Good afternoon, everyone. It is 12.02. So we'll get started and others can blow in as they wish. Thank you for attending today's webinar. My name is Rachel Brandhorst. I work as the Department of Justice Grant Administrator for the Washington State Health Care Authority. Under our adult drug court program, we have partnered with the Center for Justice Innovation to implement an initiative called the Washington State Treatment Court Opioid and Overdose Response Plan. This project offers a unique opportunity to meaningfully respond to Washington's challenges around adherence to best practices, equity and inclusion, overdose, and access to evidence based treatment. We are pleased you could join us today. This webinar will be recorded and also made available on our forthcoming training and resource website that is being developed to support Washington's therapeutic court practitioners expected to launch early this fall. So this website will also serve as a hub for practitioners to access resources regarding treatment court best practices, national technical assistance and training websites. It will also offer a calendar of relevant in-person and virtual trainings, as well as some pre-recorded content. Supporting me today is Tony Walton, also our DBHR Adult Section Use Disorder Section Manager. And I will hand it off to Emily now. Thanks, Rachel. And hi, everyone. My name is Emily Mossberg. I am a technology transfer specialist with the Opioid Response Network. And the Opioid Response Network is funded by a grant from SAMHSA to provide no cost training and consultation on topics related to prevention, treatment, recovery and harm reduction. Anyone can submit a request for free assistance on our website at opioidresponsenetwork.org. We are honored to be here with you today, partnering with the Washington Health Care Authority and the Center for Justice Innovation to bring you today's presenter, Stephen Samra. And before we get started, I want to quickly go over a couple of housekeeping items. As Rachel noted, today's session is being recorded. We have a large group with us, so we ask that you remain muted throughout the duration. However, we do welcome any questions that come up, and these can be entered into the Q&A box located in the panel at the bottom of the Zoom screen. We will be answering questions at the end, and we'll also follow up on any that we don't get to today. Lastly, at the end of the session, we will be sharing a QR code that links to a quick evaluation survey for today's presentation. And we would greatly appreciate your taking just two minutes to fill that out. It does help us maintain funding to continue providing free resources. All right, I will now pass it over to Stephen to introduce himself and get us going. Thank you all. Emily, thank you so much, and hey, everybody. It's great to be here today. We have a lot to cover, and I know we have a short period of time, and I really want to be respectful of everyone's time today. Some of the stuff I'm going to go through pretty quickly, because there are certain areas that I really want to bring you some new information. And what I kind of want to – here's the learning objectives, really, that I'm hoping everybody will walk away with, and we should be able to. We should be able to talk about the most effective treatment approach for an opioid use condition. We should be able to talk about the difference between addiction and dependence. We should be able to talk about how the reward system is hijacked by opioids. It's also hijacked by other drugs, particularly methamphetamine. We should be able to talk about the potential barriers for folks who are justice-involved. We need to be able to understand the culture of addiction and why that's going to matter, and it's one of the biggest issues. We need to talk about the sort of social determinants of health for recovery, and then we're going to look at why it's important that we recognize co-occurring conditions, particularly for justice-involved individuals. So I've got to start right away just by saying I don't use the term MOUD. And I don't use the term MOUD for two reasons. Actually, for three reasons. First, using the term MOUD instantly outs me as a person with an opioid use condition, instantly. MAT, I may have an alcohol use disorder or a condition. And a lot of folks, yes, we know that MAT is stigmatized. But trust me when I tell you, MOUD is far more stigmatizing, and it's already outdated, because it should be MOUC now. It's medications for opioid use condition. That's why I use MAT. And the final reason is I used methadone for 12 years. I used buprenorphine and naltrexone, it's called Suboxone, for another five years in the last 24 years of my recovery. It's my recovery. And I used MAT, and I'm in control of my recovery, and nobody else, and nobody's going to tell me how I'm going to reframe or rephrase my recovery journey. Period. Had they asked us whether or not this was going to work, they'd have known before they ever moved it forward. Which gets to the point that it's important that we ask folks, what do you think? We're the ones who are going to have to endure that, and that unintended consequence is pretty big. I don't think I need to spend a whole lot of time here. I mean, obviously, there are a class of drugs that really deal and treat pain. Yep, we can get euphoric off them. And if you take too many of them, you can overdose. You may die, depending on where you're at and what you've taken. We know that a whole bunch of our brothers and sisters have died, really, since I think it's before the 90s, because I've been using heroin and opioids from the 70s, and I watched a lot of my friends overdose and die. And nearly 75% of drug overdose deaths in 2023, opioid. I put this in because I wanted to give some perspective. This is the 2022 overdose death rate in Washington State. This is SUDER information. I hope I pronounced that right. And it was the