Hi there, my name is Emily Mossberg and I am a Regional Coordinator with the Opioid Response Network. I want to acknowledge that the following presentation was made possible in part by a federal grant from SAMHSA. The SAMHSA-funded Opioid Response Network assists organizations and communities by providing free training and technical assistance on topics related to prevention, treatment, and recovery for opioid and stimulant use disorders. We work with consultants in all 50 states who can provide local expertise, and all the assistance we provide is tailored to the requester's unique needs. We operate on a request basis and anyone can submit a request for free assistance on our website at opioidresponsenetwork.org. Today, our consultant, Tony Vesna, will be presenting a stigma education framework that we hope will provide you with tools to bring this important topic back to the teens and individuals you work with. If further assistance is needed to tailor your own relaying of this information, please feel free to email me directly. My email is mossb.uw.edu. It is up on the PowerPoint now. We are happy to provide additional stigma training and to support you as you develop your own stigma education materials. At the close of this recorded presentation, you will be prompted to complete a brief evaluation survey. We greatly appreciate your taking a minute to fill this out. Your response will help us maintain funding to continue to provide free services. Thank you so much, and thank you for taking the time to watch this presentation. Good morning, and welcome to the Barrier to Care Substance Use Disorder Stigma Presentation. My name is Tony Vesna. I'm currently the Executive Director of an organization called 4D Recovery located in the Portland Metro area. We provide a variety of substance use disorder treatment, mental health services, and peer support to adolescents, young adults, and families. Really grateful to have you here for this presentation. I have a bachelor's degree in social work, a substance use disorder counseling certificate. I'm a QMHR and a certified recovery mentor too. Just want to give a shout out to the Opioid Response Network for allowing me this opportunity. Funding for this initiative was made possible in part by grants from SAMHSA. The views expressed, written conference materials or publications, and by the speakers and moderators are not necessarily reflective of the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. I have no disclosures here. I have no personal conflicts of interest in this. This is all being paid for by SAMHSA. Give them a shout out. So today, our objectives are to overview the stigma towards people who use drugs and the negative impacts in healthcare settings as a result of that stigma. Then we're gonna get into some different frameworks that can be used for de-stigmatizing substance use disorder in a variety of settings. Then I'm gonna provide some de-stigmatization activities and some content examples. So, when we think about someone who has survived or is fighting cancer, there's usually these words of affirmation associated to them. They're strong-willed, they're resilient, they're healing, they're a warrior, they're loved, a survivor, they're so strong, they're a fighter, they've been empowered, they're inspirational. We are so excited and we uplift people who are survivors of cancer as we should. But then we think about words that are often associated with substance use disorder. They're abuse, misuse, clean, dirty, abuser, addict, etc. Clean, dirty, abuser, addict, etc. Not positive, it's very different from cancer. You know, survivors are people who have cancer, who are going through treatments. You know, when people with substance use disorder are going through treatments, they're looked at in a different light. So today, like I said, we're gonna talk about stigma. And stigma, as I'm gonna speak to it today, refers to a set of negative beliefs, attitudes, and behaviors directed towards individuals or groups based on perceived differences or characteristics that are deemed undesirable or socially unacceptable. Now, in this training, we're gonna talk about stigma in the context of substance use disorders, which often involves labeling people with substance use disorders as morally weak or inept, dangerous, personally responsible for their condition. This can lead to discrimination, social exclusion, and internalized shame. Types of stigma with substance use disorder. So we can kind of break down stigma categorically. You know, you have stigma from within. That's where people blame themselves, they feel hopeless, they feel like a failure, and they can be embarrassed to ask for help. Then you have stigma from the general community, even in the recovery community. You know, medications are not real recovery. People are just replacing one drug for another. You know, maybe they're not able to participate in all of their community's events. And then, you know, there's a moral failing associated with them, even with their, you know, close family members and stuff. Then you have stigma that come from clinicians in the medical field. They believe that treatment is ineffective, which can create barriers to access care for healthcare and treatment services alike. Then you have stigma from the general society, which really looks at, you know, individuals with substance use disorder, particularly illegal drugs. You know, you look at people as criminals versus it being a treatable health condition. And again, stigma from within people who have recovered from substance use disorder themselves. Well, what is the impact of stigma? And this certainly isn't all of the impacts, but here's some of them that are important to note. There's a decreased confidence that substance use disorder is valid and a treatable condition. It can create barriers to jobs, housing, relationships. It can deter the public from wanting to pay for treatment, which can inadvertently allow insurers to restrict coverage and then uphold punitive laws and policies. It can stop people from accessing needed services because they feel unworthy. It creates barriers to people staying engaged in care when people feel unwelcome or judged by staff. It can impact clinical care and treatment decisions. It gets intertwined with ongoing myths about drug use and addiction. And stigma can affect culture and all sorts of other practices. So here's some of the components of stigma. You know, number one, labeling. We identify and name differences. You know, we other people, you know, calling somebody an addict alcoholic. There's stereotyping associated with stigma. And that associates these labels with negative traits. Assuming people with addiction are untrustworthy, they're criminals, you know, vagrants, homeless, et cetera. It causes separation. It creates a distinction between us and them. There's a status loss and discrimination, which can lead to social and systemic disadvantages. And then it creates this power imbalance where stigma is reinforced when one group holds more power than another. Now, stigma has an impact in healthcare and it can delay or avoid healthcare seeking. People with substance use disorders often avoid or delay seeking care due to anticipated stigma and discrimination, which can lead to worsen health outcomes. One example was in a 2020 study, it found that individuals with opioid use disorder, OUD, delayed seeking medical help due to prior experiences of judgment and stigma from healthcare professionals. And this is actually an interesting proposition because substance use disorder is a treatable disease and individuals with substance use disorder in the emergency room, who are in the highest acuity of their disorder, you know, can oftentimes be, you know, escorted out of hospital sittings by police. And so a