posted in the chat, we'll be using the chat again today. So just asking people to add their name to the chat and the organization you're with and your role there. We'll give people a minute or two to get settled here before we get started. I'll introduce myself shortly. I'll be monitoring the chat. So if you see me looking that direction. Someone's asking, so the slides will be shared with everyone. So we did part one of the series last week and then part two today. So you will receive the slides. Great, seeing a lot of familiar organizations. We'll just give it another minute for people to join and get settled. We will be using the chat feature. So please keep that open if you can. And just a reminder of that, if anybody's sharing a computer, make sure that both of your names or all of your names are in the chat. So hopefully many of you were able to attend part one last week or yeah, last week. And this training series will pause for July and August and then we'll be offered again this series as well as a new series in September. So we'll be sharing more information with you and we'll be sharing more information about that later this summer. So just to reiterate, the topic of this workshop is substance use and housing programs, offering support with a harm reduction approach part two. So last week we talked about harm reduction, how people learn about drug substance use, addiction treatment, harm reduction and recovery, some of the sources of information that shape our views, stigma and ways to reduce that. If you can just make sure you're muted, that would be great. So today we'll be shifting a little bit more and I'll talk about the topics in a minute. Just wanna reiterate that this workshop is offered through SAMHSA and the Opioid Response Network, which assists states and organizations with evidence-based prevention, treatment and recovery for opioid and other substance use disorders. Here's contact information for the Opioid Response Network. And I'll just go over this, I mentioned last week, spent most of my career working in journalism and teaching media ethics, so really shapes my approach to these topics, kind of thinking about how public education and communication and some of the messages people receive, certainly around stigma. So, I've been working on projects and offer training on topics like reducing overdose deaths, educating people about substance use disorders, improving access to treatment and harm reduction services and supporting people in recovery. I facilitate training workshops on all these topics and try to present a wide range of perspectives. Also like to mention that I often collaborate with my husband, Graham McAndrew, who's a photographer, who's been open about his history of addiction, incarceration and recovery. So, being with him through much of that experience has really also shaped my approach and understanding of these topics, but also recognize many people, even with similar experiences have different trajectories or different experiences within that. So, just reiterating today, mentioned this last week, please use the chat box if you're somewhere where you feel comfortable speaking, you can raise your hand and using the Zoom feature, try to be open-minded about different points of view. And if you do decide to speak, kind of making sure you're aware of sharing your time and being mindful about stigmatizing language, which we discussed last week. Again, just trying to avoid generalizations and being patient. Some of these topics will be familiar to some of you, but maybe new to others in the group. So, today we're going to be shifted toward talking, last week, again, we focused a lot on harm reduction, which still is kind of threaded through these topics, but really shifting into services and care for people with substance use disorders. And starting with what some of the barriers to care are, and then shift toward trying to offer low threshold or low barrier person-centered trauma-informed care. We'll talk about crisis intervention strategies and resources, detoxification and treatment options for people with substance use disorders, recovery and remission from substance use disorders, and then touch on coping with loss, compassion, fatigue, and self-care. So, just one more reminder here, if you're just joining, please add your name to the chat and your organization and your role there as you get settled. So, just starting off here, this is the same survey I talked about and showed slides from last week, the 2022 National Survey on Drug Use and Health. And again, thinking about, still dealing with kind of the pandemic during the time that this survey was conducted. So, that shaped people's responses as well as some of the data collection. So, this shows the need for substance use treatment in the past year among people aged 12 or older. So, on the far left here, you see that that's a little over 19% for that entire age group. Then for different segments of that age group, just highlighting there for people 18 to 25, the survey finding that 29% of people might need substance use treatment in that year. So, won't be a surprise to any of you who maybe work with people in that age group or have kind of seen headlines about that, but certainly something that is getting more attention now. And this shows the percentage of people who received substance use treatment in the past year among people in that same age group who were deemed by the survey to have needed substance use treatment. So, again, these are survey responses. They're not a clinician evaluating people individually, but you'll see there on the left where the red arrow is pointing, about 24% of people who were deemed to have needed treatment received it. And that's higher than typically surveys find. Often when we talk about the treatment gap, we talk about only 10% of people who need treatment receiving it. But again, just wanna remind that we also talked about the different severity levels of substance use disorders. So, someone with a mild substance use disorder maybe wouldn't have benefited from treatment services or might not have felt they needed treatment to the same degree. So, keeping in mind that there can be pretty big differences between someone with a mild, moderate, or severe substance use disorder. And again, here, you do see that higher percentages of people in the 12 to 17-year-old age group received treatment. And then it kind of drops remarkably to 16% for 18 to 25-year-olds. By comparison, from the same survey, they also asked questions about mental health. And about half of people 18 or older with any mental illness received treatment in 2022. So, you see that that's quite a bit higher than the percentage of people who received treatment for substance use disorders. And then on the right, those four bars show the percentage of people with serious mental illness. So, that's a subset of people with any mental illness received treatment. So, that's higher than 60% for serious mental illness for all of those different age groups. Any questions? Monitoring the chat here, but mostly just seeing so far people adding their names. I just wanna mention too, we will take a 10-minute or so break around just before 11 too. So, give everyone a chance to stretch. So, we talked about the percentage of the population who had a substance use disorder last week, the general population. So, the question here is what percentage of people who are unstably housed would you estimate have a substance use disorder? So, I know that's a broad question, both the population, but first answer here is 15%, second is 20, third is 25, fourth is 30, and fifth, number five is 35% or higher. So, you can add your response to the chat there. Great, so seeing kind of more on the upper end of that, those selections. So, as we talked about last week, it's really hard to collect this data. There's starting to be more focus on it. I'm gonna show some examples of data that exists from different time periods, but partly it depends on how you define the population. So, are we talking about people who unstably housed is kind of a broad way, thinking about people in shelters or supportive housing environments versus people who are street homeless, and people who might not be captured in the data. But this is an example from some older SAMHSA data that found that about 30% of people who are chronically homeless have mental health conditions and about 50% had co-occurring substance use problems. So, again, chronically homeless is a subset of the overall population you might be working with, but certainly a higher number than the general population. Over 60% from kind of a different data set, and this is from the mid-1990s, who are chronically homeless had experienced lifetime mental health problems, and over 80% had experienced lifetime alcohol and or drug problems. But again, that's a smaller subset than people who you might see currently. So, those numbers are a bit higher. This is another data source, and looks at severe mental illness, so, again, and chronic substance use disorders among shelter-seeking homeless adults from about 2006 to 2010. And these data come from annual point-in-time surveys of shelter intake records. So, consistently there you see people with severe mental illness in that population, about 26%, and then chronic substance at the time using the language abuse. Now it would be kind of more likely to be captured as a substance use disorder, about 34%. So, again, this is a subset of the population that you might be working with. And then this came out more recently, using data from 2019 that looks specifically at adolescents. So, finding that adolescents experiencing homelessness were found to have higher current rates of alcohol, cigarette, e-cigarette, and marijuana use, as well as higher rates of binge drinking. They were also found to have higher lifetime rates of cocaine, methamphetamine, heroin, ecstasy, injection drug, and prescription opioid misuse. So, you can kind of see some of that data. And again, you'll get these slides, so you'll be able to look at that a little bit closer there. And if you have any questions, feel free to add those to the chat or raise your hand. Using the Zoom feature, so I see you. So, the answer to that kind of question I open with is certainly higher than the general population, which if you recall from last week was about 17.3% with substance use disorders. So, surveys kind of generally find that it's fair to say, depending on how you define the population of people experiencing homelessness or housing insecurity, that it would be higher than that, whether that's 35% or even higher, depending on the population. So, kind of moving into thinking about more care and services for people experiencing substance use or mental health challenges, what are some barriers people face accessing care? Great, seeing the chat, insurance issues. What else? What are some barriers to care that come