Good morning, everyone. I think everyone should be connected now. My name is Emily Mossberg. I am a coordinator with the Opioid Response Network. We are happy to be here with you to provide training today. You may all remember Stephen Samra. We did a training with you all back in April, I believe, of last year on stigma. And we are back again today to talk about an introduction to substance use disorders and harm reduction. And as a reminder, the Opioid Response Network is a grant funded, and we provide no-cost training and technical assistance to enhance prevention, treatment, recovery, and harm reduction efforts across the nation. Anyone can submit a request for free assistance on our website at opioidresponsenetwork.org. We encourage you to share that resource or our resource with anyone who may benefit. So I just want to make a note, with our new grant cycle that started in October, we are required to implement a new and stricter survey tool at the end of all of our sessions. So we will be leaving time for that at the end, about five minutes, and we greatly appreciate completing that before you leave. Our continued funding does depend on it, so it's important. We are recording this session. It will be available for reviewing and sharing within about a week. If you have any questions that come up throughout the session, please feel free to put it in the chat or you can raise your hand in real time. You don't have to wait to hold it until the end. I think that is all the housekeeping items, so I will now go ahead and pass it over to Stephen. Thank you all for being here, and thank you, Stephen. Emily, it's always my pleasure, and I love working with ORN and the opioid response network, and for those who know me from, I believe it was April. It seems like a long time ago. Welcome back. You already know the kind of style that I come at this with. It's probably not the most traditional way that folks present, but I think tying it to the experiences that I've had, I think, bring a little bit of power to it, and how people put the stuff in context, because often we hear this information, and you could probably go look it up, honestly. A lot of it I did so that I had citations for it, but if you don't have the cultural sort of competence around the drugs themselves and the kind of lifestyles, it's really hard to figure out what it means when we talk about something like alcohol as the number one killer in the country as a drug, so let's put some context around it. I'll zip through the ORN slides because you pretty much know this, and the only one I would focus on is, listen, if you need TA, reach out to the response network. You'll likely end up with Emily, and we will take good care of you, and I'd check in with Deanne before I did that because she may already have some stuff cooking, but with that, here we go, guys, okay? All right. This looks like a whole bunch of stuff. It is, but it's all going to flow together, and by the time we're done, I don't think you'll have a struggle really going through any of these objectives, so we're going to talk about what a substance use disorder is. We're going to talk about some common drugs of misuse. I suspect many of you know a lot of them. We're going to look at an overview of why polysubstance use matters, and that just means using multiple drugs at the same time. We should be able to talk about the signs and symptoms of alcohol intoxication. We really want to talk about and understand, I think, more than anything, how dopamine will hijack our reward system in our brain. That's really going to matter. It's going to matter a lot when we talk about substance use disorders. We should be able to talk about the three medications that are used to treat opioid use disorder. We should be able to really talk about the difference in success rates between using something like medication-assisted treatment and coming at it from a purely abstinence framework. Then, with all that, we need to be able to talk a little bit about harm reduction's purpose. Finally, what sort of ties all this together is the shift from a medical model sort of perspective, where I'm the expert and I tell you what's wrong, to putting the person in the center and actually hearing them. We need everybody. We need somebody to tell us what is wrong, but that's not the only thing we need. We'll talk a little bit about whole person care. A substance use disorder we also call an addiction. I can tell you that it's really now a substance use condition. That's a language shift out of SAMHSA. You'll still see disorder all over the place because you're not going to go back and fix it all. As you watch the progression over the next year or so, you'll see more and more things called substance use conditions. I hate the acronym, but you'll also see that as mental health conditions, too. If we look at what the DSM-5 defines as a chronic treatable illness for substance use disorder, it involves compulsive behaviors, really bad drug cravings, and you'll hear a little bit more about that shortly. This inability to control their use despite the harm that it brings. It also can occur separately from being physically dependent on the drug. It's lifelong and has some really serious consequences, as I think all of us see today, if we just leave it untreated. An opioid use disorder or an opioid use condition is the same as a substance use disorder or a substance use condition. It's a chronic brain disorder. It is the same thing. Use of opioids, even in spite of the harmful consequences that come, one of the big features of an opioid use condition is this cycle of remission and then recurrence. Some people call it relapse still. The newer language is a return to use. It's because, and we're going to look at this a little bit, there is positive reinforcement at unbelievably high levels when people use it. That'll make sense as we get into a little bit of the neurobiology. I'm not going to take everybody down the clinical neurobiological discussion that we're all going to need a degree in anatomy and physiology to understand. I want it to be pretty straightforward and simple, easy to understand for us, and really leave us with what that impact is on the person. Some of the things that happen to us, and I didn't share this at the start, but I am a person in long-term recovery. I've had an opioid use condition for 40 plus years now. I can tell you that there are definitely problems with mood, with cognition, particularly with decision making. I haven't made many great ones while I was in an addiction status. Some real abnormal reactivity, distress, and environmental cues. Again, you'll see a little bit of that described later. Overwhelming cravings. I remember being court ordered into treatment. Many of us end up in treatment that way. I was telling my psychologist, listen, you don't understand. I'm compelled to use it. I can't make a choice. I don't have a choice. I'm really compelled. That was absolutely true. I think that was true in 1999. It's definitely still true today. That impaired insight and the impaired ability to care for yourself, absolutely. If you spend most of your time either nodding high or chasing the bag, as we call it, it's pretty hard to take the time out to eat well, take a shower, groom, get your haircut. That ain't happening for most of us. There's another reason, money. Our money goes for usually two things, a little bit of food and a whole lot of drugs. There's also this increased risk of injury and infection. An opioid use condition has the highest mortality of all the psychiatric disorders. Of all the psychiatric issues that happen, having an opioid use condition or a substance use condition kills the most of us. Sorry for that language, but it's true. Talk a little bit about the drugs of misuse. I tried to stay as calm and as possible here. Every day, some weird new analog shows up, some crazy ... Sorry, that's