I'm going to hang out here and kind of monitor. I've been getting a couple of changes in the room, so just kind of keeping an eye on that too, if anyone's lost and getting. Check one, check two, check three. Sure. And I'll help you pass them out too. Perfect. When the time comes. I'm going to start letting them in to grab food and stuff. Yeah, for sure. And I can help you with that too. Just direct me, Luna. This is your event. I am your... I wanted to do just a little like, hi, thanks for being here. Once they kind of stop, like they're done trickling through the line. We can even do like the disclosure slides too, as they're trickling in. And then we have like our first introduction thing, and then I can just hand it over to you, do introductions. Does that sound good? Okay. That sounds great. Say all the snap of things. This is the part where I start kind of winging a little bit, but not all of it. Oh my God. Exactly. I'm just scared of dogs. OK, let me check my paper. I don't know if that's sufficient. You're going to need to wrap it around your arm. You're going to need to wrap it around your arm. I don't know if that's enough. I don't know if that's enough. Of course. Yeah. I think the shower should go like this. I don't know if that's enough. I don't know if that's enough. We changed the time a lot. Are you going to cry? For today? Yeah. Or is it all good? Do you have some bronzer? I'm sure. I was going to say, I would send it out to all of my friends, you know, if they have a question. Yes. Yeah, I wish they would, like, they're only going to send it out if they have a question. Translations, right, for everyone. Okay, so we used to have a friend who was an NGDP there, and she had a GPS information. She was a friend of mine. It was my first time talking to her. I like her a lot. I know. Yeah, she walked by. She walked by. I'm on, I'm on. Okay. I'm on. Yeah, I know. All right, so as we're trickling in and still grabbing food, please definitely feel free to get food. If you haven't already, please make sure you sign in on the sign in sheet, whether you've got food or not. This is how we are going to contact you to get you your certificate of completion. Welcome. Welcome. My name is Dr. Rodin. Most of you know me as an instructor. Today I am presenting on behalf of the opioid response network or as part of the opioid response network. And we have partnered with SNAFA. Luna has been in the works getting this set up for months now. So thank you so much, Luna. This has been phenomenal. What we do with the opioid response network is we really try to work with communities. This is a SAMHSA funded operation. And so we try to assist specific communities on resources, education and trainings with regard to opioids. This includes technical assistance that is available in these evidence-based prevention, treatment and recovery programs. So what does it mean to work with communities in the opioid response network? They try to use different educators and presenters from that community that are already integrated, that know the community best. And so for ORN, they do accept requests for education and training. So if you or someone you know do have a request for any type of training or technical assistance with regard to opioid education, I highly recommend you reach out to the opioid response network. They have a plethora of tools, resources and facilitators that provide awesome presentations. So if that is of interest to you, here's the information. You can send an email, go to their website, or you can call to submit one of these requests. This is kind of the same thing you followed too, right, Luna? Awesome. With our opioid response network, it is grant funded. Here is the information on the grant funding for it. Me as a speaker, my views have obviously been vetted, but they are not the views that necessarily reflect the federal government, the Department of Health and Human Services or SAMHSA individually. So with this type of organization and technical assistance, our goal is to build on existing efforts, enhance and refine and fill in gaps when needed while avoiding duplication or not recreating the wheel. So that is the goal. So a lot of this information has been pulled from other experts and previous presentations to give you guys a nice, full foundation on our topic today on mechanisms of substance use disorder. But the overall mission of the opioid response network is to provide this technical training and assistance to enhance these prevention, treatment, recovery and harm reduction efforts in an evidence based manner. OK, so for this presentation today, we are going to be focusing on three learning objectives. We are going to be able to describe the pathology of substance use disorder, explain the role that neurotransmitters have in developing physical and psychological dependence of a substance, and then utilize strategies to address patient concerns and kind of have those tough conversations. So here's our plan. So to get started, we'll have some introductions. So I will hand it over to Luna to do some introductions and say some hellos. Hi, everyone. Most of you know me by now. I'm Luna, the one running around doing all the SAMHSA stuff. I see some familiar faces. But to those of you. Hello. Thank you all so much. So, so much for being here today. I want to do before we get too far. Give a little like thank you so much to Dr. Odin for taking the time to be here and putting all these slides. Can we give her a round of applause, please? Those of you who are interested in learning more about SAMHSA, please come see me. I will be hanging out in the back towards the end. And also, shameless plug, we do have the committee applications out. So I know all of you all got that email. It's buried. It's there. I promise. But thank you for being here again. Thank you, Dr. Odin. Thank you, Orin, for this opportunity. And I'm going to hand it back to you now. All righty. So now we're going to kind of go into an introduction, what we see with substance use disorders, and then dive into that neuropathology and some of these resources that we have in patient education skills. As we're going through this, we're in a fairly relaxed environment. If you have any questions, please do not hesitate to ask. This is a really nice way to kind of converse and dive deeper into this topic. We definitely have the time. We'll probably be talking about substance use disorder for probably about an hour. And then we'll use that last 30 minutes to work on some of these skills, go through some of these exercises, and kind of implement our motivational interviewing and assess patients in that way. Sound good? You can't say no. So what is a substance use disorder? A lot of you are in my substance use disorder elective. So I hope you're able to define this. I won't talk with you now, though. But essentially, a substance use disorder, as defined by NIDA, is going to be a chronic relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences. So what does that mean? Realistically, as a medical provider, what is that telling us? I wait until everyone took their first bite. Punitive actions won't help. Punitive actions won't help. Absolutely. And so when we have someone who is dependent on a substance, we start to see these negative consequences over and over again, right? And we're kind of questioning, why isn't this helping? Why isn't this working? And it's because we know now after studying the disease a little bit more that it is characterized by continued use despite these negative consequences. And so it's not just having a tolerance or withdrawal or this physical kind of observable instance. It's also that psychological and that kind of repercussions that go with it. So how prevalent is substance use disorder in the United States? Pretty prevalent, right? So about 48.7 million people age 12 and older, that's about 17.3% of Americans, have substance use disorder in the last year. And these are people that are identifying with it, recognizing it, being diagnosed with it. Kind of breaking that down, it shows that 29.5 million people had an alcohol use disorder, 27.2 million had a drug use disorder, and about 8 million had both an alcohol use disorder and drug use disorder. Does anyone know someone who has or has had, currently has or has had a drug use disorder, alcohol use disorder? Yeah, it's pretty rare to find someone now that doesn't personally know somebody who is affected by these substances. And so we see this incidence pretty, pretty big in our society. And it's a costly, it's a costly problem, right? So we have this table here and it's comparing the direct cost, the healthcare costs of these different disease states and its overall costs. So those direct costs and those indirect costs. We have certain disease states like using tobacco or using alcohol, and you see that the overall costs are in the hundreds of billions of dollars. Other comparable chronic diseases include diabetes that are on there, $245 billion, and cardiovascular disease at $444 billion. So we see that substance use is definitely kind of encompassing a high dollar amount of our money, right? But we also know that it's not just a dollar amount that we're putting on some of these implications. So when we have people in our lives that are using substances or dependent on a substance, it's not just the money, the direct medical costs that we're seeing as family members or caregivers, but we're seeing these other consequences as well. Number one thing we are highlighting on here is that fatal car crashes. So about 32% of fatal car crashes involved some sort of non-alcoholic drug, 57% had high blood alcohol levels, and 21% of those fatal crashes involved both. And so we see this kind of ripple effect, right? We also see that in the United States, alcohol and drugs are estimated in about 80% of offenses leading to incarceration, and this includes stuff for domestic violence and property crimes. So it's not just directly drug related. And then with substance use, it does exist in about 40 to 80% of families where the children are the victims of abuse. And then that last stat up there is showing that about up to two thirds of all people in treatment for drug use disorders report that they were physically, sexually, and or emotionally abused during childhood. And so what this slide is really trying to focus on is kind of the wide impact that substance use disorder has and how our better understanding of the disease and how it happens, how it culminates is going to be very helpful in supporting these patients and treating these patients as well. Because that's a huge problem. We saw the numbers, but we also feel the impact. With substance use disorders, it doesn't just affect the person. So it affects the person and all those people that are closest around them. So I saw a bunch of people raise their hands and you know, someone who has or currently has an alcohol use or drug use disorder. So I personally have a lot of family and friends that have had or currently have a use disorder, mostly drug use disorder. And I will tell you that it does impact those at least five people closest around them. Right. So typically their parents, their siblings, and any other partners that they might have pretty close to them. So one of my first experiences with like experiencing drug use or a drug use disorder was in high school. Um, I went to a very small high school, very Christian high school. I was very sheltered in graduating class. I don't even think it hit a hundred. And so it was, it was just tiny. I went there from K through 12. So I had a very narrow perspective of the world and my very first boyfriend obviously thought I was going to marry him. He ended up getting in a really bad car accident and he was prescribed opioids for this. And that kind of evolved over time into an opioid addiction, which evolved into a heroin addiction and kind of hit