So, welcome to Medication for Opioid Use Disorders, Considerations for Judges and Justice Stakeholders held today, April 20th, 2023. The presentation is 75 minutes in length and your presenter is Chief Judge Kim McGinnis of the Pueblo Puaque Tribal Court. I'm very delighted to have her today. I'd like to tell you a little bit about her. She was trained in neuroscience before becoming an attorney and earned a Ph.D. in neuropharmacology from the University of Michigan in 1999 and completed a postdoctoral fellowship at Massachusetts General Hospital's Department of Neurology Molecular Neurogenetics Unit. She graduated from Boston University School of Law in 2004 and in 2011 moved to Taos, New Mexico and practiced domestic relations law. She was appointed to the bench at the Pueblo Tribal Court in 2013 and became Chief Judge in 2015. I do encourage you to view her full biography, which will be available after today's course. And I would also like to do a quick thank you to our sponsors, PCSS, who through this generous grant, we were able to provide today's webinar. But without further delay, I would like to hand it over to Judge McGinnis. Judge, you have the floor. Thank you so much. All right. So, thank you and thank you, Elizabeth, thank you National Judicial College for inviting me to give this presentation. As Elizabeth said, I have a Ph.D. in neuropharmacology, which is why I get asked to do these things a lot because actually the lab I worked in did study methamphetamines and the mechanism for how methamphetamines or amphetamines increase dopamine in neuronal cells, so that's my background. And then when I transitioned to being an attorney, I worked as a public defender for many years working with lots of folks who were struggling with substance use disorders. At the time I was in Detroit, it was mostly cocaine, crack cocaine, but, of course, we saw a lot of heroin also and people using methadone and more recently in our courts, of course, we see a lot of people using buprenorphine and methadone as well as naltrexone. And I'll talk about all of those medicines as we go through this. But please feel free to ask questions as we go through it. I'm not seeing the advance button. Oh, there we are. Sorry. I'm a little rusty with the WebEx. Sorry about that. I have no disclosures. So the dog you see and the dog you saw in my bio, her name is Kiki. She was our courthouse facility dog, so she was trained as a service dog and became our facility dog and worked at our courthouse with us to work and reduce trauma in our courthouse, mostly working with people who are in our specialty court. So I preside over our healing to wellness court, which is a drug court in the tribal court. So we focus on healing, as most drug courts do. Many of you might be drug court judges or work with drug courts. And that's my focus and Kiki's focus. She's now retired, but she was a wonderful addition. So you'll see pictures of her throughout my presentation. So the objectives are talking about how substance use changes brains in ways that can lead to a substance use disorder and lead to issues and basically talking about MOUD and talking about their mechanisms of action. From a perspective of a judge, I'm not a clinician. You're not clinicians. Some of you may have been clinicians in the past, but you're not your clinicians for the people coming in front of you. So you're going to hear me say a couple times, we are not doctors. We're not medical providers. We're not clinicians. We need to know some things in order to be educated and know what's going on for folks that we're working with who come into our courts. And, you know, besides the Healing World to Wellness Court, I also do preside over the Children's Court. So I do have lots of child welfare cases where, of course, most of the parents are dealing with substance use disorders. Many people dealing with opioid use disorders. And also, of course, we're seeing a lot of people who have polysubstance use disorders. So, again, the three types of medicines for opioid use disorder are methadone, and you'll hear our participants or people who come in front of us also call it juice or fizzy sometimes, and that's what's called an agonist. So it activates the opioid receptor, and I'll talk about this in more detail, but just so you can get a little bit of a preview. And it's orally administered, mostly daily administered. And usually people just need one. You know, they go to the methadone clinic at 6 in the morning, you know, get their shot, and then they're able to function throughout the rest of the day just fine, go to work, and do everything they need to do. Buprenorphine, also called Suboxone subs, buped, stops because it stops craving. I think that's where that came from. So it also works to release dopamine, which is what methadone does fully. Usually people have to take this two or three times a day because it's not as long-acting as methadone. It can be an oral tablet or film, and now there's actually monthly subdural implants. And it's easier to use because people can get a prescription, get a 30-day supply, and with only certain requirements. It's not as hard as methadone. And then naltrexone blocks the opioid receptor, so it doesn't reduce the craving in the same way that methadone does, and I'll talk about that more. It's oral, and there's also a 30-day intermuscular ejection, and it has some dangers and some drawbacks, and I'll talk more about that. Sometimes actually overdose is more prevalent in people who have tried to use naltrexone, and then they go on to overdose. So the justice system goals for medicines for opioid use disorder, of course, are different than clinical goals. So criminal justice, our goal, and child welfare, our goal is to reduce recidivism, reduce incarceration, increase reunification, decrease chronogenic behavior, habilitation, meaning allowing people who have an opioid use disorder to use medicine to allow them to parent well, to allow them to go to work, to allow them to not be participating in antisocial behaviors in order to get their drug or to avoid what they need to do in order to recover from their substance use disorder. So these drugs save lives, improve outcomes, and so the clinical goals and the justice system goals might overlap a little bit, or do overlap quite a bit, actually. You know, we want to save lives. We want to improve outcomes, treatment