You're going to put it in, you're going to get a very quick, you know, peak and high, and then you're going to have a very quick half-life and it's going to start to wear off and disappear. And so all of, you know, your other opioids, whether it's heroin or fentanyl or other prescription opioids, they have this short-acting up, down, up, down, and that's where we get a lot of that instability of like you're kind of trying to chase this rollercoaster of like, I get the high, I'm here for just a minute, and then, you know, it's already starting to decrease and now I feel miserable and I'm in withdrawal, so I'm taking another, and it's very disruptive and it's very kind of traumatic for the biological system behind the scenes. Now, if you look at the other two blue and green lines there you got methadone and you got buprenorphine, right? Like you're going to see that there's this build of like getting built up in the body, but then you've got stability in the body behind the scenes. So we're prescribing something that is longer acting. And so methadone's longer acting than buprenorphine, but they're both long-acting opioids compared to a lot of the ones that people are struggling with in active use from, like I said, heroin, fentanyl, all your other prescription pills. So it's not just like, here, take this instead. You're telling the brain and the body that you're going to kind of balance things out because the medication's going to kind of meet you where you're at to fill some of these deficits and help balance things out. But then you're creating a steady state. And that really is important when we're looking at why it's different to be on methadone or buprenorphine, because the brain and the body do a lot better when it's stable and consistent. It can heal. It can focus on all of its other functioning. When it's chasing a short acting, it's very disruptive. It disrupts a lot of the regular kind of health and things that are happening beyond the scenes. Like if I'm on a short acting opioid and I'm chasing this high in active use, like my immune system is compromised. I've got all these other health conditions that are going to start to show out, you know, versus if I'm on a steady state, my body's not in crisis. So it does all the things it's supposed to do. And so we see that, you know, the benefit of creating a steady state is much different than kind of this up-down chasing of the short acting opioids. And so this is where we highlight, you know, that it is different and it's not just, you know, switching one drink for another, one drug for another. You're changing a lot behind the scenes and stability and consistency are important for healthy, you know, and productive long-term outcomes, just from a physical standpoint, let alone all the other things that it's easier to do, right? If we're creating stability and consistency, there's less stress, there's less glucose metabolism, there's all these other things that make it a little bit easier just to function on a regular basis. You will notice naltrexone is hanging out on there. It does create stability and consistency, right? But it's not activating the receptors at all. So it kind of functions in a little bit different capacity than methadone and buprenorphine do, but still looking at creating predictability and stability behind the scenes, because that's really what our body craves and wants. And it's not getting when it's in active use. So we won't go too far into, you know, how to prescribe. Like if you're actually in this realm, you're going to spend a lot of time training, but generally speaking, there's an introduction of the medication, and then there's a little trial and error. There's a little of art along with the science. There's a little bit of trying to figure out how to get that person up to where their steady dose is going to be most effective for them. And so there's kind of an introduction initially, and then you're going to kind of prescribe and sit back, and then prescribe a little more and sit back. And it's a bit of a process. So it can take weeks to really get to a point of kind of figuring out where that magic window is for somebody. The other thing I like to mention, even though on average we were seeing, you know, for a long time, between like 60 and 120 mgs for methadone, it can be higher or lower than that. And we'll talk a little more about right dose. And the landscape has changed. The potency of the opioids and things that are on the street have changed. We've actually seen that average shift upward a lot in recent years because of that. And so my hope is, is that we don't get caught up on like the number, but we take a step back and kind of look more broadly about what's working and what's not for somebody. Along the same lines, buprenorphine is not regulated as heavily. So there's a lot more options to be able to get connected to that. It can be done in an emergency room. It can be done in a clinic. It can be done on telehealth these days. You can do it at home. And there's a little more of an art there because keeping in mind, buprenorphine is that partial agonist, right? So like if your body's starting to enter withdrawal, then there's less of a disruption when you put the buprenorphine in, because remember it has that antagonistic effect where it's gonna kick stuff off as well. If you have a fully activated receptor, because you just took a pill or used heroin and you immediately put buprenorphine in, you're gonna get that same precipitated withdrawal. It's gonna kick you from, you know, 100 to zero and you're gonna feel kind of miserable right out the gate. Where if you time it, where your body's kind of naturally entering into that withdrawal, then the buprenorphine comes in. It's like the Indiana Jones switch, right? With the bag and the artifact, like you can be a little smoother with it and have it be less disruptive because you're replacing and meeting it kind of where