that trajectory that we see in these different ways of the opioid epidemic. But I remember when I first started interacting with him and he was using these substances, I had no idea what was going on. And I wouldn't even say that I was one of the closest people to him. I was definitely more of like a tangential, even dating this person, right? But just kind of seeing how that ripple effect impacts someone like a significant other, you can imagine how much it's impacting people who are even closer, like their family, friends, and parents and stuff like that. So it, it ripples. Everyone knows someone affected by these problems that are related to alcohol and or drug use. Um, our society really normalizes, especially alcohol use. So it's not hard to find someone who meets these criteria or who is impacted by these substances. But we do see that families are significantly impacted by substance use disorders. Okay. So it's kind of tiny on these little TV screens, but, um, this is the outline of basically our timeline on how we have viewed substance use disorders throughout time. Um, not all of time, cause then they'd be really tiny little letters, but it kind of shows you from the 18th and 19th century on to today. So when we first started kind of looking at this drug use has been around forever for human existence. Right. Um, and when we started studying it a little bit more and trying to understand it a little bit more, we had these different theories over time. So in the 18th and 19th century, it was called the moral model. And in this model, we were seeing that, um, we, we believed that it was willpower or moral strength that indicated your progression in this disease, right? So you just needed to try harder. You just needed to be more disciplined. If you had a better faith, a better moral support system, whatever it is, then you would be fine. If you were using drugs, though, you were a moral degenerate, right? That was just kind of the thought and the process at the time. As we move through time, we kind of see through the late 19th century, kind of to the early 1930s, um, there is this temperance and prohibition. And so we know there was alcohol prohibition at this time, but it was kind of widespread. So we're trying to legislate where nobody can use these substances at all. Pop quiz. Did people stop using these substances? Absolutely not. They were really mad about it, actually. We had a really big underground system with prohibition where they made a lot of money, but we also got it legalized again with alcohol. Um, so this kind of prohibition model didn't stick. And so as we continue to progress through this timeline, let's see, through the 1930s until now, we have these two different models that have been kind of ebb and flowed in its acceptance. So we have here the disease model and then the life process model. So in the disease model, it's showing that alcohol or other drugs are not necessarily bad for you, right? It's this kind of, um, continuum of use. It's the person who is an alcoholic or an addict who had an addiction, they were kind of predisposed to it, um, and, and they, you can diagnose it. It is a chronic condition, but it was someone who was, who's kind of set up to fail in that system. Right? The alternative process is going to be the life process model. This is where it's not a disease, but rather this habitual response to something you've kind of conditioned yourself to continuously ingest this substance and receive whatever effects that it is providing this source of gratification or security. And it can be understood only in that context of that social relationship or experience. And so those are kind of the two models that have predominantly kind of been shown from the 1930s and are still believed today in some circles. We know this is still a very stigmatized disease. Um, but as we progress through into the 1980s and 1990s, we started to have a lot more science behind what we're understanding in the brain. So we understood the brain a little bit better, which helped us understand how these processes and mechanisms of substance use disorder started, progressed, and continued. And so we see here the addictive personality model or the, this is your brain on drugs ad campaign. Um, does anyone remember that? And they would have like the fried egg and they crack it on a pan and they'd be like, this is your brain on drugs. That was an egg. Um, that wasn't your brain on drugs. Right? So we know that when you use a substance, it's not just frying your brain. It's not just getting rid of all these various synapses. We know a little bit more now on what's happening and how we can help treat someone and bring them back to maybe not their baseline, but pretty close to baseline, at least close to a functioning baseline. Right. And so then we see that kind of progression and our decade of the brain learning more about that. I also remember one of the commercials where I was, I grew up in the DARE era where they told us just not to use drugs. And we got a lot of stickers and I was telling our class yesterday that I got a glow in the dark, like bracelet that was like, what would Jesus do? So we like, didn't do bad things, especially in the dark, um, that also didn't really work. Right. Uh, but I remember this commercial that they used to have where it was this girl and she just like melted into the couch and they were like, don't do drugs or you'll be like that. And one of my friends had sleeping issues, so she didn't sleep a lot. She was like, but that sounds kind of nice. It's like, I don't think we're supposed to be selling whatever they're, they're putting out there. Right. So these different campaigns were not necessarily evidence-based. So as we learn more about the brain, we have more evidence-based methods on how to educate people and, and how to treat people with this disease state. So addiction starts and substance use starts on a variety of different levels, right? And so here are some bullet points that we can see. There's the personal responsibility model, the agent model, dispositional model, um, and they all kind of describe something a little bit different. And I think they show a piece of the picture, maybe a piece of the puzzle on why someone might start using substances, but they've never really captured the entire thing, right? They don't really, um, look at this person holistically and all these different factors that we now know play a role within our patients. So when we're looking at that personal responsibility model, that's kind of saying that moral failing, you're personally responsible for the choices you make and, and kind of the repercussions thereof. Um, then there's the agent model that it's kind of like, if you're going to put this substance in your body, your body's going to react to it as a substance. And kind of no matter what happens outside of that, your environmental factors, your genetic factors, the agent itself is what's going to cause this addiction. That dispositional model, that addictive personality, has anyone ever been told they have an addictive personality or heard that statement before? It was kind of popular a few years back where you just kind of have this, um, I don't know, tentative attraction to being addicted to some of these things, right? Now we know there's different reasons behind this. Like we have some neurodivergences that might hyper focus on things, but it's not necessarily that you and yourself, you're born with a personality that just becomes addicted to things, right? It is a social learning model where it is this kind of learned behavior. If you're kind of watching people around you, if it's socially accepted, you are accepting it. Um, the socio-cultural model where there's that pressures from society really trying to be integrated into that peer group and then that public health model as well. So we have these, which is more accepted today. So we have these different, different ideas on how addiction starts, but initial substance use can be used in different ways. So I'm going to have you guys answer this one. What is a situation in which someone might start using a substance to feel good? What's an example of that? If they're like nervous, I guess, sure, if they're nervous, yeah, so their kind of baseline is feeling bad, a substance might intervene in that, right? So if they feel a little bit anxious or a little bit nervous or, or in physical pain, right? We want them to feel good. Um, substances are wildly popular for a reason, right? You get high. Some people like feeling high and that might be one of the reasons they start using is to feel good, to feel that high. What about in the instance of, to feel better, can we give an example on why a patient might start? Yeah. If someone was broken up with and then they go out partying, that would be kind of a feel good. Okay. So if someone was broken up with, they're, they're trying to cope. They go out partying. They're going to use these different substances that maybe won't make them feel so sad. So trying to emotionally feel better. Could we also see that in like a physical sense of feeling better? Yeah. So there's kind of this spotlight. I think sports illustrated did an article, gosh, probably at least five, 10 years now ago where they showed how football athletes would use substances like opioids to physically feel better so that they could go out and play and continue to play. Right. And sometimes for some athletes, this would translate into an opioid addiction because of how often and frequently they were using these substances. So they were physically trying to feel better so that they could continue doing their sport. And that kind of falls under to do better as well. But could we think of another example on why someone might use a substance to do better? Yeah. Like a stimulant. So what would we be doing better at? Sure. So school or sports, if we have a stimulant on board, it is not uncommon for people to think if I can stay up longer and have this focus on the material that I'm studying, then I will be more successful going forward. Right. And so you see a lot of stimulant abuse in settings like college campuses. Absolutely. It's a great example. And then what about just curiosity? We know there is, especially when you're younger, um, maybe not for the better when your brain isn't fully formed yet, but when you're younger, you have this general general curiosity. And so you want to know what the hype is about. You want to know what these substances feel like, and you don't really have that, that formation of the risk quite yet. And so you're just weighing that benefit of understanding the substance and maybe the good feeling that comes out of it. So this is how most substances are initially used. But would you say that substance use is voluntary? On this first bullet point, I have that the initial decision to take a substance can be voluntary. Can we think of any instances where it is not a voluntary choice? Lex? Peer pressure. Peer pressure. So if you are especially an adolescent, it is very developmentally normal to have such high regard for your peers, right? You want to fit in and you want to be a part of that group. And so if somebody is very much so pressuring you, especially somebody you're close to and somebody you love, um, we might not see that as full informed consent, would we? Maybe coerced consent. What's another instance that we have some involuntary initial use? Yes. If someone in their family gave them drugs. Okay, so someone in their family gave them drugs. Absolutely. I'm originally from New Mexico and there was a point in time early on in the opioid epidemic where opioids, such as heroin, were seen as almost like medicine in some rural counties. And so you would see parents or grandparents giving this substance to someone else in the family, like a child or niece, nephew, et cetera. Absolutely. Yes. If they grew up