Hello, everyone. I see some familiar faces there, but for those of you who don't know me, my name is Trevor, and I'm the Byrne Community Liaison here at CCS. Today, I'm happy to introduce you all to Nick. Nick is a seasoned professional in the mental health field and an expert in harm reduction. We have had the opportunity to work with Nick in developing this presentation on harm reduction. Nick has extensive knowledge about substance use disorder and evidence-based approaches for SUD treatment. Today, we have the opportunity to learn from Nick during this presentation, and we highly encourage you to ask questions and speak out while we share this time with him. So with that, I will pass the torch to Nick and we can get started. Trevor, thanks so much. Thanks for the introduction. And it's great to see you all out there. Can I get like a wave? I can see, hey, all right, right on, awesome. So the way we have our Zoom set up is I'm not gonna be able to see you all on camera once I start sharing my slides, but I really wanna re-emphasize what Trevor asked and really invite questions. So I'm gonna ask Trevor and Sarah also. Sarah's gonna be keeping an eye out. I'd really love it if we talk about any points that are really relevant or important to you or build on some of the work that you're doing. I'm guessing there's a lot of experience in the room with us today, and we need all of us working on this stuff together. And it's a lot more fun when we do this and talk as colleagues, rather than just have me kind of drone on for, well, we're together for an hour and a half today. So I'm really gonna ask that for your participation and for your energy in this, we're gonna take on some complex issues and some real dynamic stuff to talk about that's both complex and emotionally charged and all that sort of stuff. And so really wanna invite you all using either your verbal skills to jump in and awkwardly in front of this entire room, gonna ask folks to just cut me off. I'm cool with that. And then if you're not comfortable doing that or both, to just raise your hand up there. Do you think we can agree to do that? Are folks willing to do that a little bit? All right, nice. I saw people clapping. I saw some hands up in the air. All right, cool. All right, so with that, I'm gonna go ahead and share my screen so you all can see the slides. Sarah's gonna, I'm gonna hand it back to Sarah for some introductory stuff, and then we're gonna dive in. Good morning, as we're waiting for the slides to come up. My name is Sarah, and I work with the Opioid Response Network, which is how you guys are getting Nick to come in here and talk. I have been working with Cara and Lisa and Trevor for the past, ooh, goodness, year and a half, maybe? I don't know, time flies when you're having fun. So we've been working together, and we started to talk about harm reduction, and we decided that a training would be really great to kind of start talking about harm reduction. So with that said, I'll just tell you a little bit about the Opioid Response Network. We are SAMHSA-funded, and we provide technical assistance. Technical assistance is a lot of different things, training and education, and we do that by using consultants. We try local, but we're across the US, so we can pull in people who have experience related to whatever topic we're talking about. And we do, I've already said all of that, so we're good. Sorry, I'm not a good slide remover. That's okay. And so if you're interested in learning more about the work that we do, feel free to go to our website. You can also email ORN, you can ask Trevor or Cara to poke at me, and I'm happy to answer your questions. You can call the number, I'll be very honest, not sure who's gonna answer it, but I'm pretty sure somebody will. So, you know, take it or leave it. All right, so basically what we wanna do is we wanna help you guys not recreate the wheel. There's already a lot of work being done around harm reduction, and you guys don't have to start from scratch. And with that, Nick is gonna go into why and how you don't have to start that from scratch. So, Sarah, thanks for that. And I just wanna also let everybody know, this is my contact information. You'll have access to this. This is my phone number. I love to hear from folks afterwards. If you wanna reach out to me, if you have any questions or comments, that's how you can text me, you can email me, look me up on LinkedIn. I just really love to connect with folks in that way. And so please feel free to do so if you want to. The other thing that we're really gonna focus in on for our training today is, yes, of course, we wanna talk about harm reduction, and we're gonna blend that in. However, you know, I'm very lucky. I get to talk to a lot of different groups across the country about evidence-based practices and approaches, whether that's harm reduction approaches or implementing SBIRT, if you're familiar with screening, brief interventions and referrals to treatment, a way to screen for substance use disorders and to provide folks with language to talk about those screenings, or like you all, some of the great work you're doing using medications to treat addictions. And when I talk about those things, one of the biggest challenges we face in the field a lot of times is really stigma, a reluctance to utilize some of these evidence-based, science-based approaches. And that has to do with really, unfortunately, decades of misunderstanding about addiction and substance use disorders. And so we're gonna talk today about a little bit about why that is, because I think it's really important if we're gonna ask our field to change, we have to understand a little bit why we do things the way we do them and to determine if that makes sense to continue or if it's some stuff we wanna keep or if there's some things that we wanna change. So we're gonna talk a little bit about addiction and substance use disorders in a couple of different ways and then blend into that, hopefully a discussion on harm reduction. And so what I'm gonna ask for you to kind of do as you're sitting there is to really start to be aware just for today about how you think about addiction. When I say the word addiction, when I think about substance use disorders, who comes to mind, those sorts of things, because what we're trying to, and you don't need to share those things or anything like that, but just to be aware and mindful of what are our beliefs about addiction, how it works, what it does to people or what people do who have substance use disorders and also our perceptions, how we see those things. And so why are we still, after all this time, still talking about addiction and substance use disorders? How do we continue to find ourselves? It seems like decade after decade, crisis after crisis, in this pickle. And so we're gonna talk about addiction and substance use disorders from kind of three areas. We're gonna take a look at some data. We're also gonna bring in some history and policy history, and then we're gonna anchor that in with the new neuroscience. And so as I go through some of these pieces, our challenge as you sit there and think about your beliefs and your perceptions is do our beliefs match what we're learning about the data, the history and the science? And I love this quote, for every complex problem, there is an answer that is clear, simple and wrong. And addiction and substance use disorders certainly are a complex issue. And unfortunately in our country, we've fallen into a trap of trying to find that simple, clear answer. Just say no. Either you're in recovery or you're in active addiction. It's a clear line, black and white. You're either in or you're out. And we know that it's much more of how do we start to operate in the reality of the gray? And so that's what we're gonna dive into. Now diving into some of the data, this likely is not a surprise to anyone who's paying attention to any sort of media, nevermind us in the field of the overdose death rate. And we know that we just broke unfortunately the 100,000 mark for overdose deaths according to the CDC data. Some good news coming out is that we're seeing and some of the provisional data is showing a decrease of 2%. So we're hoping that that holds. But you can see that this is a disturbing trend. So I'm gonna risk it all and try and bring out a pen here. Let's see how this works. Is this working? All right, cool, here we go. So also I forgot to ask, someone could just shout and let me know, do we have access to the chat? So if folks in the room also wanna ask questions, I'm guessing we can't use the chat cause we're all kind of around the table there. But Sarah, maybe you can let me know too in the chat if there's questions that come up or we wanna interrupt or talk about something in more detail I'll keep an eye on the chat as well over there. Okay, cool. So if you see me