most current that I could get. And you're right in the middle. About 33, 33 per 100K. It's about right in the middle from what you see out of all the states. You can see West Virginia's number. That's scary. And then, you know, South Dakota and Nebraska kind of bringing up the rear. But generally speaking, I think, you know, Washington State has, you know, sits basically, you know, at the median. I don't want to spend a lot of time here either, because I think everybody's aware that the opioid overdose rates have been climbing. But what I do want to point out is a couple of things. Look at from, you know, on the first one, deaths by age group. Basically, everybody 35 and older has increased. It's lovely to see the folks 25 to 34, you know, maybe getting a message or getting exposed to, you know, maybe fentanyl test strips, maybe different ways of ingesting. Who knows? But that's a nice trend. And then you can look across, again, this is the by age group heroin. The one thing I want to point out, look at the far right, age 65 to 74. Look at that spike in heroin death. That's interesting. And I'm not exactly sure. I don't know a whole lot of my brothers and sisters that age who are still using heroin. I know we're out there. But that's a really interesting trend. And I think it deserves, you know, probably some more attention as we move forward. Fentanyl overdoses all the way through, basically, you know, the age 25 to 34 folks, again, getting those messages. And then when you look at deaths by sex at birth, you know, women are down. And I'm not surprised. And, you know, honestly, I tell my wife this all the time. Really, women should just rule the world because some of us guys, we just we can't really navigate our steps very well. So it's just, you know, I think that's a really positive trend. And I'm really glad to see my sisters getting, you know, at least some arms around the issue. Of course, we know there are disparities. And we know that our Alaska natives, American Indians, 41 percent higher than our national rate. White folk, 21 percent higher. Our black brothers and sisters, 15. I mean, you might as well round it out. Folks who have less than a four year degree at an increased risk for mortality. There is a higher risk when folks are divorced, when they're separated or when they're widowed. And if you're rural, if you have some neighborhood issues, we're talking about social determinants of health here. We'll talk a little bit more about that. And, you know, limited access to treatment. Yeah, we've got a problem and we'll have increased mortality. And you can see we have witnessed higher mortality compared to urban areas for 20 years now. And I just showed you West Virginia's number. I was just in West Virginia. It's mostly rural and it's been devastated. And folks who are living in deprived areas in, you know, really challenging neighborhoods, they're really likely to stop treatment. And there's a reason for that. And it has some connection to these subcultures that we're all operating in. I snagged this. This is, again, suitor information and why I wanted this one. I looked at all the quarters. I went through every one of them. This is the highest one. It was the last quarter in 2022. I don't know what the numbers are beyond that. But what it's told me was great. It just keeps rising. It just keeps going. And it'll be really fascinating to see where we're at. Twenty twenty four data. So, you know, to understand what happened, this is what I'm going to share around this. There's plenty of information out there. But what I can tell you is that in the 90s, I could get Percodan, Percocet. I could get the lot. I do show up and tell them I had a sore tooth. I could get handfuls of opioids. They were everywhere. And I raided my medicine cabinets of all my friends all the time and they were everywhere. Well, thanks to, you know, Purdue and, you know, what happened with Oxycontin. They they were flooded into the market and every doctor out there could prescribe them. And then we saw people freaking out that a lot of folks were dying from all of these prescriptions. Right. And so we told docs, hey, time to rein it in. Well, when they reined it in, a whole bunch of us went from being dependent and functioning to straight into withdrawal. And now we are headed towards addiction. And, you know, it's a freight train and you're not going to stop it very easily. So where are we at now? What's happened? There's a big demand. Who's going to fill the supply? We know the cartel did. And as the cartel did it, they made it better and better or worse and worse from our eyes, stronger and stronger, cheaper and cheaper. And more and more of us were just sucked right into that. And where we're at today, that's where we're at. And it is scary. You know, it's scary. And I understand why we're doing what we're doing. We have a prescription opioid use condition in this country. And if you look at the right side of that screen, five percent of the population and we consume 80 percent of the opioids, the prescription opioids. So I want to make it clear. And when you look at these, you know, these little blue boxes, about 80 percent of people who use heroin first misuse prescription opioids. All of us that I have ever met. That's how we started. I started mine on Tuscan X cough syrup. I was 16 years old. I'll never forget. It was the most wonderful thing I'd ever had. And it fit who I was and what I needed at that time. There is a what is an estimated four to six percent who misuse prescription opioids actually transition to heroin. I've never met anybody in my whole life who said, yep, I've only done heroin. I've never met that person. They may exist. I don't want to rule it out, but I've never met them. And boy, I think they're far and few between. So what is this substance use condition that we're talking about? But we're talking about addiction when we're talking about, you know, a substance