person, and this happens in the emergency room. So a person in the emergency room, you know, who's using methamphetamines, who obviously, you know, is acting in ways that can be disruptive, is in the emergency room where they should be getting immediate access for their substance use disorder given that methamphetamine can be a fatal disorder, methamphetamine disorder can be a fatal disorder, yet they're excluded from care. And this is an interesting thing to bring up. I think we should all think about that and how could we more create processes and systems in healthcare that get people more immediate access when they come into it. An additional impact is low quality of care and also misdiagnosis. Healthcare providers may hold implicit bias leading to misdiagnosis or dismissive treatment of people with addiction, especially when they present with pain or complex systems. In a 2018 study, it showed that patients with a documented history of substance use were less likely to receive adequate pain treatment in emergency departments. Again, looking at healthcare systems and how bias can impact an individual's ability to have access to care that they need that otherwise a person who wasn't believed to have a substance use disorder would have received the proper care. It can reduce access to treatment and continuity of care. Stigma can influence policy and clinical decisions, including the underutilization of Medicaid-assisted treatment, MAT, for opioid use disorder. Example, clinicians often under-prescribe or avoid initiating MAT, buprenorphine, or methadone due to the stigma around those medications, despite strong evidence of their effectiveness. So we tend to have a bias perspective. And this bias is created by the lens we look at how people get healthy. So oftentimes, patients who improve and leave are completely forgotten. But the patients who do not improve and return frequently, they're remembered. It leads us to think that most patients do not improve, contrary to the science. And for me, my sort of example of this in my early career, I believe that methadone clinics, OTPs, were just like these licensed dope dealers or drug dealers. And the reason was is because outside of the OTPs, I would see people, and they would be like selling drugs and trading prescriptions and stuff. And it was about 30 people, and they would hang out down by the McDonald's down the street, and they would do drugs and sell drugs and be smoking cigarettes. And some of them would have stolen goods and stuff from stores. And my mentor, when I brought this up, he said, yeah, Tony, you see those 30 people at that clinic, that clinic serves about 1,000 people. So there's 900 people that are doing just fine that you're not seeing. So don't let the fringe inform your general perspective of the efficacy of the practice. And for me, that really drove home something important about thinking critically. So we're gonna use a de-stigmatization framework. The premise of this framework is that substance use disorders are medical disorders, and that substance use disorders are treatable using a variety of evidence practices. We'll cover the following areas. We'll talk about language, we'll talk about education, and we'll talk about exposure. And my hope is that you'll be able to take this framework beyond personal education and personal transformation, and you'll be able to use some of this framework in institutional settings to change systemic practices. And you'll be able to use this for the foreseeable future. I tried to develop this training to be as general as possible so that it can be used for an extended amount of time. So I wanted to give a little bit of history of recovery advocacy in America. Really saying that the conversation we're having today is based on a lineage of advocates and movements in America to try to shape society to treat substance use disorder as an illness and demonstrate the fact that people can and do recover. This is based off of Slaying the Dragon by William White. William White is in recovery, has been a researcher and an advocate, a practitioner for a long time, has wrote many, many books, has done a lot of research about substance use disorder and recovery. So if we start in the early 1800s to the 1900s, it's really the foundations. Now, I do wanna say that even before this, there was Native American talking circles that were sober circles, where they were fighting for recovery before any of this other sort of advocacy movement started. But in the early 1800s, there was a temperance and prohibition movements, which viewed addiction as a moral issue. Now, this is in the 1800s and here we are in 2025. That just tells you about how far we still have to go. But these temperance and prohibition movements sought to moderate drinking in the beginning. Then they progressed to focusing on abstinence and they thought it was society's and the government's moral responsibility to curb drinking. Then in the early 1950s, there was this movement called the Washingtonian Movement. And the Washingtonian Movement promoted peer-led recovery and destigmatization. They had many mottos, but one that I pulled out for today was that, the drunkard is a sick man, not a wicked one. Now, the Washingtonian Movement rapidly proliferated. And then as fast as it proliferated, it expired. And the main reason that it came to an end was that the Washingtonians diversified their advocacy efforts into all sorts of different issues. And that diversification caused division within the movement and it fractured it and ultimately ended it. Then a little bit after that, there was these early treatment centers like the Keeley Institutes and they treated addiction medically. One interesting thing about these early treatment centers is that they use these secret ingredients. It was a shot and it included gold in it. And Keeley never found gold. Keeley never fully gave the ingredients to his magic shot, which was often criticized by medical professionals, but they included in addition to residential and peer support and expanded to a whole bunch of centers internationally, which really helped to destigmatize substance use disorder. Then a little bit later in the early 1930s to the 1960s, Alcoholics Anonymous was founded in 1935. And one thing about Alcoholics Anonymous is that the founders of it, they had reviewed prior attempts to developing these sort of what I'll call like recovering societies, recovering movements. And they came up with a set of principles and standards that guided the organization. And these were developed to have a singleness of purpose or focus, they called them the traditions. And they were kind of like the bylaws of Alcoholics Anonymous. And one of the core tenants of the traditions was singularity of purpose. So they saw what happened to the Washingtonians and were very mindful about ensuring that the fabric of this organization focused solely on recovery and did not fracture off into other interests, sort of to coagulate them and keep them stuck together. And then in 1944, there was the National Council on Alcoholism that was founded by Marty Mann. Now, Marty Mann was one of the founders of Alcoholics Anonymous. And she led a public education and stigma reduction effort in the US Senate, that alcoholism was a treatable disorder, not a moral failing. Now, oftentimes people are unaware of the co-founders of Alcoholics Anonymous participating in political advocacy and public education. And another one of the core tenets of Alcoholics Anonymous is this idea of anonymity. Now, anonymity in the context of Alcoholics Anonymous means nameless, titleless. And really the intent was that anybody who came to AA meetings, they were just as good or valid as anybody else. And when you walked into the door of an Alcoholics Anonymous meeting, you left your name and title