Good morning, everyone. I'm just giving you a few seconds for everyone to get connected. Okay, it looks like everyone is good. So thank you for joining us. My name is Emily Mossberg, and I am a coordinator with the Opioid Response Network. Before we dive into the training today, I'm just gonna share a little bit of background information on the Opioid Response Network and the work that we do. So the Opioid Response Network was initiated back in 2018 in response to the opioid crisis in our country. We are funded by a grant from SAMHSA to provide no-cost training and technical assistance focused on enhancing prevention, treatment, recovery, and harm reduction efforts across the nation. And to do that, we use a pool of consultants who are the experts and who are able to provide services and assistance locally. And all of the training and technical assistance we provide is tailored to the local community, so it's not a one size fits all. We do operate on a request basis, which means that anyone can submit a request for assistance on our website at opioidresponsenetwork.org. If you know of anyone who can benefit from our free services, please feel free to spread the word. And today, we are going to be talking about Substance Use Disorder and Opioid Use Disorder 101. This will be the first in a series of four sessions. We will also be covering harm reduction, an introduction to medications for opioid use disorder, and an introduction to motivational interviewing in future sessions. All of these sessions will be led by Paul Hunsaker, who I believe you all are familiar with and who needs no introduction. He also is one of our go-to consultants with the Opioid Response Network in this region, so we are glad to have him here with us. One note, this session is being recorded. All the sessions will be recorded and will be available as a resource within a few weeks after. We do encourage questions, so you can put questions in the chat or raise your hand just as they come up. We'll be checking for any questions. We want you to speak up with any questions in real time. I think that's everything, so with gratitude, I will now pass it over to Paul. Great, thank you, Emily. You went through the slides without me actually moving through them. All right, so I'm going to move through a couple of them. Yep, that basically says what Emily just told all of you. Great, it's good to see all of you today. Here's the contact info, and we can make these slides available as well for folks in PDF form later that will have all the information. Here's the contact information for the ORN and information about the grant, and okay. Oh, I needed to, oops, I realized I didn't take some of the objectives out here. So these objectives, there's more objectives here than that we're actually going to cover today. This is, we're taking this from a prior deck of slides that went from a whole day summit, and so we're really going to be focusing on the first couple of two objectives here today. We're going to be looking at understanding of brain science related to addiction, and we're going to be looking at information specifically about opioids and methamphetamine. It says stimulants in general, but we're going to be focusing mainly on methamphetamine. Let's see. So diving in right away here, now kind of talking about how addiction starts. Let's kind of, what I've got listed up here are the five kind of, and some of the things that you might be familiar with are lumped under some of these, so I'm going to describe them a little bit, but they're kind of the main ways that we believe addiction may start. What I'll say before I even get into this list here is in reality, we really don't know why addiction starts or how it starts. We have some really good ideas. We're getting some clearer and better information and theories, but we're still in the infancy of understanding all of the facets of the ways that addiction starts. At the same time, all of these that are on the screen here likely have some part in how addiction starts. So these have valid points, they just, none of them make the whole picture. So personal responsibility. So this is, sometimes we can even lump the moral failing under here, and you may have heard that terminology. And we tend to move away from moral failing because the moral failing is this idea, kind of the idea behind moral failing is bad things happen to bad people. That is wrong, flat wrong. At the same time though, personal responsibility isn't totally out of the picture. You might be familiar with Alcoholics Anonymous and Narcotics Anonymous. They do use a fair bit of the personal responsibility here. It's the idea that the person is making choices and those choices are going to have consequences. And so the choice, if the choice is to use substances that likely can lead to having addiction. There is a choice in you putting a substance in your body. So we can't completely escape it. The problem is, is that we also know a lot more about brain science and things that go in. And so it goes way beyond that choice. It may be an initial choice, but there's a lot more involved. So there's a tiny shred of truth in there, but again, it is by no means the whole picture. And then we have the agent model. And this is what a lot of our law enforcement and the DEA follow a lot with this, of the idea that it's the drug itself that's the problem. And the reason I bring up that is cause that's the model where it's like, if we can prevent people from getting the drug, then they're not going to have a problem. Yeah, there's truth to this. If we didn't technically have access, it wouldn't be possible to become addicted. The problem is, is it's next to impossible to completely remove access. There's also a lot more going on with it. So again, a shred of truth there, but by no means the whole picture. Then we have the dispositional model. And so you might be familiar with this. It's the addictive personality. This was big in 80s, maybe early 90s. We still hear that verbiage today. You hear all the time, oh, I think I have an addictive personality. Largely this has been disproven. The challenge though is there do seem to be, and there's some crossover with possible genetics of certain folks are drawn to certain substances. Some of where this can sometimes come out is someone will say, oh, you know, I tried alcohol, I tried cannabis, it was useless. But the moment I tried opiates, it was kind of like, oh, where has this been all my life? And so this comes into this part here of, are there certain aspects of people that might be drawn to certain substances? Or the reverse could happen with amphetamines of like, you know, I've tried everything else. It was like, eh, and then I tried meth and it was again, like, where has this been all my life? So again, tiny shred of truth in there, but largely disproven. So we gotta see how that fits in. And then our next one here is social learning theory. So this is the idea of learned behavior so that, and we'll talk about this when we talk about the brain science in a moment. What we're going to talk about is how the brain changes when we take substances. And there's one idea of this is the disease model, which we actually don't see up here, but I'll bring up where it kind of fits into the mix here. And the disease model is the idea is that the brain is changing because the substance is there. And that's a sign that of a pathology or a disorder or something that's wrong. Another way of looking at it though, is that this is how the brain responds to the environment. It makes changes. So an example, and I'll bring this back up when we're looking at brain models, to hopefully make the point more clear is when we're born, we're able to actually make all the full range of noises that a human can make. Over time though, and no language, no one language uses all of the noises that a human can make. Over time, as we learn our language, we lose the ability to make certain noises, the noises that are not used by our language. This is why an accent develops. And what's happening when we're losing that ability is our brain is pruning off the neurons that help us make those noises. And so that's an example of learned behavior. But in that process, your body is destroying neurons. And so this is the idea here of that a brain that has learned to handle the substance, there's validity to this. And I don't believe that it's either disease or learned behavior. I think both can coexist, but it is important to bring up that there are ideas out there that our brain, we learn, our bodies learn how to handle the substance. There's the sociocultural model. And so this is pressures from society. So this is essentially marketing. Or it commonly, a big part from our culture is the idea that college students drink or folks in the military drink because they're young adults. And that's part of being a young adult. And so it's culturally the time that that happens. And so there's a pressure from society to do that. There can also be pressures in society to perform. So potentially using amphetamines to help like truck drivers who would use methamphetamine to stay awake so they could keep moving there. That would be pressures potentially from work or society for that. So there's truth to that. Again, not the whole picture. The last one on here is the public health model. So the public health model is a bit different because it takes all of these into account, including the disease model, which you might be very familiar with. But the public health model really looks at, there are risk factors that everyone has for developing addiction. And depending on how many risk factors you have and how you work with those risk factors will depend whether or not you've developed the addiction. So I've thrown a lot of ideas out here. And some questions for you to think about, and we'll have some time to ask questions in a moment too, but some questions for reflection for yourselves. Kind of looking at that list and thinking about that list that I just showed about ways that addiction might start. What are ones that you have tended to believe in? Maybe ones that you knew you believed in or as I talked about it, you realized, oh, wait, I've kind of thought that way. I sometimes have