a terrible term. Some just off the wall, new way to get high shows up. You can go all the way to the final bullet, the last bullet on this slide. Mad honey, scorpion venom. You may have all heard of frog licking. Over-the-counter cough syrups, robitussin. People misuse that. They're not the most common things that you would probably find on your street in your community, but they're out there. In fact, you can order mad honey online. I looked it up because I wondered what the heck it was. Google it. You'll understand. It comes from some kind of a flower, specific flowers, I remember. It has hallucinogenic properties to it. We know that alcohol ... All of us understand that alcohol is widely available, and a lot of times it's misused. I think what we don't all know is that out of all the drugs that out there and that have the potential to take a life, alcohol is the number one killer of all of them. I know that we're focused on an opioid use issue right now and an epidemic. We've been in an epidemic of alcohol for a very long time. The only difference is that because it's legal and because our culture has used it to celebrate, it's just one thing, but it makes it really acceptable, super acceptable. While it's really, really acceptable, it's also really, really killing a lot of us too. Benzodiazepines, these are the Xanax, the Klonopin, Valium, things like that. I've got some of the slang names up there, Xanese and Mother's Little Helper. Some of you old-timers might remember that from an old Rolling Stones song. The pins just as a general biazepines slang. Then there's still hallucinogens. I was really surprised to see online again a listing for various levels in micrograms of LSD. That's just shocking to me. I used a lot of LSD and I understand what those levels are because it's the intensity of the experience, but to see it online and to see it readily available was just shocking. Masculine, Mass Peyote, PCP, another big one that we all angled us, that we often kind of don't hear much about anymore, but it's still out there, particularly in some of the inner city areas. I know Detroit still sees a lot of PCP. Salvia, Ayahuasca, that's a big one for folks who are looking for more of a spiritual experience. Ayahuasca, I mean, that's the ultimate. It goes above peyote and that's the one. The other one, the things in the parentheses there, those are all terms for LSD. I pretty much have done all of those terms, the drugs themselves in my lifetime. Of course, we have cocaine, coke, white, rock, go fast, toot blow. It's referred to by many, many things, but those are the most common. The go fast is interchangeable with methamphetamine or amphetamines, but you get the idea. Anymore today, I think it's probably pretty hard to find straight heroin. I mean, I'm sure it's available, but it's because you can cut it with things like fentanyl, which is dirt cheap. Nidazine or xylosine is even cheaper. Of course, folks are going to cut it. If it potentiates the effect like xylosine would, then they're going to cut it more. You're seeing mostly fentanyl and things like xylosine in your heroin supply. It's called all kinds of things as well, Mexican mud, China white, the madness, fenny, black tar, chasing the dragon and smoking it. Being gout, that's a West Coast term for being heavily under the influence of something like heroin or OxyContin or any opioid. I'm sure it's called other things in other areas. I just happen to be familiar with that West Coast slang. Then of course, we have prescription opioids, which started this opioid epidemic for us, at least this time around. You have everything from Oxy's and OxyContin and Oxycodone, which is really what we're getting at here. Vicodin, that's hydrocodone. I'll just say that when people start using things like heroin and fentanyl, all of these prescription opioids become pea shooters. They don't have the effect anymore unless you have direct access to Dilaudid number four or straight morphine or straight Demerol. You're not going to feel any of them, particularly if you're moving into what we call dope sick, which is the withdrawal period. Once you graduate from prescription opioids, and again, you'll hear a little bit more about this later, it's pretty much over. You can't go back. That can be a real problem, think about this, for folks who were prescribed for pain legitimately, were reduced or completely deceived from that med when we got all freaked out about how many prescriptions doctors were putting out of opioids. Those folks, a lot of them went to the street, and a portion of those folks went to heroin. The sad part of this is the heroin spike today is pretty much from those of us who are older adults. That's also scary since I've become an older adult. Talk about methamphetamine, and I'll share something that makes methamphetamine really insidious as we get farther on, but it's called crystal ice, go fast again. The big ones you hear are tweak, crank, and sometimes you hear it called bathtub dope. Tobacco has been around forever, still abusive. I have been chewing Nicorette gum for 10 years because I don't want to smoke and I don't want to chew any tobacco, so the gum seems to work. Of all the addictions I've had, tobacco, I can't beat it. I can't beat it. Addiction is powerful. I already talked about the less common stuff there. I won't spend much time here because we pointed out that alcohol is a pretty serious drug when you get right down to it. We know that alcohol deaths increased more than 25% from 2019 to 2020, and adults under 65 died from alcohol-related causes in 2020, more than from COVID-19. Alcohol was killing us at a rate higher than COVID-19, but you didn't hear about that. We didn't hear about that. There's a big amount of advertising and lobbying money that alcohol has behind it. It's like big pharma, big tobacco, big oil, same thing. Lots of money keeping it where it lives today. I have this up because it's important we understand that most of the folks who have really graduated—that's a terrible way to phrase it, but it's kind of how I see it—graduated beyond things like cannabis and alcohol. It's just rare that we're only using one thing. I've never met somebody who has been alongside me injecting heroin who didn't take a head off a joint if it was passed around or might add a little cocaine to their spoonful of heroin. I certainly did that. Let me see if this will play. I'm not sure because sometimes it doesn't. When it comes to mixing drugs, you may think you have a safe approach, but the truth is, your body can react differently every time, even if you've done them before. Using multiple drugs can put extra stress on your heart, making it easier to overdose and stop your breathing. It can even be fatal. Know the risks. Be aware. There is no safe way to mix drugs. For more information, visit cdc.gov slash stopoverdose. So I share that because while we do that intentionally, a lot of folks also now are doing it unintentionally. And you can find fentanyl, you know, caught in damn near everything today. You can find cheap things like methamphetamine, which is a fairly inexpensive drug to manufacture and you know, on the street. You can find that in a lot of things as well. And there are folks who have been using, you know, non-opioid drugs that they've injected who have become addicted to opioids as a result of that. I mean, to me, that's good grief, you know, you get far more than you bargained for. And so that that unintentional poly use is, I think, you know, one of the more insidious parts of, you know, unscrupulous dealers and manufacturers. So let me see if I get beyond that. So this is a tricky thing to do in a training like this. But I will just say when we talk about an opioid overdose, this is not a training to teach you how to respond. But what we're looking for are things like blue lips or nails. And you know, I've overdosed three