Hi, my name is Tina Nadeau, and I'm the Chief Justice of the New Hampshire Superior Court. I was fortunate enough to be in Reno with some specialists on addiction psychiatry and other judges, and we had a chance to get together and talk about the nature of addiction and how we need to be understanding it and addressing it in our courtrooms. So in this session, you're going to hear from Dr. Fuehrlein about stigma, language, and how we can misunderstand substance use disorder. It's so important when people receive treatment and also when they're in the courtroom that we use the right language, that we understand they are suffering from a condition that affects their brain. And so if we use language that stigmatizes them, they will not be open to treatment, they will not be open to changing their behavior, and they will remain stuck in our criminal justice system. And so this module will talk about those and some other ideas, including peer support, like Alcoholics Anonymous, those groups are extremely important to keep people engaged in recovery. And while they aren't necessarily treatment models, they're important adjuncts to treatment, so that people will remain actively engaged, and so that they know they're with someone who understands their journey. Enjoy this module. Hi, everybody, my name is Brian Fuehrlein. I work at the VA in Connecticut. I'm an Associate Professor of Psychiatry at Yale, and I'm the director of a psychiatric emergency room. My specialty is in substance use disorders, and today I'm gonna speak on substance use disorders, but specifically a few key concepts that we think are really important for you to understand, particularly stigma, the language we use, and a few misconceptions. So I have nothing to disclose, no financial relationships. I do wanna thank the AAAP for this. And it's truly a pleasure to be able to speak to everybody, and I really do hope that this is a valuable activity for you. So a few learning objectives. We want you to understand a bit about the reward system. So there's a process in the brain that leads to substance use disorders that I'll speak about. There's a really important role for substance use disorder treatment for peer-led support groups, for example, Alcoholics Anonymous, and not very many of us know about AA or have learned about AA. So I'm gonna spend a few minutes talking about a few key concepts surrounding Alcoholics Anonymous in particular. Again, as I mentioned, language is a very important thing, especially when it comes to mental health and substance use disorders, the language that we use can make a big difference. And I'll go through a few examples of how that is true. And, again, I'll wrap it up with a few basic misconceptions, a few things that we need to remember when we're working with clients who have substance use disorders. So I'm gonna open up with a little bit about the disease process and how substance use disorders are not choice. They're actually a disease process. And I'll start with a question, if you have a client with an alcohol use disorder, who, let's say, if we do an example for me, as a physician, if we do an example for me, where a patient might be in an emergency room setting and they're there and I'm recommending treatment, and the patient says, "I don't need treatment because starting today, I promise I'm never gonna drink again." You can think of an example in your world, where maybe a client is on trial for perhaps a DUI, and you're about to recommend treatment for this person, and the person says, "I don't know what you're talking about." I don't any treatment I'm not gonna drink anymore, I promise. Just starting today I'm never gonna drink again. And when I make a promise, I never break it. I've learned a valuable lesson, whether it be from being sick in the hospital or being in trouble with the law, I've learned a valuable lesson. I don't even like alcohol. I don't need treatment. Starting today I'll never drink again." And the person sounds incredibly honest and sincere with his or her notion that he absolutely will never drink again. So how do you interpret that? How do you interpret this person saying, "I promise you I won't drink anymore." Either this is a confident person who is clearly motivated by whatever trouble he got into, so therefore treatment's not really necessary, because we have a motivated client. Or do we say that since he has an alcohol use disorder, he probably should be in some kind of treatment. Whether or not he's confident he can do it on his own or not, the key issue here is that since he has the disorder, he needs treatment. So over the next few slides, hopefully I'll be able to answer this question for you, and hopefully demonstrate to you that the correct answer is B. Now I like to use an analogy to help people understand substance use disorders. If you can imagine holding your breath, and if you're listening to this in your office or at home, and you're holding your breath, and maybe there's something going on around you or I'm speaking, and you're able to concentrate on what's going on around you, you're able to listen to me. You're holding your breath for 30 seconds. It's not a big deal. As time goes on, you get more and more uncomfortable. And if we raise the stakes on this analogy and said we're actually holding your head under water while you're holding your breath, and the only way that you could breathe is once your head lifts up out of the water, that's the only way you can breathe, that's gonna be distracting for you, right? At some point, maybe 30 seconds in, a minute in, you're gonna get really uncomfortable. And at some point, you're gonna tune out everything that I'm saying. You're gonna tune out everything else that's going on around you. And you're gonna become fixated on the fact that you have to breathe. If you're able to continue to hold your breath, at some point, the next breath you take will become the most important thing in your life. Because if you don't rise up from underneath the water and take a breath of air, you'll die. So at some point, you would choose that coming up for air and breathing, you would choose that over anything else. If we told you the only the way that you could take that breath is if you left your job as a judge, or if you stole money from your