behind because there was no power dynamics. Nobody was above anybody else. Everybody there was for a common purpose. Now, this concept of anonymity has been applied by some individuals in Alcoholics Anonymous and other 12-step organizations in general society. And it's kind of been poo-pooed on to talk about your own recovery in general society and advocate. But this is a misnomer as evidenced by the co-founders participating in public debate around how to treat alcoholism. This movement in the 1930s to the 1960s helped ensure that treatment and stigma reduction became public and political priorities. Now, later on in the 1970s to the 1990s, we saw criminalization and suppression. The War on Drugs increased incarceration for addiction, disproportionately impacted poor people, people of color, specifically African Americans through the crackdown on crack. Now, this War on Drugs kind of killed that previous movement I was talking about. Right before the War on Drugs, a ton of people in recovery were advocating. Celebrities, sports players and stuff in recovery were all coming out and they were openly talking about their recovery. A lot of people were. And the War on Drugs kind of drove people back into the underground to some degree, where their anonymity, their identity and their recovery status was no longer felt to be safe in general public based on these negative views that were shaped by the War on Drugs. Now, some advocacy continued through this, really looking at the AIDS crisis where this public health framework was really born as a way to reduce communicable disease. And then harm reduction and methadone started to gain slow traction. Then if we fast forward to more contemporary movements, we had the recovery movement reignited in a major way in the early 2000s. So in 2001, Faces and Voices of Recovery launched. Faces and Voices is a national organization fighting to increase recovery. I participate in Faces and Voices still. They had an emphasis on visibility, policy reform and recovery identity. And then peer support and recovery capital, this idea that there's these different domains in a person's recovery journey that can help them recover quicker was instituted nationally. In addition, recovery centers began to gain traction. And there was a conference hosted by SAMHSA talking about recovery centers. Now, recovery centers are places where people go to hang out who are in recovery. Think about like you need an alternative to a bar. So once you quit drinking, you still want to go hang out and socialize. You just want to do it with other people who are in recovery. And so these recovery centers were born. They were looked at as different than clinical treatment. There was no diagnosis or assessment or treatment plan needed. There's no prognosis that was applied to people. They weren't worried about how an individual became to have a substance use disorder. There was no pathologizing. It was just focused on, hey, you're in recovery. I'm in recovery. Let's hang out. And recovery centers have been gaining traction ever since. And then if we look at even more contemporary issues, starting in the 2010s, we have the opioid epidemic, which raised urgency. Now, the opioid epidemic was responded to differently than the crack epidemic in the early 1980s. The opioid epidemic really mobilized the government to provide a variety of treatment services and support, specifically medications for opioid use disorder. It also expanded to harm reduction, equity, and trauma-informed care. Now advocacy includes the decriminalization and other system transformations. It's important to note that the same sort of framework could have been applied in the 1980s, but it wasn't. So we have to ask ourselves, why? Why is that? Is it because more individuals who are not impoverished, who became addicted through prescribing? Is it because it started affecting white people more? These are questions we have to ask ourselves. And I think it's probably a result of all three of those combined. The good thing about this is that it expanded treatment and really created a political opportunity for recovery advocates and other allies of the recovery community to mobilize and pass legislation that helped everybody with a substance use disorder, not just individuals who had an opioid use disorder. So where are we at today? So today, we're really still focused on the destigmatization of substance use disorder, although it is not as overtly present. We've made a ton of progress. I've been lucky enough to participate in that progress, but we still have a long way to go. So one of the things that was created as a way to continue promoting recovery through the destigmatization of substance use disorder was the utilization of person-first non-stigmatizing language. For example, a person with a substance use disorder, instead of calling somebody an addict, can reduce bias among both healthcare providers and the general public. Evidence found that the terms used to describe individuals with addiction influence perception with stigmatizing terms leading to more punitive attitudes. When a person says clean, for example, it can be sort of problematic depending on the context. And the reason it can be problematic is it implies that someone who is actively using is dirty. So if we say, oh, they're not clean yet, that means that they're dirty, and that can be stigmatizing. And we wouldn't use that term for other health conditions. I will put a little caveat here. Language is tricky. Different communities use different language. Some communities aren't allowed to use certain language where others are, just because of the historical context of it. But it's important to note that many people in recovery identify as addicts, alcoholics, and use terms clean and sober. Also, people in recovery can joke about sort of their experiences while in substance use disorder about tweaking and cracking and stuff like that. And it's more of a therapeutic use of the word and kind of looking at their disorder in a past time and kind of a way to laugh about it. And they may call each other addicts, alcoholics, but their terms of endearment, it doesn't have the undertone of stigmatization or discrimination. It's really embracing a former identity as a way to overcome it. So here's a cool little infographic talking about language that matters. And this one says, instead of using this, try this. And this is something that you could post around the office. So instead of saying an addict, alcoholic, junkie, you could say a person who uses drugs or alcohol. Instead of saying addiction, you can say substance use disorder. Instead of saying substance abuse, you could use substance use. Instead of saying clean, you could say not using, substance-free, abstinent. Instead of saying former addict, reformed addict, reformed addict. Instead of saying reformed addict, you could say a person in recovery, person who previously used drugs. Instead of saying habit, you could say substance use disorder. And then over here, there's a list of words to avoid. Addict, user, abuser, junkie. And then they have words to use. Person with an opioid substance disorder, person who uses drugs, et cetera, et cetera, et cetera. And so you have these slides at your disposal. And then this is something that you could reference in the future. So I'm going to talk about the real stigma of substance use disorder. And I just want to give a big shout out to the Recovery Research Institute. And I would encourage you to go check out the Recovery Research Institute. Now, there has been a tremendous amount of research on both the origins of substance use disorders, what is the underlying causations that generate substance use disorders in our society. And then there's been a lot of research on the efficacy of treatment interventions. And