use condition. I'm not going to use the acronym for substance use condition. Just not going to do it. I don't mind saying it for opioid use condition, but I don't like I don't like that acronym at all. Basically, what we're looking at is the severity based on some guidelines and system symptoms. Right. And you can see what those you know, what this might be in terms of levels of severity. Mine certainly was severe. I had all of these symptoms. And there are a lot more when we look at what the characteristics are. But anybody who has been dealing with folks who particularly in a therapeutic court setting, you know, will take larger and larger amounts. We sometimes try, but usually we're unsuccessful, particularly with methamphetamine and opioids. We spend all of our time, not large amounts of time, all of it trying to find it, buy it, get the money for it. Use it. Enjoy the 20 minutes we get and then start the whole thing all over again. And we crave and there's there are biologic there's some neurobiologic reasons for that, as well as, you know, the you know, the dopamine need that comes with this. We do use and it's you know, we can't keep our normal life activities going. There's no way because of the nature of that addiction, particularly an opioid addiction. Our whole focus is finding, you know, identifying that, you know, where's the money? Where's the where's the man? Where's the you know, where can I get my, you know, my equipment? Where can I use work over and over and over every day, every single day? And there's no time for anything else, really. None at all. And then, of course, tolerance. Right. We just need more and more of the drug. And of course, if we're showing signs of withdrawal, I think you pretty much know that folks are really struggling with an opioid addiction. So in terms of what's the difference here between dependence and addiction, this is really important for us to understand, because a lot of us are dependent on medications. I'm certainly dependent on my blood pressure meds. You know, for a long time, I was dependent on methadone. My wife is dependent on cholesterol meds. I mean, we have a lot of things that we're dependent on. But when we're dependent, usually, I mean, normally, it's because we are under a medical care. We have some chronic condition that requires that. It is OK to be dependent on that medication as long as it's managed by you and your physician and it's managed appropriately. Folks go their whole lives on opioid painkillers. Folks go the rest of their lives on medication assisted treatment, too. I could have stayed on it up to today. It was my desire 15 years in to actually give it a shot because I had gotten the rest of the areas in my life, health, home, purpose and community. I had them going on. 15 years in, I had them going on. And I was comfortable at taking the chance and even thinking about how terrible this withdrawal is going to be. And I don't want to do it. I still did it because I just was done. The addiction side is what you see and why they're in front of you in court and why they're usually in front of you several times in court. You can't control it. It's just out of control. And it doesn't matter about the harmful consequences. Listen, the strongest black tar heroin I ever did, I got in Folsom Prison. And not only did I get the heroin there, I met the connection. And for those of us who are out there in that world, the connection is everything, everything. So, you know, we're pinning our hopes there. You know, thank God that the therapeutic court is trying to divert folks from going there because that's, you know, that's probably the worst place we can send folks who have something like an opioid use condition. So, you know, we do have that increasing tolerance and we are, you know, it's impossible for us to really hold a job. I've done it. I went to college. I got my master's degree. Actually, I got my bachelor's in full addiction and got my master's in recovery. But I did it because I knew that I had to find a way out. I had a felony conviction for nonviolent cultivation of cannabis, but I had a felony and I knew what that meant. And the only way I could see getting out was to advance my education as a great equalizer. And it worked. So I've been asked in the past why I share this and I'm not sure why that's a question because co-occurring conditions exacerbate the potential for us to end up incarcerated. When we are only looking at the addiction or a mental illness or trauma, we do not have that person in a whole person lens. And it must be, because as you all know, you've seen how many folks need support and the wide variety of what that support looks like, right? So if we know that, you know, folks who misuse substances, we are at risk, right, for developing some other conditions. We're more likely, and I have, you know, several mental health challenges, including a bipolar disorder and ADHD, severe inattentive type, and CPTSD. So I'm right here, right? And there are no specific combos here that we can look at. A lot of us will misuse several different types of substances, but I'll be honest with you, most of us who are out there for any length of time, yeah, we're already doing that. We're all poly drug users, okay? Don't be fooled. We may not, you know, we may have preferential drugs that we'll use, but again, I don't know anyone ever that I've met who said, yep, only done heroin. We pretty much, by the time we get there, yeah, we're poly drug users. And folks who have this medical, this co-occurring disorder setup, we're six and a half, 6.7 times more likely to be incarcerated. That's the highest between substance use, mental illness or mental health conditions, and the comorbid pairing of the two. It's the highest. It's why we need to understand what the impact is of somebody who has a co-occurring disorder. And a lot of us have that. A lot of us have co-occurring disorders. Honestly, when I think