thought there might be an addicted personality or I do think there is a choice there. Kind of thinking about how that falls in. And then in your own mind, how and when does the behavior cross the line to becoming an addiction? So in other words, when is it a problem? And then to what extent do you think that addiction is a brain disease? So moving this in here, do you buy into the disease model or the disease concept or not? Does anyone have questions or want to share any thoughts at this point? Move ahead a little bit here. I forgot to mention logistics. We'll probably take a short break about halfway through, maybe a couple of minutes, just because it's two hours is a long time on Zoom and we'll finish up at 11. Sorry, I forgot to mention logistics there. Now getting to an idea of how do we define addiction? So one of the better definitions that are out there is put forward by ASAM. So it's the American Society of Addiction Medicine. They're an organization that's existed since the 1950s. But they're most famous for, they create the level of care criteria that we use to determine whether or not someone needs inpatient, outpatient. So because of that, they need to have a definition for addiction. So we've got this definition here that addiction is a primary chronic disease of brain ward, motivation, memory, and related circuitry. So it's taking in brain science into this account. In fact, it's actually trying to thread the needle of disease model, learn behavior, and several of the things that we've talked about already. Now going further, it says dysfunction in these circuits leads to characteristic biological, psychological, social, and spiritual manifestations. So really big picture here. Then this is reflected in an individual pathology, pursuing reward and or relief by substance use and other behaviors. So he mentions reward, relief, which both go to learn behavior as well as disease concept. So now the American Society of Addiction Medicine is really trying to look at addiction in a broad term. They are working not just with substances, but also with process addictions, which would be like gambling or porn addiction, those kinds of things as well. So they use the term addiction. The trouble with the word addiction is it's actually not scientifically accurate because it's too broad of a tent. One of the other things that we're, and you're going to hear me moving forward here, talking about and try as much as possible to use the terminology substance use disorder, because substance use disorder is scientifically accurate. I mentioned addiction here just because we're familiar with it and it's part of the verbiage from ASAM. But technically, ideally, we would be doing that, or even better if we know if the person has opiate use disorder or opioid use disorder or methamphetamine use disorder, we would name the specific disorder. So this is, it's a very involved slide. I'm going to take some time with this here. So this is discussing, it says the stages of the addiction cycle. It's trying to explain our most current brain science around addiction. So let me explain a little bit of the structures that are going on here. So we've got, in here, you've got the thalamus, the hippocampus, the amygdala, all of this stuff in the middle here. This is really in the middle of the brain. If you were to turn, if you can see my picture, my image, it's right around the ear, it's right around the center of the skull. Sometimes this is called the lizard brain. It's one of the early, it's just above the brainstem. It's one of the earliest parts of the brain that formed. There's a lot that happens in that part of the brain. A lot of our emotions like the amygdala is a major emotion, memory, center of the brain. Thalamus is largely responsible for things like body temperature, sleep regulation is all put in here. A lot of our emotions actually are regulated through this part of the brain. That's why I call it the lizard brain because it's a lot about instinct. There's not a lot of thought to it. So some of the primary areas and things you may have been aware of are, there's what's called the pleasure pathway in here, which would be the dopamine pathway. Which becomes very important for substance use and recognizing that because dopamine is a neurotransmitter. People call it the pleasure chemical. It's not just pleasure, it's actually also, we call it a reinforcing neurotransmitter. So anything that activates dopamine, we're going to want to do again. So every substance of use that has an addictive potential somehow interacts with dopamine, if not directly, indirectly, and so it's going to be within the center of the brain here. There are other mechanisms that occur within this part of the brain. Most drugs of use, except for cannabis, use or activate this central portion of the brain. So the upper part of the brain, the wrinkly part is what's called the cortex. That's where thought happens. That's actually the area of the brain that cannabis affects, which it's not part of this training, but it does talk, it explains a lot of why cannabis can be so different for people. Then the other part of the brain that's really important is this part here, the orbitofrontal cortex or the frontal cortex. It's the size of a deck of cards here. If that, it's the very, very front part of the brain. It's the last part of the brain to develop and it's not fully developed until we're at least 25, 26. The way these three parts of the brain work, so the lizard brain, the cortex, the wrinkly part of the brain and the prefrontal cortex. The frontal cortex regulates the communication between our emotions and our thoughts. It's part of why we're pretty impulsive until we reach our mid-twenties. Because we can't really regulate those things very well. That prefrontal cortex is not fully on board. Explaining enough about brain structures there, how substances get involved. When we take substances, no matter what substance it is, it somehow will affect dopamine or come back to dopamine, which will be in the pleasure centers of the brain in the middle. Now we're going to go to the outer part here. We've got response to the drug. They take that in. We're looking on the left side here. We've got intoxication. You get the effect of the drug, which is going to potentially lead to the dopamine effect. Then you get the negative effect. It may not be withdrawal yet, but even if it's not withdrawal, you're still going to have a negative effect when you start to come down from the substance. Then what you get is anticipation to use again. Then the cycle can begin again. You'll notice that the circles keep going round and round. Because what's happening as you keep using, what's happening is these neuroadaptations are starting to happen. Neurocircuits will be affected. They're being affected by the substance itself, the synaptic systems, which hopefully you're familiar with those of looking at dopamine and other synapses are affected. Molecules and then the epigenetics, what that's really talking about is, take opioids for example. They impact what we call endorphins. There is something unnatural neurotransmitter that we have. What will then happen is our brain will get that flood of effect on the opioid receptors. It's like, whoa, we can't keep having that effect. What it does is it tends to trim the synapse receptors. It makes it so that there are fewer receptors there, meaning that you need more opioid in order to have the effect. Then what starts to happen with that is you start to go in, you start to binge use because you're starting to need to use a lot of the opioid in order to get an effect. What can then also start to happen is because you have fewer of those neurotransmitters your body starts to need the opioid in order to actually even get the effects. It starts to rely on it and that can start to cause withdrawals, which then causes stress, causes you to need more, it starts to cycle. What this all ends up being in the end, the connections between the prefrontal cortex and the lizard part of the brain, or the central part of the brain, tend to get broken down or damaged. If you remember, the prefrontal cortex is really a big part of what helps us with judgment. It eventually gets to a point where the person actually can't make judgments around their substance use anymore. It's a really weird thing because there's damage to the brain there, but it's not universal. It's not like they can't make judgment about anything. They just can't make judgment about the substance itself. Why this is important is, this is an example of a concept of the disease model. The brain is eventually being damaged by repeated use. It also can be the social learning theory because it's our body is learning how to respond to this. But what it ends up being is that people, they don't even have judgment anymore once the drug becomes involved, whether they see it, they think about it, or they're under the influence of it. It's not even a conscious thought anymore. This gets away from that personal responsibility because literally, they can't think about how not to do it. We start to see things like, I'll use alcohol as an example, I'm going to only have one beer, and they go out and have a case, or they go and drink themselves to a stupor. That's an example of this broken communication between the frontal cortex and the center part of the brain. I just explained a lot there. I'm wondering what questions that folks have, and I know I've been talking for a while, so sorry about that. Because this is really important to understand and move ahead, but any questions that anyone has? Hi, Paul. This is Dwight. Sorry I was a little bit late joining. I wanted to ask, when it comes to this, will people generally know if they cross the line? Because I guess I think of friends who will go out and be like, I'm going to have a drink, and then they have three because they're having a good time with their friend. Is it because when it's prolonged, or is it... Great question. You're going to, what I'm going to try to lay it out. Yeah, I believe so. Unfortunately, no, they won't. And so, yeah, it's this shift will happen, and they're not aware that it's changed. The pieces is like, and even going to the question of like, friends