that research is really strong. It demonstrates that these treatment interventions really work. They help a lot of people, and it's great. But little research had been done until as of recently with the Recovery Research Institute about the impact of recovery. What happens when people get in recovery, long-term recovery? And so the Recovery Research Institute is really bringing an awesome academic paradigm to sort of a strength-based, long-term efficacy framework to look at the power of recovery. Now, in this specific study, participants were asked how they felt about two people actively using drugs and alcohol. Now, in this study, one person was referred to as a substance abuser, and the other person was referred to as having a substance use disorder. No other information were given about these hypothetical individuals. The study discovered that participants felt the substance abuser was less likely to benefit from treatment, more likely to benefit from punishment, more likely to be socially threatening, and more likely to be blamed for their substance-related difficulties, and less likely that their problem was a result of innate dysfunction over which they had no control. And the individuals referred to as a substance abuser were also perceived to have the ability to control substance use without help. So this really highlights the power of language and bias. And you have to note that these beliefs that were generated by the substance abuser could translate into poor medical, healthcare, and treatment practices. So let's talk about the first little practice that we can implement around language, or several practices we can utilize to help improve language. One would be scrub stigmatizing language from institutional materials. Now this can be a big overhaul, and I feel partially bad for whoever has to do this. I run my own organization, we have a lot of paperwork, and a lot of onboarding materials, etc. But given the positive outcome it could generate, encourage people to do it. So you could scrub stigmatizing language from trainings, from forms that you use, policies, procedures, etc. You can do staff training and continuing education, onboarding seminars, etc., about how to use person-centered language. You could post visible language guidelines. The Recovery Research Institute on their website, has some materials that you could use. You could update your public-facing content. So things on your website, any sort of public relations, communications that go out, etc. You can create a culture of positive language in your own immediate proximity, wherever you work. And then, you know, really for our healthcare leaders, executives, administrators, etc., they can model the positive language, which can have, you know, sort of a trickle-down effect for everybody else. So you can have education campaigns. Education-based interventions, public education campaigns that present addiction as a treatable medical condition, rather than a moral failing, can reduce stigma. These programs are most effective when they include accurate information about the causes, course, and treatments for substance use disorder. What causes it? What is the course of a substance use disorder? You know, many people get into recovery, so what does the recovery process look like? And what are the treatments and the effectiveness of those treatments for substance use disorder? There was a study done in 2017 that found that educational efforts emphasizing the neurobiological basis of addiction can improve attitudes and reduce stigma. Next, we're going to talk about what is a substance use disorder. So very simply, a substance use disorder is a chronic, relapsing medical condition involving compulsive drug use despite harm, compulsive substance use despite harm. Now, it affects brain circuits related to reward, motivation, and memory. So it's a brain disorder, and that's what can sort of stump people when they're watching people who have severe substance use disorders, and they continue to use despite all the negative consequences. You know, they know that the person cares about these things that they're losing, but they continue using despite that. It just baffles people, and that's why often I think it's been categorized and characterized as a moral failing. But it's not because it's a brain disorder, and that's why people have such a hard time overcoming it sometimes. The important thing to note that substance use disorders are chronic conditions comparable to other chronic illnesses, diabetes, asthma, etc., and they're comparable in treatment and also recurrence of use patterns. Okay, we'll talk a little bit about substance use disorder in the brain. I'm not going to get into this a bunch, but in the most general sense, drugs hijack the brain's dopamine system, which impair the natural reward process. The brain areas that are affected are the prefrontal cortex, our decision making, our amygdala, our emotions, and our nucleus accumbens, our motivation. This is why people continue to use despite the consequences of it. I just cannot iterate the importance of just understanding this on a basic level, that a person's brain is malfunctioning. They're driven to continue to use even when they don't want to. What are the causations of substance use disorders? Well, it's a mix of biological, psychological, and environmental factors. Some of the biological factors are genetics, neurochemistry, early onset of mental illness. What are the genetic risk factors for individuals with substance use disorder? It can be a family disorder, it can be passed down through genes. Some of the psychological precursors include trauma, low coping skills, people are self-medicating for emotional distress or for their mental illnesses. There's some environmental factors. This would be adverse childhood experiences, poverty, social acceptability, and peer influence. Then you have the developmental. Early use affects brain development. Now, we know that the earlier an individual uses, in their teen years especially, the more it affects their brain. And the more likely they are to have a lifelong substance use disorder. Despite this widespread knowledge, it's not refuted. People are arguing against it, especially the early onset. Despite that, we do little to prevent, little investments into primary prevention to help safeguard kids from using in the first place. And I think, and suspect, one of the primary reasons is that it's not politically salient. And what I mean by that is, there's no immediate crisis that's averted. A lot of our politics are driven by acute crises, things that are happening in the moment. Putting money into prevention, it's hard to see the outcome. It can take time, but prevention does work. OK, so now we're going to get into the recovery aspect of this. Recovery is possible. Evidence-based treatment, like medications, counseling, and peer support all work. And recovery rates are comparable to other chronic illnesses. So you can do grand rounds and in-service trainings, host regular educational sessions on the neurobiological, psychological, and social dimensions of addiction. Education on the medical model improves provider attitudes and reduces moral judgment issues that can come up with providers. You could do myth-busting campaigns and clinics. You can post infographics and pamphlets debunking addiction myths. For example, substance use disorder is a choice versus substance use disorder is a brain disease. You can frame addiction as a medical issue, which increases support for treatment and reduces stigma. Onboarding modules for new employees. You can provide addiction science education to all new hires, not just clinical staff, everybody. And these structured messages reduce stigma among professionals and the public. Now, I was student body president of a large