about it, this is anecdotal and it's only mine, it's 80% of us, maybe higher. All right, let's dive into what the science of this addiction and treatment is, because this is a real quick, easy neurobio lesson that you don't need an advanced degree in anatomy and physiology to follow. I mean, I think it has some value. Any time someone hears the term motivation, they should really supplant that with dopamine, because without dopamine, you don't have motivation. All drugs of abuse cause this unnatural rise of dopamine. And because of that, they're among the most potent and most dangerous drugs in the world. And so, if you don't have the right motivation, you're not going to have the right treatment. And so, if you don't have the right motivation, you're not going to have the right treatment. If you don't have the right motivation, And because of that, they're among the most powerful experiences our brains can have. Individuals struggling with addiction are actually battling millions of years of evolution, because our brains are exquisitely evolved to seek rewards. The body decreases the production of dopamine. Eventually, you can't even get enough dopamine produced to get out of bed, let alone produce good relationships and good decision-making. Methadone is our gold standard. It's the most studied, it's been around forever. You attend a methadone clinic every day, you get a dose of medication, it fills your receptor sites so that the cravings don't happen. I think that that video has such a good message, and it's really easy to understand. And it also answers this question, and I get this all the time, and this is one of the big myths about using MAT. Why do we use an opioid to treat it? It's because the opioid that we're using, it has a slow onset and a very long, what we call set of legs, a very long half-life. So the legs on something like methadone are 24 hours without being sick. I don't think anybody who's not ever had a sick, a dope sick, understands what that means. That is miraculous. That is miraculous. And with buprenorphine, whether it's straight buprenorphine or buprenorphine combined with naltrexone, which is an opioid antagonist, we'll talk about that in a minute. Combining those two still means that you've got about a 34 to 36-hour set of legs. That's, again, just a miracle, how long you are well. And while you are well like that, and it's just a steady, not these big spikes of an injection, the euphoria, the crash, the injection, it's not that at all. And over time, dopamine levels stabilize. And this is why you cannot put a time limit on whether or not somebody's going to come off of this program. They have to make that decision because it is terrifying to think that they're going to be forced off it at some point in the future, in the near, even in the long future. It's terrifying. And I'll show you why in a minute. This appropriate treatment doesn't cause euphoria. You can get euphoric off of methadone if you take too much. But today, you're not going over 100 milligrams unless you have peaks and troughs drawn. And if you decide to do that, you're not getting any take-homes from most clinics anyway. So most of us would never do that. OK. And we know that this is an evidence-based medication that is really, as she said, the gold standard for opioid treatment. All right. So why the heck does all this matter? And why is it so damn hard to get us to come in? This is why. When you look to hope, there needs to be something tangible there. I don't know why, but this thing keeps giving me this weird... Substance use disorder and addiction is... ...weird ad. I've never seen that before. And that is just terrible. It's physical torture. It's mental torture. You skipped the ad, Steven. We got it. You're literally coming undone at the seams. You're crawling out of your skin. I mean, you know, it's basically like you're living in hell. Back then, OxyContin didn't have the same ring as heroin, nor did we have the knowledge that, you know, that little pill was going to lead me down a path of self-destruction. And when we first started doing it, we were doing it on the weekends. We were doing it at parties. And slowly but surely... Everything started centering around getting that pill every day. Monday through Sunday, a couple pills a day, and that went on for a long time. When you're high, like, your body is, everything feels normal. Everything feels like, you know, it's exactly how it's supposed to be. You remove that drug and that chemical from your system, you know, your body just unravels. Anxiety kicks in when you don't have any money, when you don't have any source, when your dealers run out, you start going through these chaotic thoughts. You're just drenched in sweat. It's like all your bodily fluids are coming out of your body. Your stomach is twisted and knots. A lot of people end up puking. I wasn't really a puker when I was sick. I was more the person that, you know, violent diarrhea, pissing out your ass. Your bones ache. You know, they say flu-like symptoms. You know, it's pure agony. I remember, you know, I was dope-sick, apoxies, curled up like a baby, and I couldn't afford another pill. And, you know, somebody brought a bag of heroin to me. And at that point, it didn't matter what it was. I was so sick, I just didn't want to be sick. So I share that because Matt nails a couple of really important things. First, and we're going to talk about this as soon as we talk a little bit more about the social determinants of health, because they really apply. But if you've heard Matt's progression, did it on the weekends. Yep, that's an acultural involvement in that subculture. And then, you know, it started revolving all around that I had to get this pill. This is bicultural. He's still living in the mainstream community, but he's being pulled more and more and more into the subculture of addiction. You have to be, because those are the folks that get you