outcomes, but we're also focused on making sure that we're safe for the community, that the people who are using opioid medicine for opioid use disorders have their safety enhanced, have the community safety enhanced, and allows them to either move forward with their case plans if it's a child welfare situation or, you know, comply better with probation, you know, or not recidivate and not show up again in our criminal justice system. That's the justice system goals. So as judges, we are not allowed to say you cannot use a medicine for opioid use disorder. There's a lot of controversy in some areas. Some 12-step programs, AA, NA, believe that it's just using another drug, that it's substituting one addiction for another, and I'll talk more about that. But as judges, you know, again, we're not clinicians, and we are not allowed to say in order to get off probation, you have to get off MOUD. In order to graduate from our drug court, you have to get off MOUD, or you're not allowed to be on methadone or buprenorphine. If you're in our drug court, that is not permitted. If you're getting federal funds, it's not permitted by the DOJ for any kind of federal grant programming in your courts for drug courts. It violates the Americans with Disabilities Act. It also arguably violates the 14th Amendment due process guarantees and prohibitions against cruel and unusual punishment for us to say you need to get off your lifesaving medicine in order for you to be compliant with probation or be compliant with the drug court, or in order to graduate from our drug court, you have to get off these lifesaving drugs. So just so we're all on the same page, and I know you've all had lots of trainings about addiction and substance use disorders, but I've just, you know, I've broken it down to what I need as a judge to understand when someone's coming in front of me who has a substance use disorder. So it's a chronic relapsing disorder of the brain, and I know you've all heard that before. And so just like diabetes, just like any other disease, cancer, there could be recurrences. And for a substance use disorder, a recurrence means a return to use. So to be diagnosed with a substance use disorder, there's three basic elements, a loss of control over the substance, so use despite negative consequences. And those negative consequences can be getting a DOI like the gentleman we see here, losing your children, losing your job, losing your family. So use despite negative consequences. So even though you're having it negatively impact your life, you continue to use the illegal substance. The second piece is a high motivation to obtain the substance. So you're very motivated to go get the drug. You're not necessarily motivated to go work, but you're motivated to, you know, go meet your connection to find money to buy the drug. And so everything's focused on getting the drug. And when I say drug, I also mean alcohol. And then a persistent craving for the substance. So when people go into recovery, things that might get better, especially initially, are they don't have the loss of control over the use. So they're in recovery, so they're either cut way back or they're, you know, working really hard to not use. So that is not negatively impacting their life. And then their high motivation to obtain the substance decreases. People may continue to crave the substance, especially in early recovery, middle recovery. Early recovery is one year of abstinence. So even after one year of abstinence, people are still in early recovery and still very likely may be craving the substance. And then there is, you can use illegal substances and not have a substance use disorder. You know, we've all seen films from the 80s and 90s of, you know, the people on Wall Street using cocaine on a Saturday night. And those people did not necessarily have a substance use disorder. Just like people can go out and drink a lot on a Saturday night, it doesn't mean that they have a substance use disorder. So you can use a low amount or low risk of use, so use where it's not negatively impacting your life and not have a substance use disorder. Even methamphetamine, heroin, cocaine, just like alcohol, you can use them low risk. And, you know, I have a cup of coffee there because one of the main parts of addiction is use despite negative consequences. So for me, I love my coffee. That's, you know, a beautiful cup of cappuccino there. I love it. And I have a very high motivation to obtain coffee. I have a persistent craving for coffee. It has no negative impact on my life, so it's not an addiction or a substance use disorder. The other thing is that a lot of times we hear about children or babies born with neonatal abstinence syndrome as being addicted. Babies cannot be addicted. You know, babies can be born with neonatal abstinence syndrome. Babies can be born having withdrawal symptoms, but they are not addicted because babies don't have any high motivation to obtain the substance. Just a little pet peeve of mine. So again, just to reinforce dependence versus addiction. So people who have diabetes may be dependent on insulin or they have type 2 diabetes. They may be dependent on medicine for type 2 diabetes. People who have opioid use disorder may be dependent on suboxone or methadone because it reduces the symptoms of their disease, the disease being opioid use disorder. So using buprenorphine, using methadone, using naltrexone may reduce the symptoms, the craving, the desire, you know, the high motivation to find their drug of choice, their use despite negative consequences. People, if you're using the medicine the way it's prescribed by their clinician, if you're using buprenorphine or methadone, then it's not having negative consequences on their life because they're able to go to work, they're able to raise their children, they're able to be present, they're able to drive without being impaired. Now, I know sometimes people on methadone and even buprenorphine might be having some effects. And so they, just like somebody who is using Benadryl, sometimes, you know, I have allergies and if I take a Benadryl, it makes me exhausted. So I know I cannot drive immediately after I take a Benadryl. I have to wait until I'm no longer impaired. People can be impaired on Benadryl. It doesn't make it something that I shouldn't take to relieve my allergy symptoms. It just means I need to monitor