So hi everyone, my name is Emily Mossberg and I am a technology transfer specialist with the Opioid Response Network. Before we start today's training, I'm just going to briefly share some information about the Opioid Response Network and the work that we do. So the Opioid Response Network was initiated back in 2018 in response to the opioid crisis in our country. We are funded by a grant from SAMHSA to provide no-cost training and consultation to enhance prevention, treatment, recovery, and harm reduction efforts across the nation. And to do this work, we utilize a pool of consultants who are located all over the country and who can respond to local needs. And we do operate on a request basis, which just means that anyone can submit a request for assistance on our website at opioidresponsenetwork.org. All right, and today we are honored to be here with you to provide training on substance use disorders, stigma, and harm reduction, specifically among individuals with intellectual or developmental disabilities. And I do want to address a couple of housekeeping items first, so please note that this session is being recorded and it will be available for sharing within about two weeks. And at the end of today's training, we will be sharing a link to a quick evaluation survey and we very greatly appreciate your taking a minute to complete that before we leave today. It does help us maintain funding to continue to provide free training. Lastly, we will be taking a break about halfway through, and we also encourage you to ask any questions as they come up, so you can feel free to put any questions in the chat or you can raise your hand, just whenever you have a question, feel free to share it. You don't have to wait to the end. I will now go ahead and introduce our trainer for today, Lorian Eldridge. Lorian is an assistant professor at East Carolina University in North Carolina and a public health implementation scientist. Her research is designed to bridge the gap between research and practice by the translation of empirical evidence into evidence-based curriculums, interventions, and the establishment of policy change. She focuses on how the impact of laws, policies, regulations, access to services, and healthcare delivery are affected by social determinants of health. Her research has been influenced from 16 years of professional applied experience with individuals with comorbid diagnoses of mental health, physical and intellectual disabilities, and substance use disorders. Thank you, Lorian, for being with us today, and I'll go ahead and pass it over to you. Thank you. I'm going to get this screen and share the presentation so everyone can see it. And I want to just thank everybody for being here today. As we shared earlier, please just, if you have a question, a comment, or have anything to say, please just put it in the chat, unmute yourself and start talking. There's just a few of us here today, and so I would like for this to be as interactive as possible, and I'd like to hear from your experiences as well. And there's a big mouthful in that bio, but I want to share that, in very simple terms, is that my work is based on the experiences that I had in working with people that have substance use disorder and intellectual disability and mental health diagnosis. I worked in the field for 16 years before transitioning into an academic role at a university. And so my work, and the reason why I transitioned into the academic environment is because there was really not much work happening in this area, and I knew that the people that I were working with were struggling to find resources, trainings like this, and other materials to help our clients. And so my real goal is, when I'm doing these trainings, is that we're able to take this information, pick something, one thing out of what we talk about today, and start using it in your day-to-day practice. And that's where that implementation comes in. I'm going to talk about a lot of different things, but I just think if we pick one thing, sometimes when we go to trainings and we learn things, it's like, all this stuff sounds great, and it seems very overwhelming, but I think that there's a lot of power in the fact that we can just have very significant change with making one, just picking one thing. And so we're going to talk about that today. I'm going to give you some ideas. The first part of this training will be regarding stigma and the intersection of substance use disorder and intellectual disabilities. As Emily mentioned, we'll take about a five-minute break, and I will bring up our next presentation, which will focus more on substance use and the intersection of intellectual disabilities. So if you do want to contact the ORN, here is their contact information, take a screenshot. Again, it's going to be recorded, so you will have this information as well, or if you have any questions or anything and you want to reach out to them, there's the ORN contact information. Before we start, I like to always start off my presentations with kind of defining some terms so that we're all on the same page. Now, some of these terms you're probably really familiar with. You guys are providers in working with people with intellectual and developmental disabilities. But I think it's really important that we are all on the same page when we start. And so I'm going to define a few terms that will guide this presentation and our next presentation as well. All right. So intellectual disability, this affects the cognitive functioning, such as learning, problem solving, and judgment. It also affects the adaptive functioning, such as activities of daily living, communication skills, social relationships. It occurs prior to the age of 18 and the early developmental years. And I'm not going to go into great detail about intellectual disability, but we have a base understanding. We're very familiar with this term and this diagnosis. And then we have a cognitive disability. So cognition is different than intelligence. Often cognition and intelligence are used synonymously, but they're very different. And cognition refers to the person's ability to think, learn, remember, use judgment, and make decisions. And intelligence refers to the person's capacity to learn and understand the information. And so it's important to remember that some cognitive disabilities may affect a person's intelligence, but this isn't always the case. So there's lots and lots of examples of cognitive disabilities. Intellectual disability falls in that. Autism spectrum disorder, aphasia, attention deficit, hyperactivity, dyslexia, dementia, traumatic brain injuries, stroke, and even persistent mental illness. So these are all examples of cognitive disabilities. Now, it is important, for example, a person diagnosed, let's say, with ADHD or dyslexia may not have an intellectual disability, but they may have a cognitive disability. And this means that the person's ability to learn the material may be affected, but it does not mean that the person's unable to learn that material. And so when we're thinking about a cognitive disability, we want to make sure that we're not using it in the same way as that cognition and intelligence are two separate things. And when we're thinking about cognitive disabilities, again, this may help. This may affect memory loss, trouble concentrating, completing tasks, difficulty remembering, following directions, and problem solving. Again, someone with an intellectual disability, they're going to have a cognitive disability. And it may affect those areas of their life. You may have heard this term, neurodivergent. This is a non-medical term that describes people whose brains develop or work differently for some reason. This means a person has different strengths or struggles from people whose brains develop in a more typical manner. While some people who are neurodivergent do have a medical diagnosis, it also happens that people where the medical condition or diagnosis hasn't been identified or they don't have one. And you may find that some people you work with will prefer the term neurodivergent versus a medical diagnosis or term. Some of the people that I worked with, they had an intellectual disability, but they would prefer to use the term neurodivergent. Often related to stigma, which we'll talk about. And we will be talking about substance use disorder. And substance use disorder is a medical diagnosis that affects the person's brain and their behavior. And someone with substance use disorder is not able to control their use of drugs or alcohol, even when it causes problems in their health, in their work, in their school, in their home, and all in relationships. And there are many different ways in which a person may experience a substance use disorder, but most commonly it's related to having issues related to health, work, school, home, and relationships. We'll be talking about health literacy. And health literacy is defined by Healthy People 2020 as the degree to which individuals have the capacity to obtain, process, and understand health information. And then to make appropriate decisions about their health. So as providers and as people that are engaging in care with people that have an intellectual disability, it's really our responsibility to assess their level of health literacy and to find out what is the best way for them to obtain information about their health? How are they processing it? Is it better to have pictures? Do we need to repeat it over and over? Do we need to do role play? Do we need to have a time where we process one-on-one? Do we do it better in a group? So all these things, when we're working with an individual, we want to know how does the individual process this information and to help them understand it, right? And a great way to assess health literacy when an individual with an intellectual disability is engaging in health is to ask them, what are you going to do with this information? And by asking that question, you're assessing at that point, are they able to make appropriate health decisions, right? And if they're understanding that information and understanding from their words, right, of what they're going to do with the information that they've received. So let's talk a little bit about some current research on the intersection of substance use and intellectual and developmental disability. So people with intellectual disabilities, cognitive disabilities, they have a higher rate of psychopathology than their counterparts. And this displays in higher risks and rates of dual diagnosis of substance use and mental health diagnosis. So what is shown from the research is that individuals that have intellectual and developmental disabilities, when they're engaging in substance use, they have a higher likelihood of also having a mental health diagnosis than an individual that did not have an intellectual disability that was engaging in the same substance, okay? People with intellectual disabilities may have a higher risk of developing a substance use disorder because their brains are maybe developed differently. And they often experience more adverse effects from the use of substances. And there's really a lack of substance use disorder treatment, prevention, recovery, and harm reduction programs that are serving this population. And overall, there's really an insignificant amount of research on this topic. There's a little bit of research happening in Europe, but other than that, there's a few of us here in the U.S. that are really trying to, you know, pound our drum and get some stuff going here as well in the United States. Because we know because of our practice experience that this is happening, that people with intellectual and developmental disabilities are using substances. And often, they are not being identified as using substances until it's really in a crisis situation. Mental health is being involved or the justice department. So, let's talk about stigma a little bit and what stigma is. And we're going to go through the next few slides and talk about this diagram, attitudes, behavior, stereotyping, prejudice, and discrimination. And what I'm going to do through this is that we are going to discuss how these five items may contribute to a person having a strong feeling or contribute to stigmatizing behaviors. We will provide a definition for each of these and an example. And I'd like to, you know, just make note that the