- All right, so without further ado, Ashley Collins, so thank you so much for being here. This is a spring
- care, Monroe County CARES community meeting. I'm Lee Muser, the CARES coordinator, and Ashley Collins
- is giving her time today to present to us on substance use disorder 101, what you didn't know. All right,
- thanks Ashley.
- Thanks. Yeah, of course. Thanks, everyone. If any of you guys already know me, know I love like nerding
- out about the topic of substance use disorder is one of my topics I love to nerd out about. So my name
- is Ashley Collins. I am a
- I'm a licensed clinical social worker and the director of adult and family services here at Centerstone.
- I'm over the West region, which includes Monroe and then the Spoke counties around it, which are Morgan,
- Owen, Lawrence and Brown. So I'm going to dive into this and so yeah, definitely jot down your questions
- as you have them so that I can get to them, but I'm going to be talking kind of fast.
- What is addiction? It is a chronic, often relapsing brain disease that causes compulsive drug seeking
- and using despite those harmful consequences to the person using the substances and those around them.
- Drug use changes the structure and function of the brain. And you're going to hear me repeat that frequently.
- And so a lot of times people are like, well, they had a choice. Initially,
- they, most of the time people have a choice, although I have definitely worked with people that their
- first use was not their choice. But most of the time it is. However, what ends up happening is that
- use then changes the structure and function of their brain and it's no longer a choice anymore. Their
- brain's telling them they're going to die without that substance. And we're going to dive a little bit
- deeper into how addiction affects the brain in a little bit. And so what
- is a drug. A drug, it's important to realize there are legal and illegal drugs. So it's really any substance
- that is absorbed into your body that results in psychological and physiological changes. So I'm going
- to go over a little bit in terms of like the categories that this falls into. So we're going to review
- a little bit of each one of those. So depressants
- do what it kind of says, it depresses, it slows down your central nervous system and reduces arousal
- or stimulation. One of the most common legal ones is alcohol. We also have benzodiazepine, which are
- generally prescription drugs, although we're going to go over something that
- there are now benzos that are not pharmaceutical grade. But historically, benzodiazepines have always
- been pharmaceutical grade medications generally prescribed to treat anxiety. I refer to people, I refer
- to benzos to people as alcohol in a pill form. It's very similar. If you like one of the substances,
- you pretty much like the other. And while there's no research on this,
- whatever reason, when you combine the two, people rack up a lot of theft charges. Something
- about benzodiazepine and alcohol giving people sticky fingers. There's no research that shows this,
- but if you're in this field long enough, you will absolutely see that correlation. There's also GHB,
- kava, other things that fall into that category. Then we have stimulants. So that's
- The other side of the spectrum in terms of depressants are depressing your central nervous system, stimulants
- are speeding up your central nervous system. So we have amphetamines, which are pharmaceutical grade
- medications that are generally prescribed for ADHD. Then you have methamphetamine, you have crack and cocaine,
- and then nicotine and caffeine, which are completely legal substances. I do want to take time to talk
- a little bit about methamphetamine here. Methamphetamine, the way it's being made now is very different
- than how it was. When I first came in in this field, methamphetamine was frequently being cooked in
- people's backyards, in their homes, and that. So what ended up happening, how this
- Why is it cooked differently and this is this is the chain reaction of events well. One of the things
- that where people were able to make it in their backyards and stuff was access to pseudo ephedrine.
- Pharmaceutical like you get it at the pharmacy.
- They're all over the counter now. Now you have to like give them your license and all of that. So we
- put things in place where people cannot unlimitedly access pseudo phedrine any longer. Because what
- they would do with the pseudo phedrine is they cook it and do chemical reactions to cook it down into
- a phedrine. So what we had was methamphetamine that was a phedrine based.