myself. And that's the same with people using medicines for opioid use disorder. And, again, that's versus addiction, which is the loss of control, the use despite negative consequences. So I'm going to talk a little bit about changes to the brain due to substance use disorders and a little bit about trauma because substance use disorders and trauma are very tied. And so people who have opioid use disorder and other substance use disorders also generally have some sort of trauma in their lives. You know, they may be using those drugs or fell into the drugs because they were raised in chaotic households because they had a trauma. So treating the trauma really goes hand-in-hand with treating the substance use disorder. But also the changes we see in people's personalities, people's reactions, sometimes frustrating behaviors are hand-in-hand about the changes in the brain, changes in connectivity between the prefrontal cortex and the limbic system, the feeling part of our brain and the thinking part of our brain. So there's a lot of changes due to many types of traumas to the brain, including a trauma as far as an event, but also trauma in the sense of using illegal drugs, fetal alcohol spectrum disorder, historical trauma, so generational trauma, intergenerational trauma that can be passed down from generation to generation, survivors of genocide, survivors of the Holocaust, survivors of famine events. So there's a lot of things that are shown to have long-term effects, and I'll just touch on that briefly. And then traumatic brain injuries. So our veterans, many of our veterans have traumatic brain injuries. So when we're interacting with veterans, we need to understand that even if they don't have an actual physical blow to the head, if there are loud noises, then those loud noises can cause the post-concussive symptoms that we see, and also, of course, PTSD. Many of our domestic violence survivors have traumatic brain injuries that are being battered. So those are just things we need to keep in mind. And again, so the prefrontal cortex is the brain of the brain. That's the front part of our brain. We know that's the part of the brain that's not well-developed in juveniles, and the thinking part of the brain stops impulses. So with juveniles, we know that they don't have good impulse control. So the limbic brain, this part of the brain is the limbic system, and it's the go, go, go part. It's the part of the brain that says, sure, get on your skateboard and ride down this really steep hill. That'll be really fun, and really, there probably won't be that bad of a crash at the bottom. Even the thought of a crash comes into the brain. But when you have your limbic system, I mean your prefrontal cortex fully developed around 25, of course, me as a 58-year-old, I'm going to be at the top of the hill going, I don't even want to walk down this hill, much less ride a skateboard down it. But as a 25-year-old, I was not riding my skateboard down the hill, whereas as an 18-, 19-year-old, I was riding skateboards and being an idiot with my skateboard in traffic. But this part of the brain stops it. This part of the brain says, go, go, go, have fun, see where the amygdala is, and I'll talk about that in a minute. So there's always this kind of weighing between the amygdala and the cortex. The amygdala, the fiery part of the brain, the emotional part of the brain and the cortex. So, you know, we've all experienced that. It's called amygdala hijack, so basically where your amygdala takes over everything of your brain. And we see that when we lose our temper. So you think about, you know, having a road rage incident or, you know, and even if you're not having an actual physical road rage, you might get pissed off at somebody else and lose your temper. And even if you're inside your car, you might be, like, flipping off below the steering wheel or something, which is not behavior that we, you know, are proud of. But that's because your amygdala has taken over because it's a fear response, really. And so, you know, when we have a fear response or when we are afraid, you know, we have that fight, flight, freeze, surrender response. And one of them is getting mad. That's a fight response. And so, in people with severe trauma histories and with substance use disorder histories, the neuronal connection between the prefrontal cortex and the amygdala, the limbic system, the thinking part of the brain, it's weakened. So there's not so much neural connectivity. So that's when I talk about changes in brain architecture, that's part of it, is that there's this change. And so, the amygdala is going, going, going. And the connection, the connectivity to the prefrontal cortex has been decreased. So there's not as much pressure on the brakes, meaning. And so, the brakes are kind of offline, they're broken, and the go, go, go part of the brain just goes. And that's what we see with people in our courtrooms who, you know, somebody wants to fight the bailiff, you know, why would somebody want to fight the bailiff? It's because they're probably having a trauma response and their prefrontal cortex is offline for whatever reason. It's a substance use disorder, other kind of traumatic brain injury, trauma, their thinking part of the brain has gone away. And we know when people come into our courtrooms, they're extremely stressed, right? So if they're coming out of jail and they have a substance use disorder, they have an substance use disorder, you know, they're coming in front of us and all they're doing is waiting for us to stop talking so that we will release them and they can go find their drug. You know, we've all seen that people, they're just basically, you know, moving. They just want to get out of the court because all they're thinking about is how can I go out and get well? You know, they're going to be afraid of us, of course. They're afraid of what we can do to them. We can, of course, send them back to jail. So we brought them into the court. Maybe we're going to let them go and maybe we're not. They don't know. Or maybe we're going to take their children away. Maybe we're going to say you can't go back home because, you know, you're accused of assaulting somebody at your home. So you have to go find somebody else, a place else to live or maybe they don't have a place to go at all. They don't know what they're going to do or what they're going to tell