examples that I'm sharing with you today were obtained from focus groups that I held with people who had intellectual disability who were receiving substance use disorder treatment. So, every example that I share with you is from a person with lived experience. These were not made up. These were actual examples that were given to me when I was developing this training. And I think it's really important that we hear their voice. And as we're going through this, these next few slides, I'd like for you to think about your clients and think about how stigma has shaped their behavior and how they navigate things maybe a little differently because of the stigma in which they're experiencing. We're going to first talk about attitude. When we talk about stigma, we usually associate it with an attitude a person has. An attitude is a way of feeling or acting towards a person, a thing, or a situation. It is the set of emotions, beliefs, and behaviors towards a particular object or a person, thing, or event such as a love of a sport or a dislike of a color or being negative towards something that you need to do. And here's an example of attitude. Quote, if I share my diagnosis, people will think differently about me. This person thinks that if they share their diagnosis, that there will be an emotional reaction. The person believes sharing will affect the way they are treated due to prior established positive or negative beliefs that they've learned. And behavior, we usually associate behavior with stigma, with certain behaviors. A person performs a behavior is how someone acts. It is what a person does to make something happen or to change or to keep things the same way. Often, you guys are probably very familiar with behavior. I'm sure you work with ABCs. And when we talk about behavior, we know that we are, you know, a lot of times, individuals, we engage in behavior because we want something to happen, right? We want something to keep happening. We want something to change. We're trying to get something to happen. So, behavior is a response to things that are happening around us. And this can occur either internally, such as in our thoughts, our feelings, or externally. And so, behavior is a response to things that are happening around us. So, our thoughts, our feelings, or externally, in our environment, including other people. And an example of behavior is, quote, my mom is overprotective of me because of my disability. And this person really believes internally that their mom is acting very protectively because of their disability. And this person thinks that the environment in which they are living is being adapted to prevent them from experiencing their full independence. Stigma is usually associated with stereotype, stereotyping. And stereotyping is when we overgeneralize what we believe about a person or a group of people based on what we have been taught or seen. And stereotypes can be hurtful because they're usually not true. Here's an example of stereotype. Quote, people with disabilities can't read. This is simply not true. This is a stereotype, opinion, formed on uneducated, not well-informed guests. I just have to say that in my practice experience working with individuals that had ID and substance use disorder, majority of them actually were able to read. And cognition was a problem. And so that was one thing that we really worked on. But they were able to read. And so this is definitely one of those stereotypes that people have about people that have an intellectual disability. A prejudice. Stereotypes can lead to prejudice. And prejudice is believing those stereotypes and disliking others without knowing them. And so people who are prejudiced have a negative or even an aggressive attitude towards a particular group for no reason. So here's an example of prejudice. Quote, they put us on the back burner. This person thinks that all people with disabilities are not important. Now, this might be just this person's internal or subjective attitude. But nevertheless, it has been informed by actions that have been observed towards them or towards the group of people they identify with. And this person believes that other stereotypes are causing this action and are identifying these activities as prejudice. All right. Discrimination. So other words or actions that can help define stigma are discrimination. Now, we must understand that the word discrimination means identifying differences between objects and sounds and colors. And discrimination can be harmful when we discriminate against an entire group of people with that same trait, such as age, gender, race, religion, or disability. All right. And so here's an example of discrimination. Quote, people think differently about me. They put me down. I have to work harder to be accepted by them. End quote. This person is experiencing being excluded because of their disability. Because of their disability. They feel they need to prove themselves constantly to be respected and valued. They must work much harder to earn respect in their community than people without disabilities. And they have been discriminated because of their disability. So stigma is when people have a strong feeling of disapproval or something about something. And sometimes these opinions can lead to behavior. We just discussed examples of attitude, behavior, stereotyping, prejudice, and discrimination. And we shared how these five items may contribute to a person having a strong feeling of disapproval or how they may contribute to stigmatizing behavior. All of these examples, attitude, behavior, stereotyping, prejudice, and discrimination are part of what makes up stigma. So what I'd like us to do is I'd like for you guys to take just like about 60 seconds here. And I want you to think about one or two examples that fall into either attitude, behavior, stereotype, prejudice, and discrimination that you've experienced in your workplace with your clients. And I'd like for us to share back. So I'd like for you can unmute. You can put it in the chat. And just share with us what your experiences have been regarding stigma in your clients. And Emily, I am not able to see the chat. So if somebody puts something in the chat, if you could read it out, that'd be great. Absolutely. Thank you. And you can also unmute. So we'll give you guys about 60 seconds, and then we'll come back and share. All right, so we'll get started. Was there anything in the chat that was shared? From Chloe, she said, being fired from their jobs without proper notice. They don't do the full protocol when letting someone go. Okay. So termination from employment, not following the typical protocol. Chloe, I'm going to ask some clarification. Would you say, like, in a typical position, they may receive some notice, like they might get written up, and then maybe they'll receive some kind of performance improvement plan, and that did not happen? Yeah, that's correct. Okay. Yeah, that's a great example. Do we have any other examples in the chat? I wish I could see the... Maybe I can see the chat. No. Oh, here we go. There we go. I'm not seeing anything else. Okay, great. Okay. All right, well, I'm just going to call on people. This is interactive, so unless somebody wants to unmute and share, but I see everybody's name, so I'll just kind of call on you. We'll have other opportunities, so I'll just call on a couple of you right now, and when we do some other opportunities, I will call on other people. So, Christina, you are one of the first names. Christina, were you able to think of any ideas or examples of stigma that you've experienced or witnessed with the individuals that you're working with? Are you there, Christina? Okay. We'll go up here to Bernard. Bernard, do you have any examples of stigma that you've witnessed that your clients have experienced? That you've experienced that your clients have ... that you've witnessed that your clients have experienced? Here, I'm going to ... I'm going to ... You're muted right now. There you go. Hi. Not really, but at times, the stigma I have seen is like when somebody is in that state, kind of becoming ugly in some things. When you ask questions, he feels like you are threatening him or something. Okay. Okay. So, asking when you're engaging with your clients and they become agitated with the questions being asked. Okay. Okay. And that may be kind of what one of my clients shared with me, which was they were feeling like their mother was being overprotective and they weren't able to experience their full kind of freedoms in life, right? And so, that might be ... And that can be related to maybe some of these experiences with prejudice or what they feel like they're having to, as my client shared in one of these quotes, they had to continue to prove themselves over and over again and they had to work harder to have people trust them or believe them. And so, I think it's really important that each of you, as you move forward, you think about the stigma related to intellectual disability. These individuals that I interviewed had intellectual disability. They also had substance use disorder and they were experiencing stigma. As you can see, they talked about it very clearly. These few slides that I shared were developed specifically for people like you guys that were working with clients to go back and share with your clients about stigma. The information is simple. It was developed in clear language with examples so that individuals that have intellectual disability have the opportunity to talk about how stigma is affecting them in their day-to-day life. We also got some comments or example of going to a store and one of the cashiers doesn't want to serve her because she had previously been in confrontation. Yeah, that's a great example. That is an excellent example. So, they've had this maybe experience before and now every time you go in, even if it was with that person or another person, they may feel like, we don't want to engage. How many of you guys, I'm sure that being discriminated by your race is a big deal. Being discriminated by your race, yes, race is another way of discrimination that can happen. And imagine an individual that has an intellectual disability and is navigating that stigma along with race, right? There's a lot that they have to navigate with that. How many of you guys have attended, just raise your hand, a doctor's appointment with your client? So, just go ahead and raise your hand if you've attended a doctor's appointment. I'm gonna raise my hand, I've been to hundreds of them. Okay, Chloe's raising her hand. Okay, I'm not seeing anybody raise your hand. Okay, Bernard, thank you. There is a hand emoji, there you go, Cassandra, thank you. Pearl, have you ever gone to a doctor's appointment? Christina, Elizabeth, is it Elizabeth? If you guys have gone to a doctor's appointment, which I'm assuming that you have, and Josephine, I see Josephine there too. How many times has the care provider spoke to you and not the client? I can tell you that happened almost every single time. And the doctor, that would be, I'm sorry, say it again. Oh, okay. Frequently, sorry. Frequently, yes, frequently, yes, frequently, right? And I would often remind the healthcare provider, the appointment is for X and I would gesture to them. I'm here to add their advocate and to help support them. And remember that word, that definition I gave you, that health literacy, that's why I was there because I wanted to make sure that we could work through and that they were able to understand and make decisions about their health. And we know that doctors are very busy, PAs, nursing, I mean, healthcare is busy, but oftentimes the action would be directed towards the care provider and not the client. And that is a part of stigma as well. And so we wanna make sure that we're recognizing when this stigma is happening and it's happening often in our clients' lives, which then affects their behaviors, okay? All right, we're going to talk a little bit about developing these pathways of care. We just gave that example of engaging with healthcare providers and kind of what that experience is, but we're gonna talk about specifically with substance use disorder, how we can improve access to care. And then a few slides, we're all gonna engage, okay? So just get prepared, everybody that's here, I'm gonna show you some videos, you guys can put on your cameras and we're gonna talk for a little bit and just