- Now, that's not the case because we put things in place in the United States to stop people from having
- access. Well, folks in Mexico were like, this is great. They can't make all of their own stuff. So we're
- going to make it for them. So then we saw that there was that shift. Right. So the United States works
- with the Mexican government to be like, hey, we need to work on stopping to allow people to have either
- accessing precursors to make ephedrine or ephedrine itself. So they crack down on that. Then the people
- that are cooking the methamphetamine are like, well, what do we do now? They went back to using a cooking
- method called P2P method. This used to be used back in the 80s and 90s when biker gangs were in charge
- of the methamphetamine distribution in our country.
- What you get when you do this 2P2, there's some perks in terms of cooking it like this. A, using the
- P2P method, you can make significantly more amounts of methamphetamine. And two, you can interchange
- different ingredients. So say if like one of the ingredients you're using, they put stop gaps so you're
- not able to access that, you can change that out for some other chemical to
- do the same thing. So what happens when you're cooking it this way is you have two products at the end.
- Those names are really, really long. But basically you have the stuff that gives you that euphoric high
- that people, why they like to use methamphetamine. And then you have this garbage that just really super
- speeds up your central nervous system. And that is the crap that's causing skyrocketing rates
- of methamphetamine induced psychosis right now.
- there's a lot of issues that are occurring with that, but you see that shift. In fact, in a book, I
- read somebody who was in the military, he had
- been using methamphetamine it actually he had trauma before he went to the military when the military
- had more trauma than when he came out he would use methamphetamine to be able to socialize with people
- because if he wasn't on methamphetamine he was locked in his apartment not talking to other people so
- he went from using methamphetamine as a way to socialize with other people to one day he's using it
- and he's like I know exactly the date that the meth changed and
- He went from being able to socialize with people to a little bit further down the road. He's ripping
- out the drywall in his apartment because he's convinced his girlfriend has hidden a man in the walls.
- That is the difference in how it's responding to the same person being cooked in those different manners.
- So I did want to talk about that because I get a lot of questions about that and that's helpful to understand
- that background. So we have opioids.
- One of the things I want to talk about here is the word opiate versus opioid. So opioid is this umbrella
- term that includes having semi-synthetic, synthetic, and then opiates, which are natural opioids such
- as heroin, morphine, and codeine. So these come from the opium poppy plant. So it includes all of them.
- So when you hear opiates, you're talking mostly about heroin, morphine, codeine.
- If you say opioids, you also have like fentanyl, any of the semi-synthetic things are also included
- in that. So there's a lot of knowledge out there about opioids, so I'm not going to spend a whole lot
- of time on this, but know like this is really serious, especially with fentanyl, carfentanil, all the
- different opioids that are coming out. Psychedelics and hallucinogens.
- have their class of psychoactive substance that produce change in perception, mood, and cognitive processes.
- So the primary purpose is to trigger a non-ordinary state of consciousness, which people frequently
- refer to as TRIPS. And again, you have multiple different things that fall under that. Cannabinoids,
- I think everyone knows about marijuana.
- What I want to take a moment to talk about here is spice, is synthetic marijuana. It started out as
- synthetic marijuana. What it is now, I don't feel like it should be called cannabinoid anything. A lot
- of times people are having really crazy reactions. They're similar to people being on bath salts. You
- guys remember bath salts for a while.
- Spice anything that's like considered Synthetic marijuana is now frequently causing really high fevers
- like lots lots of issues that we're seeing with this and what I will say is I feel like I the active
- ingredient the most active ingredient I've been aware of is they're using like hornet insect Killer
- on this like on this stuff like that's awful for sure and so
- What I will say is there's some people that have been heavily using spice that I feel like they never
- return to the same person because of the chemicals that are in there. And I see some people nodding
- their heads as like anyone that's experienced this. I think this is long lasting brain damage that it's causing.
- So then we also have dissociatives. So this is characterized by distorting sensory perceptions and feelings
- of disconnection or detachment from the environment or self. So ketamine, PCP, DXM, nitrous oxide are
- some of those dissociatives.