times. The third overdose for me, I remember looking at my nail beds. I have a background as a paramedic, so I understand what cyanosis is. And I can remember looking at my hands when I came to and they were blue. And when I looked at my face, my lips, they were so blue that it shocked me. And my skin had that onion skin complexion like, you know, I was like that close to death. So it's really prominent, even in our brothers and sisters of color. You'll still see, you know, a bluing of the lips a little harder to notice, but it's there. And definitely in the nail beds, you can be really dizzy or confused, which often gets confused with either just high, right? And it can't be woken up, even if you take, you know, your fist and your knuckles and rub them on their sternum, that is the classic way that it's called a sternal rub that we pull people up and see if they're responsive. If you hear them choking or gurgling or sounding like they're snoring, that's how my dog saved my life in the first overdose I had. He and there were two of them, heard me gurgling, started freaking out underneath me. I was at a bar at, you know, the bar at my house, and my wife heard it, came out and pulled me on the floor. And I woke up to, you know, paramedics standing over me, slow, weak, you know, breathing. If we're there, we're this close to being gone. And if it's difficult for us to stay awake, we need some Narcan. And we probably need it now. Let's talk about that. So we want Narcan on hand. And if you're working with folks who have the potential in any way to have a substance use history condition or an opioid use condition, we definitely want Narcan in hand. The thing to understand, and I won't dive too deeply here, you can get it in nasal spray, they have it injectable, you know, Naloxone or Narcan is really, you know, sort of pervasive now and very easy to use. The thing that is important to understand about Narcan is that particularly with fentanyl, that's a powerful narcotic, and it keeps people down a lot harder than a typical opioid, heroin, for example, or Oxycontin. And that means that they are more likely to lose the impact of the Narcan because the drug itself is overpowering it, and it'll take them back out again. So folks who are using fentanyl particularly really need to be monitored for a couple of hours, maybe a little bit longer, until we know that they're not going to fall out. And that's what we call it when, you know, out you go. So one thing to know, I was awakened in the back of that ambulance by somebody who gave me an injection of Narcan, and they pushed it too fast. And I woke up as sick as I've ever been. And all I wanted to do was run out of that ambulance. And that's exactly what I did. So I didn't get violent. Some people start swinging. That's really rare. Don't, you know, don't be fooled by that. It's really rare. Usually we're so sick, we can hardly move. And that's how you're going to find most of us. That way and ready to run. Okay, this part that I want to talk about is probably the most important piece if you're trying to figure out how is it that I can engage with people in a really productive way and reach them in a way that resonates with them, not with how I think it should or what it is I want them to take away from it. And so to understand that you really need to understand the culture around things like addiction, incarceration and homelessness. And you know, it's occurred to me as I've done this training over and over that what we're talking about are subcultures on this bigger level, addiction, incarceration and homelessness. But within those things, there are all kinds of these little microcultures. For example, I might be an opioid user and don't do methamphetamine. That's how I am. I don't hang out with people in the methamphetamine microculture. So I don't really get that culture a whole lot. Although if I needed to, I could easily, using what I know about my subculture of addiction involvement, I could make that transition pretty easy. If you've not been there, you can't. And we know that you can't. And we know that if you can't and you can't speak our language, then you don't know anything about us really. And we're more likely to keep a lot of things secret from you. In fact, we're more likely to just say, yeah, we're not interested, which is what happens all the time. When you think about this, it's important that we recognize, and this is from William White and some other research that SAMHSA has done, there are three different levels here. And, you know, if we talk about the acultural level, that's folks who are, you know, they, I mean, they, they might smoke some cannabis, you know, on a ski trip or, you know, I don't know, maybe take some peyote or some mushrooms while, you know, out on some camping trip, who knows, but they don't live there. And they're not, when they, when they're done with that, they leave that all behind, go back to their job, go back to their family, go back to the mainstream culture, and they're done. The bicultural folks, I always think about those folks as weekend warriors. They're the ones who, you know, they live in mainstream culture, function well, but on a weekend when they go get that eight ball of Coke, they've had to learn how to be part of that addiction culture, otherwise you're not going to be able to cop, you know, what they're trying to do, get their, get their drug. The enmeshed folks, that's where you find people who have opioid use disorder or opioid use condition, people with very serious hardness of methamphetamine to hardcore addiction. And the reason that it's considered enmeshed is that's the culture you live in. And if you are an opioid user, I'll speak from my own experience here, you have a really tight circle of people around you. And the people are the folks who use with you and the dealers who sell to you. And pretty much everybody else is on the outside. And we need each other like, you know, nothing else in our life, because if Joe has a little bit of stash and I'm really sick, Joe might kick me a piece knowing that when he's really sick and I've got some stash, I'll do the same. And I would. Right. That's, that's how it works. So you are constantly, here's the routine. You got to find the money somehow. You got to go find the dude. You got to find the dope. You got to find what you need to inject it with. You got to find a place to chill out. And then you got to find a place where you got a couple of hours where you can get up, maybe take a drink of something, maybe have a, you know, a Snickers bar on the way out and you get to do it all over. That's the life. That's life. I spent 20 years doing that. And it's very difficult to pull people out of that and back into mainstream culture. It's almost impossible. And that's why I really see like four to 10% of folks who need treatment in treatment because they're trapped here. And when I say trapped here, let me show you something that I think, you know, may, may help kind of solidify that if I can get it to move forward, Tom, I own you. There we go. All right. If this starts playing music inadvertently, I apologize. The reason I have this slide up is because both of these songs, and I also have a, you know, a newer version of this with Garth Brooks and Friends in Low Places. But in each one of these, if you look at Cheeba Cheeba, it's a song about cannabis that came out in the 90s, I believe, by Tone Loak. It's an awesome song. You know, I still get moved by it because cannabis was a large part of my life. And, you know, when I hear this song, I'm right back there in the cannabis culture. And then when you look at 30 Days in the Hole, you have to understand that song came out in 1967. And the entire song is about heroin, hash and cocaine, the whole song. And if I played it right now, I promise you, I would instantly be jamming along, really into it, because this is who