going out, and then they end up having three. Well, how often is that happening? Is that something that happens every now and then? Not really an issue. If it's happening a couple of times a year, okay, we're starting to cross a line of, were you able to not choose that? Or, I mean, because there can also be the factor that, yeah, they realized three would be okay. And even three, I wonder about, because generally what we see with this is in, I'll go out and have one and just hang out with friends, and then they drink to blackout. Like it's, they just lose all control. So then my next question would be, so then is it typical for somebody to, I'm thinking like college students who will like blackout, and then be like, I'm going to go blackout again. And then again, is it like, after like the fifth time in a year, that's when there is like a whole problem, or would that be a case of it just being like new or something to them? Oh, there's a whole question of whether someone who's regularly drinking to blackout, whether or not they have a problem, just because it's usually, generally people regret what happened during their blackout. And the hope would be they would kind of learn from that, and then halt. This is tricky though, because plenty of people grow out of that. So it would meet the criteria for an addiction. But again, is it going to continue to go? For some it will, and for some it will turn around. Okay, cool. Thank you, Paul. Thanks, Dwight. Great question. Okay, I'm going to move ahead a little bit, but by all means, please keep asking questions as we come through. What I want to talk about now is and connect this to that brain science that we were just talking about is and talk about kind of the criteria for substance use disorder and connect them to what's going on in the brain. So I want to bring up here first pharmacological criteria. So these are the only two criteria that are actually related to the body and biological changes that happen are directly related to biological changes within the body. So with this, we first have tolerance. So needing markedly more to increase those to achieve the desired effect. So this is I mentioned before how the body would change with the synapses, how you take an opioid on and it will affect the endorphins and it will cause there to be fewer receptors for those endorphins later. Other things will change as well. So for like in the case of alcohol, your body will start to produce more enzymes to break down the alcohol faster. For methamphetamine, there's a similar there's an even sharper drop in the number of neurotransmitters that are there. And because what the body is trying to do is it's trying to come back to what it calls homeostasis. So homeostasis is normal is what things how things are when everything's stable. And so every time you take the substance, the person might like it, but their body is like, no, we really need we can't keep doing that. That's throwing us off balance. We we need to make changes so that we can keep homeostasis even if even if the person keeps using the substance. So that will and it will the body will keep doing that for a while to a point. And sometimes when we're looking at criteria for tolerance, we're really looking if we can determine someone needing at least twice as much as they originally did, because that's a good marker that there's a significant, significant increase in tolerance. So the part with tolerance that's important, though, too, and this comes into play probably with a lot of the folks that are working with is the body will that homeostasis at some point changes. The body will realize, OK, you're going to continue to use this. We need to rethink or recalibrate what homeostasis is. And there's a point where where homeostasis or what's considered normal is when the substance is on board. And you'll see this a lot with opioids. It happens with pretty much every substance to some extent, but opioids especially that they're not even necessarily using to get high anymore. They're using to either avoid withdrawal or using just to feel normal. And it's a it's an example of tolerance, what we call tissue dependence. But it's all what it really is, is the brain or the body and the brain have decided, OK, in order for us to be able to maintain homeostasis, we have to make homeostasis now having the substance on board. And this is where you'll see people needing to get a hit in order to be able to have a meal, needing in order to be able to function, needing to be able to get up for the day. They need it just to function. Then we also get withdrawal. And so this is connected to tolerance in the fact that, again, if the body is used to having the drug on board now, when it's out of homeostasis is when the drug is not on board. And so you'll start to feel sick, so a syndrome that occurs when blood or tissue concentrations decline in an individual who has had maintained prolonged heavy use. So again, the body is used to having the substance on board. And now when the levels get too low, they start to feel ill. Very much a big deal with opioids because the withdrawal syndrome is very severe. It's one of the big ones that come in, but it also can be important with methamphetamine. One of the things with this, why I bring this slide in first, something that's really important to note is it is possible for someone, especially with opioids, but to have, probably could be any substance really, for someone to be dependent without being addicted. And this comes up when we talk about, especially when we talk about MOUD, so medication for opioid use disorder. But it also can occur, and I bring my father's can be an example of this example of dependent but not addicted. He had cancer and he needed opioid medication and he was dependent, he was very dependent on it. He would become ill. In fact, we had a trip that had to get cut short because he ran out of medication, partly because they didn't fill it at the right way, because we were worried he was going to have pretty severe withdrawals. The thing for my dad was, if he ran out of his medication, he wasn't going to go hunting for it. He wasn't going to go try to find heroin to replace it or fentanyl on the street to replace it. He wasn't going to go selling things to get it. He was just going to feel really sick. And the difference there with this is that would be an example of dependence without necessarily the addictive parts on top of it. The reason I bring this in is because we're going to talk now about what the addiction part are. I'm using the term addiction, but there's a relational and some other behavioral components that come in that would mark that this has become a substance use disorder. In fact, you would have to have one of the physical and at least one of these other ones in order to have a substance use disorder. Now we're getting into the impaired control. This is where someone is using larger amounts over a long period of time than originally intended. So that example of going out for one beer and ending up drinking yourself into a stupor would be an example of that. Other examples are just, yeah, using more than you meant or going on a bender and going out for several days and using even though you hadn't planned to do that. Also impaired control is that they very well could have a desire to cut down or stop, and they can't. So this is something when I regularly work with folks, especially with families, is they'll say, well, they don't really want to stop. Like, hold on, if they've ever said it, I believe them. It's just that this impaired control is preventing them. So there's the side of them that wants to stop, and then there's the addiction or the substance use disorder that makes it so that they can't. And then there's a great deal of time spent obtaining the substance. And actually to fully flesh it out, a great deal of time spent obtaining the substance, using the substance, recovering from the substance. Essentially it's a full-time job. And you'll see this with folks that are using and are very dependent. It's majority of their time is spent figuring out how to make sure that they have at least have something available to use or they're under the influence of it. It's a significant part of their daily life. And then last one on here is intense craving. Intense craving really is someone who can't think of anything else. They're just overwhelmed with the desire to use. That's impaired control. So that all goes to that prefrontal cortex piece, how that judgment is cut off. Because you can look at that of using longer or larger amounts than they meant to. The mechanism that was going to tell them to stop didn't work. Persistent desire to cut down. Even though they want to cut down, like their cortex wants them to cut down, the pleasure center of the brain isn't allowing that to happen. It's just consuming their whole life. They're allowing it to consume their whole life. That comes in. And then of course intense craving. And then we also see the social parts of it. So they're failing to meet obligations at work, home, or they're failing to maybe meet stuff in their housing setup. This can all be part of the substance use disorder. So a lot of the challenges you might be running into with folks in the residencies is part of this piece of they're not able to meet their obligations there, which then leads to regular recurrent social or interpersonal problems. So they're maybe getting into fights with people. What's happening for many folks, especially further down on the substance use disorder line, they tend to be very isolated. And then lastly, we see they withdraw from social or recreational activities. So they're really just not involved in things that maybe they used to do. Or they're just, they don't hang out with anyone unless they're people that are involved in using. They don't, their circle of folks that they interact with is pretty small. Related to the impaired control is using in risky situations. So using in situations that are physically hazardous. So traditionally we think of driving under the influence. That is included in here. But it also can be using in situations where you can be victimized. You could have stuff stolen. You could be assaulted. Or using in