- And lastly, we have empathogens. So these really increase an individual's feelings of empathy and benevolence
- towards others and increase those feelings of wanting to be social, feeling connected to others. You
- have the EM or ED, I'm sorry, blah, MDMA. And now, you know, seeing how that
- all spelled out. That's why they call it MDMA. Could you imagine if you had to say that whole word that
- whole time? So there's lots of different street names for this. Ecstasy, Molly, E, Flippers, Caps, Ekis,
- M&Ms. Some people like a certain brand with a certain, a lot of times as you see in the picture, there's
- certain stamps that are put in there and be like, this is the Bluebird. So like also you have different
- variations called that based on like what it is. I'm sure like these things are called dominoes. This
- is probably called skull, you know, so on and so forth. We also have bath salts and PMA, PMMA, and things
- like that. So I also wanted to
- to touch on some of these more emerging drug trends that you're seeing. So everyone knows about fentanyl.
- What I want to hit on in this slide is historically when we're talking about naloxone, we were always
- trained you give naloxone to somebody that's using opioids. I tell people now you're giving naloxone
- to anyone that's using any substance you don't know
- what is in it. So there's a lot of times we've had overdose deaths with people who were intending to
- just use methamphetamine, but fentanyl was in it. And so you're seeing more and more fentanyl is pretty
- much in any substance that's out there right now. Warning, this is graphic. Xylazine, also known as
- Trank Dope, Benzo Dope. This is
- really horrible stuff. Number one, it's bad because this is not an opioid. This is a veterinarian
- tranquilizer. It was never meant for human consumption. There's no studies on human consumption. Therefore,
- we weren't really sure what we were going to see. Now we know one of the worst side effects is the fact
- that you have this kind of flesh grossness that's causing skin ulcers.
- that can become necrotic requiring amputation. People that are using xylazine are losing their hands,
- their feet, their legs, their arms. Now, one of the things to know about this is I think a lot of times
- people just assume that, like for instance, this person must have been shooting up in their legs. That's
- not necessarily accurate. In fact, a lot of times, regardless of where you're shooting up,
- It's showing up on your limbs, on your arms, on your hands, on your legs, on your feet. It's very rare
- for it to show up in the trunk of your body. If it is showing up, that may in fact be an injection site
- where that's happening. And I wanted to show you, this is somebody that went into one of our facilities.
- And as you can see, this gets like really hard and
- It goes down deep too, because it's almost like eating you from the inside out. This is what these two
- indicators here, this is what it looks like before it becomes an open wound. So I would say within 24
- hours, this is going to be an open wound. So it almost looks like kind of like a little bruise, a small
- abrasion, but that will in fact turn into an open wound.
- In taking care of these things, the guidance really is to avoid alcohol, rubbing alcohol and hydrogen
- peroxide because those two things dry it out. What you want when you have these wounds is to keep them
- covered and keep them moist because as you see, this person wasn't putting any kind of protection on there.
- infection is an issue but also when it becomes hard like this it becomes harder for your body to heal
- so it almost is like that scab and again it goes in deep becomes almost like a cork and your body can
- only heal so far because as you can see there's like pink granular tissue it's healing however it may
- get to a spot where like you know there's there's still a line it's going deep and it's hard for your
- body to heal that piece
- So really clean it with soap and water, clean water. And I know like you and I are like, of course,
- clean water. Tell your clients use clean water. If it's dirty water, then that increases chances of
- infection. Cover it with something that isn't going to actually stick to it. So non-adhesive and then
- wrapping it.
- And if you do want to put something on it, they recommend using vitamin A and D ointment instead of
- like neosporin. So if that's not bad enough, we also have metatomidine, which is very similar to xylazine
- in the fact that A, it was never intended for human consumption. This is only veterinarian-based use
- that's approved of.