I was for a very, very long time. And to pull me out of this culture and back into a culture where none of this is celebrated, and in fact, often we're persecuted, and many times we're prosecuted. It's really hard for us to, what do we share with you? Right? That we love Humble Pie? If you know who Humble Pie is, you know, that could be a red flag right away. So music plays a huge role in reinforcing the culture of addiction. And that's not the only thing that it does. Bear with me, because I may have to do a few clicks here. All right. Words matter. Hey, Stephen. Oh, yeah. Sorry to interrupt. No, go ahead. There was a question. I think it was back on the Naloxone slide that came through in the chat. I see it. Okay. Yeah. I don't know if you want to address that. I see it. Okay. Perfect. Yeah. Thanks for pointing it out. So, Jay, absolutely. Any dose of heroin is unhealthy. And if you reach overdose status, overdose is going to be, and, you know, I'm giving you sort of a layperson's overview of what, you know, I would call an overdose. And I think it's going to be really, really, really close to what the, you know, official signs and symptoms would be. Shallow or no breathing, unconscious, unresponsive to sternal rubs, stimuli. And you know, if you're lucky, you have a very faint and weak pulse. That's an overdose. And if it is a person found unconscious, like that, one of the first sort of protocols today is to administer Narcan, because it's likely, particularly if, you know, the person is within, you know, I don't know, their 30s to their 60s, it's very possible that, you know, what's happening is an opioid overdose or a poly drug overdose may have been inadvertent. But does that get you to, you know, understanding when you might want to administer Narcan? And let me just say before we, you know, we leave this, there's not a, not warrant the administration of Narcan. If you find somebody like that, Narcan is pretty benign. So if you give it to somebody who doesn't have opioids on board, ain't going to do nothing. It's just, you know, you just basically wasted a nasal spray. But if they do have an opioid on board, you will see it almost instantaneously bring them around and bring them around fairly quickly. Let me know if that, you know, if you need more information on that, Jay, I'm happy to get a little bit deeper. But I hope that that, you know, gave you sort of that overview. One of the things that really drives addiction is our internalized stigma. And I, you know, if you attended my stigma training, you've heard all this stuff. But it drives addiction, and it drives return to use in ways that, you know, I don't think there's anything else, at least in my experience, that's been so powerful. And it's why words really, really matter. And, you know, I use this slide all the time. But what this is talking about is a little bit of, you know, case study by the Recovery Research Institute. And they gave the same case to two different groups of clinicians. And the only difference was that one was called a substance abuser, and one was called a person with a substance use disorder. And when they labeled it as abuser, the folks actually, the bias was so strong that they felt like that person less likely to benefit from any treatment, more likely to benefit from punishment, more likely to be socially threatening, more likely to be blamed for their substance-related difficulties, less likely their problem was the result of some innate dysfunction over which they had no control, like a hijacked reward system. And they were more able to control that use without any help. Versus the exact same person having a substance use disorder, none of that applied. And so if you're wondering, you know, why, think about this. If I say the term addict to you, you know instantly what flows up in your head. But if I say person with a substance use condition, it's kind of blank. I mean, we have an idea, but that could be a big, wide range of folks. Everybody from grandpa who has been, you know, taking, you know, Percocet for 20 years for his bum knee to, you know, the folks on Kensington Avenue in Philly who are cutting off limbs in order to keep using. There's a big old, you know, range of folks out there. So, and you can see these attitudes, yeah, Jim, give me one second, okay? You can see how these attitudes, you know, in terms of magnitude, they're not small. I mean, these are big, you know, big discrepancies. And it's important that we recognize, you know, how powerful just the term substance abuser can be on a person's bias unconsciously. We don't even know. And I guarantee you, you know, the folks who did this, they didn't know. You know, it's not like they were substance abuser, yep, I'm going to make life really miserable for them and then have sudden compassion for a substance use disorder. Same case, same notes, same words. So I think you get the point. I won't, you know, belabor it any further. Jim, what it means that an abuser is more likely to benefit from punishment was the response that some of the folks in that substance abuser side of this experiment said that, you know, what we should do is we're not, we shouldn't treat them, they should be punished. Well, let's talk about mass incarceration for a bit. And how did that work out for us? That's that attitude. Benefit from punishment. No. No, we don't. And you'll see, you know, hopefully the last slide I have today or one of the last is, you know, I talk a little bit about that from a personal perspective. So how is this all set into the, you know, the harm reduction framework? Well, to understand harm reduction, what it is, is really, it's a philosophy and it's, it's, you know, solely based, it's not primarily, it is solely based on the idea of social justice. And that separates it a little bit from the recovery community because on the harm reduction side, they're not particularly interested in, you know, pointing people towards recovery. What they're more interested in is giving people, you know, the chance to reduce harm to themselves and let them live their lives the way that they see fit. That's social justice for them, okay? And, you know, I don't disagree, but I will say this. If you're pairing harm reduction with the recovery community, then the ultimate harm reduction, at least for me, was the cessation of illegal drug use. And if we're gonna bring harm reduction into the recovery community, I don't think we can just stand on this idea that, well, harm reduction is social justice and they do what they want, while over here, you know, we're trying to drive folks into a new culture, the culture of recovery, and what that actually means in terms of, you know, how they're gonna live their lives moving forward. So it's, you know, it's important to understand that there is a pretty strong distinction. The two work hand in hand really, really well, but they need to be integrated. This is my perspective, and I think we're gonna see a bigger discussion on this in the next year or two, so stay tuned. I know there's a report coming out. I was at an event in Denver this summer that brought harm reduction and recovery together. Very interesting, and we, you know, we've got a ways to go. You can see on the slide why there is an individual and a community benefit to harm reduction, and that really drives a lot of us. There's a lot of, you know, there's a lot of folks who think at the, you know, with the purse, and you can see a lot of stuff is cost effective. There's folks who are looking for, you know, does it impact recidivism rates? No increase in criminal activity. It also honors dignity and humanity of people. It doesn't forfeit a person's rights. You know, again, social justice. So the biggest issue to take away from the harm reduction sort of movement is that the movement doesn't set what harm reduction is available in your community. Your community does that, and