children, or your parents to pay for the oxygen, or if you did something else that you didn't otherwise want to do. But that was truly the only way that you can obtain oxygen, would be to steal money from your family to pay for it. You would do it, because it's life or death. You would hope that you can clean up those consequences later. You can apologize. You can make amends. You can do whatever you need to do. But at the time, that breath is gonna become the single most important thing, kind of like if you're starving to death right now, and you need to eat food, suddenly this presentation, your job, your family, those things become a little bit less important, if you're truly gonna die, unless you eat. You're gonna figure out a way to eat. And then what happens when you take a breath? So you figure out a way to pay for this oxygen. You come up for some air, you take it breath, you feel normal. You don't feel high. You don't feel intoxicated. You don't feel on top of the world, You feel normal and now you can function. And now you have to clean up all those messes you just made, whether it be from quitting your job, or lying to your family, or stealing money, or whatever it might be, you now have to clean that up. And you're gonna have guilt and shame about those things that you did to obtain this oxygen. And, again, it's not necessarily to get a high or intoxicated, it's to feel normal. So if you imagine people with alcohol use disorders or drug use disorders, this is what they go through. For reasons we'll talk about in a minute, that brain is convinced they need that thing to continue to survive, whether it be alcohol or drugs, "I have to have it and I'll do anything to get it, 'cause if I don't get it, I will die. Life depends on this thing. I must have it. And I will do or say anything I need to do or say to have it. And when I get it, I don't necessarily feel high or intoxicated, I just feel normal again. I can function again, until the next time I feel starved of this, which may be four hours later or six hours later. So this is a process that's constantly going on in the brain of someone addicted to a substance, and it's not pleasant. So how does that happen? We have this reward system in our brain, and you don't have to know what all of these parts of the brain are. Some of you may know a little bit about this. Some of you may not, and that's okay. You just have to understand that deep within the brain, this being a human brain, and that large squiggly part on the outside is called the cortex, and that's where most of the high level functionings occur, that's what separates us from animals. And then we had that deep part of the brain, these really deep structures that are very primitive, that animals have. They haven't evolved the cortex, but they all have these deep structures. And these deep structures contain things that keep us alive. The reward system deep within your brain is designed to keep you alive. And it does that by rewarding things that are necessary for survival, things such as food, things such as water, things such as shelter, sex. These are all things that, without those, either we as an individual would die, or our species would die. We have to live long enough to make it to reproductive age, and then we have to reproduce. And that's the only way that our species continues, and that reward system, which is deep within the brain, sees to it that that happens, by giving us a reward or pleasure for engaging in these activities that ensure our survival. If you think about animals, a squirrel or a mouse or a bird, that's really what they do all the time. They're constantly looking for food, trying to raise offspring, trying to find shelter from other animals or from the cold or the heat. This is what they do all the time. But we as humans have that cortex, and we are not usually in a situation where we're dying. So we don't often have to worry about finding food right now, because we're not starving. We don't have to worry about obtaining the next drink of water, because we have water. Many of us don't even want children. We're in a society where we don't have to worry about our genetics not being passed on. Many of us don't want children. So this reward system is there. It's present. It's powerful. But most of our activities day-to-day are really driven by a cortex, which is designed for long-term planning. How did we become physicians and judges and lawyers and everything else, it's through our cortex, truly delayed gratification, right? Putting off financial security and all this other stuff for as long as we can to go through all of our training. That is always driven by your cortex. Your cortex is the reason you're listening to this today, for whatever reason it might be. Your cortex is why you choose to eat healthier foods for lunch or for dinner. Your cortex is why you aren't late to the bench. These are all things that your cortex is telling you to do, but you have this powerful system deep within your brain that's constantly saying let's do some of these things that are more rewarding. For example, let's eat a really calorie dense meal, or let's engage in sexual activity outside of our committed relationships. This is something your reward system is constantly telling you to do, these things would feel good, right? It feels good to eat your favorite fattening food all the time. That would feel nice. You would enjoy that. But you don't do that necessarily, because your cortex says, yeah, you might enjoy that food, but it's not good for you. And if you eat too much of it, you'll have health consequences, so let's only do it in small amounts and in moderation. And, yeah, there's other person over here whom you're attracted to, it might feel good for one night to engage in something sexual, but it's not worth it, because we're in a committed relationship with someone that we love, and we don't want to do that. So you have this battle going on between your cortex, which is designed for long-term planning and thinking, and your reward system, which is designed for immediate gratification to help you do things you need to do for survival. And in the balance that we want, that cortex is driving all of our behavior. The cortex tells us what to do every day. We follow what it says. Sometimes