up? Yeah, denial. So, kind of not recognizing or not feeling that they need, you know, help or treatment. Trust, you know, a lot of mistrust might have had bad past experiences kind of trying to seek care. Certainly stigma. Transportation hurdles, just not ready. They might recognize that they have a situation that's impacting them. Fear of the unknown. You know, people hear a lot about what treatment, you know, whether that's through media, social media, past experience, people around them. You know, not having the support system, great, to navigate the hurdles that it can take. Yeah, not being aware of what care is out there. So, they might have kind of stereotypes about what treatment looks like. Lack of quality resources. So, you know, if they had a negative experience or, you know, went through it one or more times in the past and felt their life didn't change, you can see why they'd be hesitant to do that again. Limited availability, you know, whether it's wait lists or if they do need, you know, particularly for the unhoused population, residential care, yeah, not knowing who to reach out to, great. Embarrassment, so people feel shame kind of ties into the stigma there. So, you know, this slide kind of presents, you know, particularly unstable housing and barriers to care, but many of these things have been mentioned. You know, for many people with no or unstable housing, survival can be more important than personal growth and finding food and shelter can be a higher priority than treatment for addiction or a substance use disorder. And motivation to stop using substances may be low. They might be using, you know, drugs or alcohol to cope with their situation. Other barriers to services, you know, have been mentioned, those long waiting lists for treatment, lack of transportation, lack of insurance coverage or insurance not covering the thing that someone might be interested in or need. Lack of documentation or IDs necessary to enroll in programs, that can be a big barrier. And lack of a social support network. So, you know, being estranged from friends and family who can be that person who, you know, can call and look for and fill out applications and just kind of help with some of these things like transportation hurdles. And then stigma due to their housing situation and substance use and, you know, perhaps other factors. Yeah, and shame is a big one too, you know, part of acknowledging a problem is just feeling, you know, so ashamed or people mentioned embarrassed about that, you know, to actually ask for help. So, you know, there's been more attention in recent years on this idea of a low threshold or low barrier access to care. So, you know, have a photograph of a steps here. You know, if you think about barriers as steps or hurdles to overcome, you know, if you were trying to enter a building and it was just a flat entrance at street level, that's easier than trying to get up these steps, you know, that kind of represent some of the things people have to go to. So, you know, this low threshold or low barrier approach to care is about removing barriers by helping people find available appropriate treatment providers, programs or beds, helping enroll in or navigate insurance coverage or appealing denials, perhaps providing transportation to programs or services and advocating for care that meets someone's individual needs, whether that's for medication, disability accommodations or other factors. And, you know, all of these services can influence access to and then retention and treatment. So someone actually staying in treatment. So you may have heard, you know, or kind of use this phrase in your work, you know, person-centered care. So, you know, this graphic comes from a video by the World Health Organization that, you know, really represents person-centered care as more of a partnership, you know, and you'll get the slides and can click on the link to watch that. But, you know, it means ensuring that health services are tailored to someone's individual needs and provided in partnership with them rather than simply given to them. You know, particularly within healthcare, you know, there can be this sort of hierarchy and people feel they might have the feeling of being told what they should do, you know, so really kind of trying to view that as a partnership and acknowledge that, you know, people have individual characteristics and needs. And so, you know, a one-size-fits-all approach often isn't the best approach. So these are kind of some bullet points that kind of capture what else is, you know, meant by person-centered care. So respecting the participant's own treatment and life goals, recognizing the treatment as an individual process that may vary among participants, understanding that any positive change is a step toward greater well-being and health, you know, so not necessarily insisting on, you know, making a lot of radical changes all at once, offering services without judgment, you know, trying to avoid punitive policies, you know, a bit of a movement away from that in treatment, you know, kicking people out for small infractions, prioritizing starting and continuing treatment despite any setbacks, and prioritizing culturally sensitive care with respect for participants' diverse identities and backgrounds. Any questions or comments? So part of kind of person-centered care is, you know, trauma-informed care, which is probably also something that, you know, you've heard or are working on within your own work and organizations. And, you know, this is just kind of thinking an overview trauma is one of those words that kind of if you're asked to define it, you might pause. So helpful to kind of have that definition or description thinking about it as experience or situations that are emotionally painful and distressing, and that can overwhelm someone's ability to cope. I think that sense of feeling overwhelmed is really critical there, you know, so trauma informed care is understanding, recognizing, and responding to the effects of all types of trauma. So broadly it emphasizes physical, psychological, and emotional safety for both survivors and providers and helps survivors rebuild a sense of control and empowerment. So you know, these are just some examples of trauma, you know, could be recurrent sexual, emotional, or physical abuse, witnessing death or violence towards someone else, incarceration, particularly solitary confinement, experiencing or witnessing an overdose, being forced to leave home for a variety of reasons, could be eviction, a natural disaster, foster care, war, or other situations. You know, not having basic needs met, living in poverty can be a form of trauma. Experiencing racism, misogyny, homophobia, transphobia, or other types of discrimination, and negative experiences with systems and service providers. So you know, that past experience someone has with systems of care can kind of be brought into, you know, the places where you are encountering them. And you know, adverse childhood experiences, often referred to as ACEs, kind of also overlap with this idea of trauma and responding to them as part of trauma-informed care. So you know, this specifically refers to stressful or traumatic events that occur, you know, up to age 17. You know, they can undermine a child's sense of safety, stability, and bonding, and their effects can persist for a long time. So you know, this comes from SAMHSA, and about 45% of children experience at least one adverse childhood experience. And females and racial or ethnic minorities are at a greater risk for experiencing four or more ACEs. And then this pyramid graph, or image on the right, kind of shows where there are a bit of gaps in research and scientific understanding of how these experiences at the bottom might impact someone's social, emotional, or cognitive functioning. You know, their likelihood of adopting health risk behaviors. You know, how that might turn into, or impact, or contribute to disease, disability, or social problems, or at the top, even early death. So you know, just helpful to think about that, as there's a lot we don't know. You know, just because someone maybe had these at the bottom doesn't mean that, you know, it's a guaranteed pathway to some of these things. So different people can come out of these experiences in different ways. And so those arrows on the right just kind of highlight that there's a lot that's not known. At the same time, you know, anybody who does this work is familiar with what some of the effects of trauma or ACEs might be. So you know, someone might be experiencing anxiety, such as panic attacks, emotional withdrawal, and then it can impact sleep, you know, leading to insomnia. Certainly depression can be an effect of trauma, or suspicion of other people and institutions. You know, someone may not feel safe or feel threatened. They may be in denial. You know, sometimes people even repress traumatic experiences. It can manifest as anger, you know, including with service providers. And certainly kind of contribute to substance use, mental health problems, and you know, sometimes suicide. So this, you know, some data coming from the National Coalition for the Homeless and a study that was done a while ago in New York families in emergency shelters, transitional housing and permanent supportive housing programs. So you know, finding that about 79% of mothers in the study were traumatized as children, you know, most commonly due to interpersonal violence, including physical assaults and sexual abuse. More than two thirds had been physically assaulted in adulthood, and half had been sexually abused as children. And study findings indicate that trauma, depression, and substance misuse can co-occur for mothers experiencing homelessness, you know, compromising their ability to form safe and trusting relationships. Any questions or comments about that? I'm just going to ask, are you I'm hearing some loud noise in my background, if you could just say shake your head yes or no, if you're hearing that. Are you okay with the audio? All right, sounds fine. So it'll just be impacting me. Life in New York City. So great. I appreciate those responses in the chat. So kind of moving on, or the question for you is sort of, what strategies have you found helpful when working with people who have experienced trauma, you know, and if you feel comfortable speaking, feel free to raise your hand or else, you know, use the chat. But, you know, trying to think about this as an opportunity to share strategies with each other as well. Great. And I'll just read some out as they come in. You know, so using empathy and active listening, yeah, easing them through the conversation. You know, so sometimes that means not just starting with kind of abrupt or really tough questions or waiting for them to raise difficult topics. So someone's mentioned, you know, both meeting people where they're at, which we talked about