what might work in, you know, McCook, Nebraska, which is a teeny little dot on a map in the middle of, you know, what many people call flyover states, that ain't gonna cut what they're doing in New York City, and vice versa. It is community-driven, and what the community will accept is what the harm reduction level will be. It doesn't have to mean that in the recovering community, you know, that's where we stay, because we can do all of the harm reduction, you know, work that we need to, but in terms of community, yeah, what the community wants is what the harm reduction level will be in that community, and there are a lot of variations. You may not have syringe exchange programs. You may not have Narcan free at the pharmacy. You know, there's all kinds of things that, you know, I can't see a supervised injection site opening in McCook, Nebraska, ever. It's never gonna happen, at least, you know, in the rest of my lifetime. So if we talk about this thing called recovery, well, SAMHSA talks about it being a process of change, and through, you know, how we can improve our health and wellness and live a self-directed life, and to me, it is to find that satisfying and productive spot in our community that many of us have always wanted. So you can see what a recovery orientation is, and, you know, I think it's, I wish we could do this for all of us as human beings, honestly, person-driven, multiple pathways. What we choose to go into recovery is ours. If you told me you went into recovery from, you know, a broccoli spear, I'm all for broccoli recovery. Whatever works, right? It's holistic, full person. It uses people like me to support our brothers and sisters who are still struggling. It's relational. There's a big cultural piece. We're already talking about that. Definitely trauma-informed, and today, very healing-centered. There's strengths and responsibility we have, and we get some respect, and the biggest piece is it drives hope. Without hope, you know, it's, I mean, it's hopeless, and I mean that sincerely. So what isn't in this definition? What do you guys see that might not be in this definition? If you got a thought about that, put it, ah, Jay, you'd bomb. They don't talk about abstinence here, and it's partially because, you know, we don't wanna say that a person using medication-assisted treatment isn't in recovery. Ah, awesome. Thanks, Jay, that's kind. But, you know, we also today can't say that about cannabis. There's a lot of people in recovery, I'm just gonna be honest with you, who use cannabis as part of the mental health therapy. They do, and we talked about that at the harm reduction meeting this summer, and there were a few people in recovery, and I was really surprised to see this, that stood up and said, yep, I am a person who uses cannabis, and I still am a person in long-term recovery. So, you know, we're gonna bump up against a little bit of that, but if you remember the definition of addiction, chaotic use, you know, without care of the harm that it is doing to you and to others around you, it's not that hard to separate folks who are casually using things like cannabis, and certainly using medication-assisted treatment from folks in full-blown addiction. It's just not politically correct for us to do that yet, but, you know, it's coming. So, absolutely, yes, there is a huge decrease in hope, and I can just say, we'll watch the next one year in this country, and depending on the direction we go, I would expect to see a giant spike in both substance use, homelessness, and incarceration. I really feel like it's coming, and we're gonna see if, Paul, you know, we're right here, but you can look at the research and the data. Yes, there is a decrease in hope, an increase in substance use, and an increase in people dying. All right, I wanna talk about why we're gonna treat an opioid addiction with an opioid, because this, for many of us, self-included, never made sense until I actually got the treatment, and even then, I didn't know why. I just knew I felt better, it worked, and I could go on with my life for the first time in 30-plus years. That made a huge difference. So let's talk about that, and to get there, we need to understand the difference between drug dependence and addiction, and if you're dependent on a drug, yep, you require a dose every day to prevent withdrawal. Many people who have chronic pain are addicted to an opioid. They're dependent, I'm sorry, they're dependent on an opioid, and they function just fine. They go to work every day, they do what is required of them in their normal life, and they're honestly living their most productive and successful life in their community, unless they're not taking it, and then they experience the same kind of withdrawal, or dope sick, that anybody with an addiction will have, and how they respond to that will mean the difference between just riding out what's happening or moving into that addiction phase, okay? When you're dependent, you have been using it a while, you built the tolerance to the medication, you do experience withdrawal when you stop it, but you can medically manage that withdrawal. It ain't gonna be fun, but you can do it. I've done it three times now, where when there's addiction, compulsive use, you don't care about the harmful consequences. I've gone to prison for it, and in fact, if we're in our hopes there, the strongest heroin I've ever done, I got in prison. So, that's worthless. You can't stop using, I said, when I met with my counselor, I'm compelled. You don't understand, I'm compelled, I can't stop. Failure to meet work, social, or family, left it all, and entered that subculture, enmeshed in that opioid subculture, and increasing tolerance to the drug and withdrawal symptoms when that drug is stopped. Yep, absolutely. So, let's see a little bit about what's going on, right? What is happening in the brains of us and the bodies when we have an opioid addiction? If I can get this guy to play. Come on, baby. Every now and then, I get a little bit of a, a challenge with this. I'm not sure why. Hey, hey, just be patient. Just be patient. Anytime someone hears the term motivation, they should really supplant that with dopamine, because without dopamine, you don't have motivation. All drugs of abuse cause this unnatural rise of dopamine, and because of that, they're among the most powerful experiences our brains can have. struggling with addiction, are actually battling millions of years of evolution because our brains are exquisitely evolved to seek rewards. The body decreases the production of dopamine. Eventually, you can't even get enough dopamine produced to get out of bed, let alone produce good relationships and good decision-making. Methadone is our gold standard. It's the most studied. It's been around forever. You attend a methadone clinic every day. You get a dose of medication. It fills your receptor sites so that the cravings don't happen. I've taken all three of those medications. I started on methadone, and then I stopped methadone in 2014 after a two-year reduction under a medically supervised withdrawal. It took me two years to reduce from 80 milligrams to zero. That's how powerful the addiction piece, the fear of being dope-sick really was. Two years. I came down about a milligram a month, sometimes a couple, but I also noticed as I got farther and farther down, it got easier and easier to reduce that dose. That's not something that we as folks with an addiction would typically think is accurate, but it was. The reason I have this slide up is because both serotonin and dopamine play a big old role here, but I want to focus on dopamine really for this discussion. When you look at this slide, it always stuns me about how ... To your point, Amber, it is why you can't stop eating chocolate. I hope that chocolate cake didn't send you on a bender, but great food gives you that. I suspect everybody here