it's already entering withdrawal. And that happens naturally instead of us kicking into withdrawal. So generally speaking, and there are a couple of other creative ways out there, but by and large, this is really the method that we're seeing of looking at at least creating some time from your last use of a full agonist opioid. So whether it's heroin, fentanyl, any of your prescription pills, and then methadone, right, is very long acting. And I know we had talked earlier where someone had mentioned someone trying to transition off methadone. Takes a lot longer because we just talked about how it's a long acting steady state, doesn't disappear as quickly. And that's very beneficial if you're in recovery, but if you're trying to not be on it, it's not an easy like, oh, I just, I'm off it now. Like there's a very mindful transition that has to happen. And then more importantly than not, it's not the hours, it's really looking at the symptoms. What are the signs? Are there at least enough signs to show someone starting that withdrawal process? Then it's that magic window of starting the buprenorphine where they're gonna start to feel better. So I know we always counsel our patients of, you know, you gotta start feeling crappy, but then I don't need you to feel crappy for 10, 12, 14, 18 days. Like I just need you to get into that space a little bit, and then we take the medication. And then it's pretty quick. I mean, within 45 minutes to an hour, you're starting to kind of see that there's some of that relief. You're already building up a little of that steady state. You're creating, you know, the lack of the withdrawal, you know, symptoms. So you're covering up those uncomfortable things. You've got medication now in there. So if you time it right, it's really smooth. If you time it wrong, it can be a little bumpy, but if you stick with it, you can still kind of get through some of that precipitated symptoms and kind of still get to the other side. So there's a lot of educating and trying to help people find that perfect window to time it. And then once you're in, you're in. Then it's a lot easier to maintain and keep it moving. So to talk a little more about all this stuff, and then we'll pause after this for comments, I promise. Looking at what we're talking about when, you know, we're like, it's just swapping one drug for another, or it's fighting fire with fire. Like, here's another way to look at it. I know this isn't a great image here, but there's a really cool, they call it the donut theory of addiction, which just makes me hungry. It's lunchtime now. But this idea of like metabolism plays a huge role in addiction. And the whole metabolic system behind the scenes and all that is heavily influential in understanding what's going on with substance use disorders in general, but you know, also with opioid use disorders. And so generally speaking, a closed ring means you've got normal metabolism, your body and equilibrium, everything's in balance. It's doing what it's supposed to. So it's rocking and rolling. It's a closed circle. It's not feeling like it's missing something or disruptive at all. But if you've got a deficiency in this system, which is caused by opioid use disorder, then we've got a gap, right? Like, so if I take the drug out, I take the heroin, I take the fentanyl, I take any of that out, that circle isn't just going to close on its own. And if it is, it's not going to close immediately, right? So now we have a deficiency behind the scenes. And so if you're just using short-term opioids, right, as soon as that circle kind of becomes unbalanced, right, you crave, you use, you fill that circle again temporarily, and then that's going to wear off, and then you're in this cycle of rinse and repeat, right? But if we're putting the rest of that circle in with a long-term, longer-acting medication, you're going to fill that circle, but you're also going to create that stability and consistency, so you don't have to kind of chase this, I'm feeling a deficiency I need to use, I'm craving, like we're creating that stability and consistency, we're filling those deficiencies behind the scenes. And if we're filling that circle, it also creates something called narcotic blockade, meaning that once that circle is complete, like using on top of that doesn't get you the same type of response because the brain's in balance, the metabolism's in balance, all of these deficiencies have been created in balance because of the medications. And so as long as you're medicating at a high enough rate to fill that circle, then you're creating a blockade kind of to the other use or other medications or other, you know, illicit substances that are going in there. So we need to make sure that we're medicating at a dose that's high enough to help us fill that circle, if that makes sense. So we don't want a donut with a bite out of it, we want a full, brand new donut, untouched, that nobody's eaten. So if we only put a little bit of methadone in and saying like, oh, you don't need all that, we're not going to fill the donut, we're not going to fix all the deficiencies, and ultimately that means you still have a donut with a bite out of it, and the body is going to crave and seek something to fill that space. So I know that's a lot. Let's pause there. How are we doing? Any questions, comments? What do we need? Let's see. Sandra's got a person's never used. Absolutely. So, I mean, and thinking about, right, the brain scan. So if y'all looked at Sandra's question, basically, if you have a period of recovery, but you're still feeling urges and cravings, can medication play a role? So think of the brain scans, right? That's five years in on average for the participants they used in that study. So even though you may be in recovery, doesn't mean that the brain and body has figured things out, that it's corrected all the deficiencies. Maybe it's corrected as much as it can. Maybe there's