out there looking over here, I have another screen over here and that's what I'm looking at. Okay, so back to our data, right? So like we're hoping that we see this decrease coming but we see this disturbing trend and we're gonna talk about the history a little bit too about kind of what's gone on in these different parts of this data curve from 1999 to 2020. And so what we're seeing here in the blue bars is the total death rate and then we see overdose death rate. And then we see it broke down by male at the top here and female on the bottom, more orange looking line. And so there's some interesting trends here, right? We see kind of this curve going upwards and we see that right around here, the onset of the opioid epidemic. And then we're gonna talk about some changes in between this area here and then this area here. So we're gonna talk about one, two, and then three. All right. Let's see if I can erase that. That worked, great. All right, so that's a look at a chart that likely you're all familiar with but this is also interesting too. This is from 1999 until 2017. I don't have any more recent data yet but it breaks down the overdose death rate according to the drug. And so if you think about our screen prior, right? You look at this trajectory going up this way. I shouldn't have done that and I have to erase it. But we look at our trajectory here and you can see how certain drugs are certainly in the increase. So if you think about the overdose crisis for us, right? What did the overdose crisis start with? Which drug? You could just shout it out. Oxycontin, right? So pills, right? So we're looking for prescription opioids, right? That was the issue. And so here we see this huge trend from the late 90s, right? Where we see this, I don't know why my mouse is making those crazy lines there but we see this trajectory going this way. And so then we talked about the second wave of the opioid epidemic. Anyone know what the second wave of the crisis was? Heroin, right? And so heroin here, we see the second wave, this huge jump, right? Sorry guys, I don't know why those lines are showing up. We see this huge jump, now we look like a very complex diagram. Let me see if I can undo this. All right, so we got our prescription opioids in blue, right? And now we see this jump in heroin here. And then how about the third wave? Anyone know what the third wave of the opioid epidemic was? It's probably a word that we all know now so well but maybe 10 years ago, I'd never even heard of. Fentanyl. Fentanyl, yeah. Is the same person answering all the questions for us? I think it sounds like they are. Thank you, whoever's doing that. I'm just sitting closest to the mic. Okay, great. Well, thanks. So you're kind of being our mouthpiece for the room, is that right? Yeah, you're just gonna hear from the computer guy a lot. Oh, you're the computer guy. What's your name? Mike, thank you. All right. So thanks for letting me know, Mike, because I was like, wow, I gotta meet Mike. I mean, he's got all the answers to all this stuff. All right, cool. And so the third wave is fentanyl, right? And look at that dramatic rise in fentanyl. I mean, that's just so dramatic, right? So we're gonna take a look at kind of what was going on that contributed to some of these pieces. And part of what helps us understand this is a look at the history of the opioid crisis. So now we're gonna look at our history a little bit and connect it to the data. So to get started, and again, this is a brief history, right, just an overview of some of the key pieces that I pulled out of the history, but there's many, many, many more things to look at. The war on drugs and those sorts of things certainly play a huge role in drug use in the entire country. But to start with, one of the interesting pieces is in the early 1900s, there was this thing called the Harrison Act. And I'm gonna erase that, is the Harrison Act. And so the Harrison Act is a Supreme Court decision that basically indicted physicians for prescribing medications to treat people with addiction. So we wonder why a chronic health condition, which is what addiction is, a severe substance use disorder, a chronic health condition, is pulled out of the healthcare continuum and put into specialty provider care, right? And separated from this chronic health condition are our physicians, our prescribers, who 25,000 are indicted for these violations. Fast forward to the opioid epidemic, and now we're begging who to get involved with what. We're begging our physicians to get involved with addiction because we need them to do what? We need them to prescribe life-saving gold. The gold standard to treat opioid addiction and opioid use disorder is to use medications for opioid use disorder, drugs like methadone, drugs like Suboxone, Vivitrol. And so we see this rift that occurs that I think helps us start to understand why we see some of the resistance that we see in the field around utilizing medications to treat addiction. Fast forward to the early 90s. Again, most of us are very familiar with the impact that the pharmaceutical industry had on the opioid epidemic. It's why literally thousands, millions of dollars are being now opened up into our counties from the opioid settlement money. But that goes back to the bad players in the pharmaceutical industry. And based on a letter written by Dr. Porter and Dr. Jick that was published in the New England Journal of Medicine, and this letter was a letter that was written, if you're not familiar with it, just saying, hey, we treated, I think it was around 30 patients in the hospital for pain, and they did not return to the hospital. They did well on this pain medication, opioids, and they did not develop addiction. That's all it said. The pharmaceutical industry through commercial detailing, right? The commercial detailing meaning, and this has been clamped back a bunch now, but how doctors used to be taken on cruises to prescribe certain medications, and everybody has a Prozac pen, and all the dinners and the pharmaceutical sales reps and all this academic and trainings. This letter was used to prove that opioids were not addictive. And that letter transformed literally and took on a mythology all its own to become a study. And that study ended up in textbooks training our physicians. So we see the impact that this kind of detailing had on our medical community, and the money involved in that was no match for the academic detailing and public health approach to treatment. At the same time in the mid 90s, now we see OxyContin brought to market in 1996. Also in this perfect storm, we're going through during this time in the medical community, a history of untreated pain. And so we were not doing a good job in appropriately helping patients manage their pain. Docs were very wary of prescribing pain medications. And so there was a lobbying effort that got all mixed into this that made pain the fifth vital sign. So if you've ever gone to your doctor, now this has been backed off a bit, but if you've gone to your doctor and you're there for maybe a sore throat or you have a stomach ache, and they are asking you on a scale of one to 10, where's your pain? I remember I was a young, I was a brand new social worker. I had just graduated with my MSW and I was working in the drug and alcohol rehab in New York City and the joint commission, JCO, had us start doing pain scales. I think it was every week, we had to make sure that we had a pain scale completed. And I was in a rehab program for a substance use disorder at the time. And so we start having this greater awareness around pain. Like most things in our country, unfortunately we swing from one side of the pendulum to the other where we were untreating to now we're starting to pump opioids into our communities. And there we saw a market where the emergence of pill mills started to open up, where bad docs who were prescribing these medications for profit are pumping opioids into our communities. And so we said, my gosh, we see the overdose death rate climbing, right? We saw the data. And we said, we got to do something about this. And we did, we started to stop the influx of these pills through law enforcement, which was good. And we also, the CDC passed things like the morphine milligram equivalency to give doctors better guidance. Unfortunately, again, we swung from one extreme to the other and didn't account for people with chronic pain. And so it made it very difficult for many people to be on medications that they needed, and so, but we did, and we also set up things like the prescription drug monitoring programs in many states, all states have them now, which allows docs to look into a patient's history to see if they are getting multiple scripts from different doctors, right? All these things help stop the prescription opioid problem, except what happened, right? What happened with our