situations where it's either too hot or too cold outside. That's especially dangerous with methamphetamine because it messes with your body's ability to regulate temperature. But using in any situation that can be risky there. On the lighter end, I always bring this up here, it's technically using around heavy machinery is included in here. There's also the concept of, many of us will like to have a glass of wine while we're cooking. Technically using in a physically hazardous situation. Because if you're using alcohol, you're around a stove or not, a sharp knife. Again with this, much like what Dwight and you and I were talking about, it's more of if this is happening regularly and it's causing a significant issue. In other words, you're getting injured. That's when we really see it as a true risk. It's one of the areas that's a little bit gray. There's also, in this last one here, continued use despite persistent physical or psychological problems that likely have been caused or exacerbated by use. This I know you're running into a lot of folks who have mental health especially, but also physical conditions. They know that their use isn't helpful for their condition. But they continue to go anyway. And so, that is a last criteria here. So, there are 11 total criteria that we just covered. And this is all of them here. Now, for a diagnosis of substance use disorder, you have to have two or more in a 12-month period. Now, two is a mild use disorder. Generally, sometimes insurance doesn't even pay for mild use disorder, so it's barely considered a problem technically. But it is, rightfully so. So, two to three is a mild use disorder. Four or five is considered a moderate use disorder. And then six or more is considered a severe use disorder. The hunch is you're probably running into folks when you do that are running into six or more that are having a number of difficulties with this. The important part, what I mentioned, and this connects back to that brain science piece. And I didn't mention this earlier. When you look at the impaired control or risky use, and then you understand kind of how the brain is changed by the substance use. When I talk to family members, usually they'll come in and they'll be like pulling their hair out of like, why is this person making these choices? And what I'll tell them is the problem that you're with what you're doing right now is you're trying to apply logic to a situation that logic doesn't apply. So thinking back to the brain science, that brain slide I was showing before, normally there's a connection between that prefrontal cortex and the emotion center and the thought center of the brain. And when that's working well, people can think critically and can make decisions because what they can do is they can think ahead to what's if I use this right now, what's going to be the consequence on the other end? The problem is there's no logic there, those connections between the brain are gone. And so many times and some of the things I know and in conversations with all of you, there's decisions that are made and it's hard to tell sometimes whether it's mental health or whether it's substance use disorder. It's probably both, but it can just be the substance use disorder of there's just funky wiring that's gone into this that makes it so that they really they can't apply logic to what's happening. Hey Paul, I wanted to ask, like we say that they won't be able to necessarily apply logic to themselves, but I guess in the same vein, I'm thinking how we can apply, understand that they aren't going to apply logic and just understanding that and just making a plan around that. And I recognize that's like something that we do. But at the same time, I feel like it's so hard to talk to people about that because like you can explain to them, like it's not necessarily them, it's caused by a multitude of factors, but people aren't really, I don't know, receptive to that or don't really care. Let's see, you're bringing up a great point, Dwight. Yeah, they either don't care or they're not aware of it. And there can be so many, like you said, so many factors that's in it. This information, if you can give it to them, great, but I don't know that they'll be open or receptive to it. It's more for all of you to kind of recognize, okay, if it's not making sense, it's probably the substance use disorder to try to help recognize, okay, this is what we're up against. You had a great part there of, in a lot of ways, what you kind of become is their like surrogate prefrontal cortex. You are trying to think ahead and trying to figure out around kind of how to work around this and recognizing a big part of this too is instead of like blaming them, recognizing that it's the disorder that's getting in the way, and then working with that, even though they might not be ready to look at that or they may not agree that it's the problem, you're there to kind of help because you're recognizing that that connection for whatever reason isn't quite working. And then it's impossible to predict, but yeah, exactly what they'll do, because there's going to be unpredictable things that come in, but you can, you probably already have good ideas of, I kind of see where this is headed. Okay, let's do some things to help make that not hurt so bad, if you will, yeah. And then I will probably get into it later, so let me know, but I was just thinking about like how to work with clients who want to make a change from that. And let me know if it'll come up later so I can just shut up and wait. It's a great place too, and this is going to really come up a number of different times, but we can totally bring this up and start bringing it up now, because there are going to be some, and I imagine many of you will talk to folks and they'll say, I know I'm addicted, but I don't care. In a lot of ways, that's great, because it's like, oh, okay, awesome, we can use this language, even though you're not necessarily going to necessarily want to use it. We don't have to kind of tiptoe around this, because for some folks that aren't aware that they're addicted, you're going to avoid using some of the language, because they're going to get triggered by you saying it. And then with that, it's just being curious, and it's where motivational interviewing is largely going to come in, of like, okay, talk to me about like, you know, what do you know about this? Let's figure out how much you do know. Are you open to me giving you more information? If so, here we go. If not, okay, what do you want and need? And then kind of testing the waters to see how much they're willing to look at this. But also, like, and the big part of it is, we're not going to, and I know for in your environments, you're not necessarily talking to them about stopping, and it's like, let's maybe, are you open to talking about how to make some of these problems less? Even while you continue to use, because some of these are bothering you, which ones are bothering you? What are you willing to talk about? Yeah. Okay. Yeah. And then I also think about, like, clients will say they want, like, to go into treatment and stuff like that. And then it'll very much be in the moment, yes, when it's time, no, and it could cause a client to, like, become really escalated, thinking that they want something and then feeling like they're backed into the corner and have to do something. I guess I'd wonder, like, is there a line that we can see that's, like, if they're acting this way, we can kind of guess, like, 90% of the time, they are wanting to follow through when they really mean it. I would believe that they want to follow through. What I tend to read that backing off is, yeah, it's scary as hell when you have to actually get, take that step, like, because you've said, I want it. Now there's the time to actually commit to it. And that's scary. And then there's also, I mean, there's so many reasons to be scared. There's, oh, crap, I've got to go through withdrawal. That's awful. I hate withdrawal. There's also, I'm curious to them about how past treatment has gone and what they liked about it. Because there's a lot about the treatment process that can be kind of traumatic. And were they traumatized in past treatment experiences? And are they afraid of that happening again? And so that, and the way I would address that, like, talk to me about how treatment's gone before, what's happened, both good and bad. And then, yeah, it's mainly that, just that part that you're, that's a stepping stone into really committing. It's most often where people back up. And so I'd almost expect it and be ready for it. Some of what I do, and we may have talked about this before, but I try to preface conversations of when we get close, what do you want me to do if you start talking about not wanting to do it? How do you want me to handle that? Do you want me to listen to you for that? Do you want me to keep pushing you? What's the best way to support you in that, if that happens? So like, almost plan ahead, just in case this happens. So that if they say, you know what, I want you to push me, I think it's important that we go, we do that. And then when that time comes, it's like, well, we've talked about this and you told me before to kind of keep going and that you need, you want to get through this a bit easier. Yeah. Okay. Cool. Thank you. Yep. Madalia. Hey. You're muted. Bam. Finally. Hi, Paul. Madalia. So I guess what a concern is, but for me, you know, I've, I've worked in treatment for a long time as a counselor. So there wasn't drugs involved. Right. I mean, there was. So if somebody got in trouble, they got, you know, they had to go to a treatment or I worked in the prisons as well as a counselor, case manager, they've done drug, alcohol related crimes. Yeah. And so it wasn't like out here, like I got, I started working in outreach, I don't know, probably 2000 and something, 13, off and on. But this, like where we're at, Paul, and the population that we're working with, it's, it's not like we could sit down and talk to them. Like we could, you know, as a counselor in treatment, hey, let's talk about that, because their drug use is so out of control and their, their mental health is so out of control. Like they're not taking