us and where they're going to stay. So they're going to be afraid, you know, they're going to be anxious about their case, like I said. And so this may lead to some frustrating behaviors because this fear, this anxiety, and usually people are also people with substance use disorders and they're having this trauma of being in the courtroom. So it might cause people to act out in unexpected ways. You know, like I said, fight the bailiff, run out of the courtroom, you know, try to flee. But they're not really going to also be able to listen to us. So we have to make sure that, you know, when we're talking to folks who are coming to our courtroom, that we talk to them, we give them a piece of paper, we have somebody else review the piece of paper with when they're supposed to come back, what their conditions of release are, you know, what their tasks are, that they have that in writing, and that also somebody again goes over it with them before they leave because, you know, they're just, people just are not able to take things in when they're having a trauma response by being in court and also by, because they're looking for their substances. The different brain regions involved in trauma and with substance use disorders, and I know I keep talking about trauma, and this is supposed to be about medicine for opioid use disorder, but they're so tightly linked that it's really important to understand both aspects are so tightly linked. So the brain regions that I'm going to be talking about, so the ventral tegmental area and the nucleus accumbens, this is the reward pathway, this is what people, you know, gets lit up, gets the dopamine release, means, creates the pleasurable responses when people first start using illegal drugs. The amygdala again, that's emotional, it senses fear, it's like a smoke detector, so your amygdala is always looking for danger, and danger is really anything different. Your brain loves habits, and your brain is lazy, so your brain takes lots of shortcuts. So, you know, the amygdala is always looking for differences, you know, we've all experienced, you know, getting in our car, starting our car, getting home, pulling in our driveway, and not remembering anything about our trip home, right? And sometimes we were supposed to stop at the CVS on our way home and pick up the prescription, but we forget because we just go into a habit, so our brain uses these shortcuts, you know, so a cue is that we get in our car and start our car, you know, and then the routine is driving home, and then the reward is being home. And so during that whole routine part, we're just driving home, and our brain is like doing its normal thing, and it's not, I mean, your amygdala is always scanning for differences, so last week I was driving home, and I actually have a beautiful drive home through Taos Canyon, so I'm driving home, you know, and it's just beautiful, but, you know, I see it every day, but there was a bald eagle coming down, flying down along the river over the Rio Grande. It was amazing, and of course my amygdala is like, what is that, you know, and see something weird out of the corner of my eye, and so I look at it, and then I see a bald eagle, and of course I remember that, you know, but, you know, the other 300 days I've driven home this, you know, and I don't remember anything, because we only remember unusual things, because our brain likes to shut off, because our brain uses a lot of energy. The hippocampus stores memory, and it works a lot with the amygdala, so they're very closely linked together, the hippocampus and the amygdala. The hippocampus stores important long-term memories, you know, really like emotion-laden memories, so I used to say, you know, we all remember where we were when September 11th happened, but that's not true anymore, but, you know, you think about something major that happened in your life or in the world, and you can remember where you were, because it's an emotion-laden memory. It doesn't mean that it's accurate, because actually if you go back and could see an actual video of what was happening when you had this emotion-laden memory, it's going to be very different than what we remember, because every time we retrieve the memory, we overwrite it and it changes the memory, so our memories are not reliable in general. And then, of course, the prefrontal cortex is for planning, impulse control, forethought, you know, executive function. So the motivation pathway is how we get motivated. It's also the reward center, so the nucleal cummins is also called the reward center. The motivation pathway, it also might be called the salience pathway, because what it does is it marks things as important. So if we eat and it feels good, then we know, we remember where we were when we ate, our brain is taking that in, our amygdala and hippocampus is taking in where were you when you found that good food, you know, and 10,000 years ago, you know, when before cities, I don't know, I'm not a historian, but I don't know when exactly that was, maybe 300,000 years ago or whatever it was, when humans were hunters and gatherers, we would need to remember where were we when we saw that game, where were we when we found those berries, where were we when we found that really great water source. And so the pleasure connected between the eating and the drinking and everything, all the environment gets connected in the motivation pathway. So you remember where you were when you found the good drug, I mean, the good food and then the good drug also. And so you can go back there and your amygdala and hippocampus remembers where you were and is rewarded for returning there. So with illegal drugs, what happens is the motivation pathway gets hijacked. So when something happens that's good, the ventral tegmental area releases dopamine into the nucleus accumbens. And so the dopamine, these are the little orange balls attached to dopamine receptors in the nucleus accumbens, and these are called G-coupled receptors for those of you who are pharmacology nerds. And then what happens is there's this series of events, you know, protein phosphorylation, other pharmacological events that cause a sensation of pleasure. So with, you know, we know when we eat good food, that feels really good. Oh, yeah. Good food. I'm starving. Or really thirsty, come back from exercising, you're really thirsty, drink some beautiful cold