- This is less likely to cause wounds. However, it is found to be stronger and longer lasting sedative
- than xylazine. And it's here. It's here in the state of Indiana. What I tell people when we're talking
- about xylazine, metatomidine, and in a minute we're going to talk about some novel benzodiazepines that
- are out there, if somebody looks like they're overdosing,
- still give them naloxone. The likelihood that there's some kind of opioid in their system is really
- high. What you might find, though, if they have xylazine, metatomidine, and any of these novel benzos,
- they may not be coming like two.
- The only thing you may be getting back is their breathing. They may still be unconscious because of
- the sedative effect. So that's really important for you to know, which makes it even more important
- for us to be getting medical personnel there to them immediately. And then we have Bro Mazelam. So.
- This first appeared in the United States in 2019 since then it's skyrocketed in fact of like it's it's
- being mixed into a lot of different things. It can be sold as tablets, powders, gummies, it's frequently
- mixed with other opioids such as fentanyl. It's very similar like how it
- reacts as other benzodiazepine. The effect occurs about 15 to 45 minutes after you've taken it. It lasts
- about five to eight hours. All of these are very similar to any other benzodiazepine. But this is not
- pharmaceutical grade. That's something that's really important to know about this. These are benzodiazepines
- that are being made in drug cartel labs. This is not something that is
- pharmaceutical grade whatsoever. And there's a whole bunch of other ones. So these are some of the other
- ones we're starting to see in there. Now, what is really important to know about these things that I
- just went over? All of these things, benzodiazepine, xylazine, metatomidine, and then opioids, all of
- those have respiratory depressing impacts.
- on something. So the more respiratory depressants you're putting in your body, the higher likelihood
- you are to have an overdose. Something else that I just want to throw out there that's not really part
- of this presentation, but something I've seen in, I sit on the Monroe County Suicide and Overdose Fatality
- Review, is a lot of people take Benadryl not as prescribed.
- You see a lot of people that die of overdoses that have a bunch of things in their system, some of which
- is Benadryl. Benadryl, you can take enough to die. That's really important for people to understand
- because I think some people are like, oh, that's over the counter. That Benadryl causes respiratory
- depression as well. So the more things you're putting into your body that are respiratory depressants,
- the higher likelihood of
- of having an overdose. So what causes addiction? I wish it would be a simple answer. It's not, it's
- complicated. So firstly, we have kind of the, oops, no, I'm looking at the right one. Okay, biology.
- So this is more of like the nature piece of it, right? So we're looking at genetics. Children with parents
- that have substance use disorder are
- eight times more likely to be biologically predisposed to addiction. And that's not even taking into
- consideration the environmental factors that they would be experiencing as well. Then you have your
- brain structure. Substance use rewires your brain. If you have chemical imbalances before you start
- substance use, that can impact addiction happening or not happening.
- Then we have here, this is more of the nurture piece of things. So the age of experimentation, individuals
- who tried marijuana or alcohol before the age of 15 were almost four times more likely to suffer a substance
- use disorder than those that wait until 18 or older. And I know there's that good old
- like fashion, like, oh, they're kids, they're going to experiment. You're like, yeah, don't experiment.
- If you want to experiment, wait until your brain is more fully developed to do that. Because the earlier
- you do that, the higher likelihood of developing a substance use disorder will be. You have peer pressure,
- right? Family, friends, community, and even work environments can expose or protect you from substance
- use. And then trauma history.
- teens who've had experienced physical or sexual trauma were three times more likely to report substance
- use. Behavioral patterns, right? We all have different behavioral patterns and that can either put us
- on the side of protecting us or putting us at more risk based on what those are. Then this, I feel like
- your psychology, that's kind of the combination of nurture and nature. Some individuals have more positive
- or negative coping skills than others.
- And a lot of times that's the caregivers you're around, whether it's your primary or not, are people
- giving you healthy tools or negative tools to deal with issues. Whether or not you have a mental health
- issue or not can contribute to whether or not you develop a substance use disorder. There's definitely
- people that are more impulsive and thrill seeking than others.