overdose death rate? We looked in the data, and it continued to what? Continued to rise, right? Yeah, because in the bottom right of your screen, there's one thing that we never attended to. The fact that in our country for decades, 90% of the people who need addiction treatment in this country can't get it. 10% of the people who need it can. I mean, can you imagine if we said that about any other chronic health condition? There'd be outrage. Yet we did all these things to attend to the prescription opioid problem, and we never addressed the addiction problem. We never changed that statistic. So we did, likely, one of the most dangerous things you can do to people who have an opioid use disorder. Anyone guess what that is? Think jails. Why is it so dangerous for folks who get out of jail who have opioid use disorder? Why are they at a higher risk for overdose death? That's it. Nick, somebody said cut them off. They cut them, right. Exactly, it's the most, so the most dangerous time for a person with opioid use disorder is when they don't have opioids in their body. I mean, that's why the MAT, M-O-U-D medications are so important. So all these efforts might've contributed to the problem. And what happened was is we cut off a safe, regulated drug supply to our communities while the need to use was still there. And so a business opportunity emerged and drug cartels from Mexico began pumping black tar heroin into our communities from Mexico. So we see a greater availability of a larger, more available, cheaper, more potent supply of opioids. And that's when we see the overdose death rate quadruple. So remember we saw our screen here, right? This is, that's what's going on when we look at, when we look at the opioids, the heroin, the jump in heroin, right? You can see that there. And that's really when opioid, drug overdose becomes the leading cause of accidental death. And now we see the third swing. We talked about fentanyl, synthetic opioids become the third wave. And now we talk about the fourth wave of the opioid epidemic. And I'll ask you to guess what that fourth wave is and the trick of it is that it's actually not an opioid. Anyone guess what the fourth wave is? That's contributing to overdose death? You're talking about methamphetamine? You got it. Yep, exactly. Methamphetamine, right? And so stimulants are now emerging as the fourth wave. And that's why, you know, our organization ORN Opioid Response Network got approval from SAMHSA because we need to not just talk about opioids. We need to talk about stimulants now too. And in my opinion, all addiction. And this whole presentation is about helping support all of us talk about addiction as a whole. So that's our, any questions about our history or thoughts about some of this stuff? We're gonna keep moving. I'm gonna pause. I can't see you all in the room. So I apologize. I can't see if the hands are up, but I know Sarah's keeping an eye on it. We're good on history. We're good on history. All right, let's keep rolling. All right, so we now know, right? Substance use disorder is a brain disease, right? Addiction is a brain disease. We also understand substance use disorder, severe substance use disorders, use the term chronic relapsing, just like other chronic health conditions. We don't use chronic relapsing anymore as a stigmatizing language, but this was a huge shift in how we thought about addiction instead of zeroing people out, right? And really began to change the way what we used to diagnose as abuse and dependence were viewed by the medical and scientific communities. But we still know a lot of stigma remained unchanged within those communities and in the general public and also healthcare providers. So we're gonna talk about actually what goes on in the brain. And these are some of the specific areas that are affected by psychoactive substances. And what we're gonna dive into, this whole entire presentation is really based on these works here. And I'll go through them very quickly, but if you're only gonna read one article this year, check out this article. It's Neurobiological Advances from the Brain Disease Model of Addiction by Volkoff, Kluge, and McClellan. It's an amazing article. I read it over and over again. I still strive to understand all of it. Really seminal piece. And then these two are the Surgeon General's reports. The first one is, sorry, this one over here is the first Surgeon General's report since the Tobacco Surgeon General's report came out, I think 30 years ago, that addresses substance use disorders. And this was by Dr. Murthy under the Obama administration that brings in and is based on this neuroscience that we're gonna talk about. Under the Trump administration, Dr. Jerome Adams, the Surgeon General, built on Murthy's work, which was wonderful to see, and with specific focus with a spotlight on opioids. All of this also is informed by the shifts from DSM-IV to DSM-V, well, now in 5TR, and we'll talk about some of those shifts and why they are so important. So for us today, when we talk about bias, when we talk about stigma, we're gonna talk about stigmas referring to negative stereotypes, right? So the idea that the way that we think and the thoughts that we have, they influence our behaviors, certainly, right? And what happens is, is when we actually behave differently in the world, when we treat people differently, then stigma changes to discrimination, and discrimination is the behavior that results from those negative stereotypes. So important for us to hone in on what it is that we believe, what it is that we perceive, how we think, because the way that we think, we know is directly connected to the way that we behave and what it is that we do, right? And it's no coincidence in this slide, I pick a pregnant woman, and I think no other group is more stigmatized, right? You hear it all the time. My gosh, if she doesn't care about herself, how could she do this to her children? How could she do this to her unborn child or the children she has? She's so selfish. All she does is care about herself, right? And so our presentation today is gonna provide you information with actually how to answer that, how to navigate that, or maybe even how to challenge that in your own mind a bit. The other piece with this is that what we talk about today for some of us, it's not our fault. I, becoming more of the more, shall we say, seasoned generation of behavioral health providers, and as a social worker, I didn't have the training I needed around substance use disorders and addiction. Our docs still to this day, although it's starting to change, don't get the training that they need. Likely most of us out there in the field are working from kind of the self-learning that we've gathered through the media, through experience, what was handed down from our supervisors, and a lot of that information, really we need to start thinking about a little bit differently because we have new science that challenges some of those old ways of addressing addiction, and more importantly, the way that we treat and build relationships with people with addiction and substance use disorders. So for us today, stigma is defined as an attribute of behavior or condition that's socially discrediting, right? And so stigma is seated in two main factors for us, cause and controllability. So I'm gonna ask you to think about cause and controllability as we go through the presentation of the neuroscience. Cause is the extent that people believe that an individual is not responsible for the attribute, behavior, or condition. So like simply saying it's not their fault, right? Kind of like I was taking us a bit off the hook here. It's not our fault that we didn't have training around the neuroscience and the understanding of addiction, substance use disorders. I mean, I got that job that I mentioned in New York City. I didn't even wanna deal with addiction. I was like, go make a meeting, stop using. And when you're really ready to work on yourself and do some therapy, that's when I wanna work with those people. Not, I don't really wanna deal with addiction. I mean, it's just kind of, you just confront people and you get them to go to the 12-step meeting, right? That's what you do. It's really kind of what I thought. And I was hired because I had a degree and the organization was desperate for folks with a degree. And the truth of why I took the job is because I'm from New Jersey and the job was in the city, in New York City. But most importantly, I wanted to party at the Jersey Shore cause I just graduated for the summer and they would allow me part-time work. So I worked there Tuesdays, Wednesdays, and Thursdays and I had four-day weekends. So I was like, yeah, I'm doing this. And that's why I took the job, but I ended up staying in the job for four years because I realized I had so much to learn. I had so much to learn. And I