as part of harm reduction last week, or being patient, you know, might take time to develop trust where someone's going to share those kinds of things with you. Yeah. Breathing. Breathing techniques, you know, a lot of research showing it's not just, you know, it really does impact kind of how someone might respond by taking deep breaths physically. Great. So a lot here, you know, so presenting choices and information. You know, partializing info. So that could be interpreted different ways. But I think that's an important thing is, you know, and I'm going to talk about this idea of maybe addressing one thing at a time, you know, sometimes people when they're emotional might just divulge a lot all at once, you know, so kind of focusing on one piece of what they shared, being kind and patient in all levels of interaction, from the front desk to the workers and frontline staff. Yeah, so important. Many of you who, of us who've experienced some kind of even medical situation, you know, you know, when you go to check in, whether it's an ER, or a doctor's office or wherever that first encounter, you know, can really help set you at ease, you know, learning how deep the trauma goes before asking them to trust you, body language, you know, if your arms are folded, what does that communicate, you know, just kind of being aware of that, you know, thinking about the space that you're speaking in, acknowledging their feelings. Yeah, sometimes people just want to be heard. Great, some of these are have been mentioned, yet trying not to know that, try not to act like I know what it felt like to go through that experience, because each person is unique. But I let them know I'm here for them. And however, I can help, I will, you know, so my experience of having a loved one in incarcerated is going to be different than many other people's. So it may be recognizing and respecting that, you know, not everybody has the same experience, or there are things that I didn't experience. Yeah, really key here, don't give them a timeline for trauma and grief, everyone processes at their own pace. And just validating feelings. Great. Removing judgment. Yeah, making it avoid making it seem like you're interviewing them, just having a conversation. Yeah, kind of being humble and maintaining humility. Great. And these things are tough to do over and over. You know, many of these have been mentioned here, you know, just a most emphasizing emotional and physical safety, you know, so thinking about that space that you're having that conversation in, you know, importantly, allowing participants to disclose past trauma, if or when they're ready, you know, it's safe to assume that anyone you're interacting with may have experienced trauma, you know, but waiting, as people have mentioned, and having that patience to let them bring it up, but keeping that door open. So, you know, they've gained or build trust in you as someone that can disclose that to, you know, avoiding blaming someone for their situation, and protecting the confidentiality within, you know, the degree that you can for what's disclosed. Focusing on participants strengths, really important, you know, starting to emphasize more in systems of care, a strength based approach, you know, so that might be telling someone, wow, you really resourceful, I can't believe you managed to get through that, you know. So finding something that, you know, the situations people have been through, you know, they do have to, you know, maybe they've exhibited, you know, loyalty to the people around them, or they've been, you know, a mentor to someone in a similar situation or environment. So kind of identifying that and recognizing that, you know, we've talked about emphasizing collaboration and a partnership and also offering people choices. Someone mentioned already acknowledging you may not understand someone's experience of trauma. You know, sometimes it's hard not to start with, I know, or, you know, I know how that must feel. Avoiding referrals or actions that may re-traumatize someone. This can be challenging, you know, sometimes there might be, you know, someone's mentioned I understand is a way there to, you know, you can rephrase that by maybe mentioning, I also know someone who overdosed or I had a friend or I had another, you know, so a different way of kind of acknowledging you have a shared experience, but not using that phrase, I understand. Kind of back to this idea of referrals, you know, it's hard to always know how someone's going to be treated at the place that you're sending them. But you know, as much as possible, kind of trying to make sure that, you know, you are sending someone to places that you know will treat them respectfully and with dignity, you know, rather than just kind of a standard list. That's tough, you know, that's tough, especially given all the hurdles we've talked about. But, you know, when you do know and someone might be hesitant that this is a place that you feel other people you know have had good experiences with, you know, you can't make a guarantee, but you can say, listen, I've, you know, referred people or I've connected people with this service, and they really had a positive experience, or most of them did. And feel free to share in the chat. I see, you know, someone has mentioned referrals can be tricky, you know, if there's anything you want to elaborate on. So, you know, there's a lot of overlap here with, you know, trauma and then a crisis, but can also be some distinctions here. You know, again, what is a crisis? A perception or experience of an event or situation as an intolerable difficulty that exceeds the person's current resources and coping mechanism. So you see, again, this idea of someone being overwhelmed in that moment, you know, thinking of maybe a wave crashing over that person, you know, so this could be a psychotic episode, a fight, an injury, severe withdrawal, overdose, threats of violence or suicide, you know, and then on the right here, you know, someone in crisis might be experiencing feelings such as denial, anger, sadness, they might be embarrassed, even as they're, you know, shouting or acting out, they might be confused or experience ambivalent, or they may be scared based on whatever they're going through. So some overlap here with the last question I asked, but, you know, are there strategies you found helpful when dealing with someone experiencing a crisis? So, you know, as I mentioned, there's some overlap, you know, about listening attentively, asking open ended questions, right? So those are questions that don't have a yes or no answer might be something like what caused you to get into a fight? Or why are you upset with that person? Giving them a chance to share without judgment, you know, making sure your body language is warm and receptive, you know, emphasizing safety, remaining calm yourself, letting them know they are safe, and giving them space to share can be really a difficult skill to kind of maintain your own or challenging to maintain and stay calm, you know, particularly in a situation where, you know, whether it's a mental health episode or someone experiencing an overdose, or other kind of reaction to substance use, trying to be compassionate and not look scared, someone has said in the chat here, great. So this kind of summarizes some of the things that have been shared, you know, and every situation is going to be different, you know, offering emotional support without judgment, you know, sometimes people just need to be heard. So allowing the participant event, you know, what happened, you know, I mentioned asking open ended questions, and that partial approach, you know, fixing focusing on fixing one problem at a time, you know, often in a crisis, it does just kind of come out where someone is, you know, sharing a lot of things at once. So, you know, choosing one thing or asking them, you know, okay, you've just shared a lot, you know, how about which which thing is most important for us to talk about right now, trying to de escalate emotionally charged situations tends to be, you know, increasingly more training opportunities that specifically focus on those skills. Seek help if someone is threatening or engaging in violence, or you need support to respond. So, you know, I've certainly witnessed that, you know, in some of the harm reduction centers, I've volunteered or spent time with, you know, that, you know, people do often respond in pairs or a team, you know, particularly when someone doesn't feel comfortable responding to a situation on their own. Yes, someone's asking here, would it help asking them where they would like to start? I think that's a great question or a way to phrase it, too. And someone else has said, yes, sometimes we do need to ask for assistance from a colleague, and we should feel okay about that. Also going to share, you know, this resource, how many of you are familiar with the 988 crisis, suicide and crisis lifeline as a resource? I know we won't get every response here, but great, see that a lot of people are. So, you know, this has been around for a couple years now, and, you know, New York is kind of promoting it as an alternative, or New York City, you know, certainly to some of the previous helplines that existed. So, you know, but it is a national service, no matter where you are in the U.S., you know, you can dial 988 as an alternative to 911. You know, it's important to know that if you call 988 and you're not sure, you know, whoever responds, if they deem or feel that 911 is a better response because someone, you know, needs that emergency assistance, you know, these trained counselors will help assess next step. But broadly, you know, this has become, you know, a behavioral health crisis hotline, not just for, you know, people experiencing suicidal ideation or, you know, that you think might be having that experience. You know, so you can call or text 988. There's also a website here for kind of the New York City site. And, you know, you can get free confidential mental health support for yourself or if someone else, you know, is experiencing a situation. You know, it's available in more than 200 languages, 24-7, every day of the year, from a phone, tablet, or computer. So, you know, good resource to know about. Any questions? Or comments? You know, or even sharing things of, you know, what would be helpful to have more support with, you know, whether it's crisis or trauma informed care, you know, feel free to add that or share in the chat. So this, as we kind of shift into talking more specifically about care, you know, this is a review of last week, you know, goals of care for people with substance use disorders. So just kind of reiterating that these can fall into different categories here. This is adapted from some health department slides. But, you know, thinking about substance-related goals on the left side there, which might be reducing, changing, or