still some things that it's trying to figure out. So that's kind of where regulations can be problematic, because we still see a lot of places you either need to be in active use to access resources, or you see the stigma of providers who are like, no, you've been sober for two years. What are you doing here? Get out of my office, like you clearly are fine and know what you're doing. And that's part of the lack of education, the lack of science knowledge, the lack of appreciating that even long term recovery might not be fixing and helping a person with all the other stuff that they're doing. Like if there's still deficits and deficiencies, medications can be useful. Even if detox is long gone, even if other things seem, you know, like ancient history, it doesn't necessarily mean that there might not be a benefit from medication-based therapies. So, and that's something, again, advocacy in that, but occasionally we get patients who come to, you know, my program where they have maintained for a year or two, and they're struggling to maintain, and they don't want to go back out and use, but the cravings and, you know, this, you know, kind of disruption is just so much that they're like, I want to talk about options. I don't want to talk about medication and where can that fit in? And so, unfortunately, like I said, sometimes our landscape isn't supportive of that, but scientifically speaking, it should support that, that there's a lot of evidence to show that even if you're, you know, a good amount of ways into your recovery, it doesn't mean that there's not benefits for medication-based therapies. What do you got, Haley? Yeah, I just thought it was a, so actually as a person who used buprenorphine as a pathway in my recovery, I came off of it, what others may have said too soon, but I thought it was just the right time, about a year and a half in, I stopped taking it, but I also knew going into stopping taking it that I was going to allow myself grace that I knew that this medication worked for me, and if there ever came a time that that lifestyle became appealing or those thoughts came back and life was just unbearable, and I was thinking about using that, I'd always allow myself the grace to go back and get on that medication before I put myself through the turmoil of active use or what the risk you run today when using opioids is, you know, death, fatality. Especially if your tolerance is low because you have been sobriety, you know, in sobriety for years, it could take very little to end up, you know, being a fatal overdose. And again, that idea of what's safer and better alternatives, medication is always a safer and better, better alternative because people aren't, you know, falling over in the streets from their buprenorphine scripts. Like, you know, those are the things that we want to keep in mind of like, you know, it's, it doesn't have to be an all or nothing, but if you're struggling to maintain, and maybe you were doing well for a while, and then it gets hard, right? And if those are some things that need to be adjusted, as far as treatment goes, that's where we want to fight the stigma of this idea of like accessing medications means something's wrong. Well, they have a place and a purpose and can be very useful. And it's absolutely better than the alternatives. Sandra, you had a hand? Yeah, I just want to thank Haley for putting that in perspective, because that's exactly what I was talking about, like, now with everything going on with the fit norm. And I mean, like, to have people to maybe to start thinking that way, where you know, like, before you say nothing, say something so that someone could possibly give you that type of option. So that you're not like, you know, I mean, because that's deadly. Now you go back out there as opposed to something that could be medically, you know, like, you know, yeah, so that's all. And this is where I like to throw in a good old, like, so let's take diabetes, right? And let's say you found yourself in a space where maybe you're pre diabetic, or you're diagnosed as, you know, full diabetic, at some point, there's a lot of things the doctor is going to recommend to you, you're going to talk about, you know, losing some weight, you're going to talk about healthy and nutritional guidelines, and being more mindful about blood sugars and eating and carbs and all that fun stuff. And then even beyond that, though, like, there's medications, if those natural pathways aren't working to create what the body needs to be fully functioning, right. So you may get prescribed insulin, or there's other, you know, medications that you can take, that will get into this space. And I like to play the devil's advocate, right? Because maybe I lose the weight, and I monitor my blood sugars and what I'm eating and all this other stuff. And despite my best efforts, right, I'm still diabetic, and I still need insulin, and I may need insulin for the rest of my life. And so we don't stigmatize that if we see someone who's done everything they can, and they're still in a space where their body just can't do what we want and need it to do, we don't make them feel bad, like, oh, you're still on insulin? It's been 10 years, what's wrong with you? Like, we don't ever do that. But with medications for this chronic condition, we absolutely see it all the time, of this idea of like, that there has to be an endgame. And so I think it's mindful about how it compares to other chronic conditions that for some people, despite all the other things that are recommended, and you do and you try, you might still need the medication, and that needs to be okay. And that needs to be something that is more accepted and is more, you know, understanding of like, if they've done everything else, and this is the only thing that's creating what they need to be happy, healthy and productive, then let's go with it, right? Like, let's keep that going. Like, let's not