well, okay? And at some point, when he did that first bag of heroin, he's fully enmeshed now. And the reason for that is, once you do heroin, those little painkillers that you get are peashooters. You can't even get well off of those anymore. So once you've made that transition, you don't go back. You just don't. There's no reason to. It doesn't even get you well. So there is a connection here, right? And it is around the social determinants of health and what that looks like. That's a whole training in and of itself. But what I want to point out are where those two purple stars are and then where that purple arrow is, right? We're talking about that neighborhood and physical environment. That matters a lot. And so does community and social context. If our environment isn't conducive to hope, dignity, respect, opportunity, then, you know, we already have a problem. And if we're dealing with folks who have been booted out of their social status, they don't really have support systems anymore. Nobody's going to engage them in this community. They get stigmatized, you know, discriminated against. They're not interested in, you know, what we're selling. They're just not. So for us, just, you know, these things do affect the wide range of health and, you know, our quality of life outcomes. They are they drive, you know, most health inequities and they're central to health disparities. And it's our I mean, this is a public health priority. Been talking about this for a while. So I use this little socio ecological framework and all I want to point out is that law enforcement and policing in the society down at the bottom with the arrow pointing out the treatment of availability and access. And then over to the influence of family, friends, and then over to the subculture involvement. Those are all really tightly connected. Right. They're tightly connected because this is exactly what happens. You get busted, you get popped, you get arrested. You are usually court ordered into treatment and, you know, you're going to a 12 step and, you know, you're likely going to be inducted in Matt if it's, you know, if it's appropriate. And then you have to deal with the family, the friends, and if you even have co workers, they're going to be involved as well. And I can tell you right now that where the most pressure is going to come from friends in that subcultural involvement. This is a major barrier to recovery, major, and there is a lot of information coming about this. It's really an issue of cultural competency right. And we talk about that a lot. But the truth is that we, we've missed three massive subcultures that people completely live in. And so when you listen to Matt lay it out that a cultural piece for him yeah I'm just getting a couple of oxys were party on Friday and then I'm going back to my normal life. And then it started to be got to get them bills every, you know, got to have them every day. But I'm still living in that, you know that other community it's great. And then when he went to the heroin. It's it, he's enmeshed in that community, he's now he's trapped in that community. And he thrives there, even though we all see this dysfunctional it not to us, that community invites us in for the same reason that our community throws us in jail, and they celebrate our behavior, and they are our community. It's the only community we have. And it's the same thing for every one of these subcultures. And if you've been in all three. I have, then you deal with all of them, and all of the stigma, all of the discrimination, all of the prejudice, all of the stereotyping that comes with each one of them. That's an awful lot of stigma to lay on a person's back and expect them to recover. Right. Bill White will tell you, as will SAMHSA, people can be a come as addicted to that subculture, as they are to the activities in it. And here's the, here's how I can share it. I've been in recovery 24 years, I have a strong recovery. I'm in front of all of you I think my recovery is pretty strong. All it takes is for me to hear even two or three chords of a song that comes from my time in addiction. And I am right back there, right in the subculture, and I am in some ways, reveling in, you know, the, you know, the music and the sort of, it's not a specific memory. It's my culture. Right. Those were my tribe. And my wife asked me all the time, what are you thinking about why is that, when does it pull you back there. I'm not thinking about any specific event. What I'm thinking about is, I lived in that culture for 30 years, and then I left it. And I'm never going back. Right, it's all I knew, so I lost the whole community. And it took a while to build a community out here. And honestly, if we're going to pull somebody out of a community like that, where they get their needs met, and they get the respect and the dignity that we won't share, and we don't show them, why would they come back. They've got to come back to a culture that's better than the one they're in. And if we can't provide that for them, it's, you know, you already see how difficult it is to force people back into the mainstream community. It's next to impossible, really, for people who are in the enmeshed status of, you know, addiction. It's really, really hard to get them back into the mainstream community. And the culture of recovery is so important. And it's why we need to use peers, people in recovery, to connect, model, coach, and show that there's another way. And when we can do that, we are the hope bringers, right? We'll carry their hope until they're strong enough to carry it themselves again. But we can't do this alone. And we need everybody who comes at this from the treatment perspective, who comes at it from the accountability perspective, who comes at it from care, and honestly, from a little bit of love. Right? These are our brothers and sisters. They are our kids. They are our wives and husbands. They are our neighbors. They