around it and it was normalized. If they grew up around it and it was normalized, yeah. It was normalized by other parental figures, people they looked up to that could certainly play a role. Yeah. Or maybe they were like in a bad situation where they weren't like aware, I guess, that they were taking it or like forced to, I guess. Yeah. In a situation where they're not aware of this substance they're ingesting, or they're in a situation where they're forced to take it. This can certainly happen in some situations, uh, where, yeah, it probably underlying abuse of some, some form, right. And you're ingesting these substances that you don't quite know. That can certainly be it. I think you've covered all the ones I have in my head. The only one I could also think of is maybe when you're admitted in the hospital and you're not taking these substances on your own volition, you need them to get better, but a substance use disorder gets, uh, from that situation, um, after a time, because of the changes in the brain, substance use takes over and that self-control becomes impaired. And so we'll see why that happens in the brain, but this definitely happens at a varying rate for some people versus other. Um, so Peyton might take one dose of the medication and be completely fine. Whereas I take one dose of the medication and that is all I can think about. And I want to continue taking it and we are moving forward, right? With whatever substance use path I'm going down. So it's different for everyone, but those changes in the brain are what's going to start that substance use and that substance use disorder. And those physical changes in the areas of the brain that are critical to our functioning include our judgment, decision-making, learning, memory, and impulse control. Does anyone know what the DSM-5 is? Diagnostic criteria. Absolutely. So this is our most up-to-date diagnostic criteria for different mental health conditions. But for this one, we're looking at the DSM-5 diagnostic criteria for substance use disorder. And so we'll go over this in different sections, but you'll see that it's fairly straightforward, right to the chase, right? 11 questions. If you score between two and three, you've got a mild substance use disorder, four and five, you've got moderate. And if you score six or above, that is a severe substance use disorder. And so one of the categories that are on this DSM-5 criteria is dependence. So this is what we think of as medical professionals. How is their body reacting to this substance? Do they have tolerance? That's the need for more medication to get the same feeling or same effect. Do they experience withdrawal? So when you stop taking the medication, are you physically reacting to that? Is your body kind of having a reaction to the removal of that substance? And so there's only two criteria that are looking at our pharmacological criteria. We have a little bit more of our criteria looking at impairment. So when we're looking at impairment, we're looking at impairment control or impaired control. And then we're also looking at social impairment. So how is this impacting how we're able to control our use of that substance? So am I talking about going out and I'm like, I'm only going to have one drink tonight, I promise. Six drinks later, we all know where it goes. You know what I mean? And so that's going to be an example of some of that larger amounts over a longer period of time than originally planned. This persistent want or desire or need to cut down. So if I'm like, okay, I'm doing dry January this year and I'm not able to do it. So I'm like, okay, I'm doing dry February this year. Two weeks in, I'm not able to do it. So I'm like, okay, I'm going to do like a less wet, dry January, March, whatever comes next. Right? So you're trying to kind of move the marker for yourself and you're trying to cut down. You want to cut down, but you're not able to. And then a great deal of time spent on obtaining that substance. So whether you are making money to buy it, you're thinking about it, all of that is going to go into there. And then that intense craving. So you're thinking about it when you're not using it. And then we also have social impairments. This is one of the bigger ones and a little bit easier to see as a third party looking in. So failure to fulfill work or school obligations. You want to study for something, but you just haven't been able to because you are using the substance or you miss work because of hangover or withdrawal symptoms. And you're not able to fulfill your schedule, those obligations, recurrent social or interpersonal problems. And so this is going to be relational problems. If you're having problems or fights or disagreements with those close around you, those social engagements, then that is going to be under this category. And then when you are fully withdrawing from social or recreational activities, so things you used to do, and you're not really doing anymore, it's going to fall under the social impairment too. And then we're also going to have risky use. So this is where we are continuing to use these substances, even in dangerous situations. And with some of our alcohol and drug use, it kind of gets normalized as like a funny story when it's more of like a funny, like, oh, no story. So for instance, when we're using substances and operating a boat, sometimes in the summertime, that is a little bit more accepted, but that's definitely going to be recurrent use in situations that can be hazardous or harmful. And then continued use, despite persistent physical or psychological problems that are likely to have been caused by exacerbated use. So for instance, I had a patient who kept getting recurrent kidney infections, but they wouldn't stop drinking even when they were treating their kidney infections or they had UTIs as well. And they were just like, oh, I don't know. I mean, like, this can't be like hurting it. Right. And it's like, yeah, yeah, I can. Let's give the body a little bit of a break, hydrate and, and finish out our course of antibiotics. And they would not, they were not able to reach that next level and put themselves at more harm and had these persistent problems because of that. So that would fall under risky use. And so when we have our DSM five criteria, all these questions fall under these categories. And the more you're answering yes, the more impact it's having on your life. And so we understand now that it's not just your interaction with the drug, but it's how the drug kind of helps you or forces you to interact with the world and that impact it is having on your overall life is going to really be what's going to be diagnosing within our DSM five criteria. So now let's kind of dive into why this happens. What's the neurobiology of it? What's happening in the brain first and foremost, why is it, why does it matter? Because if we don't understand what's happening, we don't understand how to treat it. And then we don't understand this patient population in general, right? We start creating ads about fried eggs and how that's our brain. When we know for a fact, that's not our brain, right? And so we want to understand substance use disorder and recovery and debunk some of these myths that are keeping our patients from treatment and keeping our treat our patients, um, from kind of having the impact that they want to have. So at the American society of addiction medicine, they describe addiction as a primary chronic disease of brain reward, motivation, memory, and related circuitry. And it talks about this dysfunction and what happens when this, um, this happens, right? And so it's this pathologically pursuing reward and or relief by substance use and other behaviors. So you see this theme again, right? So it doesn't matter what's going on around you. You are continuing to pursue these substances. And so this is where we really start to identify and label our substance use disorder as a chronic disease. So believe it or not, this is a fairly new phenomenon and this wasn't always believed. Um, there are some providers still that don't fully believe that it is a chronic condition. And so there is some work to be done around the stigma and education, not just with patients and community members, but also with healthcare providers that are in the field now. Um, but what I like to do to kind of get this point across a little bit better is I compare it to other chronic conditions. And so our, our most commonly seen chronic conditions are going to be things like type two diabetes, hypertension, and asthma. All of these disease states along with substance use disorder have very similar treatment adherence. So our patients are taking their medications and then sometimes they're not. Um, but when we have relapse with our substance use disorder patients, or we have non-adherence, it is seen as a much bigger issue, right? All of these different chronic disease states are very, very difficult to manage behaviorally. Um, so it's really hard to make those lifestyle modifications. So in disease states like hypertension or type two diabetes, those exercise changes, those diet changes, it can be very, very difficult. It's no different than substance use disorder, right? Those lifestyle modifications can be hard to accomplish. Um, and all of them may in part be caused by genetic factors, but they do respond to ongoing treatment and they respond positively. And then some will have to engage in lifelong treatment in order to maintain success in their treatment plans. No different than substance use disorder. It's going to be very individualized patient to patient. So with drug use and addiction, brain imaging studies do show that there are physical changes in areas of the brain when the drug is introduced chronically. And so these main areas that we're going to look at are going to be the part of the brain that's responsible for judgment. Um, so how do we make these, these judgment decisions? So these decision-making or risk benefit analysis are learning and memory, and then our behavior control. And so what that looks like and how it changes impacts the disease and its severity. And it impacts some of those impairment criteria that we see in our DSM-5 criteria. So these changes alter the way that the brain works and it helps explain this compulsion and this continued use despite these negative consequences. Because underlying in all substance use disorders is going to be dopamine. And so this is where we get nicknames for certain substances like dope, because it is a release, a flood of dopamine that is being sent into our system after using these substances. And this is our feel-good chemical. This is our, uh, feel-good chemical in the brain. That's telling us what we're doing is good. So we normally get dopamine or we should on an everyday basis. Right. And we do it for these activities and behaviors that our body wants to see more of. So if I'm going on a run, I get a little runner's high. Has anyone ever heard that term? Yeah. That's your body kind of sending out these endorphins. You're getting a release of dopamine and that's your brain telling your body exercise is good. It feels good. We should continue doing it. Right. We experienced this. When we eat a very carb heavy meal, we get those neurotransmitters that say, yes, this is fantastic. We want to continue eating these very carb heavy meals. It makes us happy and Hey, it helps us survive. So these are all good things to our brain, right? When we form relationships, when we have intimate time with our partners, this is all going to kind of release that dopamine in very small amounts. When we introduce these exogenous substances like methamphetamine opioids or alcohol, it's going to release a whole bunch of this dopamine. So it's going to give a much more, I don't know, enlarged response to what our body's telling us. So we kind of get this flood of like, Oh, this feels