learned so much from my mentors at that place. And also, most of them were in recovery themselves, incredible, extraordinary folks who literally saved their lives with some of the approaches that we use to treat the clients in that facility. And also the reckoning then later in my career that some of those approaches were at best, not trauma-informed, at worst, harmful. And to look back on some of those things and it's difficult and it's challenging. And so I share that story because this is about really, for many of us, redoing and undoing some of the things that we inherited and taking a look at why we do things the way that we do them and thinking about how we can maybe do them, start doing them differently. So cause and controllability. Cause, it's not their fault, right? For us too, the stigma around not knowing. And controllability, that's really just saying that it's beyond the individual's personal control. So controllability, a good example of that one is genetics. If genetically you have a disease or a condition, is that because you didn't work hard enough? Is that because you have some maybe so-called negative personality characteristic? No, it's because genetically you're predisposed to that condition. Nothing that you personally can do about that, right? So continued stigma really is because what we can drill part of this down to is that many people still perceive addiction as a choice and that addicted individuals ultimately really can control it. And so we're gonna dive into the question of why can't they just stop? Okay. So anyone remember this? These commercials? This is your brain on bacon. Right. Someone said, this is your brain on bacon. So these were commercials, right? Part of the just say no movement and an important part of our lineage in this country in terms of our policy and punitive, parental and kind of, you know, punitive, parental and connected to a criminal justice approach to treating addiction and substance use disorders, right? And you'd have the famous celebrity of the day come out and heat up a frying pan to, you know, some crazy temperature. You'd never cook your eggs that hot. And they try and scare the crap out of everybody by saying, this is drugs. And if you take drugs, you're gonna burn your brain. You're gonna poke holes in it. Your brain's gonna fry if you just do it once. And we ended up undermining our entire public health message towards generations of kids who then went off to high school and drank alcohol, smoked weed, took drugs and still got A's, went to college. And maybe right now, like are with us all here in this room functioning, doing really good things for the community. And so it speaks to how we have not found the honest and truthful approach to talk to, especially the children in our community about addiction and about substance use disorders. So this is not your brain on drugs. This is your brain on drugs. And hopefully there's like a ton of questions because we could spend like a whole day in here talking about this piece. And so this is from that journal article that I told you about up here in the left-hand corner, The Neurobiological Advances. And what's seminal about this work and is so cool is that it starts to bring in, I'm gonna get my pen out again here. Let's see what happens with it. Maybe I changed color, I'm gonna go to purple. So maybe we'll make those crazy lines. But the three stages of addiction, right? That's right there different. Because typically, especially in the media, when you hear about addiction, you hear about people who just wanna get what? High, right? It's all about this piece, binge and intoxication, right? Getting drunk, getting high, using the substance, right? And we have struggled and we'll see how that even relates into our previous diagnoses in DSM-IV, this over-reliance on the physical dependence piece. But also too, we forget about the withdrawal and negative affect that's associated with addiction and preoccupation, anticipation. So the cognitive component that goes on with addiction. And so here you can see our brain and this is not a nice linear diagram. It is 3D, spherical, dynamic, things are moving because your brain, we know our brains are, they're not hardwired, right? This speaks to the neuroplasticity that we know our brains are capable of, right? The neuroadaptions that occur. And so you can see here is binge and intoxication. I took the liberty, we're not gonna go into all of this now, of adding in in these brown boxes here. I don't know why that box is off, that says tolerance. But these are the DSM criteria, the 11 criteria of kind of where they show up in the brain in this diagram. I thought that would be neat to have. So we add that in. So you see, we see binge and intoxication. Here's number two, withdrawal and negative affect. Sorry, I'll go back. Oh, there's our line again. I don't know why it's done that. And then three is preoccupation and anticipation. So here are three stages of addiction. And we know that the, because, especially because of trauma research, the impact that neuroadaptions have and also epigenetics. So we're not just looking at a brain here of what occurred to a person because the environment that they live in and the family that they grew up in and the nutritional value that they had and the meals that they were able to eat. We're also talking about a brain that's been impacted by what happened to great-grandma or great-grandpa. And how those things, those genes are either turned on or turned off based on what's gone on in our ancestry. And so we look down here and we're gonna talk about these stages of addiction, one, two, and three. And this is gonna take us across time of what happens when a person takes drugs in this brain. All right, so let's go ahead and dive in. Any questions out there as I try and get this stuff off of here? No question. Okay, cool. Just cut me off, jump in. Please don't hesitate because it's more fun if we talk about what's going on in the room. Okay, so we're gonna focus on, there's a lot going on in the brain, but we're gonna, for us today, just focus on a couple of pieces. Prefrontal cortex. I mean, this is just the wonderful part of our brain that makes us miraculously human, right? It's the part of our brain that helps us with decision-making and impulse control, right? We're gonna talk about how drugs hijack, usurp those primary drivers, where really the drug, we're gonna talk about how that person who has addiction believes that their need to survive is whether they have that drug in their body or not. And so we're gonna talk about the impact of being able to pay attention to warning signs, consequences, and things of that sort. The other piece, the limbic system, right? Again, our brain is a little bit different Again, our survival instincts. Think Maslow's hierarchy of needs over here. Most of us are familiar with this, and we're talking about the bottom of the pyramid. This is the area that typically, that we're talking about when we say it gets hijacked. Things like our safety needs, safety, security, food, water, warmth, and rest, right? The limbic system tells us to eat food, drink water, take care of our kids, have sex, go to church. Why? We get dopamine when we do all those things, and they make us feel good, right? And that connects to our memory, and our memory remembers where to get that dopamine to do it again, and to do it again. And that dynamic simply stated is why our communities work so well, and why we work well together. So let's take a look at, this is the bottom part of what's going on in the brain with those three stages of addiction. So we're gonna jump into this, and this is the, this is the, sorry, let me get my pen. This doesn't wanna work. Oh, here we go. So these are our three stages of addiction that we just talked about from the, this is your brain on drug side. And here we go, one, this is two, there's my line, I don't know why, and then three. And we're gonna focus in on what happens from left to right over time. Okay, so this is what happens in the brain, and down here are the behavioral changes according to what happens in the brain over time. So we start out, and I go to a party, and I go to a party, and someone there has Oxy, and I take Oxycontin, and I get high. I feel really amazing. In fact, if I have a little social anxiety, or depression, or maybe some other co-occurring conditions, those things all go away for the first time in my life. If I have a trauma history, I'm not worried about being uncomfortable in my own body, I feel this euphoria. And then when I don't take the drug, I keep going to these parties, and Joe's at the party, and I keep getting the drug from Joe, and make sure I go to all the parties that Joe goes to, but when I don't take the drug now, I feel reduced energy, right? So the hangover, I have withdrawal and negative affect of not having that