are human beings, at the end of the day. And yep, they've probably done some really horrific things. I certainly have that I am not proud of. But that doesn't make who I am. Right? That is a piece of who I was. I am working really hard to rectify that. And by giving back, that's my purpose. That's what I'm doing. And a lot of us in recovery feel that way. And let us do the heavy lifting for you guys. They'll hear us. They listen to us. There's no bias there. Well, there is, but we won't dive into that right now. So how are these meds effective? And what I want to just show on this on this slide, and I apologize I've got a big monitor over here with you know the slide up. All I want you to understand is what we're talking about when we talk about the difference between something like buprenorphine and methadone. I mean we'll touch on naltrexone in a minute. Buprenorphine is a partial agonist. That means that as you saw in the video you figure it's more like bb's right falling into a cup and there's spaces all around here and you know so it doesn't have the kick that something like you know a full agonist like heroin like you know like methadone will have because the full agonist is like pouring you know a liquid into that receptor and it just fills it up. There's no other spaces for it to go around. They also will put that naltrexone the far right medication in buprenorphine and that's called suboxone and it helps both from you know injecting and certainly from using other opioids when you are on suboxone. You really don't feel them because the naltrexone just blocks it right so you've got your receptors filled enough to feel well and I really liked buprenorphine because I never felt it after 36 hours. I never felt it again and it really stabilized me for a few years while I got my mental health stuff under control. That mattered because if I wouldn't have done that I wouldn't be in front of you today I promise. So when we look at the far one naltrexone there are some folks who really don't think that that is a treatment for MAT or for opioid use condition. Yeah it is. It's a treatment because it's listed at from SAMHSA who controls the you know opioid treatment programs nationally. It's one of the three medications used to treat opioid use disorder. I can go with you know well it's maybe not because it's just an it's a treatment for MAT right that's what it is. You can look at you know how they're dosed out. I was on the sublingual film it's the worst taste and stuff I've ever had and I don't ever want to have to taste it again. Probably won't. But the bigger piece on this slide is are they affected? Yes. 33% fewer positives. Almost five times treatment retention. Significant outcomes right. Even when we don't have counseling services. We just get them inducted and we are doing well. And you know if we can get them into some of those behavioral services some peer support we're doing better okay. We need to stabilize them. If we can get those long legs and give them time to be normal right and that's how we'll see it to be well. It will change how they're living. It's that powerful. The first dose that I took of methadone was the last day I ever used an illegal drug in my life. That's how powerful it was. Buprenorphine equally effective. I will say that with buprenorphine I think people move out of treatment a little bit more. There's some reasons for that. It isn't quite as effective as methadone. Particularly around taking away some anxiety. And then when we get to naltrexone there's just nobody really wants to do that. And there's really insufficient evidence that it is an effective treatment for you know the opioid use disorder. So we know that you know there are a bunch of benefits from that. We know it reduces recidivism. I looked at what your stats are. I even have a slide on it. You guys are kicking ass. You guys are in Washington. What the therapeutic courts are doing is really impressive. So I don't even have to tell you that it reduces recidivism because you're living proof of that. It you know obviously decreases cravings. They're gone. That's the deal. They're just gone. And I never worried about overdosing. And if you're using suboxone, buprenorphine and naltrexone, you're real unlikely to do that. You'd have to take an awful lot in order to do that. I'll retract that. Fentanyl and carfentanil kill you no matter what. But it does increase long-term retention. And I've been in the program. I've been in recovery 24 years. I would say that it did what it was supposed to. I think you know that improves quality of life. It's going to really matter for those of us in early recovery especially because our life sucked and it continues to suck. And now we have to deal out with it all without any of the you know the candy that we used to use to cope. One of the things and I want you to see this quote because one of the things about criminal legal is that we really want to set time limits. We don't want to replace one drug with another. I get all those things. But an indefinite period of use. We don't make that decision. They do. It's the safest option for treating opioid use conditions. And we know we've got the evidence. We you know there's plenty of evidence. Methadone has been studied since the 70s. There's more more evidence around its efficacy than anything else that we have. So we're thinking about barriers here. Obviously really big misunderstanding about M.A.T. about opioid medications and the stigma is horrific. Not just the target you know self stigma intervention stigma that you know the whole intervention itself is stigmatized. The folks in the medical community who give it who prescribe it they're stigmatized. And you know it's just a it's just a never ending stigma cascade for folks. We also don't have a lot of education yet because a lot of this knowledge we've just been learning. Right. And you know the knowledge we have about the impact on the brain. You