stopping substance use. Reducing the harms associated with substance use. So talked a lot about that in part one. Provide evidence-based treatment options. We're going to move into that today. Overall health in the middle there. So preventing overdose deaths and deaths from other clauses. Preventing and treating HIV, hepatitis C, and other health conditions. Addressing mental health challenges. And on the right, you know, kind of functioning might be thought of as wraparound services. You know, helping someone meet their own goals. You know, improving social support. Connecting them to other services. So that might be legal, housing, or employment services. So, you know, can be helpful to kind of think about different types of, you know, care or goals that someone might have as you think about, you know, what are they interested in focusing on at this time. And this is a kind of information from a study, you know, often in research we don't see as much kind of focusing on, you know, what's shared by people experiencing these situations. So, you know, this is perspectives on care specifically from people experiencing housing challenges. So studies exploring views about treatment from the perspective of people experiencing housing challenges have found a preference for harm reduction oriented services. Participants considered treatment effective when it provided a positive service environment promoting health, well-being, and elements of recovery, which we'll be talking about today. Compassionate and non-judgmental support. Time to heal. Treatment that is long enough to work toward their goals. Often, you know, treatment is limited in duration but depending on insurance and what's covered or the length of the program. Choices regarding type of treatment and people expressed as very important. Opportunities to learn or relearn how to live. So kind of more life skills were cited as important in interviews with people experiencing housing challenges. And interventions that were of longer duration and offered still a bit stability were valued, especially by women. So these are quotes from some of that research, you know, that people shared, you know, at the top it says, it took me six months to sober up and another six to stabilize. I don't count my first year as looking for work or even possibly returning to school. I count it as just coming down to earth. The longer it lasts, the happier I'll be. Someone else says, just somebody taking interest in what you're doing can help heal you. Just saying that person's name, taking your time out for them. It makes a person, it fills the soul, it fills the heart. The people here mainly need compassion. And then the last one is the program is teaching us to be in a home, not like what we were used to out on the street, like relearning how to be in a house with responsibilities. You've got to make your bed, do your laundry, sweep, wash the floor, do dishes, and of course we're starting to cook. Most of us, I think, are just relearning domestic things that you would normally do in a home. So, you know, people acknowledging that coming from some of the situations people can end up in, particularly when they have severe substance use disorders or mental illness, relearning those types of skills, particularly in a group environment or setting, can be really important and helpful. Someone's adding in the chat, learning how to manage money, how to budget, importance of credit and paying your rent out on time. You know, all those things, you know, those types of kind of, again, wraparound skills or services can be really necessary and important for some people kind of in this population with substance use disorders and particularly those who've experienced housing challenges. So, as we kind of shift, you know, we'll take a break shortly here and, you know, looking at where treatment is received, you know, if you recall sort of where we started the first session thinking about media representations and social media representation of, you know, treatment and often, you know, what's shown is sort of a stereotyped image of treatment what's shown is sort of a stereotype of residential treatment followed by mutual aid participation. And in reality, that's not where most people actually receive treatment in a residential facility. And, you know, when we talk about type of treatment, historically, you know, people have focused on where it happens rather than what services are offered, what we're going to try to shift to today. So, you know, if you look at the locations where people receive substance use treatment in the past year from 2022, at the top, you know, about 13 million people receive treatment, close to 10 million of that was outpatient, 8.3 outpatient other than a general medical clinic or doctor's office, 3.6 million in telehealth treatment, and then 3.5 million inpatient treatment. Medication assisted treatment, we'll talk about medications for opioid use disorder today, about 2.4 million, medications for alcohol use, 1.2 million. And then in people who received some form of treatment in prison, jail, or a juvenile detention center, about 721,000. So, you know, these categories are not mutually exclusive, people could have received treatment in more than one setting. But, you know, you see that people are more likely to get outpatient services than inpatient or residential services there. And that's kind of been pretty consistent. So, and then this looks at New York State. So, locations where substance use disorder treatment is received. So, this is from 2020, impacted by the pandemic, certainly. So, the first category is some sort of like crisis response setting, 33%, outpatient, a little over 30%, inpatient, close to 19%, an opioid treatment program, so that's specifically methadone, 11%, and then residential, 6.2%. So, similar pattern there where the outpatient treatment is more common. Any questions? Or comments, feel free to add those to the chat. So, you know, you've probably heard the phrase, the treatment gap, might have mentioned that last session, you know, when it comes to substance use disorders, you know, when we talk about the treatment gap, that's the gap between people who, you know, have or may have a substance use disorder and then receive care for that substance use disorder. So, nationally, surveys typically have found that about 10% of people with substance use disorders receive treatment. So, as I mentioned at the beginning, these percentages have been higher recently. You know, half of people with mental illness receive mental health services. Removing barriers to treatment by offering treatment on demand and helping navigate insurance coverage, transportation, and other hurdles can help improve access. You know, and it's important to kind of note that, you know, for much of my lifetime, treatment was not covered by health insurance in the United States. So, you know, as much as we talk about people kind of being in denial or not recognizing that they need treatment, it's also important to kind of acknowledge that our systems of care, you know, require often private payment for these services, both for substance use and mental health care. Still hurdles people experience kind of trying to, when they do have insurance, actually get that covered. Many people need other support beyond treatment in order to recover from a substance use disorder. You know, we'll get into that a little bit today, but, you know, sometimes when people say, well, treatment didn't work because that person continued using or returned to using, you know, the question is what happened after treatment? You know, it's sometimes if you go for surgery, you know, for a hip replacement, for example, or knee surgery, you know, treatment doesn't end just because you're discharged from the hospital, you know, you might get physical therapy, there's follow-up care, you know. So what kind of services are people getting after they complete some kind of program, you know, and particularly housing and employment, and then restoring personal relationships that might have been harmed or damaged, you know, really key to support people in that recovery process. Some people with drug and alcohol problems achieve long-term stable recovery without formal treatment. So, you know, this is a phenomenon usually found when people have less severe, so those kind of mild or maybe moderate substance use disorders, you know, but that's something that's kind of been consistently found in research that, you know, some people are able to just stop, you know, what's referred to as sort of recovery capital kind of, you know, encompasses those resources, both personal, financial, emotional, social, that someone kind of might bring to that process that might make that more likely, or they may have less need of kind of formal treatment services. And it's important to offer services even if people aren't ready for or interested in treatment. So, you know, that's something we talked about a lot in the first session, you know, and what the rationale really is behind harm reduction, you know, even if someone expresses that they aren't ready for or interested in treatment, you know, offering other services really critical to kind of keeping them engaged and helping build that trust and that relationship. So, I'm going to pause here, you know, it's 10.52, and we'll kind of pick up talking more about treatment after we take about a 10-minute break. So, I'm going to stop my video, we'll come back at just a little bit after 11, so about 11.02, and continue this discussion of treatment. And I'll leave the chat open, but feel free to ask any questions there. See you in a bit. Great, we'll get started here on the second part. So, as we move into talking about treatment, I'm going to start off with a question, and that is, what would you include on a menu of treatment services for people with substance use challenges? So, thinking about a restaurant menu and their different categories for appetizers, main dishes, salads, desserts, drinks, you know, if we thought about treatment for substance use disorders as a menu, what are some of the things, services, so not inpatient, outpatient, that's locations, but like what actual services, behavioral health, other approaches, you know, would you think should belong on that menu? So, I see one here, cognitive behavioral therapy, great, great, vocational skills, so therapy, you know, counseling, you know, we can unpack that kind of specifically, art therapy, really great, you know, that's something that I've facilitated. So, group therapy, you know, so could distinguish between individual therapy and group therapy, you know, so if you think about that as the difference between, you know, a Caesar salad and a spinach salad, you know, maybe some people don't like spinach, maybe some people don't like group therapy, they'd rather do one-on-one or vice versa. Great, someone's mentioning