great. Oh, I not only want this, but I think I need this. Right. And if we give that to our body several times in a row or on multiple occasions, and we start to change that want to a need and we can contribute that to kind of dopamine. Right. So it's starting to change those reward pathways. And so this is where we're describing that stronger than natural rewards. So I will tell you what my very carb heavy meal or that five mile run I just did is not going to give me the same thing as methamphetamine, right? Different, different. So one of them is going to be stronger than natural rewards. To wake us up, which one do we think is going to be a stronger natural reward? Maybe the math, maybe the math, you win. You're on it. And you're paying attention. Yeah. So drugs released from two to 10 times, the amount of dopamine dopamine as our natural rewards. So this can be varied based off of the potency of the drug or what type of drug, but what we know is this very big dope of dopamine dopamine is going to affect our brains. Drugs that are introduced into our system and put into our brain faster are going to have a bigger response with this. So when we're injecting or smoking drugs, we have an onset of two to five minutes, right? Injecting it's pretty instant. And so when we have administration pathways like that, we're going to see a higher dump of that dopamine and a higher addiction potential with those substances. We know that these effects last much longer in certain substances. So when we have that longer effect, it's going to impact it as well. And the effect of such a powerful reward strongly motivates people to take that drug again and again. And so it kind of starts as that choice, right? Like, this is fun. I'm doing this to experiment. I had a great time. I'm going to do it next weekend. Okay. That was fun again. I'm going to do it again. And it starts that compulsion, right? And so these results in a decrease in the natural reward effects, such as eating or having sex, so that when you are doing some of these more normal things, you get less pleasure out of them. And it kind of reinforces the seeking of those substances so that you can get a bigger effect with that dopamine. So the brain learns to do this very well. Your brain is a very efficient organ and it's going to adapt to that scenario. So then what does that look like inside the brain? This is a picture of the brain. And so we're looking at these different pieces of it. So here in the center, we have, it's kind of difficult to see, but a little yellow highlighted area that is showing the nucleus accumbens. What is the nucleus accumbens responsible for? Reward pathway. Did you read it? It's okay if you did. Yeah. Our nucleus accumbens is going to be our reward pathway. And so this is where our body is releasing those rewards and it's driving our actions to seek rewarding experiences. So whatever makes us feel good or rewarded kind of primes our brains to seek those experiences again. And so this is the first part that's kind of being affected because of that large dopamine dump we are triggering, or we are starting that reward pathway. And then we're looking at that prefrontal cortex. So this is where we have our decision making. And so in our prefrontal cortex, we're really weighing our risk and benefit. Can anyone tell me when this is fully developed or fully formed? 25, just around there, right? So for some people a little sooner, some people a little later, but around mid twenties, it was when we're going to see our frontal lobe fully formed. So what happens when my frontal lobe isn't fully formed? What does that mean for me? Can I not make decisions poorly? Yeah, you make different, you make different decisions than maybe you would. Right. So if you kind of think back to when you were 16, 17, and the decisions that you made then, and you kind of reflect now, I'm going to tell you how old I am, but I'm thinking back to 16 and 17. And I'm like, wouldn't have made that decision twice, right? It's because you're weighing risk and benefit differently. And so when we have a less than developed or not fully developed prefrontal cortex, we are weighing the benefits of what we're trying to do a little bit heavier than the risks that are associated with that. And so this is why for a while, younger men couldn't get rental cars because of that prefrontal cortex, right? They saw the benefit of running that red light as outweighing any potential harm of possibly having an accident, right? So when our brains are having to make those split second decisions, that's what's getting weighed there. And so with substance use, our prefrontal cortex is also affected. So where we see people trying to make decisions or trying to have these types of behavior changes that are dependent on this logical sequence of decision-making, it can be impacted because their prefrontal cortex is impacted. So if you've ever experienced someone in your life or one of your patients that has had substance use disorder, and you just kind of want to be like, why are you doing that? It makes no sense. This is why they're doing that. I had a patient years ago who, um, it was with alcohol use disorder. Her partner was using alcohol and she just really didn't want him to. And her thought was if I get pregnant, he's got to stop, right? Can anyone guess if he stopped or not? Three kids later, he still has not stopped. Right. And so it's not these logical things that are, that are contributing to the risk and benefit of the decision-making, right? The substance is altering that pathway and it's altering that perception, um, to, to kind of make those decisions, those informed decisions. And so we see that really impacted with substance use. Let's see. Then we have our amygdala. What's our amygdala responsible for? Emotions. Great work. Um, so with our amygdala, it is responsible for our emotions. So how is this affected with our substance use? When our brains are not fully depending on our prefrontal cortex to make these decisions, our amygdala kind of steps up to the plate and it starts to help us make some of these decisions. So what is emotional decision-making look like? Not good. Why not? It's more impulsive. So there can be some limited impulse control. Absolutely. Probably more drastic, a little bit more off the cuff, right? Absolutely. And so we can kind of picture this. We'll go back to when we're 16, 15, our prefrontal cortex isn't quite formed yet. This is also another time in our life where we are making decisions that are very emotionally based. So we can kind of see that this primary emotion, especially in substance use tends to be fear. So it's this fear of withdrawal. It's this fear of not having the substance any longer. And it's kind of this fear of these very short term repercussions. Um, and, and that's where we start to form our, our, our new logical pathways to make these decisions. Let's see, make sure I'm not missing anything. And so we're putting it all together. We see the entire impact of this. And one of the main areas where we also see an impact is going to be in that kind of primal brain, right? So deep down in that, in that needs versus want midbrain, it is telling us that we need these substances, right? We start to change these pathways that are changing our decision-making and really kind of conditioning our brain to want and need these substances, just like it's telling you, you need water, you need food, et cetera, et cetera. And so there are considerations when our brain is changing that we need to make with our patients. One, obviously we know this is a disease state that is characterized by continued use despite harmful consequences. So really putting that into consideration with our treatment plans to, they're going to be different perceptions, different perceptions of risk, different perceptions of benefit, but also different perceptions of time. Um, and so it can be really hard when under the influence of these substances to understand things like time as well as we normally would. And so that can definitely be an impact when we want patients to show up on time, we want them to follow up on time and we want to pick their refills up on time. Things like that can really be impacted in early stage of, uh, treatment for addiction. So that is something that we do need to consider as healthcare providers. So one analogy, that's pretty famous that we're going to do here together is going to be holding our breath. Believe it or not, oxygen is going to be one of those things that our brain tells us we need, and it's going to try and force us to use this. So this is kind of the analogy where you hold your breath. You try to keep your breath held for five minutes and you just use your willpower, right? This is kind of what we're asking our patients to do when we're trying to just quit substances. When we're saying, Matt, just, just stop drinking. You got it? No, your brain at this point needs it. And so we're all going to try and hold our breath and see how long we can hold our breath and nobody's going to pass out. So ready, set. I think some of you are cheating, and that's just my opinion. Okay, now we're looking like we kind of want to breathe. Just do better. It's fine. Oh, Mona gave up. Okay, so we see the point. What are you feeling? You guys can let your breath out. What are you feeling in that instance? You wanted to win. You wanted to be the last man standing. What's going on in our brains? If you could boil it down to like one emotion. Me and my sister used to play this game where every time we drive through a tunnel, we'd hold our breath, and whoever like didn't lost, and the repercussions to that were various each time. But the one I remember was we'd punch each other. I didn't want to get punched. There were these really long tunnels, and I would try to hold my breath, and if I had to describe my emotion nearing the end of that tunnel, it would probably be panic. I was just sitting there panicking like, how do I do this? My sister, she was little, but she was tougher than me for sure. Did you guys feel similar emotions when holding your breath, or what did you feel when you were doing that exercise? A little bit of panic. When I was taking trumpet lessons, we had to, every lesson, we had to like hold a sustained note for longer than the last lesson. And if you didn't, you had to do it again. What if you were in trumpet lessons for like five years? I was in for like two. But it was once a week, so it was like panic. It was like, okay, I need to do better than last week, but not so much better that the next week I can't do better than that. Oh, you're like looking to increase by 0.1 second every time. Yeah, I think that's a fabulous example. So we can kind of compare that, and sometimes that's useful, especially when we're in these moments with family members, friends, or patients where we're just really frustrated. And we're like, why can't you just do this? But we think back to what our brains were feeling towards the tail end of holding our breath for that long. And that's the feeling that they feel in those moments, right? And we have a normal functioning amygdala and prefrontal cortex and all of the above. And so those feelings of panic that are setting in, those feelings of dread and fear and just, oh no, I need this right now. We can kind of start to, at least as best we can, put ourselves in our shoes of our patients, friends, and family that are experiencing this disease state, right? That when that kind of primal brain starts to take over and that need starts to get established, this is kind of what they're feeling like. Oxygen is now the equivalent to whatever substance is being ingested. And so there are three different stages. Sorry, this is super hard to see on these screens. But there are these different stages to our substance use. And so we have our first one, which it kind of reads here, where you