a few slides. So one of the things that I wanted to share is that I recently did an assessment of services in the state of California for people with intellectual and developmental disabilities. And looking at substance use disorder treatment, okay? And what we found in this assessment, and I looked for the entire state, is that often the providers that are providing substance use disorder treatment, when I asked them about the accommodations that were being offered to all clients, not just people with intellectual disabilities, but to everybody, what kind of accommodations do you have? They often talked about ramps, handrails, lighting, modified bathrooms. And so they talked about physical access. So physical adaptations, and those were great, they were providing those, often because by the law of ADA, they were required to do that, right? But when I dug in and I said, what about procedures, policies, or adaptions related to cognitive abilities? Now, we know that individuals with substance use disorder may have cognitive disabilities. We also know that people that have mental health may have cognitive disabilities, okay? We know that people with intellectual disabilities have cognitive disabilities. So you put them all together, right? So these are people that are providing substance use disorder treatment, and they're like, well, we don't have that. And that was across the board. Now, this isn't just the case for California. The little work that we've done in the United States has shown that this is not unique, and that this is happening in multiple states, and that very few, very few organizations across the United States are actually making cognitive adaptions for treatment for substance use disorder. And so, we know that these services, and the language that we use, we talk about tailored care, meaning that it's person-specific, or that we're looking at the individual's strengths, and we're creating a care plan that's going to build on those strengths, right? And unfortunately, in the substance use disorder treatment world, that's not happening. And so, one of the things that we want to do as care providers is to be able to advocate for those things to happen, and to be able to help provide some resources to our substance use disorder providers so that they can have the skills to do this. When I talk to care providers in the IDD world, they're often telling me, well, I don't know about substance use disorder. That was not an area that I, I mean, that's not what I do. That's not my focus. And then when I talk to people that are in the substance use disorder arena, they're saying, well, I don't know about intellectual disability. I don't know about cognitive disabilities. I don't know what adaptions to make. I wasn't trained in that. And so, one of the things that, a key thing that we should do is to kind of come together and hold hands a little bit and be able to share what works. And so, if we do have a client that we are working with that has a substance use disorder diagnosis, it's really key that we work with our providers to be able to provide some information about how individuals may learn better, how they understand and receive information. And that goes right along with health literacy. So, this is a great tool that we can use with our clients. If we are assisting them and advocating an appointment, we can help build on their health literacy. And so, health literacy is a great way to improve access to care. And health literacy is vital for all people, for you, for me, and for our clients. If people do not know how to obtain or process or understand, or even know how to act on the information that they're giving to them, then the person is not receiving equitable care or prevention, treatment, harm reduction services and substance use, right? So, if they don't know how to access, they don't know how to process, obtain, they don't know how to apply the information, it's not equitable, okay? And that's really important for us to know. Just because we drop them off at a AA meeting, or we drop them off and we sit with them during a substance use group meeting, if they are not able to apply that information, then that care is not equitable, okay? So, as providers, we really have this responsibility to provide information about the person's health that they understand and they comprehend. And so, one way that we can do that is to use health literacy. And to assess how the client understands the information. And it's done really simply. As I mentioned, I would ask very, very simply, how are you gonna use the information that we talked about today? Or what are you gonna do with X, right? Whatever the topic was or the information they were learning. How are you gonna use it? And then, that's a great way for us to be able to understand their understanding. So, if we were in, for example, if we were conducting, when we were conducting focus groups, as I mentioned in the development of this presentation, we engaged with individuals that had intellectual disability and substance use disorder. They were in treatment and they went through all these slides with us. We talked about it. They helped us develop this presentation. So, in that focus group, we were talking with people and one person shared with us, and this is their quote, they said, I get intimidated to ask for help because I don't want people to think I'm dumb. And this is very important for us to know. So, if our clients are going into substance use disorder treatment programs, which are often group-based, and they are sitting in a group and they are expected to engage and process and understand what is happening in this group, they may feel uncomfortable asking for clarification. They may feel uncomfortable asking for help. As this person said, I don't want people to think I'm dumb, which goes right back to that stigma. Remember when they were talking about, people put me down, discrimination, people put me down. I have to be able to say, people put me down. I have to work harder to be accepted by them so that it goes directly with stigma in the way that they interact with their healthcare. So, as an advocate, as a care provider, one of the things that we can do is to help them understand, have them ask you questions, right? And a great way is to find out from our group providers, what's next week's topics or what's tomorrow's topic and work with them for the next little bit so that they can engage in their health and in the group appropriately. So, this quote really is important. It reminds us to ask questions and to determine the person's understanding of the information we're providing. If we're having a very serious group and they're talking about, let's say, they're talking about decreasing the use of alcohol, okay? And they have a whole group session about decreasing alcohol use and the harms of alcohol on our body. And then at the end of the session, I ask them, so, what are you gonna do with the information that we talked about today? And they say, well, I think I'm gonna go get a hamburger. Yeah, I'm gonna go get a hamburger. Well, clearly, maybe something's missed here. So, we need to find out what that is. Is it that they want to change the subject, they don't wanna talk about it, they're hungry? Or is it really like they didn't understand that health information and they're not sure how to apply it? And then if that's the case, then we need to do some more work. And then another way that we can help and we can work with our substance use disorder providers is improving access. So we can improve access to substance use disorder prevention, treatment, harm reduction services for people with intellectual disabilities by really exploring a person's lived experience. So we want to include people with intellectual disabilities in the development and we wanna seek feedback from them when we're developing policies and interventions. So the goal should really be to create a space where a person can be heard so that the services can be tailored for that population. Additionally, ways to increase inclusivity are not to make assumptions about a person's abilities based on a diagnosis or the way they look. As I mentioned, majority of my clients could read. If somebody saw that they had a diagnosis of an intellectual disability, they may make an assumption. Oh, well, this person can't read or this or that. And that was just simply not true for the people that I worked with. And it's important to remember that intellectual disability cannot be diagnosed by looking at somebody. And often when people are going to a substance use disorder program, it is the client's responsibility basically to share what they want to share about their diagnosis. So they may not share that they have an intellectual disability. They may not share that. Language is really powerful. And we really wanna think about the language that we use and how we use it. One of the things that we can do is attend trainings kind of like this and that talks about improving inclusivity and disability. If you have some clients that are going to a substance use disorder treatment program, you could offer and say, hey, can I do a training on intellectual disability for your staff? Knowing that the staff that are working in substance use disorder programming most likely have not received a lot of training on intellectual disability or even cognitive disabilities. And so they would probably be really grateful to know how can I improve the care that I'm giving and improve the treatment that I'm giving to the clients that I'm serving. Really, when we're able to do these trainings, it really helps to improve our ability to recognize and adapt services as needed. If we need to. So we also wanna address stigma. And so stigma has been linked to clients not accessing services and due to having a disability and a substance use disorder. So studies have shown over and over again that people who are experiencing stigma, and so those are all of your clients, if they have an intellectual disability, there's stigma. If you have someone who has a substance use disorder and an intellectual disability, you got a couple levels of stigma there. Yeah, throw mental health diagnosis in there, you got some more stigma. So it's really feasible to assume that many of our clients are not accessing services, okay? So we can assume that they're just refusing services, not accessing services, not engaging in services related to stigma. And stigma can really affect the provider's attitudes and behaviors towards others. Even us as care providers in the field that we're working with, we have stigma and we should address it, we should look at it. We should look at ourselves in the mirror and say, how am I engaging with the clients that I'm serving? Am I engaging in stigma behavior? Kind of like what we just talked about in those examples. Do my clients have to work hard every single day to prove themselves to me? Am I very overprotective and not allowing them to experience life in the fullest? Do I have judgments about them? Do I feel that they can't function in society? These are all things and questions that we should be asking ourselves over and over again. One common stigma that's related specifically to individuals that are engaging in care with individuals with intellectual disability is infantilization. And this is when we treat someone like a child or we deny their maturity of age. So we may talk to them like they're a baby or even a child. We address, the example I said earlier, we address the care attendant versus the person directly. We do tasks for them without being asked. We just go ahead and do it. We don't have them ask for help. We just take care of it. We just do it. That's stigma. We're not allowing the person to express their emotions or we are not allowing the person to express and engage in life experiences. For example, maybe on their 21st birthday, they do wanna go out and have a drink at a bar. That's a very normal behavior in the US for people who are turning 20. Or they wanna have a sexual relationship with someone that they care about. And we are denying that. We tell them that they cannot swear or say a cuss word. They can't smoke. They can't go on dates. They can't go to the mall. They can't ride the bus. We put all these limits around individuals with intellectual disability. We put all these limits on them. We put all these limits around individuals with intellectual disability. And