- Also looking at them at the locus of control. Is this somebody that constantly blames everything on
- everyone else and takes no responsibility at all? Or the flip side where you blame everything on yourself
- and taking on responsibility that is not yours and not putting the responsibility back on somebody else
- that is their responsibility. The expectation of what drug use will lead to. This is something I'm not
- necessarily proud of, but
- My family, ironically, I will say this, there's a lot of alcohol use disorder in my family. But one
- of the things they taught me was like drug use. It's horrible. It's awful. Little did I know until I
- was much older, I was like, you guys were doing drugs too. It was just legal. So you thought it was
- okay. But they're like,
- drugs will lead to bad things, you will be homeless, you won't accomplish anything in your life, you
- won't have a job, you know, all of these things. That is what I was taught that drug use would lead
- to. That did not sound appealing to me. There's a lot of people I work with that their drug use is a
- rite of passage in their family. A lot of times the first time they use is with their mom, with their
- dad, with their siblings, with their cousins,
- All family events are surrounded by substance use things as well. There's a lot of times where I work
- with people that going to jail is also kind of a rite of passage in their family. Everyone in their
- family goes to jail. That's just something that happens. And then some people have more motivation in
- terms of like goals and all of that sort of thing that they're kind of just more driven in that way.
- I'm going to show you this little video and then let's see. If you're visual, this will really help
- you. The question is often asked, why do some people use drugs and never get addicted? People are extremely
- complex and complexity creates diversity.
- Each of us is a unique collection of different layers, representing our genes, brain development, parents'
- influence, social environment, diet, and many more. Each layer is like a slice of Swiss cheese. The
- areas with holes are the dangerous areas of the slice because they can let risks go through. The areas
- without holes protect us.
- because they can block risks. For example, hanging out with friends who abuse drugs punches a huge hole
- in our social slice. While playing sports, learning a second language, or hanging out with friends who
- don't use drugs can shrink the holes in the social slice. For drug abuse behavior to become an addiction,
- the risk must cross through a lot of slices.
- Usually, a few of our slices are solid enough to stop the addiction before it's too late. Thinking about
- addiction in this way helps us understand it is impossible to predict who will become addicted. However,
- recognizing the risks that can lead to addiction creates many opportunities to protect our future and
- build a healthier society.
- Right, so why do people use drugs? This is not an exhaustive list by any means, but basically in our
- brains, we are rewarded with dopamine.
- for doing the things that keep us alive. This is why you eat that delicious cheeseburger, you get dopamine
- release. You have sex, you have dopamine release. You do the things that you need to do to survive,
- you get dopamine release. What addiction does is basically hijack that. And then it makes us think that
- we're gonna die without that specific substance. So I've been in the field for a pretty long time
- I can usually boil it down to one or two reasons, and sometimes it's the combination of both, of why
- people use drugs. One is they self-medicate for mental health, physical health problems not otherwise
- treated. Two, they're using to numb, to escape, to avoid dealing with problems. And this is almost always
- related to underlying trauma. And what I will say just
- quickly about trauma is there's a lot of times I'm working with individuals and they don't recognize
- that what they've been through is trauma. And I think part of that has to do with the context of when
- we started talking about trauma in our country. It was mostly in the context of PTSD and military settings,
- right? They're like, well, I didn't have my best friend shot next to me. I wasn't in an explosion. What
- do you mean I had trauma?
- Well, if you grew up feeling as though nobody loved you or you were unlovable or you were broken or
- something was inherently wrong with you, that is trauma. It changed the way your brain developed having
- those things happen to us and those absolutely play out in our adult lives.
- Whether we want them to or not, so I think a lot of times people are in denial about how much some of
- those things are still impacting them today because we would rather just pretend like it wasn't affecting
- us. Right? So we're going to dive into addiction and brain. So a little neuro.