has probably had at least one orgasm. Well, there you go. That's the dopamine spike you get. Look at what coke does, cocaine does for you. You're not going to get that from sex. You're not going to get that from food. You're not going to get that from anything but cocaine. You can see the increase. I told you, once you move from the prescription opioids to heroin, it's all over. It's all over but the crying, really, because you're not going to be able to go back to that itty bitty baby pea shooter of dopamine spike. Now, here's the bummer. Methamphetamine, as you see, is basically off the chart. The big bummer about methamphetamine is it also has, where opioids don't, an ability to block the reuptake of that dopamine. It keeps the brain flooded in dopamine, unlike heroin or prescription drugs or cocaine, which is one of the reasons it's so hard to recover from methamphetamine and the depression is so strong at the end. Because you want to talk about being dopamine empty, yeah, a good long run or a bad long run on something like methamphetamine brings with it a type of dope sick that isn't so physically manifested, but mentally it's just as bad. I want to mention what we call the Mind F, but before we do that, I want you to see this video because I think this helps people understand why we're compelled to use. We found the Prompt had the technology that could really push us to the next level compared to our prior EMR system. It's new. It's technology driven. It's physical torture. It's mental torture. You're literally coming undone at the seams. You're crawling out of your skin. I mean, you know, it's basically like you're living in hell. Back then, Oxycontin didn't have the same ring as heroin, nor did we have the knowledge that, you know, that little pill was going to lead me down a path of self-destruction. When we first started doing it, we were doing it on the weekends, we were doing it at parties. And slowly but surely, everything started centering around getting that pill every day. Monday through Sunday, a couple pills a day, and that went on for a long time. When you're high, like your body is, everything feels normal. Everything feels like, you know, it's exactly how it's supposed to be. You remove that drug and that chemical from your system. You know, your body just unravels. Anxiety kicks in when you don't have any money, when you don't have any source, when your dealers run out. You start going through these chaotic thoughts. You're just drenched in sweat. It's like all your bodily fluids are coming out of your body. Your stomach is twisted and knots. A lot of people end up puking. I wasn't really a puker when I was sick. I was more the person that, you know, violent diarrhea, pissing out your ass. Your bones ache, you know, they say flu-like symptoms, you know, it's pure agony. I remember, you know, I was dope sick, apoxies, curled up like a baby, and I couldn't afford another pill. And, you know somebody brought a bag of heroin to me and at that point it didn't matter what it was I was so sick I just didn't want to be sick. So some of the language notwithstanding there and there's some you know kind of old language in that really could use some updating but the thing about Matt that I really want to point out is his move from a-cultural to bi-cultural to fully enmeshed when you know that person brought over the heroin and once that happened it was on and he ain't going back. So the other thing that I think is really important to understand about what he's talking about is along with all those physical symptoms there is also a mental component of this that lasts a much longer time and again we call it the mind F and it's one of the worst parts of the withdrawal. You don't always hear people talking about it but you know I've hallucinated from that you know the mind F. I have you know been so depressed I could hardly move all from that mind F. I want to talk a minute about the medications because I want to connect it to something that we heard in the first video and that was that opioids will reduce that anxiety right that'll help with anxiety. That's true with methadone. Methadone is great for that as a matter of fact. Buprenorphine, Suboxone, not so much. It does it you know it works a little but that high anxiety piece you know it's it's not gonna cut it like methadone will and I say that because as we're thinking about people who you know are considering medication-assisted treatment it's important that we understand folks who have a longer history particularly of heavier you know opioid use like heroin like fentanyl and some of us have been using that for a very long time. I did my first fentanyl in 1997 so it's been around a long time. Those folks may do better using something that controls that anxiety a little bit more because they got quite a journey in front of them. I'm not a doc. I'm not recommending that. I'm just saying from my own personal experience man if I wouldn't have had methadone and had to start on buprenorphine I'm not sure how successful I would have been because I have used buprenorphine and I can tell you that it doesn't have nearly the anxiety calming that methadone does. So and Sarah I'll get to that. I want to mention one thing about Jenny's comment about that interview on YouTube and I'd love to see that Jenny if you could put that in there if you've got the address and could pop that in the chat everybody would benefit from that but I have a I would just say this I don't think there's much that doing once a day for me would fix the years decades of dopamine misuse or honestly dopamine abuse that I've done to my own body. I've tried a lot of things. I still try them to this day but for many of us the only thing that will fix it is continued use of an opioid and that's why we don't have any business telling people how long they should be on this medication. In fact if they want to spend the rest of their life on it yay stay on it we'll monitor it we'll help you through whatever you need to. It's not our business and it's not our show to tell people when they should come off so no time limits ever on something like using MAT. If we miss that I will tell you that that person will think all the time about when that dates coming and if you want to talk about anxiety I don't care if it's three years from now that person's going to be nervous right away and as we get closer and closer it's going to get worse and worse. When we talked about when we watched this just a minute ago and we saw what buprenorphine does it partially fills the receptors they also include in suboxone not all buprenorphine but in the brand suboxone there is naltrexone in that and naltrexone or naloxone I'm really sorry it's been about two months since I did this and I've had some personal issues so I apologize for that had a bad death in our family. In any event buprenorphine has a narcan like blocker so that you can only get to a certain plateau and if you use another opioid with it you're not going to feel it that's super helpful. Methadone full on agonist meaning it brings on the full benefit and the full power and if you use other opioids you know you can contribute to it usually can hold off it's tightly bound to the opioid receptors in the brain but you do enough and you can overdose on methadone as well and then naltrexone is just a it's what we used to treat alcohol use disorder with I still do and it just completely blocks any opioid from hitting those receptor sites that's a big criminal justice favorite but we know that the evidence says it's really not it's really doesn't work very well I won't say it's a complete failure because it's not but in terms of comparison to buprenorphine or methadone yeah it doesn't really hold a candle and then Jenny that's awesome thank you and Sarah I guess what I would say about being you know having that rewired you can there's a great video and I used to