harm reduction services, so, you know, this, because we kind of talked about harm reduction in the first session, you know, kind of putting this more in kind of the treatment and, you know, things that can connect those two, but harm reduction, educating people about Narcan, fentanyl test strips, those things definitely should be part of kind of treatment settings. DBT, dialectical behavioral therapy, so, you know, really effective form of treatment for people, you know, particularly with some mental health conditions as well. Medications, we'll talk about that. Family therapy, great, really important, increasingly starting to recognize how important it is to include family, however someone might define that, or loved ones in that process. Mindfulness exercises, great, so mutual aid approaches, you know, and potentially having choices for that. Sober living, you know, as a transition. So, yes, you will, someone's asking, I'll get copies of these slides, you know, within a few days after the training. Great, health classes, I think that one is kind of underutilized in a lot of settings, you know, when we talked last week about if someone is, the reason someone is using substances, and if you kind of take away that substance use, or someone's trying to reduce their use, what are you replacing that with? Great, alternative coping strategies, so kind of, that gets at, you know, if someone's using drugs to deal with stress, or past trauma, or drinking, you know, how are they going to deal with that if they reduce or stop using those substances? Great, so this menu is kind of something I've come up with, you know, based on responses, and, you know, you'll see harm reduction isn't on here partly for space, and because it's sort of in the part one session of this training, but certainly, you know, some of those techniques can be incorporated into these settings. But what you see here is on the left, you know, counseling and mental health care as a category, right, so that could be group therapy, individual therapy, family therapy, case management, so, you know, many of you work in that area, peer support, which we talked about, you know, and then mutual aid, so, you know, starting to be more alternatives, not just the 12-step AA and A-type programs, but other types of kind of mutual aid programs, like smart recovery. In the middle, medications and medical care, so, you know, we'll talk about detox and withdrawal services, as well as medications for opioid use disorders, so methadone, buprenorphine, and naltrexone, you know, naloxone training in there, people may need psychiatric medications, HIV, hep C testing and treatment, wound care, you know, with xylosine in the middle, you know, with xylosine in the mix, particularly, that's becoming more and more critical to offer as part of these services, and then just other medical and dental care, you know, maybe someone has untreated diabetes, maybe their priority is dealing with dental issues, you know, because that can really affect self-esteem, so, you know, connecting them perhaps with some of the dental school services, you know, or where they can get that care. Wraparound services, so, you know, legal aid, housing help, employment assistance, educational programs, benefits navigation, and then really critically that aftercare or recovery support, so, you know, probably some other things that could be added here, but I think, you know, the landscape is kind of starting to shift to, you know, what would that menu look like? Or what could it look like? And, you know, if you think of people having these choices and that person-centered care, you know, and feeling like they could try something and maybe cognitive behavioral therapy wasn't that helpful for them, but what else might be? Any questions, comments? You can add them to the chat. So, you know, kind of talking specifically about some of these services, won't get into everything on that slide, but, you know, really important to talk about what detoxification is and what it isn't. You know, sometimes people can kind of think about detox as treatment, you know, particularly, you know, in years past where people could kind of cycle through these detox experiences, but, you know, really it's not considered treatment. What it is, is it refers to a medically supervised taper from substances such as alcohol, benzodiazepines, or opioids. You know, it's often provided in an inpatient setting. It can include medical and psychiatric assessments. Sometimes medications are offered to help with symptom relief, but critically it provides monitoring during withdrawal, you know, really important certainly for opioids, alcohol, and benzodiazepines that someone is kind of getting that oversight and, you know, potential care if they need it. You know, there are some cautions about detox, which is, you know, there can be high rates of return to substance use after someone's been in detox, which, you know, may just be a matter of days. You know, there's an increased risk of overdose after detox due to someone's lower tolerance. So, you know, any detox should include overdose prevention and naloxone training. And then ideally it should be followed by a longer care plan. You know, it is not considered treatment itself. So this is really monitoring during withdrawal. So connecting someone, whether it's to outpatient or potentially residential or inpatient program, you know, can be really critical in kind of supporting that ongoing care. Any questions? So before we kind of get into talking about medications for opioid use disorder, I wanted to get a sense of how familiar you are with how they work, you know, so that would be methadone or buprenorphine, you know, number one is very familiar, number two, somewhat familiar, and number three, not too familiar. So if you just want to add your response to the chat. Great. So seeing a range of responses here. Great. So for some of you, this will be a review, you know, but helpful to kind of see, I try to present a lot of graphics here. So, you know, just to start out, these are the three different categories of medication specifically for opioid use disorder. So, you know, what's called an agonist is an example would be methadone. That's something that fully occupies that opioid receptor in the brain. So you can see that green kind of symbol for that methadone, and then the pink is the opioid receptor. So, you know, that's why methadone is referred to as an agonist, if you've ever heard that. Now, buprenorphine, which goes by different brand names, some, most people are familiar with suboxone, is a drug that's used most people are familiar with. Suboxone is a partial agonist. So it only partially occupies that opioid receptor in the brain. And then on the right side, you see naltrexone, you know, one of the brand names is Vivitrol. That's actually an antagonist. So that blocks the opioid receptor. So on the left, those are occupying the opioid receptor. And then on the right, it's blocking it. So someone isn't feeling any effects of them, if they did take opioids. I'm going to put this in the chat, just, you know, you will get these slides. But, you know, this is a helpful video, you know, the screenshot is taken from that video that kind of explains, if you want to watch that later on, a pretty good overview of treatments for opioid use disorder. So, you know, starting with methadone, you know, it's a medication that prevents withdrawal from opioids and relieves cravings. It's highly regulated by federal and state governments. You know, methadone is only available in opioid treatment program settings, so often referred to as OTP settings, which can limit accessibility, especially in rural areas. Although, you know, even in New York City with transportation hurdles, you know, there can be barriers here as well. You know, initially it must be taken at a clinic every day and take home doses are typically allowed over time. You know, this is something that people have been advocating to change. You know, in other countries, sometimes methadone is available in pharmacies. So someone, you know, can go to a pharmacy and get it rather than a specialized clinic. Patients undergoing methadone treatment may be offered other services such as counseling, you know, whether that's group or individual and suddenly stopping methadone precipitates withdrawal. So, you know, tapering can take months and often, you know, if that's someone's choice is done over time where, you know, that dose would be reduced. Buprenorphine is a medication that treats addiction to opioids like prescription painkillers and heroin by stopping withdrawal symptoms and reducing cravings. So it's been offered in different formulations, including a tablet, a sublingual film, or injection. You know, some of the brand names are Suboxone, Subloquay, Bruxadi, and other variations. And it's available in various treatment settings including primary care and through some harm reduction programs now. So, you know, the injection, you know, doesn't have to, that's typically once a month, time periods can vary, but unlike with methadone or the pill or sublingual film version of buprenorphine, you know, that's something that, you know, people can choose. So they only have to kind of come back once a month. You know, importantly, combining buprenorphine with other opioids, alcohol, or benzodiazepines can increase the risk of overdose, but it has a lower overdose risk compared to methadone. Now, Trexone, also known as Vivitrol, is typically given as a long acting in intramuscular injection every 28 days or less. There's also an oral or tablet version. So it's not an opioid, so it can be an option if someone prefers to avoid opioids like methadone and buprenorphine, and it blocks the effects of opioids. It can also be used to treat alcohol use disorder. So if someone has, you know, both an opioid and an alcohol use disorder, this can be an option that would address both. One of the barriers is that someone must not use opioids for seven days prior to starting Naltrexone. You know, that time period is shorter for methadone and buprenorphine in terms of kind of initiating care. So that can be a hurdle for Vivitrol or other formulations of Naltrexone. And there's an increased risk of overdose when Naltrexone wears off or is stopped. So, you know, that's a concern in kind of offering services and kind of, you know, trying to reduce those risks. So, you know, there can be some myths out there or misperceptions about medications for opioid use disorder, you know, and, you know, sometimes it's kind of described as substituting one addiction or one drug for another. You know, particularly with the risks of the current street drug supply, you know, there's a shift in kind of thinking about it as a safer alternative that can help someone stabilize their life. You know, and it doesn't mean that someone has less willpower or is less able to function, you know, and