- biology brush up. So your brain, it's made of billions of cells called neurons. And then those neurons
- are organized into circuits and networks. And each neuron acts as a switch controlling the
- flow of information. So how does this work in your brain? So one way is drugs interfere with the way
- the neurons send, receive, and process signals
- via those neurotransmitters. So those are the chemicals messengers in our brains that transmit a signal
- from a neuron across the synapse, which is this little space in between, which can, it can be like through
- the synapse to either target cell, which could be another neuron. It could be a muscle cell,
- a gland cell. They're all made of neurons or they all are made of neurons. Yeah.
- And so sometimes it's interfering with those signals, sending it, receiving, processing it. Other times
- drugs mimic natural neurotransmitters in our body. We have opioid receptors in our body because we release
- naturally occurring opioids in our body. When we get hurt,
- signal stuff, but that is why an opioid that's outside of our body that's made from the poppy plant
- or fentanyl, we have opioid receptors because of that. So it mimics those natural opioids that we have
- in our body, which is, you know, and then there's a lot of different drugs that mimic those. Now, before
- I get into this third point, I'm going to give you guys a little information about how an antidepressant, an SSN
- SSRI, a selective serotonin reuptake inhibitor is what that stands for. So let's just say these little
- balls here are serotonin. So what happens when you're on an SSRI is, well, what would happen if you,
- regardless of being on it. So this is serotonin and it hangs out here and then it gets absorbed into
- this next cell.
- Well, what happens when it doesn't get absorbed, it doesn't just hang out there, it gets sucked back
- up into here and kind of recycled. So what an SSRI does is it prevents, it kind of puts an X on these.
- And so it doesn't allow it to be sucked back up. So it does have to stay out in the synapse. So you
- have more serotonin in your synapse for the receptor of this other cell to be able to suck up when needed.
- So that's definitely how it works. And sometimes some drugs do something similar. So some drugs cause
- neurons to release abnormally large amounts of a natural neurotransmitter, dopamine. Almost all substances
- work on dopamine. And then they sometimes also prevent that normal recycling process based on that.
- And what neurotransmitter is
- impacting kind of depends on the substance that it is. So in short, those are like a few different ways
- that it impacts the brain. And what, and we're going to highlight these three things, but the truth
- is, is like what parts are affected by drug use? All of the parts of your brain are affected by drug
- use. However, we're going to touch on these three things. So the basal ganglia
- which is this like teal right here, that is our, it activates this reward circuit. So this is where
- our reward circuit kind of sits, where we're getting natural neurotransmitters released for doing the
- thing that keeps us alive. But in this case, it's doing the substance that then our body thinks we need
- to keep us alive. We also have the extended amygdala,
- And so this plays, this is the purple right here, that plays a role in withdrawal that motivates the
- person to use again. In fact, when you work with people who, or know people who have been using for
- a really long time, a lot of times they'll tell you, I'm not using to get high anymore, I'm using to
- not be sick. And that withdrawal, you feel like crap when the
- drugs coming out of your system, so you want more so you don't feel sick again. And that is what the
- extended amygdala keeps you in that vicious circle. Then we have the prefrontal cortex, which is kind
- of our executive center of our brain. That's where, you know, we reason out right from wrong consequences
- and effects of like making this decision. It
- It doesn't completely pull it totally offline, but it's offline enough that you're, you have a decreased
- self-control over your impulses. Um, cause that's the part that's like, okay, this is a bad idea because
- of X, Y, and Z. And if that isn't online, you're not able to do that as well or at all. Um, so here,
- this is your brain survival hierarchy.