community college in Oregon called Portland Community College. While I was there, I attempted to have prerequisite requirements for all introductory health courses, really focusing on providing addiction and recovery science 101 for anybody who was going to go into nursing, firefighting, who were going to become EMTs. And my thought was that if I could get people exposed early before they entered the field, they'd be more equipped to support people they encountered who had substance use disorder. I failed at that, but it was a good effort. You can provide continuing education credits on substance use disorder science. So after CME accredited training on substance use disorder neuroscience and evidence treatment, and these will undoubtedly increase willingness to treat people with SUDs. You could host community education events. Host town halls, have panels, webinars, similar to this, big shout out to the Opioid Response Network, that feature addiction specialists and people in recovery. And these public education initiatives will improve attitudes and beliefs around the medical need of people with substance use disorder, and ultimately increase support for recovery-based services. Now, one of the hardest struggles that advocates like myself and educators like myself face is that individuals with severe substance use disorders can have behaviors that impact society and those around them, especially those closest to them. So this collateral damage happens sometimes with people with substance use disorder. Sometimes with people with substance use disorder. It can be expressed in criminal behavior, antisocial behavior, behavior that's disruptive in clinics and to the general public. And so that's kind of what people see. And I'm not saying that we negate those things. Those things are normal. But what I'm saying is that we look at those collateral damaging behaviors as symptoms of the person's substance use disorder. And what we push ourselves to do is remind ourselves that that's not the person. That's a disorder. And it's something that can be overcome. And people, when they overcome their substance use disorders and they get in treatment, in my experience of meeting thousands of people in recovery, is that they become pretty great people. And here's an example in the reality of substance use for me and many others. So these are my last eight mug shots that I had. And as you can see, I was having a hard time here, especially in, I don't know, 2011 was looking pretty bad. 2012 wasn't doing so great. And then the last day that I used any substances was July 19, 2012. Now, if you've seen this guy up here in the left-hand corner come into your clinic, I wonder how you would respond. I can tell you that when I went into emergency rooms, sometimes I had abscesses and stuff like that. And I'd go into an emergency room. Sometimes I was just seeking medications, whatever. Sometimes I just needed a place to hang out because I was homeless for many years. I wasn't treated very well. Now, just to give some context, that was over 12 years ago. And our system and society has progressed since then. But I do hear stories from other people very similar, even today, in the clients that I work with. My substance use disorder started off as an early age. I had a rough life, like many other people. I got exposed to alcohol and drugs pretty early. And I just took off right away. Now, in the early 2000s, my mother was prescribed a copious amount of OxyContins. She was prescribed over 1,080 milligram OxyContins a month. And I started using them. And I would sell them when I was ending high school. And I became very, very addicted to OxyContins. And then, later on, the federal government began to crack down on overprescribing. And the unintended consequence of that was that once the market for prescription pain pills dried up, so there was less pills in the marketplace for people who use drugs, then heroin was introduced. And everybody I know who was addicted to OxyContins switched to heroin, as did I. Later on, I lost my mother to an unfortunate car wreck associated with her heroin use. And I went down a long spiral for a very long time into intravenous drug use, in and out of jail. And ultimately, I was homeless on the streets of Portland for about five years. I went to treatment many times, several times voluntarily. But the last time, there was a criminal justice intervention that gave me early release to treatment. And for me, that was the last time that I used. It worked for me. And I'm very grateful for my life and recovery. I went to a residential treatment program for six months, followed up by outpatient. In that residential treatment program, there was a heavy focus on building recovery support in the general recovery community. People went to 12 Steps, stuff like that, whatever. I had to find support people to take me out. And really, what the program was designed to do at the time, I was unaware of it. But it was to build up supports when I left. I started going to college then. I graduated treatment and went into a Oxford house, a silver living house, which was really important for me. And I continued my collegiate career. When I went to college, there was a scholarship opportunity for people in recovery, where we would meet once a week for an hour to do some DBT, CBT psychotherapy groups. While I was doing that, I met a woman. Her name was Diane. It was in the Women's Resource Center. That's where it was hosted. That's why I was there. She encouraged me to start a club on campus. So I did. I started a Recovery 101 club. And our mission was to de-stigmatize addiction by doing community-based service work. So we'd do all sorts of stuff. We'd go out and feed the homeless. We'd help in a variety of areas that we could. We'd host events about recovery, et cetera, to show the general public that people in recovery are not the same people as when they were using. That led me to become involved in student government. That's how I became the president of Portland Community College. At the same time, I was fortunate enough to co-found this nonprofit called 4D Recovery. Later on, I was able to co-found a couple other nonprofits. One's a recovery advocacy organization in Oregon. Still going on today, it's Oregon Recovers. I act as a board advisor of that. And I progressed and I progressed and shared my story and became politically involved and have just done a ton of advocacy to help increase access to prevention, treatment, harm reduction, and recovery services in Oregon. Right now, I serve as the chair of our state's Alcohol and Drug Policy Commission. We're a citizen commission. And commissioners are appointed by the governor and confirmed by the Senate. And really, our job is to shape state policy to address substance misuse, focusing on prevention, treatment, harm reduction, and recovery, really setting up governmental policies, processes, plans, funding investments, success metrics, et cetera, for our state agencies to follow to increase access to services, reduce overall prevalence of substance use disorders, increase recovery rates, reduce overdose deaths, and reduce inequities that are in our system. So that's all to say that recovery is possible. It happens. I work with a host of other individuals in recovery. I employ over 100 people in recovery at our organization. And we're growing, mostly peers, people in recovery, I'll coach other people in recovery. So recovery can and does happen. I'm not unique. I'm not special. I'm just a person who was fortunate enough to have a good set of circumstances that promoted my recovery. And I've dedicated my life to helping others experience that same sort of transformation. So this is me now versus my little family here. This is me, my wife Rachel, my son Ashton, and then my daughter Ava. And so really proud