disrupt that. But the other side of it, right, is that there are some people that are in the other camp of, I've made lifestyle changes, I'm doing this, I'm doing that, I'm engaging in all these other kind of treatments and supports and stuff like that. But the medication may go away. And it might not be something that you need long term or for the rest of your life. And you're able to kind of find and create whatever your recovery journey looks like and find something that works for you. And so this really goes into that idea of like, people are in both camps, and it's okay to like, do everything in your power and still need a medication. Like, it's not a crutch. It's not because you're doing it wrong. But it does still play a medical based role of helping create some of these stability and consistency, helping balance out some deficiencies, helping create things that maybe the brain and the body can't do on their own anymore, because of the length of history or the amount of using or just our bodies in general don't always do what we want it to do. So kind of being mindful that it's not again, a one size fits all some people get on the medications, they use them for a couple of years, and they get off. Great, awesome. And you know, we see a lot of those. But when we also people that find that long term may be the only thing that is working for them. And so again, that step back and not micromanaging someone's treatment, but looking more big picture, what's working? Is it working? Are you happy? Are you healthy? Are you present? Are you productive? If those things are happening, then let's not focus that they're on a medication based treatment modality, right. And then you Frederick, you do put in there, right. So our systems of care are still not great, because you do see guidelines, even in insurance, where they're going to stop paying for it, or they only, you know, will support it for so long, access to care is huge. There's a lot of barriers that come into making these types of things affordable and accessible. And when we put our advocacy hats on in here, you know, that's where we want to continue to try and see growth in those areas. So that, you know, ability to pay doesn't become a guiding practice. And unfortunately, we see that with other chronic conditions to that, that inability to pay absolutely impacts treatment access and impacts long term outcomes. We've seen it in cancer patients, you know, with oncology studies, and all these other things, like, it's unfortunate that there's kind of this financial discrepancy that determines long term outcomes. And that's where advocacy is so important for substance use disorders, that, again, those red tape systems of care should not be dictating what is and is not needed or best practice for that patient. So don't, I mean, we go down that rabbit hole, there's a lot of barriers there. And it's unfortunate. And that's hopefully why we're all here. And what we're trying to do what we do is to make a positive impact and, you know, advocate for change and to reduce stigma and increase access and make things affordable, for sure. Because again, we wouldn't, you know, treat someone with cancer, man, like, Oh, well, you know, it's been two years, we're not paying for your cancer meds anymore, like, but we see it happens, then we feel really bad for those patients. And yet we don't sometimes feel that same empathy or compassion for someone with substance use, who's being told, hey, you can't access care anymore, then it's kind of like, Oh, figure it out, or you're fine. It's been two years, like we have a lot of stigmatizing things that we hear, unfortunately, in this realm. And that's where it's frustrating, because it should be treated like every other chronic condition. But even then, our other chronic conditions aren't always supported by the resources and care that's available out there. Just to wrap up, right, so naltrexone is that that other category, I know, we didn't talk as much about it. But since it is a full antagonist, and it's going to empty out those receptors and block it, onboarding, you know, naltrexone is a little more mindful, you have to have gone through detox, I think it's down to a full seven days. Now, it used to be 14 days, then they kind of scaled it back to 10. Now they're finding that they can introduce a kind of seven days into the detox process that there's enough, you know, that the body has worked itself out, you can introduce the antagonist without causing a huge disruption. We talked about comes in a couple of different forms. It also works for a couple of different substance use disorders. And it generally is used in the shot for opioid use disorder, it's long acting. And so every 28 days, you're going to go back in and kind of re close that door so that if you were to use on top of it, you're not going to feel anything, those receptors aren't going to be activated, you're not going to get a high, you're not going to get any of that. And so scientifically, it blocks things, but then it also is meant to, you know, help as a deterrent of like, if I'm not going to feel it, then there's no sense in using. So maybe I should look at other skills or other supports or try some other things. So all of these medications still are recommended to be used alongside, you know, other types of behavioral and clinical supports and other recovery supports. Medication isn't, you know, the golden ticket to the chocolate factory, like it's not going to fix everything and make everything amazing. But it's a very useful tool, especially when it's used alongside other types of things. And then I assume everyone on this call knows what naloxone is, knows what Narcan is. If not, we already kind of talked a little bit about it, it is going to kick off those overloaded opioid receptors, it's going to allow breathing and blood flow and oxygen and everything to resume, which is why it's very effective in