have your binge and intoxication. So this is kind of like the fun part that people see, especially if you're using substances to feel good or out of curiosity. You have this binge and intoxication where it's kind of the peak, right? You have all the dopamine, all these positive neurotransmitters, your serotonin, and you're feeling pretty fine. As you progress through this stage, you're feeling euphoric, then you're feeling good, and then you're escaping dysphoria. So you're kind of escaping your worries, all of those, until it translates into this withdrawal and negative affect. And so when we start to remove that substance after chronic use, you start to feel a little different, and your body's not responding normally to our pleasurable activities. So it's hard to get those positive neurotransmitters back up into their normal stores. And so when we're feeling our withdrawal and negative affect, we can have this feeling of reduced energy, we can have our feelings of reduced excitement, and then feeling depressed, anxious, and restless, on top of any other physical withdrawal symptoms that we're feeling. So it's going to be different from each disease state from one to another, but essentially that's kind of what we're looking at for withdrawal. And then once we kind of get past that, we're going to move into that preoccupation and anticipation stage. And so this is in our DSM-5 criteria, where we're constantly thinking about how we're going to get our next whatever it is, when we're going to use all of these things. And so it's kind of where you're looking forward to it, you have your desired drug, and you're obsessing or planning in order to get that substance. So this graphic kind of just shows that culmination, that response to the drug, and how this cycle just continues to go and go and go to produce those changes in the brain. Any questions on this or the changes that we do see in the brain? All right, so then let's look at some of these long-term effects that we have from chronic substance use. So we know that the brain adjusts to the overwhelming surges in dopamine by producing less dopamine on its own, right? So our bodies do this very naturally. So anytime it doesn't have to expend energy to create something or make something that you're putting in the body, it's not going to. And so when our brain's adapting to this, it is producing less of its own dopamine and reducing the numbers of the receptors that is kind of taking in dopamine. So this is one of the functions behind tolerance and behind that negative affect when you stop using the substance, because you're really not making it endogenously at that point. Dopamine's impact on the reward circuit of a substance user's brain becomes abnormally low. And so we, again, need more of that dopamine in order to produce that same or similar response. And so we might not ever get back to that initial experience of just our number one dopamine dump, but between trying not to feel our withdrawal symptoms and that fear and all of the such, our dopamine's just not going to have the same impact, but we're going to keep using those substances. And then the ability to experience any pleasure becomes drastically reduced. And so this becomes a really big barrier in our treatment plans for our patients. It doesn't mean that they'll never get back to feeling pleasure in some of our daily activities, but there is a really deep depression that happens when you start to initiate treatment for different substances, especially dependent on the agent or the pathway that you choose to pursue in that treatment plan. But you can certainly see a steep depression no matter what substance we are kind of tapering off of or stopping. And so really kind of being able to support our patients in that realm, whether that's with counseling, peer support or whatever that looks like, can be really beneficial into keeping them in treatment. This manifests in the feeling of being flat, lifeless and depressed. And this can be really hard to dig out of and it can be really hard to see the end of. And so a lot of our patients are using substances for different reasons, right? They're typically using it to honestly self-medicate in some instances. And so it's a coping mechanism. I would say I'm really, really anxious at parties. I don't really like talking to people, but I really want to talk to people. And so I just stand in the corner and like sweat and eat. I don't want to do that anymore. So I use cocaine for the first time. It makes me happy. It makes me affable. It makes me friendly. And I am able to talk to anyone and everyone about everything. I'm not really even hungry. So I don't even think about snacks. Like, honestly, this feels really nice, right? If I continue using cocaine for long periods of time and I initiate treatment, my coping mechanism for those social interactions has been taken away. So unless I'm given separate tools or different interventions in order to help with that coping mechanism, the next time I'm in a situation where I need to talk to people and I don't want to feel that way, couple that with that kind of being flat, lifeless and depressed, it can be very difficult without any other coping mechanism. So we really try to enhance our treatment plans to not just be a drug or just counseling or whatever. We want to encompass it and look at this person holistically. And so the brown, the brain now needs the substance to bring that dopamine level back to normal. But your body does go back to baseline over time. Just depending on the substance and the treatment plan, it can vary on how much time that takes. But I even have to talk about this with my smoking cessation patients, too, right? That's been their coping mechanism for a really long time with stress. And so when they decrease their use of tobacco, I mean, they're really agitated. So sometimes they have to give their partners or their kids a little heads up to say like, hey, I'm going to need a little bit more grace this next coming week. Right. I'm doing my best. I'll get back to baseline. But I'm just not going to have the same coping mechanisms that I once had. And that can be a hard conversation. And so with our drug use, there can be these not these negative cognitive effects that we've kind of been discussing. So it's not always just resistance and noncompliance. Right. I think it's kind of easy to blame that as health care providers or family members or friends to say, oh, Matt just doesn't want to do it. If he could, he would. Or if he wanted to, he would. Or whatever the saying is. Right. With these patients, we know that there are different cognitive effects. So it might not be this intentional act to be noncompliant to your medications. And so we do need to take that into account and form that trust with our patients. There's this thing called episodic memory. And so this is where times, places, associated emotions and other contextual who, what, when, where, why are kind of distorted. And so you have this episodic memory that might not be a true translation of memory on what has happened. And so remember, amygdala is on overdrive. So those feelings are going to be the main thing we remember and maybe not necessarily the details. And so that can be really important if we have complex treatment plans, complex taper regimens, whatever else it might be. We just need to keep that into account with our patients. We also have different emotional processing. So, again, our amygdala is on overdrive. So this is going to be at the front and center. And for a lot of these substances, they're numbing our feelings. They're numbing our processing of what we are experiencing around us. So if you've been doing that for years, you can imagine kind of the distressing feeling that it might feel when you have to reengage with some of those negative feelings. And if you don't have those tools in your toolbox, it can be really hard. And then we have our executive functioning, this planning and this decision making that can be very, very difficult where it looks like an easy thing to us, but it feels really debilitating. I don't know if anyone's ever experienced any issues with executive functioning. I have ADHD. So sometimes there are points in my life where initiating a process or starting something or just making a decision, I feel like I am pushing a boulder up a hill and it's on top of me and I still can only lift 10 pounds. You know what I mean? So it's just this huge, massive weight that it's hard to imagine that somebody else understands. So it's hard to describe it. So if you have a patient who is experiencing this, oftentimes they're not just going to tell you, hey, I'm having issues with executive functioning. That's probably not what's going to happen. You're going to see that paralyzing kind of staring off into the distance or this want and this desire that they're talking to you about in your patient visits and this inability to follow through. So as a provider, you kind of have to translate those behaviors into what's happening and how we can support. And so substance use disorder, again, it's not different from other disorders, chronic conditions, it is going to change our anatomy, right? So these are going to be some scans. So we have our heart on the left. And so in our our healthy heart, this is going to be someone who does not have any issues. They're pumping normally. They're normal. Then we have our disease chart. So this is coronary artery disease. And so we do see the changes in that end organ function because of the chronic complications of coronary artery disease. So with addiction, we do see the same thing. So on the left, you do see a healthy brain. And on the right, you do see what is labeled as a disease brain. And this is just showing that kind of dopamine and reward pathways within these different images to show how your brain changes after prolonged or chronic substance use. So with our heart on the left, we can anticipate that the heart is not going to function as it normally once did, right? With those changes that scar tissue, it's not going to have the functionality that it once had. Same thing with addiction, right? So we can kind of anticipate some of these changes in mood, behavior and decision making, because our brain is the primary organ that is responsible for that. And so these these PET scans tend to display that. But what's really cool about substance use disorder is with with effective treatment, we can see our brain go back into closer to normal baseline. And so what that means is it may not go exactly back to what your brain once was, but we can reform those neural pathways and we can have a better functioning and less severe disease, right? And so on the left, you see what is put as a healthy person in the middle after one month of abstinence from methamphetamine. And on the right, you do see 14 months of abstinence and the progress that has been made in just about a year for this patient. So your body adapts and it does come back fairly quickly, which I think is really hopeful. And I think it's really cool. We don't see that with other disease states, specifically things like coronary artery disease, COPD. Once that organ is damaged, we don't get that functionality back. We just try not to hurt it more with our chronic treatments. And so this is kind of our basis for withdrawal, too, right? We talk about our body being really efficient and it's it's trying to anticipate some of these different substances that we're introducing into it. So we're looking at withdrawal. This is where our body is trying to maintain homeostasis. It's gotten used to whatever you're putting in your body. It's readjusting some of your neurotransmitters, usually your stress hormones. And and it's it's trying to get you to baseline. But when you quickly remove that substance, everything's back out of whack. Right. And so it depends on what substance you're