share it all the time and it showed how the the pathway from and it was you know it was layman eyes to relay person eyes so that we could all understand it but it would it showed how the amygdala controls X it you know it hits the nucleus accumbens and I may have gotten that wrong it's been a long time since I had A&P and how that you know influences it and then how the pathway goes up to the grown-up in the head that you know that that right parietal region that you know controls your actually I think it's the left but in any event it's where the grown-up the rational thought lives and rational person in you can stave this off for a little while but it doesn't take long and it gets overwhelmed and then we just silence it and throw it in the corner and that loop is in place and it's very similar to what happens with trauma very similar I that was a real you know layperson explanation Sarah but you know if you do a little bit of more diving on it you'll see everything I just told you is really accurate and it's pretty straightforward cognizant of the time folks and I want to make sure I get through all this so let me let me kind of move us a little bit quicker I can I'm a benefit of Matt you know I've been in recovery 24 years 25 years now and I finished my master's degree you own the home have been married for 20 plus years that poor woman she's put up with me through all of this amazing you know I'm 65 years old I've lived 10 years now longer than most of my brothers and sisters of my history I'm you know look at the benefits I've had I'm healthy got it I had hep C I got that treated I haven't used an illegal drug in 25 years that don't have any infectious disease and boy do I bring hope to people who struggle because I did it they can do it they may have a different pathway we can do this and when we do we can go on to do great things and some of those great things are supporting our brothers and sisters who are still behind us struggling tons of benefits let me just say something real quick about MOU D please don't use that term I know it's the popular one but I'll tell you why I don't use it because MOU D Jennifer sort of and it's getting increasingly available but the big one that they use for you know in jail particularly in prison and in re-entry is naltrexone which is the full opioid blocker we know that's worthless in many cases and it's why we're seeing more and more influx of MAT into jails and give me one second here folks Sarah that's really kind you let me say that with MAT versus MOU D when you call it MOU D and you say that's a person with an you know with MOU D you've outed me you've outed me with an opioid use disorder if you say you know as a person using MAT I could have an alcohol use disorder doesn't have to be an opioid use disorder not your business to out me there's a HIPAA violation in that and finally it is outdated it's already MOU C now if you want to use it that way I don't and that's why nothing about us without us had they asked us we'd have told them right away before they you know went hogwild and sent it out everywhere I don't use it I hope you guys will take this to heart and you know you're gonna be forced into using it sometimes just remember what I told you about it please don't don't use it on a person so there's a whole bunch of myths with MAT everything from it that you know it rots your teeth that gets in your bones and pregnant women can't have it all of that is crap none of that is true and we know that MAT is the gold standard and you know it is successful far so beyond abstinence only treatments you can see right off the bat that you know MAT treatment holds folks around 61% versus 20% with that abstinence only behavioral intervention and if you look at the you know the text on the slide I think that you know for me the bigger piece of all this 50% managing that opioid use versus 7% I did I white knuckled so many times in a narcotics anonymous program and I could never do it and I was always shamed shame shame shame was thrown out of meetings and to this day I have nothing but respect for my 12 step brothers and sisters and I know that they're bringing you know MAT in to heart because they recognize the value but it really harmed me really harmed me that stigma from the recovery community it's terrible it's terrible because that's our tribe right and so when their stigmas I can take it from all of you if you're not part of my tribe apps you don't know but from them it really really matters okay MAT treatment is the gold standard if you want to keep people in recovery in treatment you know with an opioid use condition you're gonna be a lot better off if you can get them on medication indefinitely it's up to them okay a word about diversion because this freaks everybody out I am telling you I have used MAT for 20 years the only time I've ever even thought about diverting one dose because I know I'm gonna go sick if I don't take that dose is when I couldn't afford to pay the monthly clinic fee and when I was in that clinic it was four hundred and sixty dollars a month and they basically didn't take my insurance so if I could hardly afford that and I had a job and so did my wife I don't know how many of my brothers sisters would ever afford that so when we think about folks who are diverting drugs it's not nearly as common as I think folks might think it is and when it comes to buprenorphine especially the vast majority of misuse is to control withdrawal not to get high and buprenorphine is a terrible opioid high I know because I've experienced it terrible the NIDA National Institute on Drug Abuse says that is not a reason not to prescribe and make buprenorphine available I talked a little bit about this already that we know that you know we know what polysubstance use we also know that OUD has the highest mortality the reason I bring up co-occurring disorders is because when people have a co-occurring disorder they are more likely to use some of these substances and the substances are more likely to trigger some of the mental health issues doesn't mean it happens all the time I'm just saying that you know a co-occurring disorder they often go hand in hand I certainly have that and you know they they combine to drive both the behaviors in ways that if we didn't have that you know we wouldn't be as susceptible it's just important to recognize if somebody's got a substance use and a mental health issue you know they they need a little bit more intensive full person care so what works well we talked a little bit about it but whole person care we need medications for addiction treatment we want the therapy gotta have it I mean that was so so helpful self-help mutual help for some of us I do not do groups I don't want to be around people like like myself it's just a personal preference because I am a person with an addiction and I don't need any and I don't need any temptation period we do recovery-oriented activities because that brings us into the culture of recovery we rely on peer support regardless of the level that we've reached we practice and believe in harm reduction and we use motivational interviewing because MI allows us to make the decision not you and that's really important you know if I tell you to change that guy's crazy but if I tell myself I've got to change you know probably more apt to do that we want to reduce that harm we want to make sure that the provider and the person work together not the expert telling the person what's wrong we want to come at this whole person physical mental psychosocial living environment education employment incarceration history you name it we want to know it and the goal restore folks back to their their you know their most productive and satisfying life that we can bring them and that's what whole person care is right that's what I'm speaking of we respect the person because they're far more than addict or you know