drug in my system. Makes sense, right? And so now I'm saying, gosh, I really like to go to those parties where Joe's at. I'm going to make sure I go to all those parties, I really look forward to taking the drug, but I only take it on the weekends, right? So I have voluntary action, I have periods of absence, because I work Monday through Friday and I can't be feeling euphoric and getting high during the week. So I have constrained drug taking, but I'm taking more and more of the drug now. In fact, Joe's such a nice guy, he's like, Nick, you don't even need to go to the parties anymore. Here's my number. I'll bring it to you so you don't have to go out. And I'm kind of an introvert anyway, so I was like, cool, let's do that. You come over to my place and he just brings me the drugs. And now I'm getting the drugs on Thursday because I'm going to use on Friday, but I have a little taste on Thursday and Sunday stretching into Monday, stretching into Tuesday. And so now things are starting to change. And I've been doing that for a couple of years now, except now it's changing. Now I'm starting to take the drug when I don't intend to take the drug, or when I take the drug, I have trouble stopping taking it, or sometimes I'm taking more than I intended. So now I'm using the drug every single day, except I need more and more of the drug now. Because now instead of feeling euphoric, I don't feel euphoric. I feel only good. And I keep taking more and more of the drug to try and get back to the euphoria, but it's not working. And now when I don't have the drug, now when I don't have the oxy in my system, not only do I feel reduced energy, but now when I like go to church, eat pepperoni pizza, do things that I used to love to do, I don't feel good. I don't have that same excitement unless I have the drug in my body. So now it's not just not having the drug in my body. I don't feel excitement from other things, the hijacking, right, the hijacking. And now instead of looking forward to it, I'm desiring the drug because I don't feel good if I don't have the drug in my system. Now we fast forward maybe a couple of years ahead, been on this path, and now what's happened is I need the drug just to not feel awful. Nevermind feeling good. I need the drug in my system because if I don't have the drug in my system, I feel terrible. And when I don't have the drug in my system, I feel depressed, anxious, and restless. And now my preoccupation and anticipation of getting the drug is obsessive. Now I'm obsessing. So now I'm in impulsive action. I'm returning to use over and over again, even though I don't want to use anymore. And I'm in compulsive consumption. So this is the trajectory of the development of addiction. And we see the part that most folks focus on, getting high and feeling euphoric, has long since passed. For a person with addiction, when they say, I want to get high, I need to get high, what they're talking about is over here. It's no longer over here. It's not about feeling good. It's about not feeling awful. And that's a huge shift that we need to understand in terms of the difference between a lot of times how the media portrays drug use and getting high and feeling euphoric, which is just one small component for a person with addiction or substance use disorder. Okay, I'm going to pause here for a second just to check in. How are we doing out there? I think we're good. Okay, cool. So let's talk a little bit about how the addiction develops, right? So we're going to talk about eight steps along the pathway to addiction. Anyone recognize this, I hope? Wizard of Oz. Wizard of Oz, right? And where's Dorothy headed? Emerald City. Emerald City. Yep. How come? Why is she doing that? What's her thing? Trying to get back. See the wizard? Because the wizard is going to help her get where? Back to Kansas. That's right. She just wants to get home, right? Does anyone know what she's walking through on the left and the right there? Those pretty flowers? Someone said poppies. Yeah. Opioids, right? Or opiates. And does anybody remember what happened a few scenes before this? What happened when they were going through the poppy field? They were on the nods. So I don't know if I heard. I heard some talking back there. They fell asleep, right? Right? She nods out and falls asleep? Yep. How does she wake up? Starts snowing. Starts snowing, right? The good witch, Belinda, I think it was. Or Glinda or something like that. Comes and makes it snow. And the snow what? Wakes her up. So Dorothy did an 8-ball. So I just point this out to also kind of level set a little bit. To show how drugs have always been part of our culture. And I think this movie came out. I don't know. Does anyone know? Like the 30s maybe? 40s? It was right when colored television came out. Doesn't it start out black and white and then it goes to color? And how, you know, drugs have also been part of our human civilization, right? And I also think this is a wonderful metaphor for recovery. Because Dorothy is, you know, on the path. And for a while thinks like all she's got to do is this thing outside of herself can get her back home. Get to this wizard. But it's going to take what? It's going to take walking this path to address what's going on in her brain with the scarecrow. To help work emotionally what's going on for her in her heart like the tin man. And it takes courage. And it takes courage to do. Ultimately to find out that everything she needed was right there with her. Because how does she get home? She clicks her heels, right? She clicks her heels and then she's home. And the strength to be home is within her all along. And that really is a great metaphor for recovery. So let's take a look at these steps for us. I'm going to see if this works for us. I think it's not going to. So we'll skip that. This is just a look at what happens, the normal functioning of dopamine. That's not working. That's okay. We can go back to it later. We'll make sure you guys have the link to this. By the way, since this isn't working, what I'll say here is this presentation also is for us, of course. But there are also pieces in this that you can share with your community. With the clients that you work with. The families that you work with. For them, too, to understand scientifically what's going on in their family, with them, with their loved ones, can be such a powerful experience. Because we know the psychological impact of being compelled to do something that you don't want to do is devastating. And the shame, the guilt associated with that, we know, with folks who have addiction is tremendous. And with that comes great shame. Typically connected with trauma. And so this can play a large role in helping address some of those pieces. If you think about your clients, can you imagine being able to say this is not your fault? That's not typically something we say in addiction treatment. That this is not your fault. This isn't something you can control. Right? In that way. It can be very powerful. Okay. So let's talk about what happens. Step one, disruption. So we talked about me going to the party. The addictive substance begins to disrupt the function of my brain circuits, right? So it goes right to the areas in the prefrontal cortex, like motivation, like decision making. And also my memory of how to continue to do those things to get dopamine. Except now it's switching, right? It's disrupting from going to things like having sex, being in community, eating good food. All those rewards, it's starting to change, right? So in that normal brain, that healthy brain, the mesolimbic dopamine pathway allows a person, me, to experience pleasure in response to a stimuli, right? And that encourages and motivates me to do it more. These are some of the natural reward levels. These are studies from mice. But this is a look at what happens in the brain when a mouse eats food. When a mouse, yeah, a mouse eats food. And you can see, like, the baseline is, like, around 100, okay? The way this kind of works. And when a mouse eats food, it shoots up to 150 and then comes back down, right? We see this. Now, when the mice have sex, it gets up to 150 but then doubles it, right? And gets up to 200. And then comes back down. So we can see, like, these are the natural rewards of how they operate in the brain that are similar to us. And I think it's fun, too. This answers the age-old question that sex is better than cheeseburgers, which is good to know that science lets us know that. Okay. So that's what's going on in the brain from those normal rewards, right? Except when we have an addictive substance, it starts to mimic or interfere the brain's regulation of those natural chemicals. And literally starts to change that reward system. And this is when that primary need for survival is changing to the drug. So what's happening to a person with addiction, it's kind of