of my family. My wife's also in recovery. She's a real estate agent. She's just a great woman. And we just know thousands of other people who look just like this, who could have a before and after picture just like this. It happens so much. And there's a worldwide network of people in recovery. And I've went to world conventions with people in recovery all over the world. And the stories are always the same. I used even when I didn't want to. But then it was the hope that people found that helped bypass those cognitive barriers that we have when we try to get into recovery. And so it is important that we know that people can and do recover, and we believe in them. Because that hope is sort of the spiritual engine that helps people get over their very difficult cognitive impairments. Like I said, I am not alone. I am not alone. And shout out to the Recovery Institute again. I just want to highlight this infographic just to really drive home the volume of people that are in recovery and who overcome a problematic substance use issue. According to this study, 9.1% or 22.35 million Americans have resolved an alcohol or other drug use problem. This massive survey demonstrated that 46% of that 22 million, or about 10 million people, self-identified as being in recovery. 60% were male, 45% were aged between 25 and 49, 61% non-Hispanic white, 14% black, 17% Hispanic, 48% were employed, 46% living with families or relatives. 20 million people in America are in recovery or identified as overcoming a problematic relationship with substance use. So it happens all the time. There's lots of people. We have to believe that people recover in order to ensure that they get the services they need to achieve it. OK, so we can de-stigmatize substance use disorder through recovery exposure. I hope my little story there gave you a little snapshot into what's possible and helps you when you encounter somebody who looked like I did, believe that they can and do recover, and not see the person, see the disorder, and have a belief in what they can become and will become if they're given the right set of circumstances. Some of the negative beliefs of substance use disorders are often shaped by entertainment and media saturation of what I'll call as the mess of addiction. But proportionately speaking, there's little information highlighting the message of recovery. So we can incorporate exposure to recovering people's stories as a powerful tool to combat substance use disorder stigma. I'll just give you a little recent example. I was on the news. I'm on the news a lot. I go on the news a lot. And we were highlighting our de-stigmatization campaign at my organization. So we went on the news, and we did this great segment. We had 10 minutes. We talked about our mission, what we're doing to de-stigmatize addiction, promoting recovery, everything like that. Well, the news, they use B-roll in the background of people injecting drugs and people who are homeless and stuff like that. And I had a meltdown. I was so mad at the irresponsibility of the media in that situation. And oftentimes, when we see stuff about homelessness or people, the fentanyl crisis and stuff, all they show is these damaging and detrimental images of the mess. And they never talk about the recovery. Or if they do, it's in short order. And so I've really been pushing the media to highlight stories of recovery. And they've been responsive to it. They were like, we didn't even think of that. But once I approach them with this narrative, they'll be accommodating to the degree which they can based on their editors. But the point that I'm driving home is that I advocated for it. I had to advocate for it. So I would ask you to do the same thing. So you can bring recovering speakers like myself or pick one of the other 20 million people in America. And you can invite them to speak during trainings and orientation. This can increase empathy through personal storytelling and question and answer. And this may be really important in some settings where staff are sort of saturated with the mess. Maybe you're in the emergency room. And you're only seeing the people in the height of their acuity. And maybe they're disruptive. I sure know I was. I mean, I was not a saint. When I was in the emergency room, I was stealing stuff like syringes and scalpels and stuff like that and people's purses and stuff. I was a little bit of a problem when I was in the emergency room. And I take accountability for that. But I became empathetic to individuals working in the emergency room, because I understand that that's what they see every day. And if that's what you see day in and day out every day, how can I expect somebody to have a different perspective about people with substance use disorder? And so you've got to think of how can you help shape the attitudes, beliefs, and values around substance use disorder in your specific settings. And this is just one example in doing that. You can employ individuals in recovery on clinical teams and use peer recovery coaches to guide patients before discharge. Facilities trust and connect to treatment resources, teachers, teach people about the reality of recovery. You can increase advocacy for patient clients. You can reduce provider bias, help establish recovery center policies, procedures, and practices, all by employing people who are in recovery to be peer coaches. Now, there can be some rub when you bring people in recovery in, because they're going to bring a different perspective to what's happening. It's going to be a recovery-focused, strengths-based sort of lifestyle perspective when that can be in conflict with clinical perspectives of what's happening. And then what I've seen in helping pilot some of some of these projects is that there can be a little bit of a distaste that happens from the medical professionals when the peers are able to connect with these patients and help motivate them to make behavioral changes. And it really shouldn't be like that. It should be the opposite. You know, if you're a medical professional and you have a peer recovery coach working in your, you know, department, and they're able to connect with people and help motivate them that you were unable to do, that should be celebrated. And you should look at that as a benefit to the overall health and well-being of the individual. So don't do that. Okay. FYI, don't do that. It's not good. Okay. People, even medical professionals, can stigmatize methadone and suboxone. Okay. And there's lots of different, what I'll call is replacement therapies. Okay. Whether that's for like methamphetamine disorders, people take medications during alcohol withdrawal, Nicorette gum, et cetera. So there's lots of these replacement therapies that are incredibly effective. Now, when it comes to methadone and suboxone, people tend to lose their crap. Okay. So let's just take an example of alcohol use disorder. Okay. So, you know, an alcoholic goes into detox and treatment on January 1st. Okay. Takes benzos for a week or two to withdraw off the alcohol. Very important. Now on January 30th, 30 days later, they collect a 30-day coin at an AA meeting. And nobody really bats an eye at this. They're like, yeah, yeah, that person. Yeah. Yeah. They had to take some benzodiazepines to withdraw. Yeah. They're doing great. They're not drinking alcohol anymore. They got the 30-day coin. Yippee-ki-yay. Now imagine this situation here. I'm going to use nicoderm patches for an example. Okay. Imagine somebody saying, those patches have nicotine in them. You're not really clean off cigarettes because you're basically still using. You might as well just go back to cigarettes until you're ready to get clean for reals. You need to keep smoking and smoking until you hit rock bottom. Then you can forget about them patches and gums