know we know it from MRI scans. You know what I'm guessing anymore. Your reward system has been hijacked. If you have trauma your worldview has been changed. That's just irrefutable. That's that's proof. And so we're dealing with folks who've had significant brain changes and who feel like it's their fault. One of the biggest things that happened to me in my recovery that allowed me to look in the mirror again is realizing that those things happened to me. And while I'm responsible for the crap I did and I'm going to fix it. It's not all my fault. You understand how powerful it is when we can say that oh my God I'm not a moral failure. Maybe I'm a good person. Maybe I'm OK. And this really you know this happened to me and I'm you know I didn't have any control over that. Yeah that's exactly true. And when we can get beyond that and we can realize that you know what I've got some control right now and then I know what I want to do. I know where I want to head. That is beyond the powerful. We need folks to be motivated. Right. You can go into treatment and let me tell you medication assisted treatment that the Medicaid the medications themselves that is not recovery. And I know folks want to hear that it is. It's not. It is treatment and recovery is what comes when you stabilize in the treatment and you begin to learn how to live your life in an honorable ethical moral honest way. All the things that you wanted to do while you were out there using but couldn't couldn't do it. Right. So we need guides on that journey. Right. You know our behavioral health counselor and you know the prescriber they can't tell us how to get to recovery. You know you go in you break your femur. You know what will happen. They'll take you to the ER. They'll put you in a traction splint. They'll pull it back. Hopefully they'll give you an opioid when you go through that. Although today you may not get that. And then they'll set that bone. That's the treatment. And then the next day physical therapy is going to come in and say hey you want to go home. You need to walk to the end of the hall and back and then I'll let you go home. That's recovery. That is not treatment. That's recovery. There is a difference and I can't have us you know trying to combine the two because I don't want folks to think that their treatment just because they're using MAT that they are on their recovery journey. They've started that journey by that treatment. OK that's the deal. And I get that you know we want to really think about it as recovery but it's not. And I know that because I spent five years thinking it was before I even began to realize wow this is not at all my recovery. This is what's helping me access and achieve my recovery. When I talked earlier about you know why it's important for co-occurring disorder understanding that you know the impact look at the far right comorbid comorbid SUD and mental health highest of all of them highest of all lifetime odds of going back to prison or being incarcerated. Co-occurring disorders are really important for us to understand recognize screen for you know and then treat if you know if we can. Whole bunch of myths here. I only take a couple of them. It isn't trading one addiction for another and now you know why. It does not delay and disrupt your recovery. It facilitates it. I'm living proof and thousands of my brothers and sisters are too. Cold turkey is never better than that. And when you go cold turkey you have less than a 20 percent chance of success. Obviously it doesn't increase it decreases overdose risk and worse than abstinence. No no because I can't function without medication. I need mental health medication and for a long time I needed addiction medication. You know I need I need the men to do what I do. And no it's not only for short term treatment. It is never about short term treatment unless the person themselves say hey you know what I'm ready to do a medically supervised withdrawal until they say that oh for gosh sakes don't bring it up because it'll terrify them. You saw how it is when you're sick and I'm telling you you'll do anything to avoid that sick and you guys see that. Okay so when we're thinking about those behavioral only interventions here's the difference. And I want to make sure we know that we can give these meds even without behavioral supports. We just want to get them stable right and well. And they'll usually start coming to us. May take them a while but they'll usually they've got now time to think and do stuff and you know that recovery stuff you know there's some interest there. It does reduce the risk criminal behavior. We know that you know I gave some of these stats before. These are all really this is you know the data. And you know you can see that you know buprenorphine is very similar to what methadone does. If we you know if we remove that treatment you know 20% of our brothers and sisters die. And notice that it says doses of 16 milligrams per day or more keeps you in treatment twice as long. And it reduced positive drug tests by almost 15%. The big challenge here is when we're prescribing and this happens a lot in you know in the criminal legal system and I understand why. But when we prescribe lower doses and we prescribe short treatment durations it it doesn't work. And we walk away from that thinking oh yeah that Matt stuff. That doesn't work. Just giving them another drop. The final thing I'll say is look at the you know the bottom line. There is insufficient evidence that oral nitrexone is an effective treatment. And you know we can force that on folks. But I'm telling you it is not effective and the data says so. I have this slide up because I want folks who are working in particularly probation, parole to understand that this happens to 90% of us. And when it happens to us it makes it usually comes on about 90 days after you've left you've you know you know ended your your medication assisted treatment you're