medicine, which they were at one point in time, somewhere down the line, but they're still trying to self medicate. Right. So I'm just wondering, you know, I understand about the motivational interview and I understand about all these, you know, I get it, but honestly, Paul, this is a totally different ballgame. It's so, it's just, I can't even put it into words, you know, so what, what, what, I mean, first thing, you know, you can have patience and you can have, you have concerns, you have this, you have that, you know, but this over where we're, well, I'm not there, I'm, thank God I'm outreach, but I do fill in, I fill in for folks, I cover shifts and stuff. And there for a while before I ended up going full time and outreach, I was there covering until, you know, we had hired some folks and it's so, I can't, like I said, I can't even put it into words. It's like, once you walk in the gate, there's a fence, once you walk in, you're in a different world. Yep. It's so out of control, so out of control. Can you help? Sure. Yeah. I mean, with the motivation, it's going to look very different than what counseling will be. Cause yeah, you're not going to have the, like a full hour to sit with someone. And even if you did get that time, it would be kind of chaotic. It would, it's, you're going to get these little snippets. So much of the work is gauging, where is this person at? Are they, is this a moment where there there's enough clarity to be able to get a, like even a minute or two of, of interaction in? And if not, okay, I'm going to come back. And then also like checking to make sure that they're okay, that they're not overdosing. If they're using substances, if they're having a mental health crisis, of course, figuring out how to make sure they're, they're, they're physically safe or that other people are safe. Though the hope is, is even in that chaos, still trying to find those shining moments where you do get a little bit of clarity, if you can, where you can get that quickly in of, Hey, like, in other words, I think Dwight was bringing up if someone, cause it sounds like people do sometimes bring up that they want treatment. Okay. I've only got a few minutes here. Let's see what we can get to and see where they're at. And then make sure to keep following up with people. That's going to be the trick. And then the chaos is figuring out how to keep circling back and trying to have enough points of contact where you can get some of the stuff in. It's a hard job, but it is kind of like getting a minute or two here, a minute or two here, a minute or two here. And hopefully that will build up when we talk about, am I, I'm going to talk a lot about how to use it in very short bursts. And so, and, and specifically for the, for the environment, though, it is really kind of putting together a collage of these moments instead of having the like one hour chunk. Yeah. Not a perfect answer. I know, but yeah, it's that it's, it's kind of what we piece together. Yeah. Thanks for that. Thank you, Paul. So I'm going to move ahead a little bit here. So let's look at opioids. So opioids, so, and you'll hear me sometimes trip up and say opiates. Really the standard term is opioid because it's all encompassing. Opiate, what that means is naturally occurring and from the poppy seed. Morphine and codeine are the most common ones. Morphine where they, these were some of the first that were distilled from this. I mean, opium came from, from this as well. In fact, heroin is technically partially synthetic because it's a, it's a modified version of morphine. So opiates are pretty rare. We don't run into too many of them anymore. Opioids are what we tend to have and we're tending to find the fully synthetic ones. Now fentanyl, fentanyl is pretty much taken over. Still important to look at of going back. Opioids are all manufactured. There are semi-synthetic like hydrocodone, hydromorphone, which, and so heroin falls under the semi-synthetic line. And then fentanyl is, has nothing to do with the opiate, the poppy plant. It's all synthetic. Methadone is another one that's also fully synthetic. Let's see if this connection works. Nope, it doesn't. All right. I'll have to come back to that video. So hopefully I'll come back. Basically the video that is there, it talks about how, what opioids do is they mimic our endorphin system. So if you've ever had a runner's high, if you've ever gone for a run and got a little bit of a lift after the run and it feels kind of nice, one of the nice parts of going for a run, that's actually our endorphins. Our endorphins are activated a number of times. They're our natural, our body's natural painkiller or one of the natural painkillers. And they're used for other things, emotion regulation and other things as well. There are receptors all over the brain. What opioids do is they will bind with that endorphin. It's called the opioid receptor. And it's specifically the mu receptor is the one that is most likely going to be activated. And that gives you the effect, it's kind of like a super strong runner's high. And what then happens, your brain, your body will reduce the number of synapses. It makes changes to the point where you need more and more opioid essentially to have that. It's a very quick description of it. The part that's there that's important to note is because opioids are prescribed all the time. And we, most of us will take opioids after a surgery. And we might even take opioids to the point where we actually start to feel a little bit of withdrawal. But what happens is we just go through that little bit of discomfort, and then we're fine and we move on from it. But for some of us, whether it's prior trauma, prior, and some of you might be familiar with the ACEs, the adverse childhood experiences, could be genetic components to it. But for whatever reason, there are some of us that will continue to go with that, that they'll continue to have problems with it. One example of this, even heroin, you can find this case of Vietnam vets, an incredibly large amount of Vietnam vets came back from Vietnam having used heroin. The vast majority of them just stopped. It's not everyone that gets addicted. There's other factors that will add that on. So the fentanyl analogs here, so fentanyl is now king. Ever since about 2019, it's really taken over. It's, I believe, what you're pretty much just running into now. I don't even know, sometimes wonder whether or not folks are even seeing heroin anymore at this point. And these are just analogs of different fentanyl. You've got the more common ones, you've got carfentanil on there. Carfentanil is the one that gets a lot of press because it's used for large animals, for veterinary work. So it's super potent. But there are different analogs coming out all the time. It makes it somewhat difficult to regulate as well, because as they change the analogs, it can be difficult because they have to sometimes rewrite laws based on the new analogs. But yeah, there are different versions coming out periodically. I'm not sure how much people know what analog they're using. We talk about fentanyl, one of the reasons why we focus on it so much is because it's so potent. Dosing is in micrograms versus heroin, which is the dosing is in grams. It's quite a bit larger and sometimes you can see pictures of the amount of fentanyl needed versus the amount of heroin needed. Dahlia? You said, were you talking about the analog? Mm-hmm. Can you explain that a little bit? I'm sorry, if I said the analog? The what? What about the analog? Yeah, like just I'm trying to understand all of that. So these are basically, so fentanyl is made, there's chemical precursors. And what they are figuring out, they end up figuring out different chemical compositions that they can use to create molecules that have the shape of fentanyl that will activate the opioid receptor. And so all of these are just using different chemical formulations. It's part of what makes it a little bit tricky to, because they can, there's so many different ways they can make fentanyl, it makes it a little bit hard to regulate. I mean, the one that stands out here is Carfentanil, just because of its super high potency. But yeah, these other ones will have different levels of effect on their, I don't know how much folks are focusing on what analog they have. I don't know that anyone even knows. They're just wanting to know that it is fentanyl. Yeah. Yeah. So it's there just for information. It's not, I don't know how useful it would be. So also, oh sure, yeah. So with the fentanyl, there can be some scare around fentanyl because of its potency. And to note, it is extremely powerful. Some things to note, and this is important for all of you if you're running into it. And I know, I think we had some discussion in one of our meetings a ways back. The risk to you is not super great with it. Even if you came into contact with it, fentanyl doesn't tend to absorb well through the skin. In fact, this was, they created the patch, fentanyl patches. They needed to actually change, modify the fentanyl makeup in order for it to be able to be absorbed through the skin. There's also some videos out there of like police officers and stuff, opening trunks up and collapsing. Those unfortunately were, they were probably having an anxiety reaction. It wasn't a fentanyl overdose that was happening. In other words, it doesn't aerosolize very well either. In fact, the fear about aerosolizing actually comes from a situation in Russia where they were using weaponized fentanyl to flood a movie theater that was taken over by terrorists. The key there is it was weaponized fentanyl. And so the cartels of the folks producing it for use are not actually looking for, they're not looking to do, they're not weaponizing fentanyl. The reason I bring it up is just generally if you've come into contact with it, if you can just wash your hands, you're going to be fine. Even if they're exhaling the smoke, it's not going to be most likely enough to be an issue. Yeah, you don't want to sit there and keep inhaling it, of course, but it's generally not much of a risk to you. If you want, you can have gloves and a respirator on for extra protection. That's probably going above and beyond