reversing an overdose. I want to make sure everyone's aware though, it is a temporary effect. So Narcan is in that short acting camp. So it's going to be very effective in helping empty out and close that door. But in like 45 minutes to an hour, the naloxone is going to wear off. And if you've got heroin that at best, you're looking at maybe 12 to 24 hours where it's out of your system, like you can go back in to an overdose again, because naloxone is just a temporary. So it's very important to follow through with medical care, you know, make sure that you know, they've got people around them watching them because you're not out of the woods yet there is a gap there between how effective naloxone is versus how long acting, you know, even the short acting opioids are. With that, it's effective 93% survival rate when it's been deployed in studies. So meaning that when it's, you know, out there, 93% of the people survived because of Narcan. It means that 7%, you know, weren't able to be revived or weren't able to be brought back, or maybe it was too late or too far gone. But with that, it also means that those that do survive doesn't mean that they're going to continue to like be able to rock and roll recovery just because they got, you know, a temporary relief from that overdose, right? naloxone is not treatment. So all you've done is reverse a fatal condition by opening up those opioids and letting things, you know, resume normal functioning. But what have we changed? The same person they were 30 seconds ago before I, you know, gave them this naloxone, what are we doing to connect them to care to actually get plugged in for treatment, naloxone, you know, a very acute intervention, it's not going to fix everything. And it's absolutely not helping somebody beyond that initial intervention. So it has, again, a role and a purpose and an importance because it allows people to have another opportunity to get access to care and figure things out. But even then, it's not a fix all like it needs to be paired with referrals and resources. And sometimes we don't always see that sometimes you were revived, you know, EMS rolls out, they leave and you're left with nothing. And so there's a lot of other advocacy in that realm to just a note about and we've talked a little bit, right? It's not the right dose is not a number. It's not it has to be this. And this is the number for everyone, like anything, there's an optimal range of what works and what doesn't generally, but then there's an individual thing that's going to work for each person. The biggest takeaway I want people to be mindful of is this is a medical decision that's made by a medical provider and a patient. So everyone else who wants to have an opinion should not have an opinion, it's not your place. Don't try and micromanager dictate someone's treatment, right? Like, if they're under the care of a doctor, and they have the ability to be, you know, their own advocate in those spaces, we can support them in other ways, maybe they're not happy with their dose, and they need some help, and we can get some release of information signed, or we can support them, or we can ask, you know, if they have a case manager that we can connect with and help them advocate and have a voice. But at the end of the day, and even legally speaking, no one but a provider gets to dictate that. So we do see POs that like to, you know, dictate that I know, on the stigma poll, we talked about judges, are they allowed to mandate somebody, you know, reduce their dose or get off of medication? No, legally not. Do they do it? Yeah, unfortunately, you know, and that's outside of their scope of practice. They're not a medical provider. And even let's say they were, and they have an MD, they're not that person's doctor. And so there's a lot of advocacy in the CJ realm to make sure that, you know, medical practice and medical scope can coexist and be, you know, dictated appropriately by those that should be making those decisions. So again, more advocacy of being in that space. And there's a ton of resources out there, when especially from the CJ side, if anyone oversteps to try and help educate and inform that that's not what's recommended. And that's not what's legally allowed. Toxicology, just a note, right, of it's not about catching someone and be like, I know you're using like, let's figure it out. And I, you know, I was right, you were wrong, you did use it came up positive, like, it's not meant to be that. It's also not meant to be punitive. We're not supposed to use it, you know, to discharge people, you know, punitively, or to create other things punitively. But we do need to use it in a way that does inform treatment. So sometimes that does mean more accountability, more, you know, visits more, you know, testing, things like that, but the idea that, you know, it's being used constructively and not, you know, to make somebody feel bad about what's on there. It's just a tool to be able to know. From a prescriber standpoint, it's also important for safety. So if they're prescribing a medication, they need to know if there's other substances that don't play well with that medication. Toxicology helps with that. So that if there are other things that they can look to minimize or create change so that you can still prescribe but to reduce any chance of these, you know, severe medical interactions that can happen when some medications or some substances don't play well together. So again, it's meant to be informative and useful. It's not meant to, you know, catch someone or make them feel bad or punitive or, you know, it's a balance there, right? And we want them to feel safe and comfortable and able to, you know, kind of just, this is what I've got, right? Here's my urine screen sample and let's talk about it and let's figure out what's working and what's not and go from there. And so creating a space for that, again, not something that always happens