and quit for reals. Okay. If this happened, it would be irrational. Everyone would believe that this was an irrational approach to cigarettes. Everyone would be like, you quit smoking cigarettes. You're using nicotine gum or patches or whatever. That's awesome. Great job. The problem is that the same belief is not applied to medication-assisted treatment. People will be like, don't use MAT because that's still using. You're just replacing one drug or another. You need to go out and you need to hit rock bottom on heroin and or fentanyl and get clean and sober for reals. Well, the problem with this is that rock bottom can be death, especially with fentanyl. It's incredibly potent and fatal. The fatality risk for fentanyl is so high. Why would we apply this positive affirmation and belief to nicotine replacement therapies, but then have a such a negative belief to medication-assisted treatment? It doesn't make any sense. Okay. And medications for opioid disorder are a great thing. They're a great, they're FDA approved as the safest option for treating opioid use disorder. People with opioid use disorder are 50% less likely to die when treated with long-term buprenorphine or methadone. Two, research provides that medication-assisted treatment decreases opioid use, opioid related overdose deaths, criminal activity, and infectious disease. And this treatment intervention improves patient survival, increases treatment retention, increases the amount of people who become gainfully employed when they're on it. So this is a really great thing. This is great. We should celebrate it. Now, we want to think of sort of the cognitive impairment of being addicted under this framework of ambivalence. Okay. And this is the, just the biggest predicament that people with substance use disorder have. Okay. They get caught in these stages of change driven by their ambivalence. Now, when I'm talking about ambivalence, I'm basically talking about having two opposing motivations or beliefs around the same thing. Okay. Now what will happen, and it's very interesting, what will happen is people will alienate and discriminate individuals who can't quit using drugs. And they'll be like, this person just doesn't really want it. They don't want to quit. If they wanted to quit, they would. And so that's not true. That's not true. People can want to quit and want to use at the same time. Okay. And this is pretty normal in human behavior. Okay. Just want to think of you to take a moment, think about yourself. Okay. What are some things in your life that you're trying to change? And sort of this, you know, mental acrobatics that you do to try to get there. You know, I'll just talk about, you know, food, for example, sugar, you know, exercising, you know, how many people go and exercise on the first of the month, your first of the year, sorry. You know what I mean? As a new year's resolution. And then, you know, they fall off like two weeks later and they're like, oh yeah, just, you know, I'll do it next year. How many people are like, I'm not going to eat, you know, unhealthy food anymore. You know, I'm gonna start eating healthy. I'm gonna be eating salads, you know, I'm gonna eat lots of vegetables, you know, I'm gonna get on some keto or whatever. And at the same time, they're saying that they're like eating a biscuit. That's like dripping with butter at the side. They're like at Popeye's. They're like, this is my last chicken sandwich that I'm gonna have. And after that, I'm gonna quit for real. I'm gonna get healthy for real. You know what I mean? They see a little ad on Facebook, somebody doing a little workout and stuff like that. And they're like, yeah, I could, I could do that. I'm gonna get me a bike. And then, and then they don't. So it's very normal for human beings to be caught up in a state of ambivalence. But when people are caught up in ambivalence about drug and alcohol use, they're automatically sort of categorized as being, you know, morally incapable of doing it or lacking the willpower. And so what we use in substance use disorder treatment recovery services is we use a stage of frame framework where we understand that there's a sort of progression to a person's willingness to change. You have people who are pre-contemplative or who don't have any problem identification, zero. They don't identify having a problem. They don't think they have a problem. You know, you're the problem, you know, say stuff like that. The PO is the problem. The works, the problem, the boss, whatever. Somebody else is the problem, not the drug use. But then people move to sort of this contemplative stage where they, you know, begin to explore, explore, well, maybe, you know what, maybe the drug use, the alcohol use, maybe that is a problem for me. You know, maybe I'm open to trying something different. And then you have people start preparing to make a change. You know, they've made a commitment to make a change, but just haven't followed through yet. They identify the problem, like, yeah, you're right. I have a problem. I should probably go see somebody about that. Then you have the action stage, you know, where people begin to take action. They made appointments, they're attending appointments, they're actively involved in treatment or peer support, whatever. They're making steps in progress. And then you have the maintenance stage where people have made that change, and they're maintaining that change. Now, the important thing to note is that this isn't necessarily a linear process for everybody, okay? People will sort of oscillate between these different stages of change, you know, over a course of time. And, you know, for some people, they have what is referred to as spontaneous remission, where they just, all of a sudden, they're like, I'm done. And they never do it again. You know, it's miraculous. Some people will say that it was like, you know, a higher sort of power came and spoke with them and just alleviated their desire to use. You know, other people will go to treatment for 23 times. And the people who go to treatment for 23 times, you know, they can be sort of talked about negatively. You know, and I would challenge that. Because somebody who's went 22 times and tried something and failed about it and went back a 23rd time, to me, that says they really, really want it. Like, despite the failures, they're still there. We should celebrate that they're there. We should encourage them and keep motivating them to keep coming back until it sticks. Just as a person's problem recognition motivation to change and participation in the change process is on a continuum, so is a substance use disorder criteria. Now, when we look at substance use disorder criteria, we're looking at, you know, how much does the person's substance use impact their life? And we're looking at sort of a Likert scale here from mild, moderate to severe. You know, what is the amount of substances that they're using? What is their ability to control it? How much time do they spend? Do they experience cravings? Are they repeatedly unavailable to carry out major obligations, you know, at work, in their family life, school, etc.? What are the social impacts that the substance use has on their life? Does it impact any, you know, regular activities? Is it hazardous to their health? Has harm incurred on the person? Has the person developed a tolerance where they need to use increasingly larger amounts over time to experience this, the same effect of the drug? And, you know, do they experience withdrawal, you know, a physical response to no longer having the drugs in their system? And different substances have different withdrawal symptoms. And so knowing this, not every person who uses substances, you know, meets the criteria of a severe substance use disorder or what most commonly referenced as an