what's even necessarily needed. The problem with fentanyl is just the risk for overdose to the people using it because of its potency. So, naloxone, I'm guessing you probably all have naloxone on hand. You're familiar with it being a nasal spray in its most normal, most common form. It's a short acting. Hopefully you're kind of aware of this. So there can sometimes be this idea of naloxone not necessarily working and you might need to use multiple doses of it for fentanyl. It does work for fentanyl, but yeah you may need to use either more than one dose unless you have one of the high dose versions or what is more common is you'll use it but if they don't get emergency help soon enough the naloxone will wear off because it's a short acting opioid antagonist and so it eventually will wear off and then the person could go back into withdrawal. So what naloxone is doing, if you are not familiar, is it's basically blasting the opioid off the receptor. It binds to the opioid receptor but doesn't activate it and so it blasts the opioid off the receptor and then blocks the opioid from being able to reconnect. What that does is it blows, it knocks someone straight into withdrawal. So they frequently wake up with a gnarly headache and they're not happy. The headache is caused by their brain being depleted of oxygen because what's happening in an overdose is their breath rate is dropped so low that they're actually not oxygenating their blood well enough. In fact that's how someone, that's how we person dies from an overdose is they tend to, they end up suffocating to death essentially because they're not getting enough oxygen to the brain. So they'll wake up with a headache and they're also feeling like crap basically. So yeah there is that newer higher dose. Is this the, what, do you have that newer higher dose on hand? Do you know, anyone know whether at the residencies you have or is it the standard dose? I'm seeing minus four milligrams. Okay so it sounds like it's the lower dose. So yeah it might be helpful to realize there are higher dosages out there. This is in response to the fact that folks are intending to need to sometimes use more than one for fentanyl just because it's so bad and especially with folks that use large amounts. But yeah these are, there are eight milligram and 10 milligram ones that are technically available. I don't know that I've asked any of you, are you seeing xylosine? Has that shown up? Have you had anyone talking about it? Have you had anyone, any situations with it being used that you know of? No, not yet but I'm familiar with it. You're familiar with it okay. Familiar with it from your work here because I know Madalia you've worked in other parts of the country. Yes from other areas. Yeah it's big and then on the East Coast. So let me move ahead here. So xylosine and it's important to note that King County and this is coming from King County so it's local for y'all. It is, it has been showing up. I've had several trainings recently where I've been talking with folks in both Washington and Oregon where they are saying they're starting to see it more. King County Public Health has said that they're seeing it a little bit but not a ton yet. What xylosine is, it's a veterinary tranquilizer. It's not approved for human use and it's more and more being cut with fentanyl. Again, mostly on the East Coast and in the Midwest. It's a central system depressant, not an opioid and so it's used, it's again, it's a tranquilizer. It's used as an anesthetic in veterinary settings. So it, someone under the influence of xylosine could look like they're ODing because they're, being a tranquilizer or anesthetic, it tends to put people out and makes it look like they're just, they're comatose or asleep. And so it's, the hard part with it is looking at, if you do give them Narcan, they're not going to respond. Well the Narcan will work on the fentanyl but it won't work on the xylosine. And so it adds an extra complication. It's also, yeah, there, it's, it probably is going to start popping up here more. It is something to kind of be aware of but it is in the, in the, and sometimes folks will look for it. So. Okay. And was this, no it doesn't. Shoot, my video links didn't work. Let's take a quick break here. I'm realizing we're at the top of the hour before we go into methamphetamine. Let's take a five-minute break. It's about 1010. We'll come back at 1015. Okay? Okay. Let's see. So now let's talk a little bit about meth. So meth, now it used to be made in the, we heard about labs that were like in apartments and difficulty with it. There was the law passed in 2005, there was the law that made it so that you had to buy like pseudoephedra behind the counter. So pseudoephedra is the stuff in like Sudafed and it's the really effective decongestant. That was a precursor to methamphetamine that they would use and because of that law it made it so that the home labs were basically impossible to run. So it was actually a very effective, effective law. What that did though was it, it caused methamphetamine to fall, it used to fall off at first. But then the cartels ended up figuring out how to get the chemicals to, chemical precursors to meth and started producing it. And then meth has started to flow over the border and be brought in, yeah, due to this. It's actually caused there to be a surge in meth and unfortunately the cartels kind of came online right as we started focusing on the opioid epidemic. And so opioid use started to fall off because it was harder to get your hands on prescription opioids and that was right when meth started to get, to be more available from the cartels. And so we saw a move from opioids to meth, then fentanyl became king, and now we're in what's called the fourth wave which is methamphetamine and opioid, and fentanyl really. So symptoms of meth use. So increased attention and decreased fatigue. So meth actually, it's interesting folks will say that, I've heard folks say that ADHD meds are just like prescribed meth, prescribed methamphetamine. It's not true. There is this tread of truth in there. There is technically a very, one form of prescribable methamphetamine that is rarely used for things like ADHD and narcolepsy. But it is technically out there and the reason I bring that up is because yeah, you look at increased attention and decreased fatigue, there is potential benefits. There's increased activity and wakefulness, decreased appetite. The reason why many folks continue to use it is because of the euphoria and rush that you can get from using it. Other things that are going on are increased respiration, so there's an increased breathing rate, increased and possibly a regular heartbeat, and then also hyperthermia. This is why meth use in really hot conditions is very dangerous because it could cause you to overheat very easily and we'll talk more about that. And one of the problems is that people will tend to, in Arizona they were having a really hard time with this during some of the heat waves because people were not realizing that they were overheating while they were using meth and unfortunately got into dangerous situations. It's a little less common here, but it is possible. So some of the things, now meth, opioids for a moment. Opioids are actually not toxic to the body. In fact, someone dying from an overdose, it's not the substance that's causing it. It's the fact that, well, the substance is causing the body to shut down its respiration. It's not actually doing damage itself. But we see with opioids, the damage that's done to the body from opioids is people not necessarily taking care of themselves and or if they're injecting opioids, there's bacteria that can come in with the needle and that's what tends to cause the health problems and cause the damage to the body from opioid use. So the opioid itself is not toxic. Now meth is completely different. Meth is what's called neurotoxic. So in long-term use, it causes significant problems. It causes major deficits in thinking and motor skills. It really can increase distractibility. Unfortunately, folks who are using meth, they can be, depending on how long they did, they can be fairly compromised and it can take a long time to heal and there may be some permanent damage. There can be memory loss. There can be aggressive or violent behavior, which is some of the stuff that you may be running into. Significant mood disturbance. So they tend to be very depressed, but in that depression, they can also be very irritable, which can add to the aggressiveness and the violence. Significant weight loss can occur over long-term. The dental problems you hear of meth mouth, and it is a real thing. And what it is, is your meth will actually reduce the amount of saliva you produce. And when we have less saliva in our mouth, it's more likely we'll develop cavities and then cause tooth decay. And it's eventually what causes the significant dental issues. Further with this is physical dependence, which is mainly like depression and that they just can't really, they can't feel not depressed. There's also psychosis. Now psychosis, it's interesting, is both short-term and long-term. So someone going in a precursor to a meth overdose is frequently acute psychosis. And at the same time, someone continues to use meth, they can eventually develop psychosis, such as paranoia, hallucinations, even very repetitive motor activity, which is that can be associated with this. So it's a particularly problematic substance. It makes a lot of things a lot worse. And then hence the changing in brain structure, as well as ways the brain works. The reason why this is, again, the drug itself is toxic. And you see this where like, even if people inject, it will do a lot of damage to the injection site because the substance is so corrosive. It also is toxic to nerves because we're most, we're talking about opioids where they'll bond to the endorphin receptor. What meth does is it actually not only bonds to the neuroepinephrine, it's a different neurotransmitter, but it will actually go into the pre-synaptic neuron. It soaks itself into the neuron and forces the neuron to release neuroepinephrine. And the fact that it soaks itself in is what makes it toxic. It will eventually kill