this is often related to, as I said, infantilization and that's based in stigma. So think about that. Think about yourself and it can be difficult when we think about it. We're like, oh, yeah, I have done that. I've done that. But it's time to think about that and to make some changes in the way that we engage with our clients. There's really a, during our focus group, one of the individuals shared about their overprotective parent. And they said this, quote, this is part of stigma. She worries too much. It makes me feel like I can't do things on my own. I am an adult. My family feels I can't make proper decisions about my life. And so again, that's all. This is, again, that feeling of not being able to experience life. So what do we do? How do we take action? So some of the ways that we can take action are to build awareness about substance use disorder treatment, building awareness about substance use disorder treatment and intellectual disability is a really important first step. So we address biases towards disability. That's a really great start that we can talk about. Again, when we have a client that has a substance use disorder diagnosis, the individuals that are providing care may not have experience working with people with intellectual and developmental disabilities. So we can provide some resources for them. We can provide a training. We can talk to them about what we just talked about today, about stigma, about increasing inclusivity, about language, right? Tailoring services encompasses the entire agency. So, and that for people who are providing substance use disorder. And this includes from the person who's answering the phone to the front desk attendant when you walk in the door, the intake staff, all the employees. When an agency approaches substance use disorder with a person centered approach, it creates an environment where the person may feel more welcomed to share or practice a new skill. So one of the things that we can do as care providers when we are advocating and supporting our clients in these environments is to help those environments engage in those practices. The great thing is, is that substance use disorder treatment programs have a lot of the same kind of core beliefs that we have as providers of people that have intellectual and developmental disabilities. They really wanna do a person centered approach. They really want to meet the client and where they're at. These are all things that we wanna do as well. And so we find those common grounds and we build on that. When providers really encompass the approaches of care listed on this slide here, it creates an environment where a person can really ask questions. They can ask clarifying questions. They can seek clarification. They can be honest about their treatment. They can engage in their treatment. And this is really, really important for people that have intellectual disabilities. Often when I was working in mental health before I started a program specifically for people that had intellectual disabilities and substance use disorder, when I was working in behavioral health, many people would come in that had an intellectual and developmental disability. And often the people that were engaging in group, the facilitator for the group would write in the notes that the person was unengaged. They didn't cooperate. They didn't participate. They were uncooperative with treatment. And this is often related to the fact that we were not approaching the person with that person-centered approach. We weren't adapting and the way that we facilitated or the way that we engaged. And so often the person would disengage or not participate in the program, but not because they didn't want to, but maybe because they didn't feel that it was safe to, or they didn't feel that it was a place that was comfortable enough to do that. So some of the things that we want to share and we want to engage in with our clients are these kind of considerations for practice. And we wanna make sure that when we are engaging with outside care providers related in the substance use realm is that we are able to talk to them about cognition levels and that there may be certain words or concepts that are difficult. And we wanna be able to share that with the providers so that they may be able to make some changes such as avoiding complex words or concepts, abstract language. Often substance use treatment uses a lot of metaphors and a lot of sarcasm. Metaphors and sarcasm are really difficult. And so if we can avoid those, that would be the best. So if we can share that, that's really helpful. These are items that you can just bring in and you can talk to them about. And this even goes for all healthcare providers. We wanna think about language skills. We wanna think about how do our clients convey their thoughts and ideas? Do they struggle with this? It may be helpful for us to repeat or clarify. What we're saying. Literacy, so being aware of the printed material. Are they able to read? Do they have difficulty with comprehension? Understanding that. Same with number of concepts. Our learning, reasoning and problem solving. Now we know that learning requires memory to gain skills and knowledge. And so we wanna make sure that we are offering patience and that we may need to repeat. We may need to revise the way that we're giving the materials. We may need to clarify what we are providing so that we can really ensure that it's being understood. We should work with our providers about memory and let them know that sometimes stored memory and remembering information may be difficult for our clients. And so we wanna determine strategies that could be helpful together. And when I say together, we wanna do that with our client. What works for them? What helps them? Is it writing it down? Is it images? What is that? Personal care, hygiene may be an issue and this may affect the way that other individuals want to engage with our clients. We want to be able to help them to be able to engage in personal care. And if somebody is using substances and is not interested in stopping, we wanna be able to talk about harm reduction and using equipment that is going to be safe or if they have a wound because of, sometimes my clients, they would use their smoking equipment would cause them to have burns on their lips or their hands. And so they would need to clean those wounds. And so being able to talk about that wound care was very important and being able to take care of their health. We wanna work on increasing self-esteem and their ability to navigate the community safely. These are all concerns that some of our clients may have. We wanna be able to provide that one-on-one support. Is it appropriate for a advocate or care provider to join them in their sessions to help do that? Could that center provide that support? And really think about the communication in which we are engaging in. So I wanna talk about some practice. We're gonna practice now. So this is a time where you guys listen to these brief videos. These are based on experiences that I've had with clients and not one specific client, based on some of my personal experience of being in practice. And so what we're gonna do, we're gonna watch a video. We have a couple of videos here. We'll probably do two videos here because of time. And then we will take a break after we share. So what I want you to think about in these videos, a couple of things. Was there any stigmatizing language or experience that the person had in this video? What was that? And how might you provide some assistance? We talked about some of these approaches to care and considerations towards practice. What might you do to help this individual? And all of us are gonna kind of engage and chit-chat about this. So we're gonna watch our first one here. Hi, my name is Sam. I use he, him pronouns and I'm 38 years old. I'm kind of a quiet person and I don't have many friends. And when I was growing up, I was in special ed in school. I had two friends there, but I graduated when I was 22 and I didn't see them anymore. I stay in a group home with three other people. There are staff members that come to check on us and make sure we take our meds and stuff. They help us to make food and clean up. I have to take meds because I get really nervous all the time. A job coach from the program helped me to get a job at a grocery store doing stocking. Having a job is hard because sometimes I have trouble reading the labels on stuff or a customer will come and ask me a question and I don't know the answer. I get really stressed out if I have to ask for help because I don't want people to think I'm stupid. I used to be so worried about messing up at work that I would miss days every week. A good thing about my job is that I have one friend there. We like to watch movies and collect cans to turn them in for money. One time I had missed so many days at work that I got in trouble with my boss. I got so scared about losing my job and my friend shared a medicine with me called Vicodin to help calm me down. It really helped me. My friend gets it for me and I use it every day now and I have hardly missed any work in a while. One time I ran out of the Vicodin and I got really sick, like puking and stuff, and I was even more nervous than normal. Now I make sure I don't ever run out because I don't ever wanna feel like that again. Don't tell anybody I told you, okay? My friend said that they can get in trouble if other people know and I don't want them to get in trouble. Okay, so I wanna open it up to the group here and you can also put it in the chat. I was able to open the chat on the side here, Emily, so I'll look at that. What I wanna, again, I want us to think about was there any stigma that you saw or felt that was happening in this example? And also how might you as a care provider help Sam? How might you do that? Hi, it's on my end I have Rachel and Elmo with me, and we were talking about, about how the stigma of him not understanding things so he doesn't want to ask questions to make him sound stupid. Right, it's definitely a stigma that I think everybody has not just necessarily people with intellectual disabilities. Right. Yeah, we don't want that judgment right of people thinking that we don't know something. I, I often talked to my, even my students about that, about giving a, you know, asking questions and I will share examples of when I was scared to ask questions. That's one way that we can address that stigma is being able to say you know there was this time where I was really scared to ask a question. Right. It makes it, it normalizes it right normalizes that you have that experience I've had that experience, a lot of people have that experience. And when you share, especially if you have a trusting relationship with a client, and they're comfortable talking with you. It makes it real to them and they go okay, like, you know, Brenda had that experience, and I have that experience so we can talk about it. Maureen, I will help Sam by assuring him that asking for help doesn't make you stupid it just shows how brave you are. At the end of the day, nobody knows everything it's okay to ask for help. Yes. And so I think we yeah we were just talking about that and by, I really think by sharing experiences that we've had, especially if we have those trusting relationships, and it doesn't have to be, you know, an embarrassing, you know, very personal story, but it's, it normalizes it for them. Talk to the client about seeing his PCP to help with his anxiety. So Pearl, that's, that's a great, great suggestion. We know that Sam is experiencing a lot of anxiety at work, related to asking for help, but there, there may be some mental health stuff going on right there may be an anxiety disorder there may be something else happening. So we'd want to talk to a medical professional and engage in a discussion there. You may also want to talk with, with a therapist, or even a, a ABA therapist or even a recreational therapist and engage in some ways to decrease anxiety. Right, like, what can you do what, what can you do in your daily life that can help with that anxiety. We also know that Sam became ill when he did not take his Vicodin. So what does that tell us. Yeah, Chloe, he might have an addiction. He may have an addiction, but there's clearly some dependence happening. We're going to talk about dependence in just a little bit. But there's clearly a physical reaction