like this. Let's say you go, it's one of those cold, cold winter days, but you have a brilliant sunshine out. And actually it's warm enough you can just kind of go for your hike in a sweatshirt and you're good to go. But you go on this long hike and you get lost out there. And it's been hours and the sun has set and the temperature's plummeting. And you know that if you don't make it back, you're going to die of hypothermia. And so you continue on and on and you start thinking about your bucket list and all the things you haven't done and your family and how you're not ready to leave this world. And you feel this drive inside of you to keep pushing on. And thankfully up ahead, just a quarter mile away, you see a cabin off in the distance. And it's got a light. It's got a light on. And you know if you just make it to that cabin, you're going to survive. And you only have, say, half an hour, hour left. So you carry on and you make it. And as you're coming up to that cabin, and I don't want anyone to answer this right now. It's just for you to think about on your own. What would you do to get in that door? What if the person didn't let you in? What would you do to get through that door to the inside of that cabin, which is going to save your life? That doorstep is what a person with addictions brain is telling them they need to do to get the drug. Because the drug has hijacked, mimicked, robbed that same fight or flight response for survival. To trick the brain to say the survival is about using cocaine or heroin or alcohol. And that's why we see the level of cravings that we see in addiction and substance use disorder. So we're seeing now these changes to the cues and triggers. So what we're talking about is people, places, and things. It's connecting with the memory. The connections between the dopamine and memory circuits that enable me to remember things are now being associated with the drug. No longer with some of the other social cues that we are all connected with. So I'm just going to ask folks to kick back for a second. Look into this slide. And it would be fun if you yelled this stuff out so maybe I can hear it. What are you thinking? Some images are going to come up. What are you feeling? What's happening to you? In your body? What are you noticing? What are you seeing? All right. I heard a bunch of things yelled out. I heard salvation. Did you hear my stomach? What's that? Did you hear my stomach growling? Right. So me too, right? And I put the sweet and the savory on here for everybody. I'm a savory person. It's the pepperoni pizza that gets me every time. My mouth is literally watering. And by the way, I've seen this slide 372 times. It's my slide. I'm the one who made it. There's no surprise here to me. But I'm triggered by it, right? I'm activated by it. And here's the other thing. We can't even smell this. It's not real. They're just pictures. It's a PowerPoint that you're seeing over Zoom. So that's how strong and salient these activators are for us. And so what we're getting when we see these things, we want the dopamine. Right? That's what we want, right? When a person takes drugs, those areas are being activated at such a higher level in ways that those areas were never intended to be activated. So they're activating those areas way more powerfully than the natural rewards ever intended to. And so I just put that up because it gives us a sense of how strong those cravings are, right? Oh, this is working. How does meth change our brain? When we use meth, it Were you guys able to hear that? I don't know what happened. Okay. I hope I can do it again. Okay. So this is going to be an example of what happens in those systems for a person using methamphetamine. Okay. Here we go. God, I hope I can do it again. How does meth change our brain? When we use meth, it enters the bloodstream and travels to the reward center of the brain where it invades the sending neuron. Meth causes dopamine to unnaturally leak into the neuron, then spill into the synapse, making matters worse. Meth blocks the transporters, which recycle dopamine back into the sending neuron. This keeps levels abnormally high, overstimulating our brains. We feel a powerful wave of pleasure. The rush can last 8 to 12 hours from just one dose. Okay. So that just shows, it's just a great visualization of that sort of thing, right? And so this is the effect of drugs on dopamine release, right? Back to our mice. And if you take a look at this, right? This is alcohol. Remember our baseline is about 100. Alcohol gets us up to 200. Nicotine spikes that up a little bit to, say, 225. We see cocaine gets that up even higher, right? Maybe 350 or so. And then look at methamphetamine. Methamphetamine, we need a whole new chart. We're looking somewhere around the 1,200, 1,300 range. Just incredible. And this is why, if you work with folks who have methamphetamine use disorder, you see how they are dealing with more challenging dynamics, like anhedonia, like treatment retention. Much more challenging because, I mean, just look at what's going on in the brain there. Longer levels, higher doses, and wrecking havoc on those systems. Okay. So step five, right? So we see these changes in the systems of our brain. And then step five is what goes up must come down. So here's how we start to talk about the addictive process as almost like a Greek mythology or some kind of devilish, satanic scheme. Because here's what occurs, right? The person with a substance use disorder, that person's getting triggered and activated, that those substances are available. So the brain is telling the person with addiction to use those drugs more and more and more, like they're life dependent on it. At the same time, the more a person uses the drug, the response to the drug decreases. Tolerance, right? So the response to the drug itself, but also like natural reward, they drop, they diminish. So my brain is telling me I need more and more of the drug to activate that same level of reward, to get back to where I can never get back to. Because the more I use the drug, the further away I get neurobiologically to get back to that point. At the same time, the brain tissue in places like my free frontal cortex that have to do with decision making, and remembering reward are increasingly damaged. So what's happened is we're seeing the erosion of control. So simultaneous repeated substance use erodes the ability to exert inhibitory control. What we're saying is the go and stop circuits in our brain, the compulsion that drives behavior is being damaged, right? Think about like the go and stop is the gas and the brake in the car. The go is the survival brain saying do this more and more is like the accelerator and we've strapped a cinder block to it all the way down, pedal to the metal. While at the same time, the stop part of our brain, which helps us with self-regulation, don't do this anymore, it's like the brake lines have been cut. And so the go circuits are overactive, the stop circuits are becoming dysfunctional. And what we're seeing is the same drive for Maslow's hierarchy of needs, except the base of that pyramid is now the drug. And so in step seven, we see both time increases and decrease. What we're saying here is that the drug related cues, the craving, become stronger and stronger and stronger. Drug craving becomes more and more compelling while the individual is less able to inhibit impulse control to use the substance. And the high, and we talked about how the high has changed, experience is diminished. So over time, cravings increase, my ability to control use decreases, and I go from feeling euphoric to feeling bad when I need the drug just to not feel bad, nevermind, I've lost the ability to feel euphoric, to feeling good, and then ultimately I'm just trying to escape feeling bad. And so this is what comes together for kind of the hallmark when we talk about addiction of having the erosion of voluntary control. And this is the pathway that leads to many of the symptoms that we see in DSM. Okay, so let me, I'm gonna pause here just for a second, that was maybe a lot, and I just wanna check and see if folks have thoughts about that. I had a quick question, so on the what goes up, what must come down, the same theory, I guess, what goes down must come up, is that why the rise in meth is because people are using it to come up off of heroin or meth, like they're using one to counteract the other, is that? Yeah, and it's a little more like this one, like we, exactly, right? Like, so the effects are getting diminished, so that's why like we like to combine these things, right? Like if drinking a few beers is good, well, drinking a few beers with a cigarette is really good. And not only that, but if I also add sex into that, that's even better, right? I'm increasing all the dopamine on that, right? I mean, it's the classic, we don't see it as