in every clinic, but best practices is it should be more of just informing treatment and not things that are problematic. I'll throw this out just for fun because I find it absolutely fascinating. And so there's something in the medical realm called the number needed to treat. So they call them NNTs. And an NNT is basically what they do from research and trials and long-term outcomes they're analyzing on some level, how many people do I need to treat to prevent one negative outcome? And so there are some things that have an NNT of like, if somebody is on a statin for high cholesterol, the number needed to treat is, I need to treat 39 patients with a statin medication who have high cholesterol to prevent one negative outcome. So that means a lot of people may be treated that may or may not have an impact. Like I have to treat more to ensure that I catch the one that is going to benefit from that. There's NNTs for all of our drugs and substances out there that are being prescribed. So like with somebody with high blood pressure, 125 people need to be prescribed a blood pressure med in order to prevent that fatal heart attack at the five-year mark of somebody who has a history of that. So there's this idea of, we kind of over, like it's not going to hurt, but it could potentially help you, especially if you're that one, right? So making medications and access to medications available to reduce as many negative outcomes as possible. So like for aspirin, low-dose aspirin, right? We prescribe that for a lot of stuff. You have to treat 1,667 people with low-dose aspirin to prevent that one fatal heart attack, right? Everyone's on aspirin. Everyone's taking aspirin. Pregnant moms now, a lot of them are on aspirin. Like everyone's getting low-dose aspirin, and yet we really aren't seeing that we're preventing a lot of negative outcomes. But again, if you're that one, you want to be in that camp where it's going to help you and save you, right? So taking this mindset of like, we prescribe a lot, sometimes knowing that maybe only a small people will benefit, with buprenorphine, the NNT, if you're using low dosages of the medication, so if you're using like a two to six mg dose, then we need to treat four people to prevent kind of one negative outcome. So it works better than some of these other drugs that are out there, you know, for aspirin and statins and things like that. But if we start to increase the dose to, you know, up to 16 mgs, well, now we only need to treat three people to prevent one negative outcome. So we're getting a little better here, right? We're finding that there's more support in a higher dose. And then same with buprenorphine at 16, like greater than 16, so 24 up to 32. We only need to treat two people at a higher dose to prevent that one negative outcome. So like, it's buy one, get one, right? Like I'm going to treat two people, and I've already increased the chances that I'm going to help one person, right? And so this is a hugely effective medication, meaning that if we make it available, we make it accessible, we make it available at the appropriate dosages, right? Like we can have a huge impact of people who benefit from that. And yet we are very kind of close-minded about getting people access to it. We don't like that they have access. We don't want them to have access. If we do, we only want them on low dosages, but we're not being as effective. And so the NNT for methadone is less than three. So it's right around that same, that idea of if we create access and allow people to have medications, we are preventing negative outcomes at a very high rate. Yeah, not one for one, unfortunately, but just from a perspective of number needed to treat, it's much better than the 1,667 people were given low aspirin, and we pass that out all over the place, but, oh, this is a narcotic, and now we feel differently about it. We don't want to create access. And again, I like numbers, and these numbers tell me a lot about where we're at and that we could do a lot more if we just embrace the idea that it is effective if we can make it available and available at the right dosages. I won't spend a lot of time, mostly because we're almost out of time, but there's a lot of regulations around these for methadone and for buprenorphine, and there's constantly things changing at federal and state and local and clinic and all these different acts and things that are adjusting and changing, and it's frustrating to be in a space that is so highly dictated, right? Because we just showed it can be very effective and helpful, and yet there's all this red tape, all these hoops, and all these other things that we have to get through. And so I think we're seeing some stuff gets rolled back a little bit. They've increased the ability to get access to buprenorphine. Prescribers don't need a waiver anymore. More prescribers have the ability to prescribe. We've also seen some rollbacks on clinics. So OTPs are opioid treatment programs. So like a methadone clinic falls under here. We're seeing some of those rules get rolled back, at least on paper, we're not seeing it kind of rolled out in practice yet. But this idea of like COVID happened and we relaxed a lot of guidelines and things didn't fall apart, right? Chaos did not ensue. And so hopefully we continue to see kind of chipping away at all of these barriers so that we can create better access and we can allow people to get the things that they need. And fingers crossed, if the numbers are accurate, we may have the first dip in our total overdose counts for the first time since before the pandemic. So maybe some of these relaxed guidelines and things are starting to slowly chip away. I mean, it's still 105,000 people, but that's better than 112,000 people. So we're slowly trying to see what's working, but I think there's a lot of advocacy to be put out in that realm. Lots of studies. You guys will get a copy of these slides if