off the medication and all of a sudden you you show up for a probation appointment and you look dope sick and you're weird and you're totally different than the last time you saw your PO and you got some of these things going on. Yeah I would think instantly oh my gosh that person's relapsed look at them they're freaking out and they're looking dope sick. They may not be and all I would ask of you when you see somebody who has come off that medication and they're 60 to 90 days out. Believe them and verify because if you just accuse them it'll destroy them. They've worked really hard to get here and now they can't understand why they've been pulled back and feel dope sick. And they need you to believe that they really have you know they're honest with you they're trying okay. So yes listen you know what I've heard about this I believe you right now let's verify it it's just you know let's keep us both honest and then you know we'll talk about what we can do after that. It's really really important okay. We know that whole person care works. I don't want to spend a whole lot of time here because everything on that left side you guys are doing. If you weren't then I know that you know you wouldn't have the results that you do. So yeah can you improve them? Absolutely but you know what you're doing right now is really working. I just want to say really quickly a word about this diversion issue because I know we're all terrified. The truth is and as a person who's you know had the opportunity I got monthly take-homes I could have diverted up my ottawa zoo and methadone is a dollar a milligram. So if you're on a hundred milligrams you know that's a lot of money for people. The majority of the misuse though it's the control withdrawal and cravings. You see how many people when you look at the common reasons for diversion to get high or alter mood. Buprenorphine sucks for that and nobody I know who has an opioid history likes that. It's a terrible buzz. Terrible. I know because I've had the endurance. Horrible. Where we will divert two ways. One to alleviate withdrawal and the other one and this is the one to pay attention to. I can't afford my clinic fee this month and if I can't afford my clinic fee they're going to rapid detox me and kick me out. I would rather sell a bottle or two go sick for a couple days and get the money to pay my clinic fee so next month I'm good. That I've diverted for and I don't know anybody who really wouldn't. They'll tell you they wouldn't but I'm telling you I would much rather do that two-day sick than have a five-day rapid detox and be out of the program. As you can see MAT benefits do exceed the diversion risk so don't let this scare you. Just be vigilant right and finally you guys have rocked it. There's no question. I've already said that the results of what you guys are doing are phenomenal. They really are and I'm you know I want to say thank you on behalf of my brothers and sisters who are going through your program because you've given them a shot at life. You really have and I don't care if they've had to go through the justice system. I did too. Sometimes those are good lessons. Good lessons to learn and they do hold you accountable. The last thing I just want to say is honestly and all these things are you know that's me in Folsom prison. The worst impact of my drug use it wasn't the use you can see I'll be 65 in December. I think pretty handsome devil still right. I'm pretty healthy. I've got high blood pressure but the mental health stuff the trauma I went through affects me every day to this day and you can see all of these pieces every one of them were a driver to substance misuse every one of them and you know to get out of that that was my recovery journey and it's not recovery folks it's discovery because I don't want to recover anything from that past. What I want to do today is discover how to live in recovery how to be a productive and you know satisfying citizen living to the fullest potential that I can bring. Every one of us should be able to do that and with your help and understanding what's going on we can make that much more a reality for many more people than what we're doing now. We got four percent we need a hundred percent to believe that treatment works and with that folks I know I'm a little over time. I am really sorry I took up more than the time that you know I was allotted. I'll turn this back to Emily. I know she's going to ask you to scan that survey QR code and thank you for listening. Always happy to respond to questions. I know it's out of time and I'm always happy to talk to anybody further about any part of this so thank you for listening. No worries Stephen you're not over time you're perfectly on time and we still have 15 minutes for questions actually but yes if you all are able to scan the QR code on your screen you can also enter the link which might be harder to type out but with your cell phone you should be able to scan it it just takes a couple minutes really appreciate your feedback and I'm looking at the question box I don't see any questions. Thank you Heidi for the kind comment. Does anyone have any questions? I can you can either enter them in the box or if you want to just come off via at this point that's fine as well. My work is done for today. No questions? That's OK. That's OK. All right, well, thank you so much, AJ, Rachel. Does anyone else want to say anything before we close? Thank you so much to Stephen and Emily. And please look out for more information for future sessions, future training sessions. So thanks. Thank you all. Thank you, Stephen. You're welcome. And Michael, I see that fish. That's beautiful. I see it. And thank you, guys. Have a lovely afternoon, OK? You as well.

Washington State Treatment Court

Opioid Response Plan

Rachel Brandhorst

Center for Justice Innovation

Medication-Assisted Treatment

Stephen Samra

Opioid Use Disorders

Peer Support

Mental Health