taking, on what is going to be internally adjusted, where we need another internal adjustment that's necessary. But this is those neurotransmitters are where we're going to basically be seeing our withdrawal symptoms. So for alcohol, for example, glutamate is going to be the number one thing our body is going to try and balance out as we are introducing ethanol or alcohol. So when we very chronically introduce ethanol or alcohol into our body, it's a depressant. We're lowering our blood pressure. We're lowering our heart rate. We're lowering our inhibitions, all of the above. And so when we are anticipating that our bodies are anticipating it, we're going to see a little spike in blood pressure. We're going to see a little spike in our heart rate so that we feel normal within normal ranges using that substance. So if I quit using alcohol, even though I've been drinking two glasses of wine every night while I make dinner, my body's going to react and I'm going to feel anxious. I'm going to have this high heart rate. I'm going to have this high blood pressure. And it's really going to affect right because of that glutamate that is increasing based off of that internal adjustment. So that is kind of the basis for withdrawal. So here are some of these key concepts. We have the parts of the brain that have become changed from the substance that are overriding some of our factorial memory storage. And that's what's happening in our hippocampus and our logical reasoning or prefrontal cortex. And that is what is translating into these behavior changes. Right. And so some of these decisions that might not seem logical to us at the time are because of these different brain changes. What questions do we have on brain and brain changes. Okay, then I'm going to kind of introduce this concept of the spectrum of substance use because just because you use a substance doesn't mean that you are addicted to that substance. Right. But the riskier you use and the higher consumption that you use, you tend to see more severe consequences. And so this pyramid just reminds us that there is an ebb and flow to this and and just because you're at one spot in this pyramid now doesn't mean you stay there, you can go back down to low risk use or abstinence but abstinence doesn't have to be the end all marker. So we do know some factors that make patients or people more vulnerable to addiction, or a substance use disorder. We know that some drugs dump dopamine faster than others. So our very high dopamine drugs are drug of choice, or choice of drug is going to impact how quickly or if we do become dependent on a substance. We know that route of administration is going to certainly be impactful. So the faster we get past the blood brain barrier, the more likely we are the more vulnerable we are to becoming addicted to that substance. So like we talked intravenous or inhaled or kind of smoking something are going to be our two fastest methods, followed by sorting something or the light. We know the dose is going to be an impact. So the higher the dose, the more dopamine that's going to be released, that more vulnerability we have to becoming addicted to that substance frequency of use higher the frequency higher the vulnerability length of use, the longer we're using it, the higher the vulnerability, and then our motivations for use. So if we have some pretty capital T trauma that we're trying to treat with our self-medication, that can make us more vulnerable to being addicted to this substance. Additional vulnerabilities that are a little more outside of our control are going to be genetic factors. So it's believed that substance use disorder is about 40 to 60 percent genetic components. So can't change that. And genes are not destiny, but they are data. Our developmental vulnerabilities. And so when we're looking at that, we are looking at a few different things, right? And so kind of our developmental age, how we have developed within our brain. And so the sooner we introduce substances into our brain, it is going to affect how our brain develops. And so that can really increase our vulnerability to these use disorders. Chronic pain can also increase our vulnerability, which is again, outside of our control in most instances. And if we have any dual diagnosis, what do I mean by dual diagnosis? What would be the second diagnosis or additional ones? Maybe something affecting like the mental health of the person. Yeah, maybe something that's affecting mental health of the person. So you kind of use the example of anxiety before. That is certainly a dual diagnosis that could be impactful for this. What else do we think? This is our time to wake up. Other chronic diseases. Yeah, especially if they have that chronic pain component. I don't know what additional vulnerability something like cancer would have, but it is mostly going to be in that mental health space. So if we have dual diagnoses like bipolar personality disorders, anxieties, PTSD, those are all going to be higher vulnerability. But we also have some environmental contributions. And so the availability of the substance, how easy it is to get a hold of the acceptability, or we kind of talked about that peer pressure, whether it's your family's success, acceptability, your friends, whatever it looks like, that can increase your vulnerability alternatives to drug use. So if you have absolutely nothing else to do except drink alcohol or except use drugs, you're going to have a higher likelihood of using those substances, the settings. So how you are using the substances and where you're using them can really be a contributing factor to your vulnerability. So you have lower vulnerability in a controlled setting, like a religious ceremony, where you're observed, you're coached, and it's kind of part of that religious ceremony versus parties or using alone are going to have higher vulnerabilities in substance use disorder and some of our harm, harm reduction settings. And then presence of these conditioned cues. So kind of, you know, the Pavlov's dog where there's the ding and they want food or however it goes kind of same thing, right? Our brains are very easily trainable. Um, I learned recently that my mom potty trained me by running water and I just never understood why I always had to go to the bathroom. Every time I heard running water, our brains are constantly being conditioned with different stimuli, right? So there are the presence of different conditioned cues that can impact your substance use moving forward. So if you are always using a cigarette or always smoking a cigarette on a road trip, the next time you hop in the car for a road trip, you might say, wow, cigarette sounds really good right now. And it might take a whole lot of extra effort to not smoke that cigarette or not go buy a pack of cigarettes in that instance. Right. And so it just kind of depends on what those condition cues are. Okay. So we're going to do a little, a little activity. I'm going to read a couple different sentences to you. Don't say anything now, but after I finished reading these different statements, I want you to talk in your group about how you feel about them. All feelings are valid. And I don't mean that in like a cheesy way. Right. So I really hope you have this robust discussion and I'll kind of walk around and chat with y'all about your interpretation and your feelings on it. Um, and it's okay to go with your gut reaction. That is what this, this exercise is about. Okay. So first statement, substance use is a normal part of life. Okay. Substance use is a normal part of life. Problematic substance use is a moral failing or is a sin. People who use drugs should be considered a group with rights that need to be protected. Professor Carl Hart, a neuroscientist states that he uses heroin recreationally. All right. So those are our statements. Let's chat in our groups about how we feel about those different statements. Okay. Let's see. What did we think? All right. We're bringing it back. We're bringing it back. Hello. All right, y'all. So what did we think about this first one? Substance use is a normal part of life. Okay. So it seems like universally we kind of said, yes, this is probably, I heard your group kind of talking about it where you were saying substances are all over. This could mean anything. Is that right? Yeah. Okay. Yeah. Sometimes when I think about this, I think a caffeine as students in a doctoral program, I'm assuming you're using a lot of caffeine. Substance use is a normal part of life, right? It can just vary. Problematic substance use is a moral failing or sin. What did we kind of think about this? What are some themes we talked about if you got to this question? Like this group didn't really get to it. This group here had some really good ideas on just that definition is so different for different people. So they kind of brought up the gray on what is a moral failing. What is a sin? If you're someone who is not religious, you're pretty agnostic. Not going to mean much of anything to you to say you committed a sin, right? But if you're someone who is deeply religious and you do kind of have that within whatever religion it is that you're practicing, that is going to have a different definition for you. So little, a little gray there. We're introducing some more gray in this. What about this one? People who use drugs should be considered a group with rights that needs to be protected. What do we think about this? Yeah. When we asked you about like what protected meant and you told us kind of about like with like studies and how there are like protected groups, like elderly people or like people that are like low income or like young kids and stuff that are protected, then we were like, okay, that makes sense. Like people with like use disorders aren't thinking straight or like, like they normally would if they were healthier. So we said that they should. Yeah. Great points. And we had a nice discussion on this and just what does protected mean? And so it doesn't mean that they aren't held accountable for laws, rules and regulations that we have put in place, but it's recognizing that they do have this chronic brain disease that does alter their perception and risk and benefit. So having something like a patient advocate or someone else that can advocate on that patient's behalf for good treatment or whatever rights might be in question could be useful. So yeah, a little, a little gray presented in there, but that one seemed a little more straightforward, but I think Carl Hart got your all's attention and probably most of your conversation. Is that fair? What do we think about Professor Hart? Yeah. We kind of focus our conversation on what recreationally meant because like my understanding was recreational. I didn't really say it was like an abuse, but it was just not medically, but like not medically related. And so if it was like, if you use it every three years, we did that. And then we also focus on like, if you switched out heroin for cannabis, it sounds like it has a different other goal. Yeah, that's a really good point. Okay. So I'm hearing two different themes here. One, you wanted a little more information on what this meant, how frequently is it using, maybe how it impacts his life, what that looks like. Cause with our DSM-5 criteria, and I talked about this with this group over here too. It's not just if you're using a substance, right? Just because you have a glass of wine, doesn't mean you have an alcohol use disorder. Just because Professor Carl has used heroin doesn't mean he has an opioid use disorder, right? But if we had more information, maybe we could kind of determine where we're at on that scale. So that's a great point to bring up. And then the second point I heard there was, if you kind of swap this out with a different substance, how does that change your perspective and your gut reaction to the scenario? So your