you wanna see anything. Biggest thing, right, is we don't know what we don't know. This is a chart of your beautiful state and this is from CDC's drug overdose mortality tool. And so obviously kind of the darker blue means areas that are measuring it more. The other side of it though, is there's a lot of those kind of beige colored ones. That means insufficient data. That means we don't know what's going on out there. And that's problematic too, right? How do we allocate funds and resources and make sure that people understand what's needed in our communities? And so don't assume that everyone just knows because you know and you're seeing it on day-to-day. Make sure you're being that voice to make sure people understand what your communities need, what it's lacking and what other places are doing that could be implemented in your settings. So what's next? Education, right? Any of you old enough, remember the more you know, with the little star that went across the screen. Education's the key here, right? Education reduces stigma, it gives us science, it gives us facts, it ends myths. It also empowers patients, narratives end stigma hugely. Peers, peers with stories, people in recovery, like that stuff has been so impactful and we're finally starting to see those being embraced more and utilized more in education settings to kind of take the nuance of there's numbers. No, this is someone who's in front of me and this is their journey and this is what they're sharing. And that person component makes it so much more real and that truly combats stigma, we've seen it. Educated, the slide should just say everyone, like all of us, like no one's got all figured out and we do figure it out. New research comes out and updates everything, but everyone can benefit from being educated. There's tons of ways to advocate. You can advocate hands-on with the patients, with other peers, with other people in your organizations, loved ones and family members of the people that we might be working with. There's committees, there's groups, there's Capitol Hill Day, there's policy types of things, there's a lot of different ways to advocate. And I always tell people, right, there's kind of big A and small A, figure out which side of the fence you're on. Big A is the big systems level, going and testifying on Capitol Hill Day or writing letters or different types of white papers or research reports for your congressmen and the people who are making rules and regs on things. So there's big picture stuff, but don't discount the small A advocacy, right? Like the smaller actions, the personal peer-to-peer stuff, working directly with the clients and patients we might be working with, communicating needs at a broader level. So there's a lot of ways that you can throw your hat in the ring and be an advocate and find which one is exciting to you. I'm absolutely in the small A advocacy. I enjoy that. I like working within our programs with other providers in our communities, really focusing on tangible things that are right there in front of me that we can improve. But I have a ton of staff that love policy, that want to inform bigger decisions, that want to work on that top-down systems level type of stuff. And I love that they love it because it's not my passion, right? Like, so we balance out though, because I know that some people really love that stuff and some people love the boots on the ground stuff, but there's just so many different places that we can advocate in this space that we're in. I like this chart. Again, you're going to get the slides. It's helpful. The difference between drugs and medications, right? It's a lot more than just swapping one thing for another, right? You're using a drug to get high, medication, you're using it to prevent and treat an illness. You know, all these types of things are different. Quality of life improves when you're on medication. It spirals downward when you're in active use, right? Like, that's a big difference. There's, you know, a lot of things on this slide. I won't read it all. You guys will get a copy, but really I print these out. We have them in our clinic. Whenever someone comes in, I'm like, no, I don't want to be on medication. Like, all right, like, or family members that don't understand, you know, enough about addiction or medication need a little boost of like, I don't want them taking Suboxone. Well, let's give you some stuff to think about, you know, what's, what are some things that really distinguish medication being different from, you know, the street drugs or the street pills or everything else that they're, you know, potentially misusing in their active addiction. So I like this one. I like tangible stuff. Take it with you. Leave it on your counter. Read it when you're, you know, on the bus ride home. Like, just something like that. Take with you a little, little food for thought type of thing. In your space, if you struggle and don't know what you're doing, every state has a federal liaison, a state opioid treatment authority liaison who's been assigned. I've worked with them in many states. I've not worked with the one in Georgia yet, but they are your advocate. They're supposed to be connecting kind of the federal, the state and the boots on the ground and to help in a lot of different situations. Maybe there's, you know, stigma that we're dealing with, or maybe we've got a patient who's not getting the quality of care that they're supposed to at a clinic, or maybe it's a natural disaster. And you're like, what do we do? Like, know your soda, know how to reach your soda. Every soda I've worked with in other states are very accessible. They're very committed, and they're very understanding of all the different levels that kind of play in from boots on the ground to those at the top. So they get their own slide and all my presentations. Good to know that you've got someone in your corner that may have a little more power