those neurons. Some things you may also run into, of course, are sores and scratching from itchy skin. This can be from feeling like there are bugs crawling under their skin, or there's something crawling under there. So meth comes in a few different forms. I think you all, you do give up pipes and recognizing it's a safer way to use than it is to inject. But yeah, it can be smoked, snorted, injected. It can even be taken intrarectally and intravaginally. It's pretty rare that we see that. It's also pretty rare that we see people take it orally. There is a medication that's taken as a pill, but yeah, it can be used in any number of ways. The most often we see though is smoked, snorted, or injected. Of course, smoking and injection get there for the fastest. Snorting or oral ingestion, it can produce the euphoria, an intense rush. Snorting produces effects within three to five minutes, whereas oral can take 15 to 20, where smoking and injection can be within seconds. I mentioned this before, the fourth wave. So just a little bit of history here. So there have been now four waves of opioid crisis. The first wave was in the early 1900s. So it was actually over 100 years ago. And some of you may be familiar with, there was the rash of, they would put heroin into like cough syrups. And there was an example of a pope advertising a wine that had cocaine in it. Coca-Cola had cocaine in it. Coca-Cola had cocaine in it. There was an opioid crisis that developed there. And then the law passed, 1916, shoot, I'm trying to remember the actual year. But it was the first law that made drugs illegal. And it's the moment that heroin was made illegal. And so that curtailed the first wave of opioid use. The second wave took quite a while. It was actually a long time in between wave one and two. The second wave was the Vietnam War. And that was when Vietnam vets were, when they were in Vietnam, they were having access to heroin. They tended to use a lot of it. And I mentioned how many of them just stopped. Those that didn't, it was methadone was one of the big things that helped the vets when they came back. It's something that's interesting that is left out, but methadone really helped us curtail the second wave of the opioid crisis. It's kind of forgotten because there's a lot of stigma around methadone, but it was a majorly powerful tool in helping us at that time. The third wave is actually in the late 2000, or I'm sorry, the 2010s, when OxyContin, if you remember that coming in, it was a big deal. And then we saw after OxyContin, they kind of zeroed in on it, heroin came back in a big way. And then that fell off as we started to focus on the opioid crisis and we started to change prescription methods. And then what happened is meth kind of came in and now we have fentanyl and meth are actually combined for the fourth wave. So meth here is second opioids for overdoses and overdose deaths, and that was since 2020. So they're being used together, which I know all of you are kind of seeing. In fact, and you probably may have seen this, what's happening with meth and fentanyl being used together, but also they can be used, like they go to the dealer and the dealer doesn't have fentanyl, they might have meth. And so they'll use meth to kind of help make it so that the withdrawal, take the edge off the withdrawals. And a lot of times what they'll do is they'll, their tolerance to fentanyl gets too high, they'll use some meth to bring their tolerance down to give it some time and then go back to fentanyl, vice versa. They kind of, they work symbiotically to kind of help mitigate some of the feelings of withdrawal. They also can be used together and kind of enhance each other's, the experience that the person has on it. It's particularly dangerous when they use it together because if someone is having an overdose from methamphetamine, what that is, is usually a cardiac experience and the fentanyl can make it so they don't feel what's happening. So the other side of it too is that, yeah, they can end up using more than they mean to because they feel with the methamphetamine, they think they can handle more. So there's some significant risks in combining them. It is common that it's done. And then of course, there's also the risks too of fentanyl being added to things that it wasn't. We didn't use to see this as much, but we're starting to see it more that fentanyl being added to meth. And so someone is using fentanyl while they're using meth and not even knowing it. These are the overdose deaths here. And I know there's media coming out right now. And it's interesting because there's been a dip in overdose deaths. I don't have that data quite here, unfortunately. We're still, I'm interested that CDC came out with that recently. So I haven't been able to distill that in, but it's still, even though they're coming down, overdoses are still high. And you can see from this map here, looking at primarily fentanyl, how fentanyl really took off starting in 2015 and then took off in a major way in 2019. It really pulled away from the others. However, not far behind, there's also methamphetamine emerging here in the gray. Cocaine is up still. It's still around. Heroin, we're actually seeing reduce. It's interesting because we've got antidepressants and other things on here as well. Antidepressant overdoses have stayed pretty even. But yeah, this just looks at, kind of there, the main thing we're looking at is the sharp increases here. Yep. I already covered some of this, dealers only having one or the other at a time, and then the synergistic effect. And then the dangers in combining this, okay, it's the fentanyl can mask the pain associated with cardiac event, and it increases the risk of overdose for both. So I do actually want to do questions here. So questions, and I want to, I'm going to put you in breakout rooms here for a brief moment, because I want you to think about, because we've talked about both opioids and meth, and it is important because you're seeing a lot of the use with it. And so it's these two questions here. To what extent are the problems with opioids or meth caused by the drug itself? So I'm going to put you into breakout rooms, at least two breakout rooms. I'm going to see how many folks we have here. Yeah, I'll put you into breakout rooms. I'm going to see how many folks we have here. Yeah, I'll put you into breakout rooms of about four or so. And then how much responsibility for the dependence on them is again on the drugs itself. So essentially these are kind of two questions asking almost the same thing. If all you can recall with from it is essentially how much is it the drug itself that's causing the addiction or the dependence? If you want, you can also take a photo of this. The reason I'm bringing this up is when you're in the breakout room, you're not going to be able to see this slide. So somehow holding onto that, because that's going to be the discussion point that you'll have as a group. We're going to be in the room for about seven minutes, so not super long. But yeah, if you can make sure to have a spokesperson to report back what the group's conversation with it. Okay, let me set breakout rooms up. Oh, it's going to be rooms of three. Okay. All right. So we've got any questions before I open the rooms up? Again, remember, have a spokesperson ready to report back. All right. If not, I'm opening the rooms up. See you all in about seven or eight minutes. I'm sorry if I'm mispronouncing that. Maybe they're not there. Yeah. That means I'm going to put Ricky in with, I'm going to put Ricky in with the other group I think they should be able to see the chat as well. Yeah. Oh, good. Thank you for putting that in. I wound up catching a bit of a cold, that's why I'm like eating and drinking lots of food right now. Yeah, I ran the Seattle Marathon on Sunday. Oh wow! Is that your, how many marathons have you run? Is that your first or? Oh no, I've run that specific marathon now five times. Wow! Yeah, I've probably run about um 10 or 15 marathons total. Yeah. That's very impressive. I'm not a big runner. I think I usually just run three miles when I run. That's very impressive. Oh, that's good that you run. It's great. Yeah, it's good. Um, yeah, it's each their own. Um, but yeah, then I ended up having my, one of my dogs got sick, not that the night right after, but the night after that. Um, and so I ended up having like a night where I only had three hours sleep and then unfortunately it was training and I think I caught something from someone at the training. Makes sense. It kind of sets you up with your immune system. I wonder if we should put Medalia in that room. She, she was gone I think and just joined back. Yeah, I guess I'll put them. Hi Medalia. You're muted. I was wondering where everybody was at. Yeah, they're all in, uh, well they're all in one breakout room right now. Um, they're talking about the questions we have up on the screen. I can throw you in. It's going to be kind of a large room now, but um, but yeah, or you don't have to, if you want to just, I don't mind waiting until they come out. Okay. Yeah, that might be easier. Yeah. If you can hang out. Gotcha. Okay. Thank you. Yep. Well, after you run a marathon, is there a bit of a recovery? Like, are you like bad for a day or did you just like bounce right back? Uh, there is. I mean, I, I, I haven't exercised in the last like two or three days. I'm kind of letting my body heal. Cause yeah, you definitely, uh, it's, it's, it's, it takes its toll on you. Um, but yeah, it's, uh, but I mean, as of tomorrow I'll start swimming and running again. So, but yeah. And you have to keep training, right. To prepare for those, you can't just like randomly do it. Um, I wouldn't recommend randomly doing it technically could, but it wouldn't be a good idea. It would be, it would be, it would be a lot less. I mean, it's not exactly a it's painful even with the training, but it would be a special without it. Yeah. Yeah. So that's really cool. Um, no, I'm, I'm trying to qualify for Boston, so I'm probably going to run another one in April. Um, I'm trying to actually, there's some things I'm working on with it. I'm trying to, um, get my pacing up. Um, it's so I did it in three hours and 35 