water, that feels really good. So those are dopamine being released and having pleasurable experiences. Sex is another thing. Sex feels really good. Those are things needed to survive. We need to eat, we need to drink water, we need to have sex in order to maintain our species. So those are things that happen. What happens with drugs of abuse is it causes a huge increase in dopamine release, way beyond drinking water, having sex, eating like a hundred times, a thousand times more of an effect of a dopamine release, causing a huge pleasurable effect. And your brain can't tell the difference between, you know, something that's good for you because it's water, and an illegal drug that's signaling, oh, that's good for you, because it's causing this great effect, so it must be really, really good for you, because your brain doesn't distinguish. Your brain can't distinguish between good habits and bad habits, so it sees that as being something really important to survive, and that's what people who struggle with substance use disorders end up feeling, is that they need to start to survive. Your brain is telling them they need this drug to survive, because it causes those extreme pleasurable events at first, of course, and that changes, and I'll talk about that. So that's what's going on, that the motivation pathway is taken over by these illegal substances. And this is the mechanism, so these are nerve terminals for, you know, say they're in the ventral tegmental area. So these little squares represent the dopamine. And what happens with opioids, so this is morphine, so heroin and many other opioids end up metabolizing into morphine. Fentanyl itself binds to the receptor, so some drugs bind directly to the receptor. Some drugs metabolize into something that binds to the receptor. So again, these are the dopamine receptors, so they're like little holders, and then the dopamine is like a key, and the dopamine receptor is like a lock, and then the dopamine like fits into the lock and turns it on and causes this downstream pleasurable effect in this case. So these are opioid receptors, so the neurotransmitter binds to the receptor and then causes an effect afterwards. So for opioids, the opioid binds to what's called the mu opioid receptor, and what it does is it stops the release of this other neurotransmitter. I know this is complicated, but it's important for how the medicines for opioid use disorders work. So it stops the release of GABA, which is a neurotransmitter, and normally GABA will be on these GABA receptors and will inhibit, meaning decrease, the amount of dopamine that's released. But when the opioid receptor is full and turned on, it turns off GABA, and then dopamine is slowly, slowly, slowly is released without any inhibition, and then that causes the pleasurable effect that people see with opioids because of this dopamine being released in the nucleus accumbens, and then that's the downstream, the postsynaptic neuron causes a pleasurable effect there. So that's what's going on. I know it's complicated, so thank you for bearing with me on that. So different drugs have different mechanisms. So the opioid mechanism involves two different neurons, where neuron one blocks the GABA and blocking the dopamine release. For other drugs, cocaine, there isn't a second neuron here. This dopaminergic neuron is blocked by cocaine, so it blocks the reuptake in receptor transporter. So dopamine is increased in this cleft the same way it's also increased with opioids. It's just a different way of getting it increased, and that causes lots of, you know, this huge pleasurable effect. With methamphetamine, there's these little vesicles with the dopamine, and methamphetamine causes the vesicles to go attached to the membrane and release, again, increasing dopamine, but it's different. And so that's why there are medicines for opioid use disorder. There are not medicines for cocaine use disorders, and there are not medicines for methamphetamine use disorders. So, of course, people are trying to get there, and there are some promising ones, but the ones so far that have been tested are highly toxic to humans, so not the – like the lab I worked for, as I mentioned, worked with amphetamines, and there are lots of drugs that block this release of the dopamine. Unfortunately, if you give it to a living animal, they don't do so well. So again, the motivation pathway is salience detection, what is important, so good or bad. So your amygdala will know that the scary rattlesnake, you know, is down that gorge, so you also – you want to avoid that, but it also says the great water source is down this way, and you want to go that way, so scary things, things to avoid, and things to be attracted to, or neutral things, are all encompassed in this salience detection. And so the dopamine goes into the prefrontal cortex, so you, you know, associate wanting to go someplace with the dopamine increase. The dopamine also goes into the hippocampus to remember where that was, put that into longer-term storage, and then into the nucleus accumbens for the pleasurable, so all these things are connected together. Dopamine goes into the amygdala when there's an increase in dopamine, and that also reduces anxiety and stress. So if you're cutting off the dopamine, so when people are not using their drug, or they're decreasing their drug use, or their drug use is blocked, then their anxiety will go up because they're used to having the dopamine going into their amygdala to decrease their anxiety. And so when people are first in recovery, a lot of them, they're very anxious. That's one of the symptoms, is like they have really high anxiety, and that's because changes to their brain have caused them to be dependent on their drug of choice, and that dependence, you know, reduces their stress, reduces their anxiety, and also has other effects on their brain and emotions. So like I was talking about the longer-term effects, so dopamine, increases in dopamine due to substance use disorders cause these architectural changes to the brain, and one of them is that there's a decrease in dopamine receptor signaling. So here, again, here's the dopamine receptor, and the happy little dopamine will bind to the dopamine receptor, causing that happy downstream effect. But what happens when there's overuse, your brain doesn't like changes. So if all of a sudden there's getting way too