happening because he's been taking Vicodin very regularly. And opioids in particular, you can get dependence pretty quickly. And so, he didn't like that feeling of feeling sick because he didn't have an opioid, which Vicodin is an opioid. And he actually may have an addiction. So, we may need to engage talking with our primary care doctor about that as well. And actually, not may, we will need to discuss with the doctor because he may have tolerance and dependence. He may have an addiction at this point. So, what we need to do at that point is to engage in a talk and find out what would that healthcare plan look like? What are our options for Sam at this point? So, when we're thinking about Sam and we're thinking about this kind of person-centered and holistic approach, we want to think about also, what did he talk about? His friend. He didn't want his friend to get in trouble. When he graduated high school, he missed his friends. So, there's a piece of connection that Sam is missing as well with people. And so, that might be an area that we would want to help him with. Maybe there's other activities and getting involved in community, in his community of choice, so that he can have that connection. So, when we are thinking about engaging with our individuals, it's really thinking about the whole person, not just one piece. So, we want to address the health, right? We want to think about his anxiety. We want to think about, is there an addiction? There's clearly a dependence of opioids happening because he got sick. So, there may be a dependence. Is there tolerance happening? Those are all those kind of physical things, right? We also may want to address, and we really should address, his social and emotional needs as well. And so, as care providers, when we're thinking about our clients and how we can best serve them, thinking about these areas, these kind of domains in our life, right? Our physical, our mental, emotional, spiritual selves, and how is this person engaging? So, Sam wants to connect. He wants to have friends. And he's worried about losing his friend. And this may drive additional behaviors if this is his only outlet, his only friend, and he's really concerned about missing it, missing him or getting him in trouble. So, it's important to think about that. Now, because of time, I'm going to take a, we'll take a break right now. We'll take about five minutes, and we'll come back at 12, we'll come back at 1255. So, it'll be a little bit more than five minutes. And then we'll, what we're going to do is we are going to go into our next training, and we're going to be talking about substances and substance use disorder. Like, what is substance use disorder? I've talked about it a lot in this and how stigma is affected, but we're going to talk about kind of the nitty-gritty of what substances are and what substance use disorder is. But before we go, oh, yes, thank you, Emily. 955. I'm on the east coast. I'm so sorry. I told Emily, I'm like, you have to catch me because I keep saying the wrong time. She's great. She's on it. Are there any questions before we step away? And I'll ask again when we come back if there's any questions. All right. We will, I will ask again when we come back, and we'll start off. If you have a question, you can throw it in the chat while we're gone. And we'll take about five minutes. I'll see you guys back at 955. Thank you. So, we're transitioning now where we're going to talk about substance use. And we're going to first watch a brief video about the science of addiction. This will help kind of shape the next few slides that we're going to be talking about. So, I'm going to hit play so you guys can see and hear this. Susan loves to bike. While out for a ride, she falls and breaks her arm. Special cells called neurons send a signal from the spinal cord to the brain, which interprets the signal as pain. Susan understands the pain means she needs to go to the hospital, and her body is equipped for survival, helping her not to panic so she can seek help. Many of her neurons are covered in proteins called opioid receptors. These receptors act like a brake to slow down the neuron's ability to send pain signals. When injured, her body releases natural painkillers called endorphins. Like a key in a lock, endorphins activate opioid receptors, slowing down the pain signal and preventing a panic. Susan gets treated for the broken bone, but three months later, her arm still hurts. And now that pain is making her feel depressed and anxious. So her doctor prescribes an opioid painkiller. There are many different opioids, but they all share a chemical similarity to our own endorphins. This allows them to bind to the same opioid receptors and stop pain signals. But that's not all they do. Deep inside Susan's brain is a region called the ventral tegmental area, or VTA for short. VTA is full of neurons that produce a chemical called dopamine. When something good happens, dopamine is released, giving Susan a feeling of pleasure. This helps teach her brain to keep seeking out good things. To keep dopamine neurons in check, inhibitory neurons keep the brakes on until something good comes along. Just like the pain neuron, these neurons are covered in opioid receptors. When Susan takes the painkiller prescribed by her doctor, the opioid receptors turn off the inhibitory neurons and release the brake on the dopamine neurons. The rush of dopamine temporarily eliminates Susan's depression and anxiety, and she feels relief, calmness, and even euphoria. As Susan continues to take the painkillers, her brain responds by trying to regain its balance. Her inhibitory neurons work extra hard, even when the opioid receptors are activated, and it becomes harder and harder for her dopamine neurons to release dopamine. Susan finds that she needs to increase her dose of painkillers in order to feel comfortable. This is called tolerance. Eventually, Susan's pills run out. Inhibitory neurons that had been working overtime are let loose, clamping down on those dopamine neurons and shutting them off almost completely. Now, not only is Susan in pain, but the depression and anxiety come back. On top of that, Susan feels ravaged by an inescapable physical sickness, far worse than any flu. Susan's body is going through withdrawal. Most people who take opioids for a long time tend to experience some withdrawal, but they can still stop taking the pills and return to normal. But for people like Susan, it's not so easy. Her genetics and the environment she grew up in put her at a higher risk for addiction. Her withdrawal symptoms aren't just unpleasant, they're unbearable. Susan thinks the only way to feel normal is to find more opioids, and this is how the cycle of opioid addiction emerges, driven by a brain trying to regain its balance. But there is hope for Susan. Though the road to recovery can be challenging and there may be setbacks, treatment can retrain Susan's brain. With the help of medication and therapy, Susan finds pleasure in her life once again. So, what we're going to do today is we're going to talk about what the process of addiction looks like, and we're going to talk about the different examples of substances that individuals may engage in, and we'll talk about addiction in general. So, really with the process of addiction, there's five common symptoms that happen when someone is experiencing addiction. It can be a compulsion, a loss of control, negative consequences, denial, and inability to abstain from the substance. It's a common misconception that people who are addicted to drugs are the ones who are and inability to abstain from the substance. It's a common misconception that addiction is a choice or a moral problem, and all you have to do is stop. This could be nothing but farther from the truth. As we know from previous work and research, that addiction really is a disease. And the brain actually changes when someone is experiencing addiction, and it takes a great deal of work to get back to that normal state. So, as we showed in the video, and I just think it's a great video. It's a great visual. I'm a visual learner, so it's a great visual to kind of see how hard that brain has to work, right, to be able to engage in its normal practices. The more drugs or alcohol that someone takes, the more disruptive the brain becomes. There's really three stages of the addiction cycle. We have this binge intoxication stage, our withdrawal, our negative effect, and then also our preoccupation and our anticipation. So, these stages reflect this kind of incentive pathological habits, these reward, deficit, and stress areas, and our executive functioning deficits. So, it provides a real powerful environment for compulsive drug-seeking behavior that's really associated with drug addiction. So, these domains of dysfunction correspond with those neuroadapters we just talked about and these changes in these areas, right? And they mediate this kind of drug-seeking, our brain where kind of right here with our bin, where the bin, the basal ganglia, that area really mediates this kind of compulsion and wanting to seek out these substances. When you're becoming addicted to a substance, the normal hardwiring that's helpful in our brain processes can begin to work against you. So, drugs and alcohol can hijack our pleasure and our reward circuits in our brain. And this is where it kind of hooks you into wanting more and more of a substance. Addiction can also send a person into this emotional danger-sensing circuits, that part of our brain, into overdrive, making you feel anxious and stressed, and when you're not when you're not using drugs or alcohol, making you feel like I need more so that you don't feel those feelings. Because those feelings are really uncomfortable. Often, at this stage, people are engaging in drugs and alcohol use to keep them from not feeling those feelings, not feeling bad, rather than the pleasurable effects. So, what happens with addictions is that people begin to use substances because of pleasure. Our brains are developed to seek pleasure, to seek good things that make us feel good. This is how the brain is developed. Normal. That goes for people that have intellectual disabilities and people that don't have intellectual disabilities. People's brains seek pleasure. And when they have alcohol and drugs are bringing us that pleasure, it then kind of, again, takes kind of over that hardwiring system, and we just continue to seek pleasure and pleasure. What happens is, at that point, is that when those kind of danger circuits get kind of wrapped up into this, we no longer use substances for pleasure. We use it to relieve the negative feelings that we're feeling related to our brain being hijacked from the substances. Because then we start having these anxiety, depression, and these stress and very negative kind of feelings that we would associate with negative feelings. And so then we start using substances to relieve those. So, repeated use of drugs, alcohol can damage the essential decision-making center in the front of our brain. This is that green part, that prefrontal cortex. This is the very region that would help you recognize that there's harms to using a substance. But we know that when we use substances, that part of our brain becomes damaged. And so, it really works against them. So, in brain imaging studies of people that have an addiction to drugs or alcohol, show a decrease in activity in that prefrontal cortex. So, when the frontal cortex isn't working properly, people can't make decisions to stop. They don't understand the decisions, the understanding, that impulse. All of that is affected, right? So, they have a really hard time making the decision to stop using the drug or alcohol. Even if they realize that taking it is costing them their relationships, their jobs, their homes, all those things. They're losing the custody of their children, all those things. They're going to jail. They continue to take it because that part of the brain continues to be damaged. So, addiction is a disease. So, scientists and people and researchers who do work in addiction medicine and addictions in general, they don't necessarily understand why one person becomes addicted and others don't. You know, it's, they're still working on that to figure that out. So, that's something similar to someone who may have, you know, a genetic, like a predisposition, right, of addiction. They don't really