minutes. So that sounds fast to me. So wait, you actually have to qualify to run the Boston marathon. You can't just sign up. It's like, you have to be a certain rate or a certain. Yeah, you have to. So there's, um, you, you have to get a qualifying time and even getting a qualifying time. Doesn't mean you're guaranteed a place because they out of the applicants, they go down the list. They have a certain amount they can allow in and they go down the list of who got the fastest, next fastest, next fastest until they run out of slots. Oh, wow. So they'll give you general guidelines of like what someone your age need 10, where they tended to cut off. Um, but again, it's not a guarantee. Like, and so the, the, the guideline for my age right now is three hours and 15. Um, but even running a three hour and 15 doesn't mean I'll get it. It's to be safe. It would be better to have it even faster than three hours and 15. Wow. Why is the Boston one so exclusive specifically? They just, it's kind of seen as one of like the, that's held as like a championship for the country. And it's also partly because it's Boston. So they can't, um, it's Boston and it's a point to point marathon, which makes it logistically challenging. So let as many people in. Um, so, but that being said, New York is also technically point to point. And that one's not exclusive or not? It's, it's exclusive, but it's not by running time. It's by lottery. And so you apply and then you might get in if you get catch the lottery for it. Yeah. Interesting. Yeah. That's fun though. Exciting to work towards. Yep. It's not enough time has passed. Let's see where folks. It's interesting you can see that he was talking in the breakout room. Exactly, yeah. I didn't realize you could. This Zoom account has it, my personal one doesn't. Oh. I could probably update it, and I wonder if I update it if it'll have that feature, but it's majorly helpful just to see if anyone's talking. Yeah, I thought there was some silence. Yeah. Do you have more trains coming up? Oh. All right. Nevermind. Welcome back everybody. So, uh. There was only 1 room, so if you have a spokesperson, great. Otherwise, we can also just include the conversation and. Did you get a chance to choose a spokesperson? The white graciously volunteer. I see graciously. Should I just talk about what we talked about? Yeah, there you go. Okay, yeah, we talked about how. We have preconceptions about, like, what was going on and sometimes we lean more towards, like, mental illness. And and thinking that's the, the main explainer of what's going on with clients. And then we talked about how now we see a lot more symptoms as. Substance use related, um. We talked about how it affects the, how people think and how they may act irrationally to us. Um, and then we also talked about, like. Now that we think about, like. The opiates explaining a lot of stuff. And then also how you talked about, uh. Military veterans coming back from using opioids and not getting addicted. So we also talked about how there's deeper stuff than just the substance use and, like, that. Really, they need therapists that we are not and we're not equipped to do that part. Thank you. Yeah, let me know if I missed anything gang. Yeah. Anyone else that anyone want to add or. So, I didn't a great job of covering it. So, yeah, it's kind of a fuzzy picture, isn't it? It's some substance. Yeah, I mean, it does contribute. But it's it's more than that usually. And so it also kind of, yeah, it's it adds to this picture of the substance use might be impacting things more than you might realize. What's interesting with it is if it is the substance. Does that change anything? I mean, it might of. Hey, have you used today or how's it going? It could be 1 of the questions that you ask, or, um, are you having a hard time? Are you are you in withdrawal right now? Is that what's kind of making things hard? Um, or is it, um, the other flip of it too is with math. Have they been using that if you're seeing and a lot of the and something I didn't bring up a lot was, um. So, math will tend to agitate. Mental health symptoms. Whether they're using it or coming down from it, it's 1 of the problems with math is Jenna. It's all encompassing. It will kind of always impact mental health. Whereas with opioids, you're mainly going to see mental health symptoms emerge or become problematic when they're in withdrawal. Um, when someone's actually taking the opioid, you're probably not going to, because they're, they tend to be pretty compliant, calm. Um, and so, uh, yeah, it's more of a risk of, or are they okay? And are they going to be. Silence. So, um. I've gone through kind of slides. I've had some great discussion here. I'm wondering. Like, as we now kind of, because we're coming to it coming towards a close, um. Questions or and, of course, you can bring up specifics about situations. But does anyone have anything that they'd like to bring up? Ask comment on. Anything you'd hope that cover, but maybe didn't touch on you're wondering about. Nothing coming to me at the moment. I'd love to hear somebody else ask some questions, though, on the team. Like, given our positions and the fact that we're not professionals, and I know nobody is expecting us to act as professionals, what would be some ways to kind of try to differentiate if it is, or to assess, I should say, I guess, whether a client might just be having a substance abuse issue in the moment, or if it's more of a mental health? So, I mean, if they're awake and moving, and you can ask, I mean, it's a possible ask, okay, when's the last time you used? And being, hopefully you can have that kind of relationship with them, that you can ask that question without them feeling like there's judgment behind it, of just like, hey, how are things going? How's your day? Have you been able to, have you had a hit at this point yet? Or also, if you know their cycle, something that can also be helpful to gather too is, I think, and we talked in another meeting about spending time, because they have that space where they can go use, possibly being out there and being around, and kind of catching people's patterns of like, what time of day they tend to use, if you can find out what it is that they use. So you have an idea of like, oh, wait, you know, we're starting to, like, they use in the morning, and we're starting, they're getting agitated towards lunch. Hey, have we ever, have you, have you noticed that? And what's the solution to that? Is it maybe, maybe taking another hit, or maybe splitting your hits out so that it's more spaced out. But this would be a harm reduction approach of talking to them about, okay, like, maybe you can change kind of the pattern of your use to make it so that you're not having such highs and lows. But it would require talking to them. And this, yeah, it can be helpful information with it. If they're not, like, in other words, they're too agitated, or, well, I mean, if they're, they're not waking up, you know, that it's probably opioids, and you've got an overdose on your hands. So that's going to be pretty straightforward. But if, say, they're really agitated, I don't know that you're going to be able to totally differentiate. It's more of, if they're really agitated, figuring out how to get them to a calmer environment, using some of the, what we were talking about in de-escalation, where you can get them away from the stressors, and recognizing that you're most likely the stressor. And that it's, how can you get them in a place where maybe they're away from you or away from whatever it is that's causing the stress? Because even if it's meth, if they can get into a calmer environment, they're probably going to be okay. Also thinking with it of, have they, hey, have they had anything to eat? Because if they can eat if they're on meth, but they're not going to think about it. So it's like, hey, can we get a bite to eat? Or have you had some water recently? Getting them to kind of think about their bodily needs with it. Again, you're not going to totally differentiate. The main one is, if they're calmer, they're probably on opioids. If they're agitated, they're either on meth or they're on withdrawal from opioids. Yeah. I've never even thought about, I mean, I've offered them food in general, but never thought about that aspect of it. So yeah, I appreciate that. If not, um, yep, we're coming up towards 11. So, uh, we're, we're going to wrap up for today. We have, uh, the next several of these will be in January. Um, so there'll be coming up here. We've got a trauma informed care. Um, we've got a motivational interviewing and I'm forgetting 1. what was the 4th 1? I thought we were doing trauma informed care, but the next 1 is harm reduction on this. Got it. Uh, then intro to MOUD and then last MI. Thank you. We can do trauma informed care. I, I wasn't sure. Yeah, we're, we're infusing trauma informed care into all of these. That's right. That's right. Um, so yeah, so we'll have some more of those. Um, of course, as always, uh, reach out if you've got questions. Um, and so, yeah, you all know how to reach out to me. Um, and whether there are questions about any things, of course, also, I know some of you may have disability verifications and stuff like that that you need to check in with me on. Um, but, um. Yeah, other than that, I think we're set for today. Well, Emily, is there anything because we don't need to do the, the. No, I think we're good. Um, this recording will be available within about 2 weeks, or if you want to revisit it or share it will be shared with your team. I'll be also can share a PDF of the slides. If that's helpful policy, or actually I have the deck so I can send that to Lisa, and she can share it out. But I think that's everything. Thank you, Paul for today's presentation. Thank you, Paul. Thanks, Madalia. Bye. Bye, everybody. Yeah, that's some really good information. Appreciate it. Thanks, Calvin. Thank you as well. All right. Thanks.

substance use disorders

opioid use

methamphetamine use

addiction theories

neurological changes

reward circuits

opioids

fentanyl

naloxone

methamphetamine effects

harm reduction

motivational interviewing

opioid overdoses

medications for opioid use disorder