much dopamine in this synaptic cleft, what happens is the dopamine receptors react in several ways. They down-regulate, meaning they go from being up on the surface, and they turn themselves inside so they're below the surface of the neuron, and they're not accessible to dopamine anymore. Also, with this G-coupled protein receptor, it becomes uncoupled, so these proteins move away from the receptor so they don't cause those downstream effects anymore. And you can see that in this, so this is a brain, this is from the National Institute of Drug Abuse, and it's a brain scan looking down on a brain, so this part is the prefrontal cortex, this orange, sorry, yellow and reddish-orange part is the striatum, this is where the nucleus succumbens is, and the red means there's plenty of dopamine receptors, the yellow means there's a good amount, and then the blue is where there's few dopamine, and this is a specific dopamine receptor, dopamine D2 receptor. You can see with cocaine, meth, alcohol, and heroin, and this is with any, really any drug of choice, you can also see it with people who have gambling addictions and people who have food addictions, is that their dopamine receptors are not as plentiful when they are struggling with a substance use disorder as for people who do not have a substance use disorder. So you can see there's no reds in these, very few in this alcohol, showing the decrease. So what that means is people have a very hard time feeling pleasure. So if they don't have their drug of choice, you know, over activating their dopamine system, their dysthymic, they don't have, they have a hard time feeling pleasure. And when people are going into recovery, you know, we really emphasize pro-social activities, having fun, connecting with other people, because it's very depressing their brain. It does not feel good. Nothing is bringing them pleasure because they don't have their drug of choice to elevate their dopamine beyond the normal amount to allow them to have any sort of pleasure. So you know, because of that decrease in dopamine receptor and other changes to the brain, there's lots of changes that illegal substances cause, drug use, alcohol use even moves from pleasure seeking. So you first start taking drugs, you start, you know, if you're, and many of us still drink alcohol, and again that's, and get pleasure from it every time, every Saturday night or whatever, it doesn't mean we have an alcohol use disorder. It's okay to use alcohol in a way that's not harmful to others or to yourself. But use moves from pleasure seeking to relief seeking. So instead of feeling intense pleasure by the increase of dopamine in the synaptic glab, which causes, again, the happy feelings downstream, because of the changes to the dopamine receptor, you have to keep, people have to take more to feel the same way, or you just keep taking it to not feel sick, because once they stop using their drug, there's opioids which are, their main purpose medicinally is to relieve pain, and so people taking lots of opioids, their pain relief system gets really messed up, and they are unable to regulate their pain sensors. So when they stop taking the opioids, it's actually physically painful, because they start feeling pain that they've never felt before. It's also psychically painful, because they're unable to feel pleasure, nothing brings them joy. So even eating, drinking, their children do not bring them pleasure, and they'll think, because they're not able to, just architecturally, their brain is not able to do that. And of course, I'm going to talk a little more about this, is that your brain heals. So part of what recovery is, is the healing of the brain, and it takes a lot of time. So what we see is that voluntary, goal-directed activity, so going out to the bar after work with friends, which is voluntary, and maybe it's goal-directed in the sense of you're going out with your colleagues, or you're going to, here in Albuquerque, the Isotopes is our minor league team, so maybe you want to go out and have fun at the Isotopes game, knowing that you're going to maybe drink too much and not be able to drive, so you Uber from your hotel to the Isotopes park, and then Uber home, so it's all very voluntary, goal-directed, very responsible, using lots of executive function to make plans. And then that activity becomes compulsive, and you go to the bar and drink, but you don't have the executive function to make sure you have your Uber, or your taxi, or your friend, who's a designated driver, there to take you home, and then you end up in trouble, or you end up compulsively going and trying to find opioids, fentanyl, heroin, or whatever, now it's almost all fentanyl, of course, in our area, but that becomes compulsive, that you have to go out and get it, and it becomes a habit, so the cue is you're craving the drug, the routine is going to get the drug, the reward is getting the drug, and again, it's a habit, and again, your brain does not know the difference between good habits and bad habits, so just like getting in your car and suddenly finding yourself at home without really thinking about it, the same way folks want drugs, go through the steps to get the drug, and then have the drug, without really, with it being a routine, because that's how our brains have evolved, is to embed these routines, because our brains like those shortcuts, they can't take in everything, and it can't think about everything, think about, there's an example of, think about those of you who've raised teenagers, and taught teenagers how to drive, think about teaching them how to back out of your driveway, or back out of anything, it's really hard, and it's very stressful for them, and it takes them forever, I have a 19-year-old, so we went through this fairly recently, and so think about how stressful it is for them, and how hard it is, and how easy it is for you to back out, because your brain has it down as a routine, so until the teenager has backing up, or parallel parking, or anything down to a routine, it's very, it remains difficult for them, but the brain will eventually take it in as a routine, and that's what's going on with people with substance use disorders, is the drug use is part of the routine, and the amygdala loves that routine, the motivation pathway, loves that routine, because it, again, it has learned that it needs that drug to survive, because