schizophrenic or you know whatever other pejorative term you want to use we look at the person in context because we know that you know what we're seeing right now is a snapshot and there is a huge big life around this person behind them we know that a person's mental health can be negatively impacted by harmful beliefs seeing that stigma over and over and we know that a person's overall health can be impacted by negative social challenges you know live in a you know in a homeless camp for a while under a bridge and tell me how how you know how healthy you are recognize that our overall health is positively influenced by healthy social causes and this is where social determinants of health really come in we need to be tailored and unique and individualized and importantly community specific because what happens in your community may not be going on in mine we need a team not a person not a case manager we need a team and it that team needs to be multidisciplinary and it must include a peer it has to include a peer sorry guys and then we meet and support people where they're at not where we wish they were at where they think they need to be where they are at because if you don't I don't have time for you you don't know me and you don't know my situation so this is just you know when I think about my own history the worst impact of all my drug use it wasn't the use you guys I mean you can see me in front of you you know I still have a few firing brain cells and look pretty healthy I hope it was how I was treated because of that use and you can see every almost everything here perpetuated that drug use because it was too painful too hard to get out of it was just too hard to get out of yeah I know Sarah you're right you're right so no bystanding we need to shout this stuff this is on us right they're not going to change if we don't come to the table demanding it right because there's too much money here but I'm totally with you that wraparound service model that whole person care you know okay so we'll just continue on with four percent success in treatment and watch our brothers and sisters die like flies out there is that what the insurance company wants maybe because it keeps the cost down I mean it's horrible to say stuff like that but good lord I'm becoming kind of jaded today I've seen a lot of people die unnecessarily and with that I want to leave you guys with this and before we all exit there is a survey that's different and we need you to fill that puppy out because if without it we Emily and I may not get paid to come back we'll still come I promise but they may not pay us okay so let's watch this video I'll let you get the heck out of here as soon as you're done with that survey and I want to thank you guys for just putting up with me for the last hour and a half Come on, baby. If there's captions, can you get captions on, Steven? So I know there's an option earlier. Thank you. See if we can pull it off. This is the best video to finish with. I'm so sorry, you guys. I don't know why it's not gonna play for me. All right. Oh, yes. And Jay, you absolutely can. Hey, maybe we got lucky. My name is not those people. I am a loving woman, a mother in pain, giving birth to the future where my babies have the same chance to thrive as anyone. My name is not inadequate. I did not make my husband leave us. He chose to and chooses not to pay child support. Truth is, though, there isn't a job base for all fathers to support their families. While society turns its head, my children pay the price. My name is not problem and case to be managed. I am a capable human being and citizen, not a client. The social service system can never replace the compassion and concern of loving grandparents, aunts, uncles, fathers, cousins, community, all the bonded people who need to be but are not present to bring children forward to their potential. My name is not lazy, dependent, welfare mother. If the unwaged work of parenting, homemaking, and community building are factored into the gross domestic product, my work would have untold value. And I wonder why my middle-class sisters, whose husbands support them to raise their children, are glorified and they don't get called lazy and dependent. My name is not ignorant, dumb, or uneducated. I live with an income of $621 and $169 in food stamps. Rent is $585, at least $36 a month to live on. I am such a genius at surviving that I could balance the state budget in an hour. Nevermind that there is a lack of living wage jobs. Nevermind that it's impossible to be the sole emotional, social, and economic support to a family. Nevermind that parents are losing their children to the gangs, drugs, stealing, prostitution, social workers, kidnapping, the streets, the predator. Forget about putting money into our schools. Just build more prisons. My name is not lay down and die quietly. My love is powerful, and my urge to keep my children alive will never stop. All children need homes and people who love them. They need safety and the chance to be the people they were born to be. The wind will stop before I let my children become a statistic, before you give in to the urge to blame me, the blame that lets us go blind and annoying, and to the isolation that disconnects us. Take another look. Don't go away, for I am not the problem, but the solution. But the solution, and my name is not those people. You guys, I've watched that 101 times in my life, and at least, and I still tear right up, right up. And I saw the kind words. I can't respond in the chat because it'll shut the video down, and it's kind of a drag to get it started. And I'll make sure you guys get the links. I think this deck is gonna be available to you anyway. I sure hope it is. And you guys, you've been really, really kind in your compliments and your praise. And I'm really humbled, and I'll come back anytime. Deanne knows that, and Emily knows that. So any way I can help, I'll be back. So thank you guys. I just put that link to the video in the chat. I also pasted the QR code and the survey link. I can repost the survey link if it was a bit behind in the chat. Oh, and there was somebody who asked me if they could send me a couple. Hey, listen, you guys, send me any questions you want. I'm not sure if you have my email address. I can pop it into the chat real quick if I need to. Bear with me a minute. Got to get it right, because otherwise, you'll be all ticked off, and I didn't respond. There we go. Yeah, feel free, if you've got questions, if you've got comments, if you want to talk a little bit more about it. I do a lot of personal stuff around this, too, because a lot of families and a lot of folks won't raise it in a session like this, but you should see how many people I mentor after this, after I do trainings like this, because I know how difficult it is. I know how difficult it is for folks to watch a loved one struggle and potentially die, and many of us have. So again, thank you, guys. And do that survey. My gosh. Yes, and I think folks should have been able to scan it now or click the link, so we can go ahead and close. Does anyone have any final questions they want to ask or anything else? Oh, you guys are killing me, man. Your comments are beautiful. Thank you. It's really kind. Okay, looks like there's no more questions. So thank you all for joining us today. And thank you so much, Steven, for another engaging, wonderful presentation. Like I had mentioned at the start, the recording will be available in about a week or so. You can always revisit it and then it can be shared with anyone who wasn't able to attend. But we really appreciate you all joining us and making time for this.

Opioid Response Network

substance use disorder

harm reduction

polysubstance use

Naloxone

overdose prevention

stigma and language

neurobiology of addiction

medication-assisted treatment

whole-person care

cultural competence

social justice