- one food, two water, three sleep, four social interactions. Now if you're talking about somebody who
- is an active addiction, you may have fentanyl, methamphetamine, marijuana, alcohol, all before you get
- to food, water, sleep, and social interactions. So I've had a lot of people tell me like, hey, so
- My kid said he hadn't eaten in three days. I gave him $15 to go get food and he used it to buy drugs
- instead of food. Why? This is why. This is why. And this is the nucleus accumbens. And that's the part
- of your brain that's triggered like you are going to die without this substance. Now, when I first got
- into this field and having had experience with substance use in my own family,
- I would get really angry when people would lie to me and I knew they were lying to me. A lot of people
- do, right? Like, it's not cool to be lied to. However, when you're thinking about it in this context
- of what's happening in their brain, if I need to lie to you to make sure I get that substance that I
- need or I'm going to die, I'll tell you anything you want to hear, right? And that makes a lot more
- sense when you're thinking about it in this context.
- Alright, so this is very interesting. So this is dopamine release when you're eating food. Not somebody
- that has a dictionary thing. This is dopamine release if you're on cocaine. So and something that we're
- going to talk about in a little bit when we talk about withdrawal is
- Here's the thing is like, it can take up to two years after somebody stops using for their brain chemistry
- to get back to normal. And sometimes I would argue, sometimes it may never go back to normal. Just like
- for me, because of the trauma I went through as a child, I will always need antidepressants for the
- rest of my life.
- And sometimes for them, like when they're in those two years, so like, let's say you're working with
- somebody that just stopped using and like, let's say they stopped for six months right now. When they
- eat food, they're not going to have as much dopamine release as this. And part of that is because your
- body gets used to you putting chemicals in your body to be able to have those releases, right? So your
- brain is depleted
- by a lot of the, and you're not having normal chemical stuff that's going on for quite some time. And
- if somebody has been using for like 20 years and they stop, I don't know that two years is enough for
- that to get completely back to normal. So when you think about it in that context of like, you know,
- when people are in early recovery, it can be really challenging, really tough. Life is not nearly as
- exciting. Look at all that excitement with cocaine. And now they even have less,
- excitement eating food than the rest of us do. So that's really important thing to understand as well.
- I don't have time to do this, but I highly recommend you guys going and you can probably just even Google
- mouse party. This is the site and you can go there. It's like a terrarium of all these different
- cartoon mice that are on all these different substances. Alcohol, marijuana, heroin, methamphetamine,
- cocaine, ecstasy, and LSD. And whichever one you want to learn about, you pick up that mouse, you click
- on them, and it like puts them into centrifugin. It shows you on like a chemical level what's happening
- in your body when you're using that substance. It's very informative. I've definitely used this with
- When I'm teaching staff also with clients as well, it's like, do you want to understand how this impacted
- your body? Some clients are really into that. Some clients are like, no, I'm fine. I trust you. Let's
- just move on. Okay, so co-occurring disorders. What is that? So according to SAMHSA, the coexistence
- of both a mental health issue and a substance use disorder is referred
- to co-occurring disorders. Not to be confused with comorbidity. Comorbidity is when you have a medical
- issue as well as a mental health and substance use disorder. Now, hear me when I say this, a lot of
- the people I work with have co-occurring and comorbidity, right? Because a lot of times when you're
- an active addiction, you're not taking care of yourself. You're not going to the dentist, getting your
- eyes checked, going to your regular checkups, that sort of thing.
- So what are the reasons why they occur frequently together? So the National Institute of Mental Health,
- they say that research suggests about these three different possibilities of why. So common risk factors
- can contribute to both a substance use disorder and other mental health disorders. So both substance
- use disorders and other mental health disorders can run in families, suggesting
- that genes can be a risk factor. There's also environmental factors such as stress or trauma that can
- cause genetic changes that are passed down through generations and may contribute to the development
- of mental disorders or substance use disorder. So I wanna say that again, we now know through studying
- epigenetics, we can pass down trauma to our offspring, to our children.
- So I'm like, I'm sorry, I apologize to my daughter all the time. I'm sorry I have passed down my trauma.
- So that's a real thing. And then secondly, we have mental disorders can contribute to substance use
- and substance use disorder. So studies have found that people with mental health issues such as anxiety,
- depression, post-traumatic stress disorder may use drugs and alcohol as a form of self-medication.