addiction. It can be odd engaging in conversations around suspected problematic substance use, you know, and so I would caution against saying, hey, I'm worried that you're an addict, you know, just starting out that way. You know, maybe a better way to start out is to say, hey, can I ask you a question without judgment? And a commonly used, excuse me, a commonly used communication method in substance use disorder treatment and other social services where we're trying to elicit behavioral change is motivational interviewing. I'm going to do a little bit on motivational interviewing today. Just know that this is very rudimentary and introductory. There's very advanced motivational interviewing techniques of which I'm not going to get into today. But in the most general terms, motivational interviewing is an empathic communication strategy used to elicit client-directed positive change. And so when explaining concepts, I really like to break down the root words. And, you know, my personal training approach to this is one, you know, we want to know what a person's motivation is. What drives them? Not what we think should be driving them, but what are their own motivations? And we really want to tap into that. And then the other part is really an interview process where we are exploring the details related to a person, what they want to change, why we're sort of interviewing them on what are the reasons and motivations they have to engage in a change process. One of the foundational and core elements of motivational interviewing is using open-ended questions, questions that elicit a conversation, not a single response. And so, you know, instead of asking a person, do you have an addiction? Do you have a substance use disorder? You could say, tell me about your substance use. Ask a question where it would elicit a conversation. You know, instead of saying, do you want to go to treatment, which is a closed-ended question, which would end in a yes or no answer, you could ask somebody, what are your thoughts about treatment? Tell me what you've heard about treatment. What are your hesitations to participating in the treatment process? We want to give people positive affirmations. So, we want to provide positive reinforcement that helps us develop rapport and trust. For example, if you're working in a clinic and you have an individual who, you know, shows up late to an appointment because they're intoxicated, you know, your first reaction, you know, you might be a little upset in it that the person showed up late. You know, oftentimes practitioners have sort of these rigorous schedules and they're trying to get a lot of stuff done at once, and a person shows up late can be a little bit of an inconvenience. But there is an opportunity in a situation like this to give somebody a positive affirmation. So, instead of saying, well, it looks like you're drunk and you couldn't show up on time, you could say, you know, wow, like, looks like you really wanted to get here today. And really the thought behind that is that even though the person was intoxicated, they managed to show up, which on the continuum of change really shows that they are actually ready despite the substance use. So, their motivation to change is actually high even though they're still using substances. So, what we have to understand is that substance use disorder is a brain impairment where the person, on the one hand, really wants to change. They want to, but their ability to is being impaired by this, you know, to some degree primal drive to continue using to seek the neurobiological rewards associated with the dopamine that's created by the substances they use. So, we want to look at the action of the person, not necessarily the substance use. And then the last one is using reflections. Reflections are an incredibly powerful tool. They're a part of a larger strategy of active listening that clarifies intent. You can clarify intent, you can build rapport, and you can pivot to planning and goal setting. So, in the situation of reflections, you're really reflecting back what the person has said to you. And then you're using that to affirm that you're listening and then open up more conversation, maybe open any questions to explore, you know, whatever their motivation to change is. So, doing a little deeper dive into open-ended questions, you know, if you're exploring, if a person has a substance use disorder, you suspect they do, you could say, is there anything that is really causing trouble in your life? You could ask them, what do you know about substance use disorder, substance use disorders? You just ask them, hey, can I ask you about your relationship with drugs and alcohol? And then you could ask them, what would your life be like without using drugs and alcohol? Affirmations. I see how hard you are trying. Thank you for being honest. That must have taken some courage. I appreciate how much you care about your kids, etc., etc., etc. Really affirming the positive aspects of the person, not focusing on the negative consequence of their use. Reflections. Here's an example. You said that drugs and alcohol may be a problem. Would you be interested in talking to someone about getting support? This would be premised on the individual acknowledging that they had a problem. Another example. Did I hear you correctly? You don't think alcohol has any impact on your well-being. You know, maybe a person is like, alcohol is not a problem, blah, blah, and you might say, okay, so you're saying it doesn't have any impact on your well-being, is that right? And then another one might be, sounds like you think reducing your use might have some benefits, is that right? So that would be a person sort of ambivalent about their use, but there's subtleties that they may be interested in reducing the use, not quitting, but reducing. And that can be a great starting point, is talking about reducing use. It sets up future conversations if the person's unable to do so, about some stronger interventions that could help in their wellness journey. So in summary, what we want to remember is that people with substance use disorder, they recover. They recover a lot. It happens all the time. It is a normal and expected outcome of treatment interventions. People in recovery often become amazing individuals and they lead amazing, meaningful, and often service-oriented lives. And stigma can prohibit individuals from seeking treatment and being successful in treatment, seeking health care, and being successful in health care. To increase the effectiveness of health care and treatment interventions, we want to reduce the stigma. And in order to do that, we want to reduce the stigma. And in order to do that, we have to look at the disorder. We have to believe in the possibility of recovery, even though we know and see the collateral impact that happens as resulting from the behaviors associated with substance use disorder. And lastly, if you believe a person has a substance use problem, it's okay to ask, but do it in a compassionate manner. So that's it from me today. I hope that whoever's watching this video gained some tools. I hope you might incorporate some of the concepts we discussed today. And lastly, I'd just like to thank the Opioid Response Network for allowing me the opportunity to use my lived and professional experience to help benefit systems and individuals who are going to come in contact with individuals who are like myself, who have a substance use disorder, in order to help increase their ability to have a transformational experience like me. Thank you so much.

substance use disorders

stigma

Opioid Response Network

SAMHSA

addiction

person-first language

recovery advocacy

medication-assisted treatment

harm reduction

peer support

motivational interviewing

compassionate communication