we may engage in small things that feel really good in very small doses, because we enjoy fattening foods, whatever it might be, but we're not gonna do it too much, because our cortex controls that. So in a well-balanced brain, your cortex tells you what to do, your reward system is present. You don't often need it, but it's there just in case. And, remember, if you were starving to death, or if you were dying of oxygen starvation, it doesn't matter what your cortex says, that reward system is gonna kick in and say, "We need to find whatever it is right now, or else we're gonna die." And it doesn't matter that you're late for work. It doesn't matter about anything else. We have to find right away the food or else we die. And that takes priority over everything else. But we're rarely in that situation, hence the cortex usually is under our control. Now, if we introduce drugs of abuse, particularly stimulants like amphetamines or cocaine, these are very, very, very powerful stimulators of that reward system. That reward system is driven by dopamine. Dopamine is a neurotransmitter that gives us pleasure. When we eat a good meal, we have a little release of dopamine, it feels nice, we enjoyed it, it's rewarding. We know we should eat that food again in order to survive. When you take methamphetamine or cocaine, you're gonna have a surge of dopamine that is way more powerful. In some cases, 10 times more powerful than anything you'll experience naturally. We have developed some of these drugs really to mimic what we want, which is a surge of dopamine in our brain. And methamphetamine is a direct dopamine stimulator, that's what it does. We figured out dopamine feels good. Let's develop a drug that releases it. We figured it out. We developed a drug. We can get huge surges of dopamine. So when we do that, your reward system, again, remember, which is really powerful if it needs to be, can interpret that drug as something really important, because the other things that activate the reward system, food, and sex, and water and shelter, these things are very important. There's no distinction in the reward system what these things are. It just says these things are important, we need to do them again. Methamphetamine is now suddenly 10 times more powerful than anything you've ever experienced. So that reward system says, "Whatever that was, we need to do it again." Now your cortex feels pleasure. When you eat a good meal, your cortex enjoys that, you know it feels good. But your cortex is able to control it by saying we'll just do this every now and then. Something like methamphetamine is gonna be the best meal you've ever had times 20. It's going to feel really good. And your cortex might be inclined to do it again, because it felt really good. But your cortex also understands that there's consequences to doing it again, people who get addicted to methamphetamine might have all kinds of serious health problems and other things that go on. People addicted alcohol and all kinds of problems. We don't want that to happen, so maybe we shouldn't do methamphetamine again. But it felt really good, and maybe I'd like to do it just once more. So you get this battle going on, where your cortex is trying to control the situation, trying to say, "Don't do it, because it's not good for you, but it feels really good, and maybe we can do it again." But then you have the reward system, which can start to exert an influence and say, "This thing is really important, you need to do it again." And that can tip the scales in favor of doing it again. At some point, that reward system starts to take over the control of that person. That person no longer is acting rationally by their cortex, thinking long term, they are thinking I need to get this thing that I'm addicted to right away, because my reward system is telling me I must have it. And, again, that's interpreted as this is very important for survival, even though your cortex would never say, "I need this to survive." The person who's addicted to a substance will act in a way that seems to indicate that. Suddenly alcohol or cocaine becomes more important for this person than anything else in their life. And they start to use it so compulsively that they will sacrifice everything else they care about. And that's because this reward system is starting to hijack the cortex. The cortex does not want the person to become addicted to a drug and ruin everything that they care about, but the reward system doesn't care about those things. It cares about getting this thing for survival. So you can see how, if you use the food or the oxygen as the example, and you replace that with the drug, this person's brain becomes as fixated on getting these drugs as you might if you were starved of air and had debris. So we say the reward system hijacks the cortex when the addiction develops. And when the addiction develops, this person's sole goal is to get more of whatever it is they're addicted to. And they're willing to do it at the expense of anything else that they otherwise normally would care about. So here's a little summary of the reward system. It's a very important evolutionary tool that helps us to get the things we need. And these are things that we need for survival. So they're very, very, very important, okay? The first is denial. Now I'll preface this by saying the disease of addiction is cunning and baffling. It doesn't make any sense why people say or do the things they do, when it's clearly the opposite of everything that they truly care about. If you ask someone, "What do you love more alcohol or your children?" They will say, "I love my children more." And that's obviously true. But when the children threaten them and say, "If you keep drinking, I will leave you," that is generally not enough to get people to stop drinking. And that person will be sitting at home drinking, knowing full well they may lose their children, who they love so much, but they're drinking anyway. It's cunning and baffling. It doesn't make sense. Why would someone do that? So when we think about denial, we think about someone with a severe alcohol use disorder, who maybe has their third DUI, or in my world, maybe has liver problems or heart problems, or maybe their wives have left them, or their boss has fired them, maybe