understand, but there's a lot of factors and we're going to talk about some of those factors that contribute to addiction. But there's still a lot of work in that. But addiction is a disease and it's classified by these 11 criteria that are identified in the DSM-5. So, this is taking the substance in larger amounts for longer periods of time than you're meant to, wanting to cut down and you cannot, spending a lot of time getting or using, craving, urges, not managing to do what you need to do for work or home, school, continuing to use even when you're having problems with your relationships, giving up important social and occupational recreational activities to use substances, continuing to use even with relationship, oh, we've said that one. Sorry, excuse me, we're on eight. Using substances again and again, even when it puts you in danger, continuing to use even when you know that there's physical or psychological problems that are caused or made worse. Some of my clients would use even though they know that it would cause internal voices to happen or visual hallucinations to occur that were very scary for them, but they would continue to use. Need more of substances to get the same effect. So, this would be that tolerance. Withdrawal symptoms, which can be relieved if they take the substances. This is how addiction is classified. They use these criteria. Now, there's these primary categories. So, those 11 criteria that we just talked about fall into these four categories, either impaired control, social problems, risky use, and physical dependence. So, if you have a client and you take them to a clinician, they're going to look at these 11 criteria, and then they're going to identify these areas in which they may be falling into. So, again, they may have some impaired control or social problems, risky use, physical dependence, and all those things we want to look at and understand which categories the client is experiencing. Now, with those categories, we have levels of severity. So, like other illnesses, addiction gets worse over time, and similar to the stages of cancer, there are levels of severity to describe a substance use disorder. So, not one substance use disorder is the same, okay? There's different levels. And these guidelines are used for clinicians to determine how severe a substance use disorder is, depending on the number of symptoms. So, those symptoms that we just shared, those 11 symptoms, if you have two or three symptoms, this is considered a mild substance use disorder. Four or five symptoms indicate a moderate substance use disorder. Six or more indicate a severe substance use disorder. And a severe substance use disorder is known as addiction, okay? So, that means that you have an addiction at that point if you have six or more of those 11 symptoms. So, clinicians determine the severity level of the substance use disorder to help develop the treatment plan. And the higher the severity level, the more intensive the level of treatment. And so, most patients are likely to need ongoing treatment and recovery support using a chronic care model for many, many years, and a clinician should be monitoring the progress and adjust the plan as needed with the help of the other providers in the individual's life. All right. So, there's a lot of different addictions in our world. For this talk, we're going to talk specifically about alcohol and drugs. But other addictions may be food. It may be sex, shopping, work, gambling, technology, tobacco. Often when I was working with my clients, I would see addiction of my clients that had intellectual disabilities. Soda was a huge, huge addiction. It drove behavior. They would engage even with harmful things that were happening. They would still engage in drinking soda in extreme amounts, sometimes washing out their medications to the point that they were having seizures. And this wasn't just one client. I had multiple clients that were experiencing this. And soda was a really, was one of those addictions that we talked about a lot with my clients. Food was also a very common addiction with my clients that had intellectual and developmental disabilities. All right. so we were talking just a little bit ago about some of these factors that contribute to drug use independence. So we have these biological factors, these are genetics, these are things that make up who we are and our brain chemistry. We also have psychological factors, that would be stress, mental health disorders. We know that if you have a mental health disorder, that the likelihood of having a substance use disorder can increase if you use substances, okay? Doesn't mean that just because you have a mental health disorder that you're going to have a substance use disorder, but if you're engaging with substance use and you have a mental health disorder, you're more likely to have and more at risk of having a substance use disorder, okay? This is what the literature tells us. There's social factors such as peer pressure, family dynamics, and socioeconomic statuses. Addiction tends to run in families and certain types of genes have been linked to different forms of addiction, but not all members of an affected family are necessarily prone to addiction. As with like heart disease or diabetes, there's no one gene that makes you specifically vulnerable, but it increases the likelihood of this happening. So factors that can also raise your chances for addiction such as growing up with an alcoholic, being abused as a child, being exposed to extraordinary stress, all of these social factors can contribute to the risk of addiction or abuse of a substance. Another factor is the earlier you start using a substance, the greater the likelihood of having a substance use disorder or addiction later in life. So people with intellectual disabilities are especially vulnerable to possible addiction. So some of the research that we know are that people with intellectual disabilities, they have the higher rates of psychiatric comorbidities, meaning that they have not only just the intellectual disability, but they have a psychiatric or a mental health diagnosis. We know that these, and that range is between 30 and 50% of people that have an intellectual disability also have a co-occurring mental health diagnosis. That's really high. We know from research that people that have a mental health diagnosis have a higher risk of having addiction if they engage in substance use disorder. So this co-occurrence of psychiatric disorders and substance use disorders is common, right? So it's not surprisingly that people with ID, they also experience high rates of trauma in their life. So I think if you think about your clients, you can think about have they been a victim of crime, have they experienced abuse in their life, have they been victimized? Research has shown that individuals with disabilities are four times more likely to be victims of crimes than people who are non-disabled. That's really, really high, four times. And that almost close to 90% of people with intellectual and developmental disabilities will experience some type of sexual assault in their lifetime, 90%. That's very traumatic. So we know that trauma is a contributing factor to substance use disorder. We also know that having a mental health diagnosis is a contributing factor. And so you add those, it really makes people with intellectual disabilities very vulnerable if they're engaging in substance use to develop a substance use disorder. For the next few slides, we're going to just talk about what are substances? What are these things that I'm talking about over and over again? So we have stimulants. These are known as cocaine, amphetamines, methamphetamines. The effects of a stimulant is that you have increased energy, maybe alertness, and abuse potential is very high for this substance. We have depressants, and in this class, we have alcohol or benzodiazepines. Some of your clients may be on a prescription benzodiazepine. That is a prescription medication, and they may be on that. It's very important to know what medications your clients are on, because if they are taking a benzodiazepine and they're drinking alcohol, there can be some really serious side effects, even small amount of alcohol. So educating your clients about their medications and about mixing substances is very important, and also engaging in conversations with the healthcare providers so that they know, hey, you know, my client does use alcohol and they're on a benzodiazepine. What can happen? What should I do if something happens? The effects of these medications are relaxation and sedation, and the abuse potential is very high. The other class is opioids. This would be heroin, prescription painkillers, fentanyl. Fentanyl can be a prescription. It can also be on the market illegally that's not a medical grade. These effects with decrease in pain and also euphoria, so feeling really, really good, and the abuse potential is very high. Again, some of your clients may be on a prescription opioid. It's very important to know what prescriptions they're on, especially if they're on a prescription opioid and a benzodiazepine, a depressant over here. If they're on both of those, it is really important that you have Narcan or Naloxone in your home because potential overdose can occur when those two medications are mixed together. So speaking with your healthcare providers, making sure that they know. Sometimes our clients access the emergency room, emergency departments, or drop-in clinics, and those healthcare providers may not be aware of all the prescriptions that your clients are taking. As a care provider, it's very important that you are aware and that you know that some of these medications can cause some very serious interactions, and so engaging with a pharmacist and being very aware of what your clients are taking is key to their health. We also have hallucinogens, so LSD, mushrooms. These alter your perceptions. They can make you hallucinate or make things, colors change, and you just experience things in an altered way. Right now, the abuse potential is variable. They're doing a lot of studies in this area. You may hear people talk about microdosing, and that's becoming a very new experience for a lot of people, and there's a lot of work happening in that area, so they're not sure about abuse potential. They're still investigating that, and then we have cannabis, and this is known as marijuana, and the effects are relaxation and an altered sense. The abuse potential is moderate, and again, there's a lot of work happening in this area to determine benefits and risks related to cannabis use, so one of the things that we really want to talk about is this intersection between prevention and harm reduction, and what is harm reduction? What is prevention? What are these things? A critical aspect of substance use services is the intersection of prevention and harm reduction, and understanding this primary, secondary, and tertiary efforts really helps us to develop and create a comprehensive approach to tackling substance use. Prevention aims to stop substance use before it starts, so if we have clients that are not using substances, we want to engage in this. This is a great place to begin, is to engage where education materials, community programming, and engage in discussion and talk related to substance use and maybe some of the harms. For example, as I mentioned, if you have clients that are taking multiple medications, how they interact, and if you engage in alcohol use with those medications, what can happen? Providing some of those education and key information for them. Other ways will be to promote healthy behavior, so increasing exercise, increasing engagement in social connection, and engaging in activities outside of, when I worked with my population, there were two things that my clients loved to do, three things that my clients loved to do. Three, eat, sleep, and watch television. We would talk about leisure and engagement. Unfortunately, many of those things did not engage connection with other people, which was also a very important social aspect that was key to our clients' physical health and also their emotional health. Engaging in ways that individuals can connect in their community and with the community of choice is a way to engage in prevention. Secondary prevention really looks at preventing early detection and intervention of substance use. If