much anymore, but you know, on the movie or the TV, the couple has sex, then they light up cigarettes, right? You're smoking cigarettes afterwards. You're combining those pieces. So certainly, right? You're getting more bang for your buck. And your question, I think, around addiction is exactly that, that you're trying to get back to what you can never get back to. So you start doubling down with more and more substances. Great question. Any other stuff going on in the room or thoughts? Does this change a little for some of us, if you think about the clients that you work with or even yourself, a little bit about how we think about addiction? Maybe you guys are on this page already, not new information, which is great. Okay. So that's really, this slide is like thinking about like what has been our response to addiction and does it match what we all now know about the science of addiction? Does it match what we all now know about the science? Like is punishing someone an effective form of treatment? Is forcing people to go to group? Is forcing people to go to a residential treatment center for 18 months, throwing people in jail? These are things that we have to now start to question and start to challenge based on the neuroscience, right? And so this is the ASAM definition of addiction. And it's interesting here because they added in some key pieces here. So addiction is treatable. Why would we even have to say that? Well, it's because there's a lot of stigma in the field and especially in the medical field that addiction actually is hopeless and it's not treatable and that's false, right? And it's clearly states here as a chronic medical disease involving complex interactions among brain circuits, genetics, the environment and an individual's life experience. And this is an important nod to the impact that trauma has on addiction, right? People with addiction use substances or engage in behaviors that become compulsive and often, and this is key, continue despite harmful consequences. So, right, like that's such a key piece because when I was in my drug and alcohol treatment program learning as a counselor, a key piece for us was to have clients list the negative consequences associated with their drug use so that they could somehow learn as if they didn't know or weren't aware of the wake of destruction behind them. Now, if that worked, I'd be all for it, but it wasn't effective. In fact, it likely exacerbated things like shame. And so that's why it's so important that we point these pieces out, right? And so really starting to think about do our interventions or responses, I don't know why my slides messed up there on the left, but do our interventions, responses and expectations match the science, right? So we know addictions are primary. Why do we say primary? Well, the other belief used to be that if we just treated the underlying psychodynamic issues for a person, then that would help resolve the addiction. Now we need to address those things certainly and treat conditions concurrently, but it doesn't mean that we don't not treat the addiction and hope that by curing the depression, the addiction resolves itself, right? We know also too that addiction is characterized by an inability to consistently abstain, right? Impairment in behavioral control. So think about how many programs discharge clients from their program if they use drugs. When we know from the neuroscience and the very ASAM definition is that the person has an inability to consistently abstain. So are our programs adapting and ready to help clients navigate through returns to use, right? And now we're leaning into harm reduction. Hey Nick, you have about 13 minutes left. Oh, thank you. Okay, and we know that addiction is also characterized by things like craving, right? Dysfunctional emotional responses. Thinking about do our programs, do our treatment approaches, are they ready to integrate these pieces or do we blame and shame a client for what we know neurobiologically is what's going on in the brain, right? Also too, one of the most important things that we can do is start to change when we talk about stigma, the way that we talk about people with addiction, moving away from terms like addict and these old tired narratives of antiquated drug policy. And so we know that substance use disorder and this is from SAMHSA is not a moral failing or a spiritual failing. It's not a lack of will or responsibility. It's not a character defect. People with substance use disorder as opposed to other folks with chronic health conditions do not have personality components such as denial, rationalization, defensiveness, manipulation or resistance, any more abnormally robust defense mechanisms than other folks. Now that last bullet point was a main part of many of the treatment plans I wrote back in the 90s. And so we were off on some of this stuff. Ultimately what that last bullet point is saying is that people with substance use disorders, if we need to be ready and expect people to not be forthcoming, to lie, because what would you do to get in the cabin door? Are we offering supports if we're asking someone to not use a drug? Are we giving them the support to not use it? Instead of blaming them, we need to really start to take a look at are we providing a system and offering a system that provides the care that they need, right? And ultimately what this means is they really, it's like when I go to my primary care provider and she asked me, Nick, how often are you exercising? And I say, well, three to four times a week, about 20 to 30 minutes a time, which is BS. And she knows it and I know it. But she doesn't throw me out of treatment and she doesn't confront me and yell at me and defame my character. She works with me and continues to work with me and doesn't throw me out of her practice. And that approach has not been afforded historically to people with addiction. We know folks who have substance use disorders are gonna have problems around episodic memory. That means remembering time, places. It's also associated with emotions. So contextually, the who, what, where, when, and why. They're gonna have challenges neurobiologically around emotional processing and executive function, things like planning and decision-making. So we really need to rethink, how long are we expecting people to sit in a group? How long are we expecting people to sit in an individual session? How do we treat people who miss appointments, who we know are already challenged to miss appointments and a lot of other things? Are we holding that against them and saying things like, they're just not ready yet, they don't care about their treatment. Talked about language, that's a good shift for language. Some of the shifts in DSM-IV to DSM-V that were really important. We got rid of substance dependence and substance abuse. Dependence was an over-reliance on the physical dependent part of addiction and not paying attention to those other components that we talked about. And maybe most importantly, gone is the word abuse. Because if anybody in the situation of addiction is being abused, it's the person by the substance, not the other way around. We learned that in our neurobiology. I'm being compelled to continue to do something that I don't wanna do. We've switched now to this spectrum, which really brings much more of the gray and understanding into understanding addiction. And when we talk about addiction, really what we're focusing on that spectrum is the more severe side of this spectrum of six or more of the 11 criteria. So we now know some of our evidence-based perspectives on substance use disorders, and think about, right, we're bringing back in our cause and controllability, our two seats of stigma. Half the risk for addiction is conferred by genetics. We know also, too, most people who use drugs and even have problems with drugs don't develop addiction. If we gave 100 people heroin for six months, around 80 of them would have a physical dependence but would not develop addiction and would say, wow, I love that stuff, but I gotta quit it and quit it. But the other 20% would say, wow, I love that stuff. I gotta quit it and I can't. The other 80% are like, hey, I liked it too. You gotta get off it. Stop, stop doing it like I did. And the other 20%, and this is different for me, and that's because those folks have addiction, right? So we know individuals are compelled to use drugs against their own will, right? And despite the threat of severe consequences. So I continue to use despite those consequences. It's likely those consequences, adding more consequences is really not gonna help. So ultimately this comes down to how do we answer our question from the beginning, right? How could she do this to her children? How could she continue to use? And we now know addiction is not a choice. We understand that it's the radical decay in any