group swapped it out for cannabis. We swapped it out for alcohol. And how does that look in terms of our perception on Professor Hart's professionalism or his use disorder? It can help us kind of bring it back to baseline. Cause what we've seen in our years and years of maybe not really understanding this disease state is a perpetuation of stigmatization. And so when we see this disease state stigmatized, and we see some of these substances really stigmatized, it impacts our gut reaction and our implicit bias towards these patients who use these substances, but also our implicit bias on the substances themselves. So I think it's a really good exercise to swap it out with different substances or different kind of parallels, like paralleling it to a different chronic disease state to help bring you back to baseline without that gut implicit bias that is very hard to avoid. So I think you brought up some really good points there. And so that's going to be a fabulous transition into our impact of stigma. So what is stigma? Stigma is just going to be any type of shame, disgrace, disapproval that results in an individual being rejected, discriminated against, and excluded from participating in some of these different activities. And so usually it's kind of this one attribute that it has this negative connotation that is inaccurate or unfounded. And in substance use, this often results in these inaccurate beliefs that addiction is a moral failing or a sin, right? And this can help form our implicit bias, which can have negative impacts on our patients moving forward. And so we have some different impacts of stigma, right? And we see stigma in different places. We can see stigma on the individual level. So for me, if I think all homeless people use drugs, that's gonna be a stigma I have against homeless people, right? It's an unfounded thought. It's a negative connotation against this group of people that may or may not be doing this, right? And so that is kind of an individual person's stigma. Then you have this structural stigma. And so this is where we have the entire structure, like the healthcare system, not believing this is a chronic illness. So if you think it's a moral failing, you're not gonna put these patients into treatment and you're not gonna offer them the same services you would for other chronic disease states. So you kind of see that structural stigma. And then you have this public perception of stigma. And this is where we have this kind of cultural belief about a group of people that then impacts our laws, policies, and some of our structures in our society moving forward. So if I believe that all people who use drugs are going to be harmful to my safety and my family's safety, I'm not gonna want a syringe exchange program in my neighborhood. I don't want a detox facility down the street from my kid's school, right? So that public perception or stigma within public perception is really going to impact some of our patients' options for treatments. And so we do have a very distinct differentiation intention versus impact. So some of these stigmas are well-intended, right? And some of these conversations or rules, laws, regulations have the intention of decreasing drug use within our communities, which is a fabulous intention. I think as treatment providers, as healthcare providers, as family and friends, we want decreased illicit substance use, right? However, the impact of what we're doing and saying doesn't always align with that intention. Just because we're well-intended doesn't mean we're making a positive impact. We can be doing more harm than good, even with the best of intentions. So let's look to see what that looks like. So when we use stigmatizing terms, this can affect the perception and behavior of patients, their loved ones, general public, scientists, and clinicians, and it can also affect that quality of life and healthcare policies. It also affects your treatment plans. So if I am consistently telling my patient, urine's dirty, why can't you get clean? Using these really stigmatizing terms of dirty, clean, calling someone an addict or an alcoholic, or if you're in the emergency department, calling them a frequent flyer, all of these stigmatizing terms can impact your treatment plan, but it also has a wider impact on some of these policies, procedures, and care options our patients receive, or maybe don't receive because of it. And so the number one impact we see with these, at least as healthcare providers, with this stigmatization is going to be barriers to accessing treatment. So we want people in treatment, we want them to be adherent to their medications, to follow our treatment plans, but when we have and perpetuate this stigma, we're kind of stopping them right at the door, right? So we want to be able to improve access to treatment and recovery services, and that's been one of our top priorities for the Human Health Services Administration for the past probably decade. Only half of privately funded substance use disorder treatment programs even offer medications for substance use. And so that's a really big disparity. And of that, only a third of those patients actively receive medications as part of their treatment plan in those facilities. So we have a really small number of patients who are offered all of the variety of treatment options that they could have, and it could be inhibiting their ability to effectively stay in treatment. And likely that is because medications for the treatment of addiction is still very stigmatized. And we are not sure why, but we do see that these relapse rates, we kind of talked about this in the beginning, or these non-adherence rates are gonna be similar across disease states. And so you do see patients who are non-adherent to asthma medication, hypertension, and type 1 diabetes, very similar to non-adherence and drug addiction, right? So relapse, what do I mean when I say relapse? When they come to us seeking treatment, we have a high severity of the disease. If I have hypertension, my blood pressure is 160 over 100, high severity of disease. But you put me on medication, Katie's like, you're gonna be on Losartan, 40 milligrams, take it once a day at night, come back in a week. I come back, my blood pressure is lowered. I'm at 120 over 80. Katie's ecstatic. She's like, I'm the best pharmacist in the world. Don't know why we didn't do this sooner, right? We see my severity of my condition decrease. I wake up one day and I say, I don't need to take this anymore. My blood pressure is perfect. What happens when I put nothing else in place to decrease my blood pressure and I stopped taking my Losartan? You guessed it, the severity of my condition increases. The same things happen with our substance use disorder treatment, right? So when they come to us, their severity of their disease could mean they could have loss of relationships, loss of job, they could be physically dependent on this substance going through physical withdrawals. But when we initiate treatment, including medications for some of these substance use disorders, the severity of that disease goes down. So specifically for treatments like medications for opioid use disorder, we see improvements in employment. We see increased criminal activity due to opioid use. We see improved fetal outcomes for pregnant persons. And so the severity of that disease is decreasing as we engage them in treatment. What happens if we say, all right, your 12 weeks is up, you gotta get off of Suboxone. They're not ready. They haven't put anything else in place to actually help the severity of their disease state. We're gonna see that severity of their condition increase right back up. And so we do need to keep this in mind and maybe using that parallel of different disease states can be helpful when reminding ourselves or others about treatment. And so strategies to reduce stigma are going to be to address your own personal biases. That's gonna be the best way to do it. Using non-stigmatizing language, avoiding misinformation, and then collaborating with diverse perspectives outside of healthcare and inside is going to be very beneficial. For your reference, I think you'll get these slides at the end, but for your reference, here are some of the languages that you will be using or some of the language you'll be using that is better than others, right? So you still wanna use person first language just like you do in any other disease state. So I'm not gonna be calling any of my patients an addict, a user, a junkie, even if they call themselves that. Instead, it's a person with a substance use disorder or simply my patient. I'm not gonna call someone's substance use a habit. I will call it substance use disorder. And so you kind of see the list there on what is not acceptable and what is a non-stigmatizing replacement. So now we are gonna dive into our skills practice. So you're gonna partner up. You're gonna have two people in a group. So if you don't have one person next to you that you wanna chat with, maybe scoot on over, but you are going to do a persuasion exercise. And so in this, you are each going to identify something that you want to, need to, or should change, but that you haven't been able to change yet. In other words, pick a topic that you're comfortable talking to someone about that you might wanna change. And so with this, we are going to kind of be starting the process for motivational interviewing. So please follow the instructions closely. And then we're gonna do a second exercise right after this that's gonna kind of contrast how we decided to start this conversation. So you'll be, one person is going to be the motivator, the counselor, and one person is going to be the patient. So the patient is going to come up to you and say, hello, I would like to drink less Starbucks coffee in the morning. And you're gonna try and tell her how to do that. Just dive right into it. And then you'll swap. So we'll do about four minutes on this exercise. And then we will go to our next exercise. Sound good? Thank you. And we're gonna try and do this a different way. So you're gonna use the same topic, but I want the person who is trying to convince you of the change to use a few specific techniques. One, I want you to explain why, in very simple terms, this person needs to make this change. I want you to give two very specific benefits that it applies to that person, as much as you know about them. And I want you to tell the person exactly how they should change. Instead of saying something like, well, maybe you should exercise, tell them what types of exercise for how long, maybe joining a program, give specific implementable changes, and then emphasize how important it is to change. So let's try using that to change the behavior of your partner. We'll give another couple minutes for this. Why don't you do it? I'm gonna actually give you to the heart. I actually want you to do this. I see what you're doing. I think what you're doing right now is good. There's nothing wrong with it. But you know what? Just so you know, after you do this, you know what you should do? You should do it when you're doing it as your family. So, as you wake up, I want you to wake up and see what's going on right now. So you wake up and you have to go across the room and you have to set up a family routine and you have to do something like this. You have to do something like this. I don't know, I'd just be like, that's a good melody, isn't it? No, no, no, she was done. Hey, I think I like it the way it leads. Yeah. I just thought it was good, and I loved it. It is. I'm like, I'm listening to this song again. What did you do that with? I watched her. I didn't talk to her. I didn't mention her name. I didn't talk to her. I was looking at you. Yeah, but I don't know. That's amazing. Thank you so much for watching, and I'll see you next time. All right, let's bring it back together, let's