we see that someone is engaging in using edibles regularly, or using alcohol, or smoking marijuana on a regular basis, and we start seeing this happening more and more, we detect this. As care providers, we should be detecting this. We should know what's happening, we're going into their homes. The primary care doctor is not engaged in this kind of day-to-day life, so they may not know. If we see these things, we may want to engage in some counseling services, we may want to identify what are these substances you're using, and intervene at an appropriate level. Just because a person with an intellectual disability drinks a can of beer does not mean that they need to go to rehab, or that they have a substance use disorder. Again, that goes with that stigma and infantilization, is that some individuals that are working in this field, and I've worked with a lot of people that felt this way, the moment somebody smoked a cigarette, or had a glass of alcohol, red flags everywhere around, no. We want to be able to monitor that, and have them use safely, especially if they're using medication. I'm going to say that every single client I worked with had a significant amount of medication that they were taking, and so we worked very closely with nursing staff, with pharmacy, with our psychiatrist, to be able to do a lot of education around mixing substances. If you drink alcohol, and you're using this medication, these are the harms that can happen. Really, giving those resources, and then this tertiary prevention. This is really what happens when we're trying to manage and mitigate the impact of substance use. Unfortunately, most of my clients fell in this area. Many of my clients received no prevention, and no one engaged in secondary prevention work at all. What happened is that they got arrested, or there was some very serious situation, mental health situation that occurred, and then all of a sudden, they're like, wow, oh, this person has substance use disorder, they have an addiction. This would happen, we just kind of didn't even address anything else that happened before that. Really, as care providers, we want to kind of connect in that primary and secondary area, so that we can avoid this kind of final space. But unfortunately, this happens as well, and really, our goal is to improve the quality of life and reduce harm related to these substance use. Some of our clients will want to quit that have a substance use disorder, and some will not. If they want to quit, we want to be able to provide those services. Maybe it is rehab, maybe it is some kind of treatment program, or mental health services, or a support group. It may look like that the individual is going to have safe use supplies, so if they're smoking crack, they're using clean equipment, and that might be what it looks like. This area depends on the area and the motivation of the individual in which you're working with. This kind of intersection is really important when we are addressing and looking at strategies for addressing substance use with our population. Ideally, what we're doing is we are approaching this in a very holistic manner that incorporates all three of these levels of prevention, and that we're engaging in harm reduction in each of those ways as well. When we do this, we can really decrease the harm to our clients as well, so that they are living and engaging in health practices. All right, we're going to talk about treatment and recovery. I really do like this way that SAMHSA states this is a working definition. I really like that because we're always learning, and processes can change as we change as humans. SAMHSA's working definition, which I really love that they say that, of recovery and its guiding principles is a process of change through which an individual improves their health and wellness. They live self-directed lives and strive to reach their full potential. This is such a great definition, and I think that we can see this really reflects a lot of what we're doing as care providers in the IDD world. We want our individuals to live a self-directed life. We want them to strive for full potential. We want them to want to improve their health and wellness. It's like we really have some common grounds. Unfortunately, we like to work in silos, but this is a great place where we can say, hey, you know what? We do have a lot in common. We want the same thing. This definition really underscores this individual nature of recovery. We must realize that when people are going through recovery and treatment, that it's not a one-size-fits-all. We want to remind substance use disorder providers of that because when we're engaging with substance use disorder providers, and unfortunately, everybody's overworked. You guys are overworked. They're overworked. Oftentimes, we engage in this one-size-fits-all. You come in, you come in through the front door, you sit in this group, you do this in this group and you leave. You may do X, Y, Z, it's like homework afterwards. So, and if you don't fit into that, then you're not gonna fit into treatment. But that's not really, when we think about recovery and treatment and we think about the way that is engaged, is that that's really not the way and the intention of recovery. It really needs to come from this kind of self-directed and person-driven approach. So there's a lot of impact on substance use disorder. We have these social impacts and that can increase isolation for individuals. It can strain relationships. I must say that many of my individuals that were using substances and had a substance use disorder that had intellectual and developmental disabilities often shared with me that they began using because of social interaction. They would engage going to a bar because they knew that people were there and that they could engage and they could talk to people. They use substances with their family members because that's how they connected. Or they use substances with their neighbors because they lived in an environment where drugs were being sold and used regularly and it was a way to connect with people. But unfortunately, what happens when the substance use disorder takes hold is that isolation and these relationships become strained. And psychological impact. There's an increase in mental health issues, okay? Those mental health symptoms can increase. As I mentioned, some of my clients, they would have increased auditory or visual hallucinations and anxiety, lower self-esteem. There's a huge financial impact. So the cost of treatment alone, loss of employment opportunities, spending massive amounts of time and money obtaining substances. And so what is the impact on people with intellectual disabilities and substance use disorder? So we talked about in our previous slide and previous slide about that there is a higher risk factors. There's increased vulnerability or having a substance use disorder because of some of the social factors, some of the trauma and environmental factors, okay? So there is this higher risk factor. So that's a huge impact. We also have a limited, again, some individuals with intellectual disabilities, they have limited understanding to consequences in general. That part of their brain is underdeveloped. And then we talked about how addiction affects that frontal lobe. And so then there's even additional limited understanding or ability to stop even if we know what the consequences are, okay? So these are huge risk factors for people with intellectual disabilities that they're experiencing when using substances versus an individual that does not have an intellectual disability. There's massive challenges in treatment, communication barriers, this need for tailored services. We talked about what those factors were, right? What do we need to do to kind of help build some of these tailored services? And I know that it puts a lot of pressure on us as providers for intellectual and developmental, you know, providers of people with IDD, but we're advocates as well. And ideally what we're gonna do is we are gonna go in and we're gonna advocate for our clients and for the best care that we can provide. Additionally, the impact of these support systems, you know, when we can find a specialized program, that is amazing. So if we can find a program that is really kind of specialized in tailoring services and changing the way in which the system kind of operates, so we're not gonna do, you know, as I mentioned, you know, walk in the door, sign in, go to group, participate in the group, do your homework, right? If you have a specialized program where, you know, they're receiving information before the next group and you can practice it and they can role play, they have some maybe one-on-one support and then they come into group, they can engage, right? Maybe they have a one-on-one session after the session so that they can process and work on that health literacy, right? And how are they going to utilize this information? Some of these social supports that can be provided can be provided by the IDD professionals, right? The DSPs and the care providers. We can provide some of those because some of our systems, our sister systems of substance use disorder, they might not have the ability to do that. They don't have as much time with the clients as we do. If the individual does have family involvement, we have caregivers here as well, it is important to engage in the treatment, right? Engage in understanding what is a substance use disorder? How are we, how can we help support and engage in improving prevention services, prevention services, recovery, and harm reduction programs for this population? So what do these support strategies look like, right? What does this look like? One, we can do some tailor, we can do some education and awareness. We can tailor education programs for our staff or we can encourage our administrators to provide training sessions that talks about substance use disorder. We can create programs and brief intervention trainings for substance use providers so that they understand the IDD, philosophies and adaptions and kind of the world in which navigated there. We can do awareness campaigns where we are really talking about and engaging in with healthcare providers about are you screening? Are you screening our clients for substance use, for alcohol use? Oftentimes what happens with many of our clients when these screenings during their annual visits, our screenings are skipped. Mammograms are skipped. Prostate exams are skipped. Colonoscopies are skipped. Substance use disorder screenings are skipped. These are just ignored even though they've been identified as all things that could be engaged in and should be screened for. But unfortunately with the IDD population, oftentimes they're never brought up. And so as care providers and advocates helping to bring awareness and advocating that those screenings are happening. Support networks. In the substance use treatment world and recovery world, peer-to-peer support is huge. It is effective. It brings a lot of support and that connection as we talked about. And that is the same for people that have intellectual and developmental disabilities. So if you can find peer support or develop peer support with individuals that have liked, lived experience, it will be really helpful. They can share. They can share their experiences. If you're talking to somebody who hasn't experienced the things that you've experienced, sometimes you might not open up the same way that you would if you knew that they understood, right? And so this goes for substance use. This goes for intellectual disability. One of the reasons why the focus group that I did and I shared in the previous study or the previous training was that while it was so great to get those quotes, one of the things that was amazing is the support that each of the individuals in that group gave to one another. And they all of a sudden kind of understood each other's experiences and that they weren't so different and that they could really support each other. And that group continues to talk. And so this peer-to-peer kind of support group is really wonderful. Counseling is wonderful. Family counseling, if they're engaged with their family, if they're not engaged with their family, if you can get their family involved. Oftentimes, as we mentioned, factors that contribute to substance use disorder, it means family members may be engaging in substance