rational ability to regulate these impulses, to use. Despite the threat of harm, despite consequences, despite my will, what I wanna do. So why don't those people stop? It's because the functional and structural changes in the brain that are affecting that neurocircuitry around impulse control, memory, reward, motivation, those things have changed. And that's why this person can't just stop. So ultimately what we're talking about is a shift in how we treat addiction using evidence-based care. Things like SBIRT, MAT, MOUD, harm reduction approaches, MAT medications. Congratulations to all of you for utilizing those medications. They are critical and play a huge role in helping keep our community safe. Okay, Sarah, I'm gonna go ahead and pause here. I'm gonna take the slides off. There's some resource slides here as well, but I'm gonna stop sharing and just bring this back to our screen if that's okay. So I can see folks. All good, there's still a room full of people there. I'm very happy to see that. So we have, oh gosh, we only have five minutes off, but I'd love to hear any thoughts or comments or questions. Can I just offer some appreciation because some of this is stuff I'm trying to do, but it was more factual and really good to just hear your clear explanation of a new, better understanding of addiction. And I'm all for limiting stigma, so I just think that was really helpful. And I didn't want you to think that we all meant all of it. So maybe everybody knew pretty much all of it, but I thought it was helpful. Great, thank you for that. Thanks, Nick, I appreciated the diagrams too. Can you speak to the acronym MAT, switching to M-O-U-B and kind of what the genesis is around that? Yeah, so I like to think I was on the forefront of one of the battle cry champions for MAT when we called it medication assisted treatment. And then they changed it, right? Whoever the they is, but they changed it, the powers that be, and now they want us to call it medication for addiction treatment, which is better. I was just concerned because we had worked so hard to market this stuff and we're trying to get it out there. But the genesis of that change is a really good one. The idea is that a shift from saying, wait, the medications, we need to be thinking about those first. And it's not the medication assisting treatment. It actually needs to be the other way around that actually the medications like insulin are first line of treatment. And so it showed still the stigma in the field that we have towards using medications. And fortunately, unlike some of the other things I talked about in the presentation where we swung from one extreme to the other, I think we've done a nice job of balancing this piece and saying, we need these medications, we need the counseling and the behavioral health therapies that go along with that. Ideally, we bring them together, but ultimately the most important piece is that they are available to everybody in the community who needs them and that individual person gets to choose what's best for them with the coaching and the support of professional folks in the field. And that's the ideal. And that's what I think we're all striving for and working for. MOUD is a specific effort to talk about those medications specific for opioid use disorder. So medications for opioid use disorder gets a little confusing. We can talk about this some other time, but like medication like Vivitrol is also used for alcohol use disorder. It's a wonderful medication and works in both ways. Great question. Nick, this is Cara. And I just wanted to say thank you for your presentation. And one of my biggest things that I'm hoping to come out of this is, I think everybody in this room would be able to answer a multiple or true or false question is, are substance use disorders an example of a chronic medical illness? I think everybody in this room would have said true statement, right? But I think going beyond that and being able to answer how. You know, if somebody says to you, well, okay, but why? You know, why is it a medical illness? I think that maybe some of us didn't have those skills prior to your talk. And I think that's what we walk away with is being able to talk about, you know, the three components of addiction and how that translates into brain function and our ability to, you know, have impulse control or, you know, exercise our ability to stop those kinds of things. I think that's been really helpful. Awesome. Yeah, you know, one thing that I forgot to mention too is like, just cause I lose impulse control, which I do if I have addiction, doesn't mean I'm not accountable to my family, to my community, to the laws of the state that I live in and all that stuff. Like if I get a DUI, I can't be like, well, I lost impulse control. Like, no, I'm not saying that you're not held accountable. You're absolutely, we're all held accountable. It's the spirit really of how we need to really think about how we treat people around those pieces, which makes all the difference. So I just wanted to throw that out there too. Thank you for your comment. Nick, one thing that stood out to me and it was years ago, back in 1994, I went through a deferred prosecution and a guy came in and talk about cocaine and how, I think he called the reward center, he called the pleasure center, the brain, but he used an example. If somebody's have a long-term addiction, it can take up to a year before their brain gets back to that baseline. And so the importance of what you're talking about, like how critical the person that's stuck in addiction is getting to that, trying to not feel awful, because he said like someone could win the lottery and that there'd be an initial buzz, like, oh, I just want a bunch of money, but that level of dopamine wouldn't be there because their brain has so used to flying so high, but just going so fast that they need that. And I think that has helped me with friends and family who have been stuck in addiction is to realize that they're trying to get out of that really feeling like shit all the time, not going back to the high. And I think that's a big stigma. It's like, well, they just want to party all the time or whatever, but no, they're just trying to get out of the dumps because their brain's not functioning at a level and it can't take. And then when you showed that meth slide, that's just skyrocketing even above where the dopamine was for cocaine. And so that's obviously, well, why do you keep going back to it? Because I think that helps me answer that question when I see people stuck in that. Awesome. I mean, can you imagine being robbed of the things that make you feel, like I went fishing, I blew work off yesterday afternoon, full disclosure, and I went fishing because I love it. And I'm in such a good mood today. I caught a big fish by the way. And I'm just sitting here imagining as you're talking, answering that, if I didn't get that feeling, if I didn't get that feeling, like, oh my, that would be so, that would depress me in a great way, right? So it's not, it's so complicated. It's not even, we're not even talking about the drug. We're just talking about losing the love of life that it goes, that occurs with you. And then, and then sometimes in treatment, we tell folks, I know we got to go Sarah, but then we tell folks, well, just do positive pro-social behaviors and engage with your community and get back to your community. And it's like, why do I want to do this? So sobriety sucks. I don't feel good. It doesn't feel good. Now the 12-step community gets this and they say, just keep going. And you'll get it. It'll come. And it does, but it takes years for some. And the research says five years is golden. Seven to eight years is optimal. I forget the statistics off the top of my head, but if you make it five years, it's like 80 to 90% chance that you're not going to return to use. Seven years, it goes, it's exponentially higher. So, so thinking about our treatment approaches, why are we not staying with folks for years? Because that's when they need us. Okay. I know we're out of time. Yes. So we are out of time, but we are here to answer your guys' questions. I will be sending out the presentation PDF and a survey link to Cara so that you guys can do the survey. And that will help us make sure that we are providing good information and how we can improve. And the slides, so you could look over them. And then if you guys have questions or concerns, anything that you need to talk about, please let Cara know, or also let me know so that we can set something up to answer those questions. Thank you.

harm reduction

addiction

substance use disorders

three stages of addiction

brain effects of addiction

stigma surrounding addiction

compassionate approach

informed approach

audience participation

evidence-based practices

harm reduction strategies

education

empowerment