than all of us do. So it's always good to have that person in your pocket if you come across a situation that you need some help with. Put the link back up, and that leaves us five minutes to chat. What do we got? Let's see. So I see some questions, oh, way back on Narcan. Sorry, I was in the zone. So you can refuse transport. Refusal to, you know, be taken to the hospital is quite high. There's a lot of data to support that a lot of people actually refuse that. So EMS will do the best they can with the resources that they have and the length of the time that they can commit. But best practice, right, is they're trying to get you to someone who can be with you and monitor, but they can't tie you down and drag you to the hospital, right? Like, so they are limited in what they can do, but they do at least try and inform and educate and help them make that choice. But with that, again, naloxone is one piece of the puzzle and if there's not connection in referring, this is where outreach teams, community outreach, peer-based outreach, things like that, for people who have had Narcan administered on them are super, super helpful because you can benefit from, you know, the fact that, yeah, EMS gave the Narcan, but now we're going to come in and connect and have conversations about what we can do to keep this ball rolling in the right direction. What else is in here? Yeah, Andrea, because I just wanted to say, like, I think about when you were saying about other disease and things like that, you think like somebody have a heart attack, they refuse. I guess you can refuse if you have a heart attack or a stroke or something to go to the doctor, but I guess, you know. So it's one of those, you know, again, food for thought. So I work in a space where we do work with EMS and first responders and try and maximize interactions for people who have had Narcan administered. So our team goes out, a paramedic and a peer coach, knock on doors, say, hey, you know, we revived you two nights ago. Got someone here who wants to chat with you. And then the peer jumps in and then we try and get them plugged into treatment, you know, on-demand access and things. There's a lot of strategies and programs like that that are trying to, you know, it's like community paramedicine, working with your EMS, but not expecting them to do everything, but balancing out. Like, so there's a ton of various ways to work together without bogging, you know, everyone down with more work. See what others are doing and then advocate for that. Yeah, tag team it, right? I love it. I'm like, no one should have to do this alone. It's a lot, but there's a lot of overlap. So if we can help each other, that's huge. Any other questions, comments? That's three more minutes. Space is yours. Any questions that you're like, oh, if I don't ask it, I'm gonna be up all night. Wish me luck. Any questions that you're like, oh, if I don't ask it, I'm gonna be up all night. Wish me luck. Keep me awake. Anybody's working on an MAT for stimulants? So there's a variety of studies out there. Yes, is the short answer. There's a couple of combos. Some people have actually been doing like bupropion and Suboxone together, I think. There's a handful of other studies. Occasionally I'll see like methamphetamine, you know, medications for methamphetamine use disorder studies. There's still a lot of like research level stuff happening, but we're trying to be in that space. So we're trying to understand it more. We're trying to create medication based options for things like that. So there's a few things out there. It's definitely not the norm yet. And usually it's still more pocketed. Like you can't just go to your doctor with things, but we are seeing some growth in the stimulant realm, but not nearly as, you know, settled and effective as what we've seen in the, you know, in the opioid realm. And so what Ramona was saying, like, is that like when you're talking about people using Coke or crack or something, is that a stimulant? Would that be considered a stimulant? Or I just, I'm wondering, is that something like, I hear opioid and alcohol, but like- Cocaine use disorder has some, what's the medication? And now I can't think of it, but they've used a couple of, you know, medications to try and be in that space and figure out, you know, I don't think they've found stuff that's as effective as that, you know, twice as effective at least as like buprenorphine and methadone for OUD, but there are some ones, you know, modafinil I think it's called for cocaine use disorder. So there's people in that space, but they're still, like I said, they're small and pocketed, but they're trying to find, you know, different alternatives. And I know that stimulant use is still a huge problem in a lot of areas and we don't have a lot of medical, you know, based options yet, but there's hope. People are looking into it. People are trying. We're trying to get some of that same, you know, aha moments as we've had in the OUD realm, but anything else? Snapped my- The nurse practitioner at my clinic, she is now treating for both the opioid dependence and also stimulant dependence. They are trying to do both together. This is new within the last month. Oh, that's awesome. Love to hear more on that. That's exciting. That's the kind of stuff. It is 12. I want to be mindful. Everyone's got to go. I'll stop talking. Haley, close this out. All right, y'all. Thank y'all so much for joining us. And thank you again, Andrea and Opioid Response Network for making this happen again. We really look forward to visiting with y'all and learning more with you next month. So everybody make today a great day and we'll see you later. Thank you.

Haley Sherlock

Georgia Council for Recovery

addiction stigma

community growth

Opioid Response Network

Medications for Opioid Use Disorder

methadone

buprenorphine

naltrexone

medication-assisted treatment

recovery advocacy

education access