of that huge dopamine hit that's signaled to the brain, that that's something that is necessary for survival, and again, so the trauma and substance use disorders are very tied together, and we all have our fight, flight, freeze, or surrender, and so some of you, you know, you might think about, you know, what's your response when you have trauma, when you're feeling super anxious, you know, when somebody cuts you off in traffic, what's your response, when somebody, you know, is being really mean to you for no good reason, boss is being a real jerk to you, those of you who have bosses, your chief judge is being really mean to you for no good reason, what's your response, so I'm a fighter, I tend to get really aggravated and angry, you know, I try to, I have good executive function, so I'm mostly able to keep it inside and breathe, but not always, sometimes, I do lose my temper, some people, you know, you know, flee, they'll be like, I'm sorry, and then they leave the room, or whatever, some people freeze, they just shut down emotionally, and are not there, or surrender, surrendering is also called fawning sometimes, but it's basically, you know, giving in to whatever's happening, and just saying, I mean, we see that in our courtroom a lot, actually, people who are just saying, yes, judge, yeah, yeah, whatever you say, judge, anything, anything you say, I'll do anything, yep, walk through, walk across nails, yep, you know, but we know, you know, they're not actually capable of walking across nails, so even though they're telling us they're going to do that, we know that they're not actually capable of it, even though they sincerely, in the moment, believe that they're going to do that, so those are the different kinds of trauma responses, and again, people who have substance use disorders, who are struggling with substance use disorders, they're going to be very susceptible to slipping into a trauma response, first of all, they might have PTSD history, or a severe traumatic history, and they probably do, and the neural connectivity from having a substance use disorder, so the neural connectivity of the prefrontal cortex with the limbic system is very much decreased, so that it's much more likely that they're going to slip into a response, and be driven by their amygdala, their fear response, they're going to be driven by fear, and not be thinking about whether it's a good idea to fight the bailiff, or a good idea to run out of the courtroom, it's not that they're thinking that something is a good idea, or not a good idea, they're just reacting without thinking, and so for most of us, you know, we have, you know, a healthy response to threats, you know, and I use this picture of Kiki as a lion, to show, you know, that I might have a reaction to Kiki, you know, I hear a sound behind me when I'm hiking, and in northern New Mexico, it could be a mountain lion, because we do have quite a few mountain lions up here, and so my body's going to go into a stress response, a threat response, and I'm going to, you know, I'm a fighter, so I'm going to wheel around and have my fists up, ready to go, because I'm going to hear it, it's going to go to the thalamus, it's going to go very quickly to the amygdala, so this is a signaling, and then the amygdala's going to send hormones downstream, and it's causing me to puff up, you know, my heart rate to go up, breathing deeper, you know, ready to fight or run, but then I'm going to turn around, and I'm going to see, oh, it's Kiki, and I'm just going to calm right down immediately, because I do not have a severe trauma history, I'm lucky, but for people who have severe trauma history, including substance use disorders, so the signaling between the thalamus and the amygdala is very, very fast, and so what happens when I hear a sound is the signal goes to the amygdala really fast, it goes much slower to the cortex, to the thinking part of the brain, and so before you think about what it might be, because we have to react before we think, so before we think about what it might be, you know, we wheel around already, but then the cortex, for me, will kick in really quickly, and I'll say, oh, it's Kiki, and then I'll slow down and stop breathing, but for people with trauma histories, this connectivity is extremely fast, and the connectivity to the cortex, to the thinking part of the brain is decreased, so the fear response is going to be elevated, and then it's very hard for them to come back down from that, and so for what might be a few breaths for me, they might go into a full-blown PTSD response, or, you know, just have such elevated anxiety and be unable to come down from that, and we do see that in court, people, you know, we see escalation in court, where if somebody's, you know, bad mouthing me, the bailiff gets offended for me, because, of course, they're very protective of me. The bailiff stands up and starts, you know, sauntering over to the person, you know, and the bailiff's all puffed up, because they're having their trauma response, because they are thinking, this person is threatening my judge, and then, you know, the other person, the defendant, is then going to react to the bailiff, you know, and then it just gets, you know, and then somebody's on the floor, right, so it's really important, of course, for everybody to have de-escalation techniques, and to understand that, you know, if somebody's being a jerk, then maybe we just need to take a break, and, you know, me get off the bench, or everybody just back off and let the person breathe a little bit before we go on, so that somebody's potentially having a trauma response, and, of course, it's up to the bailiff to make sure we're safe. I'm not saying to not be safe. If somebody is actually a physical threat, but if somebody's not actually a physical threat, then backing away might be better to allow them for their prefrontal cortex to come back online, and to remember that people with substance use disorders have a harder time getting their prefrontal cortex back online, because this connectivity between the prefrontal cortex and this, the amygdala, you know, thinking, sorry, emotional part of the brain is decreased, so it might take more breathing, you know, than we would expect, those of us who don't have severe trauma histories. Just to reemphasize that, you know, toxic stress, chronic stress, growing up with lots of