bring it back together, bring it back together. So let's think about this, you'll have another opportunity to test these skills out with a little bit more information, but what was it like to hear someone tell you why and how you should make a change? Not the worst? Okay. What was it like to tell somebody to make that change? Was it easy to think of some of these reasons as to why? They helped you start the conversation. So sometimes it can be helpful to hear about our patient's perspective. So does anyone want to share what their goal was? What was your goal? To wake up earlier in the morning. So was Lex helpful if she told you just do it? I did not say that. She did not say that. I was like telling myself to wake up early and you know that I'm just do better. Yeah, just do better. We're not going to tell people that, but sometimes if I didn't know either of you very well, I might listen to, hey, can you tell me more about that? Why is that one of your goals? And using those motivational factors in order to spark some of that behavior change, right? It can be really hard, especially as health care providers, to not try to do the fixing tendency, right? And so we're not trying to fix people's lives, so I think one of the harder realizations we have to come to is that they might not take our recommendations, right? They might not do what we are recommending and that's okay. So what we are, we are trying to avoid and kind of being that fixer is patients who respond in anger, agitation, overwhelm, ashamed, et cetera, et cetera, right? So this whole list of negative reactions. So we're trying to facilitate an environment where patients are listening. They're actually hearing what we have to say and we are getting them to come back, right? So a treatment plan is only working if a patient does it. And so what are ways that we can kind of do this? Well, we can try not just giving blanket advice, right? And so with this, we're not going to go into same topic, different partner. We're going to go into our patient case in a little bit, but kind of using these different tools, right? So what have you been thinking about changing? What are the three best reasons to do it? So getting it from their perspective instead of just your perspective. Describing on a scale of zero to 10, how important it is for you to change, what makes you whatever number and not a zero. And then if you decided to, how might you make this change and what do you think you might do next? And so kind of start thinking about how you would start this discussion with someone who hasn't really decided to change yet, because oftentimes with our screening and brief interventions, we're kind of cold calling it, right? Like we're initiating this idea of treatment or change that may not have been present previously. So that is something to kind of think about when we're not giving advice. And so alternatives to giving advice would be to ask their existing level of knowledge, their existing level of interest and asking their permission, right? Can I give you a couple of suggestions on how to wake up earlier? Some things that maybe have worked for me, sometimes that can be an open invitation as opposed to just telling someone what to do and how by offering affirmation information, one piece at a time and autonomy and support. So this is really where we're describing things to patients in patient friendly language. If I'm just thrown medical terms at you, that's not autonomy, right? That's not you understanding that's you kind of getting lost in the jargon. So we're really trying to offer that affirmation information in digestible pieces. So looking at those reactions, asking additional questions and asking what their next steps are is going to be the most successful. So we're going to be doing a patient case, Luna is going to help me pass them out to everyone. And it's a brief overview on just an opioid case and you have three questions on there. You have their urine drug screen results. So how are you going to discuss that with your patient? You can kind of look at if they meet criteria for an opioid use disorder for the sake of time, I think you can skip that one. And then just how would you kind of approach that conversation of starting that behavior change conversation with them? So we'll use these different tactics that we talked about in offering support and not just advice and how we would discuss with this patient. Okay. And then we will kind of walk around or I will walk around and answer questions and see where y'all are at. Sound good? All right. There's so many things. I have one, yes. But I might not. I bring it with the gown. You bring it with the gown? I bring it with the top. I bring it with the top. She said it. It's kind of like. Do you like it? I don't have it. But I think it's a surprise. Yeah, so is he aware of all the substances that are in his system at the moment? That is a great way to start that conversation. I like how you kind of chose a path that was judgment-free, blame-free, right? Just, hey, here are urine drug screens. You're positive for X, Y, and Z, so you used great terminology. And then you're describing what was positive in the urine drug screen and just asking simply, were you aware that those substances were going to be positive today? Yes or no, you kind of branch the conversation from there. So let's say he was aware that he was going to be positive for all of those substances. What's your next step in that conversation? Ask more about the history of the use. We have some social history here from his medical record, but could use more information. You have- Does he want to stop anything? Yeah, that's a great first question. I see you're aware of this. Do you have plans to decrease or stop your substance use? Yes or no. So let's say he says yes. How would that guide your discussion at that point? Yeah. I feel like that could open a door of like asking if you can provide some recommendations and stuff. Yeah. Yeah, providing recommendations. So I might ask one more question just to kind of follow up and say, okay, is your plan to decrease or is it to completely stop these substances? Because that's going to direct me on what resources I'm going to connect him with, but that is absolutely kind of the next thing. What if he says, I don't know, I haven't really thought about it. I don't really want to stop right now. How would that guide your discussion? Move it back to our alternatives to giving advice slide. Yes, ma'am. Yeah. Absolutely. So what I'm hearing you say is you're kind of assessing his motivations, both for use and for stopping, which is a great first starting point, whether he wants to stop or not. And that kind of goes with what Lex was saying too, about understanding the drug use a little bit more and kind of solidifying your understanding of it. So let's say he doesn't really know why he's used it. He's been using it since he was 15. It's just really hard to stop. So I mean, I just, I really don't want to go through withdrawal. I really, I don't know, I feel like nervous about it. How would we maybe offer some, some information in there in that conversation? Yeah, absolutely. And so we kind of want to, and so right before we offer those resources, but I agree that we want to make them very specific to where we're located and something that's accessible to him. But before we do that, we want to ask some of our, our, um, alternative to advice questions. So we kind of asked why he's using kind of understanding those motivations. So maybe we could ask some, uh, let's go back a little bit, these questions saying, okay, well, you're here to get refills on your medication. I see your blood pressure is a little bit high. Do you know if you decrease some of your substance use, you might be able to get off of some of these blood pressure medications and provide a benefit to, to decreasing that substance use, even if he's not interested in stopping. Okay. Like you, you didn't know that it's totally fine. Um, I also see here that you have have it in front of me. What else do we have? Yeah. And so high blood pressure is on there as heart rates a little bit high. Um, and pulse ox is just a little bit low. So maybe we are listening to lung sounds and it is still a little bit, a little crackly down there, right? So we can say, well, I can also hear that your lung sounds are a little outside the range of normal. This could be benefited by decreasing your tobacco use, right? So kind of giving some of those health benefits and maybe some of the cost benefits of decreasing use, and then giving that person the, how they should change. So instead of just handing them a list of resources and saying, Hey, Matt, figure it out. Um, chances are our patients are not going to do that. They wouldn't do that with cardiovascular disease. They wouldn't do that with their diabetes. So they're not going to do that with substance use. So if you tell them specifically, like you were saying, um, Hey, here's this program. This is what they do. Uh, they're going to use contingency management. So they pay you in gift cards for positive behavior change. I know the provider there. They're they're really good. They have some openings. Can I call to set you an appointment up to just talk about their program? That's going to be a specific change that could make that behavior change a little bit more accessible to that patient instead of just, here's a list of resources. So when you're thinking about these questions, I kind of want you to start practicing that, um, and start thinking, okay, I said this general thing. What's the specific that I can add to it. Right. And then you can give them the list of resources if they want to explore something more. And then sometimes just repeating or affirming what they say can be super helpful. If he told you that he, he doesn't really want to stop because he's been using for so long and he feels just really nervous about withdrawal. Yeah, no, I hear you. Withdrawal is a really difficult process on this list. We have, uh, an inpatient withdrawal management program and they do medically manage that so that you are not in severe amounts of discomfort, right? So tempering their expectations, but meeting them where they're at, affirming their fears and, and, um, kind of what they're feeling in that moment can help open up that discussion a little bit more instead of the approach of like, yeah, shouldn't be nervous. This is going to be fine. Here's a list, right? This is a little bit more actionable. So with that, we are ending our time tonight. We would super appreciate if you were able to fill out this survey, gives us a little bit of feedback on how we're doing and how to improve. It helps with grant funding for the opioid response network initiative. And I will hang around for a couple of minutes to answer any additional questions, but I just appreciate y'all being such a fabulous audience tonight and making these conversations really useful and impactful for me. So thank you. I think I might just talk without the mic. Uh, one more thing. Also, thank you again, also for everyone being so engaged tonight. Uh, as far as your certificates go, you will get an email from me within a couple hours, but basically just expect those within about a week and you're going to get them from someone named Sarah with, uh, opioid response network. And you can put them on your CDs now. Yeah. You have earned it. You'll just get the actual physical certificate within the next week or two. Yeah. We'll be hanging around. Also get more food, take home so that I don't have to pick it up.

substance use disorders

opioid crisis

Opioid Response Network

evidence-based resources

addiction complexity

chronic brain condition

genetics and environment

neurotransmitters

dopamine

reducing stigma

motivational interviewing

empathy in addiction

patient care strategies

community health

addiction recovery