they're homeless, severe consequences. And you say to them, "What are you gonna do to get sober? How are you gonna make a change in your life? And the person who very clearly has this problem says something like, "I don't know what you're talking about. I don't have an alcohol use disorder. This has nothing to do with alcohol. The reason I got the DUI is because the police were out to get me. They don't like me. And the reason my liver is messed up is because my dad had liver problems. That's genetic. And my wife left me, because we hadn't been getting along anyway, that has nothing to do with alcohol. In fact, I left her." And everything that's happened in this person's life, there's some reason why it has nothing to do with alcohol, even though to that outside person, it's impossible to think that this has nothing to do with alcohol. It doesn't make any sense. It's cunning and baffling. How could this person let every part of their life get destroyed by this thing, and then not even recognize that this thing is destroying their life. It doesn't make any sense. So we as professionals, who interact with clients who have a substance use disorder, have to understand that when someone says something like, "This has nothing to do with drugs. It has nothing to do with alcohol. I'm perfectly fine. I don't have an opiate problem. I don't have an alcohol problem." We need to understand that that's not this person being difficult or argumentative, that's simply a manifestation of the disease process. The disease is trying to defend itself, it's trying to protect itself. And one way it does that is by convincing the cortex that there is no problem. So we have to try to see through that. The second is promises, and sort of like what I alluded to in the beginning, "Your honor, I promise I will never drink again. I don't need to go to that court-ordered treatment program, because I'm motivated to not drink. Treatment's not gonna help me, because I've decided to not drink. That's all I needed to do. I just needed to make a decision. And this DUI was a wake-up call." So we have to understand as professionals that that's not how the disease of addiction works. And if we replaced alcohol use or drug use with diabetes, and imagine if your client says, "Your honor, I promise I will no longer have diabetes. I don't like diabetes. I don't need to have diabetes. This was a wake up call about my diabetes. So I don't need to go to treatment for my diabetes, because, starting today, I promise I won't have it anymore." Well, that doesn't make any sense. And we would never say, "Okay, well, you sound motivated to stop your diabetes, so we'll just bypass treatment, and wish you luck with that." So we would never do that. That doesn't make any sense. We shouldn't do that with alcohol or drugs. We should tell the person, "I'm glad you sound motivated, but that's not how a disease works. A disease needs treatment. It doesn't matter how sure you are that you can will it away, you can't. That's not how it works." And I will often tell patients, "If you had diabetes and you told me, 'I promise to stop having diabetes,' would I say, 'Okay, good luck, see you later?' No, I'd tell you you gotta get treatment.'" And the patient often says, "It doesn't make any sense. You can't just not have diabetes." And I say, "You're right, and you can't not drink. If you have an alcohol use disorder, you can't just magically stop drinking. It doesn't work like that." The third thing is excuses. And, again, it's very similar to promises, where someone might say to you, "Your honor, I can't do the treatment program now, because I have my children at home," or, "I have a job interview next week, and I don't have any money," or, "I need to get back to this, or I need to do that." Whatever it might be, there's always a reason why the person can't go to treatment now. We need to understand that this is a manifestation of the illness. Patients or clients are trying to continuously figure out ways to use these substances. And it's not because they're bad manipulative people, it's because they have a disease process that's telling them, "You gotta figure out a way to get these things to keep surviving." So one of the ways is to make excuses about anything that might help them to stop drinking, they make excuses about, so they can continue to drink. And we need to see through that. In my world, they may tell me, "The reason I drank is 'cause my dog got hit by a car." In your world, they might say, "The reason I can't go to this treatment you're recommending is because of this or this." So we have to understand that these excuses, again, they're not being bad people. They're trying desperately in their diseased brain to figure out a way to keep using. If I asked you, or if I asked you when you were a younger person in your twenties or teens, name some things that are really important to you or will be really important to you when you're in your thirties or forties. You'd probably say, "My health, my career, I hope to have a family of some type, a good house to live in, freedom." These are the things that pretty much anybody would say are important, as you get into your career, into your life, family, health, career, money. That's what everybody wants. If you think about someone who develops an alcohol or a drug problem early on, they will slowly and methodically, over a period of years sometimes, gradually destroy every one of those things that they truly believe are the most important things in their life. They will lose their families. They will lose their jobs. They will lose their freedom. They will lose their health. They will lose all of it. And they will do it over a long, slow, gradual period of time, and watch it all crumble, and continue to drink despite it crumbling, to a point where they're homeless, they have no career, they have no family anymore. They have nothing left. So if it was as simple as a choice, nobody would allow alcohol to destroy truly the things, or drugs, to destroy the things that they really do care about in life, which are the things I mentioned. It's not as simple as a choice. For free localized education and training designed to meet your needs, contact the Opioid Response Network.

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