it's not a sign of weakness or failure if someone chooses to continue medication long-term, you know, so trying not to kind of have systems that pressure people to quit or taper, but at the same time offering that option, you know, for people who are interested in that, you know, and taking medication for opioid use disorder does not mean someone is not in recovery, you know. That's been kind of a situation that some people have encountered, you know, particularly interacting with mutual aid programs, you know, which can vary in their receptivity to, you know, these medications, but increasingly kind of recognizing that, you know, that it can be part of someone's recovery process. Yeah, just kind of looking at questions or comments in the chats here. So, you know, in 2023, the federal government made it easier for more healthcare providers to prescribe buprenorphine by dropping a requirement that they first apply for a waiver before being able to prescribe it. So that has definitely expanded access to buprenorphine. It can still be challenging to find a provider who can prescribe it or dispense methadone, especially in rural communities, and increasingly kind of looking to mobile units and telehealth options to help connect people to providers in some areas. So, you know, nurse practitioners and physician assistants can also prescribe buprenorphine, so that has helped increase access. And you see here on the right, you know, SAMHSA has a website where people can look up, you know, a buprenorphine practitioner locator. So, you know, it's searchable by city, state, or zip code, and then that address and contact information are listed for each provider. So, you know, there's been a lot of effort, both on kind of, you know, for all three medications to kind of increase access and availability. So just want to ask here, you know, what questions or comments do you have about medications for opioid use disorder? And kind of, you know, one in the chat, you know, can that be abused? You know, there's certainly situations where people might sell, you know, particularly with methadone, sometimes with suboxone, you know, partly the shift toward kind of injectable versions of some of these medications kind of can help address that. It also can be a preference for people for the reason I described, you know, they only have to go once. There's different kind of perspectives and viewpoints on kind of diversion, that, you know, if it's getting to other people who need it, that that can be, you know, helpful. And, you know, as with anything, you know, including prescription medications, you know, certainly during, you know, increasing prescribing of opioid painkillers, you know, you saw that kind of same pattern. So, you know, efforts to kind of try to address that without limiting access to people who need and benefit from that care. Someone's mentioning the overdose. So, yeah, I mean, the context of polysubstance use, and we're going to talk about that too, you know, methadone can be a contributing factor in an overdose when someone is combining it with other substances. That's why it's really important that people kind of get that harm reduction education that, you know, even alcohol is what's called a central nervous system depressant that can lower your breathing rate. So if someone is using methadone and maybe using some fentanyl or other opioids on top of that and drinking, you know, that can increase overdose risk. So kind of trying to balance and recognize the reality that sometimes people do continue using other substances with, you know, the fact that, you know, with the increasingly kind of risky street drug supply that these medications are a safer alternative. And can help people stabilize their lives. And in some cases, you know, reduce or stop other substance use. Any other questions? You know, just some data that's not on the slides. In 2022, about 25,000 New York City residents received treatment from an opioid treatment program, specifically methadone. 16,000 New York City residents filled up buprenorphine prescription. Both of these data points come from 2022. So that's about 40,000 New Yorkers receiving some type of medication for opioid use disorder in 2022. So, yeah, someone's mentioning kind of, you know, people have different reactions to different medications. You know, some people don't like suboxone for different reasons or don't like, you know, the need to be at a clinic so frequently for methadone. So, you know, offering different alternatives and, you know, the injectable version is an alternative now, certainly for buprenorphine. And one that's, you know, increasingly kind of being encouraged and supported by programs just because of that, you know, less need to kind of fill a prescription. You know, it's once a month typically. So, you know, important to manage expectations with medications for opioid use disorder. Sometimes you see this described in news articles as medications for addiction. And really, you know, that's a disservice because, you know, there isn't a pill for addiction, you know, or an injection for addiction. These are specifically for opioids and then with naltrexone, also alcohol. But, you know, some of the benefits can be, they improve the control of the cycle of craving and withdrawal. You know, withdrawal is something that is so excruciating for people that, you know, it's something that they will do anything to avoid. So, you know, having these medications kind of stabilize people so they're not going through that constant cycle of using, craving, withdrawing. Being on these medications decreases overdose and all cause mortality. You know, it's not the case that someone may never overdose or that there are no overdoses, but it does decrease at a population level those overdose deaths. It does reduce illicit drug use and injection drug use. And it can help stabilize emotions and behaviors. So enhancing the ability to engage with psychosocial, so the counseling and medical services and can help individuals regain the ability to participate in their communities, families and workplaces. As I mentioned, there are also limitations. So, you know, buprenorphine and methadone address opioid use, including heroin and fentanyl, but not other substances like stimulants, like cocaine, methamphetamines or alcohol. And medications target substance use, but many people need additional services and support to help address other challenges. And then use of medications does tend to decrease over time. So, you know, researchers are kind of working to find out why and address any hurdles, you know, whether that's sometimes the cost or just the inconvenience, you know, but people do sometimes, you know, either stop or decrease their use. Yeah, someone's mentioning, I have a client whose insurance has stopped covering suboxone strips and he now has to take the tablet version with a bitter taste. I worry that this person might not stick to the regime. That's, you know, insurance limitations can be ongoing and continued hurdles both at the federal and New York State level. So kind of moving into some of the resources to find substance use and mental health treatment. You know, many of you are probably familiar with the New York Office of Addiction Services and Supports or also known as OASIS, you know, and here's information kind of about their phone number and website and their tool to find addiction treatment. What I referred to previously was, you know, New York State is fortunate to have what's known as a CHAMP Budsman program. So somewhat unique in that there is this hotline. You see that in the orange graphic here that helps patients and providers address insurance issues related to accessing substance use and mental health services. So, you know, there's a link to that flyer which I'll also put in the chat here, but really great to have that resource. I'm just gonna type that out. And that again is just for New York State. And hopefully you can see that, but you'll get the slides as well. And then the last link is New York State's Community Mental Health Promotion and Support. So providing support and access to mental health professionals. Also, National Resources for Substance Use and Mental Health Care. So, you know, these are some links and phone numbers for, you know, places at the federal level where you can put in your location and find treatment. And again, that 988-CRISIS-LIFELINE there. I also like to share this treatment locator from an organization called Shatterproof. You know, their Atlas, you know, it's not available in every state yet, but it does cover New York, New Jersey, you know, Pennsylvania and some of the other states nearby. It's a resource just to help people find addiction treatment that meets their needs. You know, they'd like to provide it in all 50 states. You see the ones, and then on the map, they're shaded darker where, you know, they have covered now. This screenshot shows, I know it's a little small here, but just highlighting that, you know, if you're thinking about, you know, what are people's specific needs or person-centered care that's tailored to an individual, you know, this allows you to put in a location, you know, using a state or zip code, the substances that that person's interested in getting help for, you know, types of treatment services. So maybe they specifically want telehealth or residential treatment versus outpatient treatment. Then, you know, the distance, you know, so there's a slider at the top there and special programs. So, you know, might be something for veterans or people who are pregnant or, you know, living with HIV or AIDS, you can check off various categories there. Allow smoking or tobacco products. You know, that can be really critical for people to, you know, stay in treatment, you know, who are not interested or willing or able to, you know, stop or reduce their tobacco use at the moment. You know, the screen gets cut off, but you can also check off other support services, different payment options, whether you're looking for a program that offers medications for alcohol or opioid use disorder, and then, you know, things like language or the availability of kind of primary care or mental health care. So, you know, good resource to know about or share with people within your network, you know, for the states that that's available in. This slide kind of gives an overview of, you know, treatment referrals and questions to ask. So, you know, this is sort of would be maybe the gold standard or the ideal if a program were able to offer all of these services. So kind of keeping in mind that realistically, you know, some of the things, particularly on the right there, might not be available. But, you know, things to consider is, you know, does the program fit the person's needs and goals? How soon can treatment start? You know, people have mentioned often their wait lists. What insurance is accepted? You know, even for