adverse childhood experiences, those can all remodel the brain and cause changes and cause lifelong changes, you know, leading, as we've all been trained on our adverse childhood experiences, up to early death, even, so, you know, this is a normal neuron with lots of little dendrites, the dendrites are the little branches that go off, and then a neuron damaged by toxic stress, and that can be childhood toxic stress, living in a really toxic environment, has fewer connectivity, so that's what I'm talking about when I'm talking about the connectivity between the prefrontal cortex and the limbic part of the brain is decreased, because there's fewer branches coming off the neurons, so there's less signaling, less connection, less ability of the prefrontal cortex to put a little break on the reactions, the emotional reactions, and, of course, substances are also toxins, so those create changes in the brain architecture also. And then the changes to the brain drive return to use, so it drives people, you know, to return to use, to, you know, go through the cue, routine, and word, and so we want to decrease stress in people in recovery, and medicines for opioid use disorder prevent that return to use. So epigenetics, again, this is passing down, I'm not going to talk about this much, but just that there are actual physical changes to the DNA that can be passed down through generations when the parent is stressed, and it's not just stressed while the fetus is in utero, it actually can be stressed from their parents and from their grandparents, and those changes, those tags on the DNA can be passed down, causing an increase in cortisol, which is the stress hormone, but this is a very new and developing scientific process. So I'm going to switch gears and talk about treatment, which includes, of course, the topic that I'm finally getting to, the medicines for opioid use disorder, and, of course, so this is the treatment standard, is we have to address everybody's, they have to address their needs, you know, high-ranking needs, if somebody's hurting, somebody doesn't have good food, doesn't have shelter, it's going to be really hard for them to get into recovery, you know, so we need to make sure that we're addressing these needs and moving up to safety and then recovery, and, you know, so it's a process. Recovery is a process, treatment is a process, and those of us in the criminal justice side, sometimes it's hard for us to be patient, because it's like, dude, you just burglared someone's house, you know, we're not going to be, you know, give you, you know, a bouquet of roses when you get out, but, you know, our job, you know, is to hold people accountable and make sure that they're going into treatment, and, you know, sometimes we have tension with treatment providers, because I'm going to order somebody into treatment, I'm not going to order somebody to use MOUD or not use MOUD, because that's a decision between them and their clinician, but I am going to order them to go into treatment, I am going to order them to be assessed with an evidence-based assessment, and then order them to follow whatever recommendations that I've given, and if they don't, because we're going to have an ROI with the treatment provider, then they're going to be back in front of me telling me why they weren't doing what the treatment provider recommended. So medicine for opioid use disorder is the gold standard of opioid use disorder treatment, so it's really the only thing that's been shown to work for people struggling with opioid use disorder. So opioid use disorder, sorry, medicines for opioid use disorder, along with therapy, counseling, is really the thing that's been shown to work for people struggling with opioid use disorder. There's lots of evidence showing that it saves lives, improves chances for recovery, it decreases recidivism, and there's nothing, no evidence shows any benefit from stopping MOUD, from stopping people from using medicine for opioid use disorder. In fact, once people stop is when often they are at high risk for overdosing. So you don't want to stop it too soon, and but again, that's a decision between the person and their clinician of when to stop it or when to taper off of it. And a lot of people are motivated to get off of it, because it's a pain sometimes to have to go every day to the methadone clinic, or it's a pain to, you have to make sure that they're, have their buprenorphine, you know, so they might want to, they might be motivated to get off of it. But as judges, it's not our responsibility to tell them when they are or are not ready. That's a decision and discussion between them and their clinician. So the medicine for opioid use disorder works by working at this MOU, at this opioid receptor. So there's the three different ones. So again, the antagonist, naloxone, is the blocker. Buprenorphine is the partial blocker, meaning it, you know, there's a partial activator, so it activates it partially. And then methadone is the full activator. And then also drugs of abuse are also the full activators. I'm going to go through the mechanism. So methadone fully activates it, meaning it fully blocks the GABA release. So there's no GABA, no GABA to bind here. And the dopamine freely flows and causes the downstream pleasurable effect. The difference between methadone and heroin or fentanyl is that methadone stays on the receptor for a really long time. So, and it's really dose dependent. So I'm sure those also worked with people who are getting onto methadone, know that the person has to keep going back and adjusting their dosage until they get to the point where they're not having serious cravings but it's also not affecting their long term ability to, you know, be a part of society. So it takes a little while to figure out exactly what the right dose is. So methadone stays on the receptor for a very long time. It's what's called a path life. It's very long. So it will stay here and hang out on the receptor. So even if somebody takes heroin while the methadone, it's not going to cause an additional impact. It allows some GABA to get out. 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medication options

opioid use disorder

role of justice system

methadone

buprenorphine

naltrexone

importance of medications

access to medication

brain architecture

trauma impacts on brain function

recovery as a lifelong journey