use disorder. The family member may have started the individual using substances at a very young age. This was not an uncommon situation in which I was told by my clients is that they began using with their parents or a sibling, an uncle, a grandparent. Looking at access to services, so inclusive treatment programming, really looking at that recovery model that I showed you from SAMHSA and sharing that with people and showing that, hey, we have the same, we kind of have the same philosophies. We're coming from the same place. One of the other things about access to services is kind of this financial assistant or supportive that really affects maybe their housing or housing in general. So providing stable, safe housing options are so critical for individuals that want to engage in a drug-free, substance-free lifestyle. Unfortunately, so many of my clients, they had very limited money. And when they were living in their apartments, they were having to live in environments where drug use, the sell of drugs was very, very common. Now, if every single day you come out of your house, your front door and people are selling drugs and are using drugs in front of you, when you're trying to live or maintain a drug-free lifestyle, it's very difficult, very difficult. And so if you also are an individual that also has a need for social connection and are missing social connection and people are using drugs, it's an easy way to connect. And so being able to identify safe housing options, so important. Engaging in employment and vocational training, finding purpose and engagement, offering job training and support really will help individuals to engage in recovery and gain skills that will help them with their financial independence, which is great. And also connection and self-meaning, right? And then really implementing these kind of, this really holistic approach of looking at the person as an individual and addressing their social, emotional, physical, spiritual needs and wants. And so as care providers, that's really what we should be looking at is looking at this kind of patient or client-centered care and then initiating in services, programs that will help increase positive interactions in those areas. So one of the things that we really wanna take away from this training today is that, is we really wanna understand and take away that addiction and its impact on people with intellectual disabilities, it's a critical issue. People with intellectual disabilities are just as likely as someone who does not have an intellectual disability to have an addiction. They can become addicted to substances and that addiction is a disease. This is not a moral or issue. This is not a belief issue. This isn't because somebody's weak or they couldn't handle it. Addiction is a medical diagnosis and it is a disease and we should address it just like we address diabetes, heart disease. If you have a client that has diabetes, you're taking their blood sugar, you are monitoring what they're eating, you're engaging in those health practices. If they have heart disease, you age in exercise and you're taking blood pressure and you're monitoring all those things. These are the same types of things that we wanna think about with addiction. Are we engaging in appropriate ways to connect with our clients? Are our clients connecting with other people? Are they just zoning out the TV or are they just zoning out in their room, right? And not engaging with other people. Effective prevention, treatment, harm reduction and support strategies can make a really significant difference in our clients' engagement with their health. And so when we think about substance use, we want to, as care providers, we wanna get to there in the beginning. We wanna do that prevention, right? We wanna prevent addiction from happening. So we wanna make sure that we're talking about substances and we're talking about alcohol use, tobacco use, marijuana use. And I use those three examples because those are our most common substances used by individuals that have intellectual and developmental disabilities. We wanna talk about harm reduction. How can we reduce our harm? Talking about not mixing certain substances together, right? Or if they are engaging in using substances, how can you use safely? Using, if they, for example, we would always encourage our clients to only use their own equipment. If they were gonna be smoking, you smoke, you don't share your equipment with someone else. It's only yours. Taking care of wounds and hygiene. And then also supporting strategies when they, if a substance use disorder and addiction is happening, how can we provide these support strategies to other agencies? And what can we do to kind of help in and advocate for our client? So we have a lot, today we talked about a lot of things that we can do and a lot of ways that we can help improve care related to substance use disorder. But one of the things that I would love for you to do, and as I said, when we first started this session, is to pick one item. We've given you so many. I just want you to pick one thing. One thing that you can take away that you can start today, tomorrow, and make a significant change in the people's lives that you're working with. And so that may be that you engage in assessing health literacy. It may be that you just ask them, how are you gonna use this information? It may be that you're gonna take some more trainings or you're gonna develop a training for the people around you about substance use disorder or about intellectual and developmental disabilities and share it with another healthcare provider and give them some tools that they can use as well. So I just really appreciate everybody's participation today and their engagement. I wanna leave some time for some questions. And so we'll open up the chat and we'll do that. And we will, so I'll stop sharing and then we will open up the chat and you guys can put it in the chat or you can also just unmute and ask as well. When I teach, I have my students always, I'd have them write down two questions. So I expect at least two questions or comments. Uh, Lori, this is Rachel, Rachel. So I don't exactly know how to formulate this question, but I'm kind of curious as to, excuse me, the experience of addiction itself. I know it has to do a lot with like, uh, how it affects brain function and stuff. So I'm just very curious if like the experience of addiction itself is different for people, um, who have intellectual disabilities, like versus someone who is neurotypical. So, so Rachel, that's a very good question. And I don't think that the, the actual experience of addiction is going to be different. They can still, they can build up tolerance and dependence. Okay. And they can still have withdrawal symptoms. What the, what experience is different are those risk factors. Um, we know that individuals that have intellectual disability, um, can not all the time, but they can have, um, troubles with executive functioning. Okay. Um, understanding, um, consequences, right. And when addiction occurs, we know that the part of our brain that helps, um, neurotypical individuals and people without intellectual disabilities to be able to, um, understand consequences is affected. So if we already know if this individual has an intellectual developmental disability, and, um, if they have issues with their executive functioning and impulse control and understanding consequences, that puts them at additional risk because using substances, they may not just engaging in substances in general, just the first time it may be very risky use, right. Um, drinking too much or walking in the middle of the street or, um, stealing, uh, you know, alcohol, those types of things. So these are, so the risk factors related to it are increased, the addiction itself, um, and the experience that happens in the brain is not different. But there are, um, we know that the brain of someone who has an intellectual disability is different, right. Um, there are actual differences. And so that's where these vulnerability and this risk really increases. And as individuals are, um, increasingly being exposed to less, um, restricted environments. So, you know, state hospitals are closing and people are transitioning maybe from like a care home environment, maybe to a smaller lived, uh, in apartments or in smaller homes, and they may have more freedom. There's more, um, opportunity to use. And if they feel like this is the way I can connect or, you know, I can engage and maybe they don't understand the consequences of, you know, mixing substances that can be really dangerous. We got one more. We got one more question. We got enough time to so I'll wait. I'm good at waiting. You can write it in the chat or just unmute All right. Well, it looks like there's no further questions. One of the, I'm going to share a question that I get asked often. As I mentioned, I worked in this field for a long time and I still engage in this field. Often, I will get a question from care providers of when should I worry? Lorianne, you share that an individual can drink a beer or cocktail and that's not an addiction, but when should I engage in this talk? When should we talk? When should I worry? What I share with care providers and advocates, family members, is that that prevention piece, where we talk about those risks and that's where we should be all the time. We should be talking about that and engaging in conversations about substance use risk, tobacco risk, alcohol risk, cannabis risk. Even if they choose to engage in it every once in a while, we can still talk about what will happen to your body. It doesn't have to all be negative. This is what may happen to your body if you use this substance. If you're using these medications, these are some risks. As I mentioned, if you are using a benzodiazepine and you choose to drink alcohol, you could overdose. You could have an overdose. You can have really negative side effects. So that they know that if they're engaging in these behaviors, negative things could happen. We want to just always be talking about it. If you are seeing that your client is using alcohol multiple days a week, or if they're using alcohol on the weekend but in excess, they're missing work, their relationships with individuals are starting to be affected, or they're missing school, they're not waking up in time to do the things that they're supposed to be doing, that would be definitely a time where you want to engage a primary care doctor and start having some substance use screening and assessment at that point. So thank you guys for coming today and engaging. I hope that you each will take one piece and apply it to your work. We have a lot of potential to make change in our life. And a lot of these skills, a lot of these trains we go to, we just kind of go through the motions. But I really hope that you take every training that you go to, that you find one thing and you make some change to better your client's experience. So thank you so much. And I'll stay on for another couple minutes if anybody wants to have a question answered, but I'll be here for a couple more minutes. But thank you so much for being here. Emily, is there anything else that we need to do for a wrap up? I did put the link for our quick evaluation survey in the chat. Please, please, if you are, no matter what, I would really appreciate your taking just a minute to fill that out. We still have a couple of minutes before we're officially on air. And this is just important to our funders, and it helps us continue to do this work and provide free training. And I put the link on your screen. So please, there's a QR code and also a link to the survey. So for the next couple of minutes, if you guys could please fill that out. Thank you. And I think you put it in the chat as well, right? Yes, yes, it's in the chat. Clickable link there. Great. Emily and Lorianne, thank you guys so much for this. We really appreciate it. Thank you. Thank you for inviting us. Of course, and I will have the recording available for sharing within, it's usually about a week or maybe it's faster, but definitely by two weeks at the latest. And you can share that with anyone who was not able to attend or anyone who wants to revisit the content. Perfect. Thank you so much. Yeah, thank you all. And thank you, Lorianne. Thank you. Thank you for having me.

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