people who have insurance, sometimes there can be other costs. You know, what are the hours and flexibility of the program, particularly for outpatient services? You know, people may be juggling, you know, work or family responsibilities, or just, you know, needing a program that meets their own, you know, possibly unpredictability of showing up for appointments. You know, what medications are available to treat opioid or alcohol use disorder? What mental health services available? You know, is there both individual or group counseling if someone has a preference? And then what other health services are available? So then on the right, you know, is help offered for kind of some of these specific needs or populations? You know, some people, you know, really it's important to them, you know, if they're LGBTQ+, you know, or a veteran or pregnant, you know, to have a program that's tailored to their needs or that offers some kind of housing or aftercare. So, you know, helpful to kind of think about this, recognizing again that it may be an ideal to be able to find something that kind of is 100% meeting someone's needs. Any questions? Comments? So moving on, you know, we're gonna talk a bit about recovery from substance use disorders. And, you know, this is gonna be a pretty brief overview here, but just it's a topic that doesn't get quite as much attention as kind of the prevalence of substance use disorders or addiction. So to start off, I'm gonna ask you to think about something you've recovered from, an injury, surgery, a disease, natural disaster, or an experience like the death of a loved one. What are some things that come to mind when you think about the process of recovery? So a couple of people have commented, you know, patience, frustration, you know, that recovery is not linear. It's not a straight upward line. It's stressful. There can be good times. Just reading the chat here, different stages, fear. There can also be bad times. Absolutely. It takes time. You know, the people tend to need support or might struggle with recovery. Then it can be overwhelming. You know, hope can be really important. There's a lot coming in fast. So apologies if I miss anything. You know, it's not an easy journey. You know, people can be very anxious. Great. Others don't always understand what you're going through. Absolutely. You know, it can be very isolating. You know, the faith can be helpful for some people. It can be overwhelming. Yeah. So great. Really appreciate all these. So, you know, we've all had something, you know, even if you just think about the pandemic and can relate to this process of recovery. So, you know, these are just kind of some common themes. Many have been mentioned. You know, it can take longer than we would expect or would like. It can involve setbacks and unanticipated hurdles. People have different experiences with recovery, even from the same illness or event. It can also change someone's perspective, priorities or identity. You know, for example, we talk about someone who's a cancer survivor. You know, when someone goes through that experience, like potentially a life-threatening illness or injury or addiction, you know, they can come out with sort of a different identity or different priorities. And certainly people usually need support and help to recover. You know, so this is just a kind of small subset of some of the things that have been mentioned. You know, someone else also mentioned the chat that, you know, you can kind of be constantly reminded of a traumatic event. So, you know, those things, you know, within the context of substance use can be what are sometimes referred to as triggers, you know, that being kind of mindful of that. So this is, you know, how SAMHSA, there's a lot of different definitions of recovery, you know, and they, different organizations have come up with different things over time, you know, but broadly SAMHSA defines it as a process of change through which individuals improve their health and wellness, live a self-directed life and strive to reach their full potential. So they've identified four dimensions that support a life in recovery, health, overcoming or managing one's disease or symptoms, for example, abstaining from use of alcohol, illicit drugs, or non-prescribed medications if one is addiction problem. And for everyone in recovery, making informed healthy choices that support physical and emotional wellbeing. Not all definitions, and particularly even some federal agencies now are not, considering abstinence, you know, a criteria for recovery, that total abstinence from all substances forever. There's kind of been some movement and shift in thinking about that. Home, a stable and safe place to live. You know, that having purpose, so meaningful daily activities, such as job, school, volunteering, family caretaking, or creative endeavors, and the independence, income, and resources to participate in society. You know, that might be a tall order when you think about income and resources, particularly at the current time, you know, but really thinking about purpose, that, you know, if someone has been spending the bulk of their days looking for, getting money for using, recovering from substances, you know, having some purpose is, can be really critical to kind of filling someone's time and giving their life, you know, kind of the meaningful daily activities that this is described. Someone's pointing out volunteering can be so helpful. Absolutely. Community, so relationships and social networks that provide support, friendship, love, and hope. So, you know, something that gets sometimes not as much emphasis is that, you know, people who are using substances or inactive addiction kind of have these, they do have their social networks of other people who use drugs or alcohol, and, you know, kind of shifting that to a social network of people who don't have substance use disorders, you know, can be really challenging, but it definitely increases the chances that someone will achieve, you know, what's called kind of, you know, stable or sustained recovery. And on the left here, you just see these kind of 10 guiding principles of recovery, you know, so that it's person-driven, respecting of many pathways, holistic, that peer support, you know, and these other factors, such as addressing trauma and emphasizing strength and things like hope are really critical. So, you know, at the same time, kind of thinking specifically about definitions of recovery, you know, there can be different ways of defining it. And one question is sort of, what does recovery mean to you? You know, kind of broadly, how would you describe what recovery means to you? Starting over, someone says. Finding hope, right. Healing. Back to balance, forgiving, a phase of new change, a reset. Finding your smile. So for one of the exhibitions my husband and I did, it was in a university setting. So, you know, students had come up with, you know, a way of asking that question in their community, and they decided to use masking tape for people to write their responses on with a Sharpie, you know, because masking tape represented kind of healing and connection to them. So very interesting to see the range of responses there. But freedom was one that came up a lot. Yeah, living a healthy life and being able to support myself, great. So, you know, I'm going to present a couple more definitions of, well, actually, this question is, what percentage of people who have a substance use disorder would you estimate eventually recover? So, you know, data can be variable on this, but, you know, first response would be 40%, number two is 50, three is 60, four is 70 or more. So if you just want to add to the chat. Great, so seeing a range of responses there. And, you know, it's a question that, candidly, there hasn't been as much effort to collect data about that, and it's kind of just starting to kind of become more of a focus, you know, including in this national survey on drug use and health that I've been showing. But, you know, for 2022, you know, the way they ask the question matters. So for people who perceive that they ever had a substance use problem, 71% or 21 million people considered themselves to be in recovery or to have recovered from their alcohol or other drug use problems. So, you know, that's a broader way of asking that question. You know, did you ever have a problem with drugs or alcohol as opposed to, you know, the criteria we've talked about for a substance use disorder? But, you know, so higher than many people might expect for that. There's an organization called the Recovery Research Institute, which is a great resource for information about recovery. And, you know, they kind of have a range here, but say that compared to many other medical and psychiatric illnesses, substance use disorder is a disorder with a good prognosis. It's estimated that between 42 and 66% of people with substance use disorders achieve full remission, although it can take time to reach that point. So, you know, the broader takeaway is that it's more the norm than the exception. You know, sometimes people can think recovery is rare, particularly, you know, thinking back to those media representations and the tendency of, you know, news and entertainment media and social media to focus more on the problem of addiction and that recovery is sometimes a bit more hidden, although that is starting to change. And even recently, you know, with the coverage of Hunter Biden, seeing much more kind of coverage looking at, you know, not just this idea of recovery, but some of the things that programs and services that help people heal. You know, shifting to another topic that, you know, will be developed more in a training offered starting in September, you know, through the Department of Health. But, you know, just want to touch on how service providers such as yourselves kind of deal with and are impacted by a client overdose, suicide or other death. You know, sometimes not as much acknowledgement that, you know, people react to these losses, you know, that happened in your work life as well as your personal life. And, you know, studies have found there can be a range of reactions to this experience. You know, whether that's sadness, guilt, anger, helplessness, you know, might be nightmares or self questioning, anxiety or frustration, you know, people can feel demoralized or devastated or exhausted or have some kind of reduction in empathy, you know, sometimes referred to as overdose related compassion fatigue. You know, and this is a little bit repetitive here, but some types of feelings that can surface after a client overdose death, you know, not just that guilt, sometimes relief, shame or stigma, but people might feel not worthy to grieve because this was more of a work relationship, you know, which can kind of blend into a personal relationship or caring about the people you work with. You know, sometimes judgment or pity can kind of be part of the mix of feelings people experience. You know, people may feel they don't have enough social support to process a death or a lack of training or professional guidance, you know, and just the complexity of people's kind of intertwined personal and professional lives. Yeah, someone's mentioning, you know, something that they have experienced in the chat. So, you know, compassion fatigue is kind of an umbrella term that actually kind of encompasses a couple different things here. So, you know, working with people experiencing housing and substance use or mental health challenges can be rewarding, but also very demanding. You know, you may feel inspired by the work, but also sad, frustrated or angry about things outside your control. You know, to provide the best care and services, it's important to take care of yourself too. And so compassion fatigue kind of refers to the physical, emotional and psychological impact of helping others. It can be a combination of burnout and secondary traumatic stress. So those things are actually kind of separated here. So burnout can include feelings of exhaustion, you know, sometimes negative attitudes toward work or just a sense of not being very effective. Whereas secondary traumatic stress can result from hearing about trauma others have experienced, especially if you're exposed to a lot of traumatic stories. You know, and noting here, someone with a history of trauma may be more likely to experience, you know, either or both of these things or compassion fatigue. Great, and so, you know, I'm not gonna read everything here, but, you know, these are some signs and symptoms of compassion fatigue, which are probably familiar to many of you. You know, some of the mood feelings of just feeling helpless, you know, that you can't necessarily provide the care that you wish you could or the services or that you're providing it, but it doesn't feel like it's having an impact, you know, feeling exhausted or overwhelmed, you know, sometimes frustrated or cynical or angry, you know, that can also manifest as these physical symptoms, you know, whether that's headaches, shortness of breath, trouble sleeping, muscle tension. And then at work, you know, you may feel sort of some reduced empathy or dread working with certain clients or that, you know, the quality of the work suffers or there's, you know, that might result in decreased client satisfaction. So, you know, this is a little bit of a preview of some of the topics that'll be developed more, you know, for the training in the fall, but just wanna ask, you know, what strategies have you found helpful to address burnout, compassion fatigue or stress? Yeah. Yeah, someone's writing, listening to my supervisor, taking time off, you know, kind of that's broadly referred to as self-care, which is getting more attention. For some people, you know, mindfulness, prayer, meditation can be really helpful. You know, again, those breathing exercises, peer support. So having the opportunity to kind of share with people who do similar work, speaking with peers and supervisors, taking a mental health day, spending time with family and friends, working out, exercise can be really a great way to kind of balance, to find that balance and feel good about kind of that exertion and what that accomplishes. Yoga, great. Music, something maybe sometimes gets overlooked, but, you know, sometimes when I hear a song and I realize how great it makes me feel, I wonder why I don't just put a song on more frequently when I'm in that movement. My husband is much more of a music fan and, you know, certainly does that, but it's a quick way to kind of, to take a break, you know, whatever music kind of does that for you. Someone mentioned writing again. So journaling can be really helpful, just even taking notes about an experience you're going through. You know, if you've ever supported someone who's going through an illness, you know, it can be a way of kind of just getting out those feelings through that type of writing or journaling. Deep breathing, knowing when to step away, whether it is taking lunch or just speaking up. You know, sometimes that having lunch at your desk or, you know, increasingly, you know, just becomes a habit. And, you know, even if you are still eating at your desk, but taking that time to go for a walk or run an errand and just kind of get that break from the workplace environment. And then feeling supported, you know, some of these things are not within someone's control as a staff member at an organization, but, you know, finding ways to express, you know, either what's going on with you or, you know, things with the organization and not kind of holding that in. Some people do retreats or are offered those. Great. Speaking about feelings, the program that my husband participated in, they would do a feelings check, you know, as part of kind of group setting. So, you know, sometimes we still kind of comment about that just between ourselves, you know, do you need a feelings check? Or that can be a prompt that's helpful. Vacation. Hopefully many of you are getting that opportunity this summer. Great. Some of these kind of repeating prayer, exercising, socializing, you know, we kind of got out of that habit during the pandemic and kind of re-engaging with that. Yeah, taking more than one mental health day. Body work, a hot bubble bath. Not feeling like that this week, but maybe a cold shower in the winter months. Really relaxing. Yeah, someone's mentioning not being aware of the range of resources years ago when they were experiencing burnout. More talk about it. I think still more work to do to make sure people get these resources. And then just the opportunity and the support for the breaks, the vacations, the lunch time, the mental health time. Therapy. Yeah. Yeah. Great. So appreciate those responses. And, you know, this will be a topic that will be developed more in the fall, kind of looking specifically at that experience of kind of coping with loss of clients or residents or participants in these different settings. And then just dealing with some of the challenges of working with a population with complex needs, you know, where it can sometimes not feel like it's the right thing to do. And then just the opportunity to kind of where it can sometimes not feel like, you know, the work that you do contributes to change. Other times you do see that. So that can really vary depending on the person and where you work and what's going on. So this is just kind of summarizing, you know, some of these things have been mentioned, but, you know, addressing compassion fatigue, you know, both at work or away from work. And also, again, reiterating these things are not always within the control of employees in an organization. So, you know, you kind of sometimes self-care puts the onus on oneself. Whereas organizations, you know, there's a lot of work to do too to support staff. But as far as things kind of within the ability of, you know, most people to kind of control at work, you know, being aware of your reactions to clients' distress or trauma, sometimes just naming it, that can be the journaling or writing things down or telling a peer that it just acknowledging that you have a reaction. And then seeing, you know, maybe there are patterns of what triggers a negative emotion or response. You know, maybe there's a certain thing that you experience over and over that is more likely to kind of increase that frustration. Allowing yourself time to cope with your own feelings or taking breaks. You know, maybe someone has returned to using substances who had, you know, at least stopped one substance or, you know, some other thing that, you know, or skipped a meeting or appointment or didn't follow through on something. You know, kind of acknowledging your own reaction to that that can be frustrating. And discussing challenging situations as well as successes with colleagues and supervisors. You know, it's important to share both so that people hear like, wow, I have this, you know, this person and, you know, they connected with, you know, maybe an OBGYN, someone who's pregnant or, and really had a positive experience or whatever it is that, you know, balances the successes with the frustrations. And then seeking out or requesting opportunities for group or individual counseling. You know, I'm looking for more kind of resources in that realm that, you know, people can seek out in that kind of peer support for people doing this type of work. You know, away from work and maintaining that balance between your professional and personal lives. You know, setting limits and trying not to exceed those limits. Yeah, someone's mentioning, you know, making sure you take that hour for lunch if that's what's built into your schedule. Developing a self-care plan that works for you. You know, whether that's adequate sleep, healthy eating, exercise, listening to music, seeing friends, you know, scheduling time for relaxation, meditation and stress management techniques like breathing exercises. You know, if you know that yoga helps you or that getting to the gym helps you or just taking a walk helps you. You know, sometimes just actually scheduling that and whatever calendaring system you use. I know for me, as I've started putting in that, you know, I'd like to do this yoga class or whatever it is, helps me, it's in my schedule. So it's not something that vaguely I might do, you know, and I make sure I'm not scheduling other things because that's a priority. So as I mentioned, you know, we're gonna be developing a separate training that kind of expands on some of these topics, you know, beginning in September. So, you know, you'll be hearing more information about that. But that's the end of, you know, part two of this training. Really appreciate all of you for kind of showing up today and what you've shared in the chat. Be sure that, you know, Katie's added some, you know, the link to the survey about the trainings and it's really helpful to get that feedback, helpful for, you know, a range of purposes. And, you know, you will get slides and certificate instructions. She's noted, will be emailed to you and as well as information, you know, for training kind of starting up again in the summer. There's some contact information there. If you need a certificate from a past training or have other questions for, you'll see the address, katherine.cunningham. QR code you can scan with your phone here, or I believe, you know, we'll repeat adding that to the chat. I know two hours is a lot of time to take out, really appreciate your participation today and hope you have ways to get through this heat and get a chance to take some breaks this summer.

harm reduction

substance use

housing programs

trauma-informed care

stigma

detoxification

opioid use disorder

Methadone

Buprenorphine

Naltrexone

compassion fatigue

self-care

recovery