- However, although some drugs may temporarily help with some symptoms of mental health disorders, they
- make the symptoms worse over time. And additionally, the brain, I lost my place. Additionally, the brain
- changes in people with mental disorders and that may enhance the rewarding effects of the substance,
- making it more likely that you're gonna continue to use substances. So because you have a mental health issue,
- using substances feels even more rewarding than if I didn't have a mental health issue. And lastly,
- substance use and substance use disorders can contribute to the development of other mental health issues
- or other mental health disorders. Substance use may trigger changes in the brain structure and function
- that make a person more likely to develop a mental health issue. And something else I'm going to throw
- out there, it's not part of this, but
- A lot of times using substances, you are frequently putting yourself in situations that are traumatic
- in nature, which then can lead to mental health issues as well. So, oh my gosh, the numbers didn't fall.
- So you're like, what is this? Yeah, this doesn't look like much without the numbers. So here in, this is 2015.
- 8.1 million. And so AMI is any mental illness, SED, substance use disorder. Here is 8.1 million.
- This is 2017, 8.2 million. 2019 here, this is 9.5 million. And then 2021, 17.9 million. Here in 2023,
- 10.4 million.
- You're like, Ashley, why? Why is there a huge difference? Well, one thing, from here to here, we had
- a global pandemic. So there was that. Also, I would say there's a lot, we're doing a lot of work on
- decreasing stigma and getting people help. And I do feel like while there's still some stigma that exists,
- more people are getting the help that they need. So I would venture to say if you were in 2015,
- We were still here. People just weren't getting as much help as they are now. But not to mention that
- global pandemic really did impact people of all of their social supports were completely cut off or
- significantly cut back when we had that. So withdrawal. Withdraw occurs when the body has become dependent
- on a drug.
- and when that drug is not used or available for use. So it might be like I'm choosing not to use, or
- it could be my dealer is out of town or my dealer is out of the substance. And the severity of the withdrawal
- is based on how much or how long an individual has been using. Some other factors, maybe age, physical
- condition, genetics, the combination of the drugs they're using,
- And also the presence or absence of a support network can impact withdrawal as well. If you don't remember
- anything I say today, please remember this. When people are coming off of alcohol and benzodiazepine,
- they can die from withdrawal.
- they can die. Now, other substances can make you feel like you're going to die. And I'm sure in complicated
- situations where somebody is like super dehydrated, that could then lead to that. However, with alcohol
- and benzos, you can absolutely die. And if you don't die, you can also end up having like seizures,
- really severe seizures. So if you're working with somebody or know somebody that is on alcohol
- or benzodiazepine, and they say they're going to stop cold turkey,
- tell them do not just stock cold turkey. You need to be evaluated to see if you need medical withdrawal.
- And what happens is say somebody is using or drinking half gallon a day, they go into treatment into
- inpatient to like to go through their medicated or their medicated withdrawal process. They're given
- benzodiazepine to slowly come off of this. That's part of the plan.
- So a lot of times when people think about the stages of withdrawal, when people say withdrawal, they're
- almost always referring to the acute stage, which is the physical body symptoms. That duration lasts
- anywhere from a few days to a few weeks, depending on the things we just talked about. The thing we
- do not talk about enough in the recovery community is the post-acute stage, or you can also hear it called
- post-acute withdrawal syndrome or PAUSE. There's emotional symptoms here. Most of the physical symptoms
- have ended. However, there can be times where you do still have physical symptoms. Now, when you're
- talking about the post-acute stage, the longer you have been in recovery and no longer using the substances,
- the less frequent those episodes should be and the
- less frequent and they should be shorter and shorter, but this can last up to two years because your
- brain chemistry is messed up. Okay. All right. So we're going to talk about medicated assisted treatment.
- And today we're going to focus on, um, we're going to focus on alcohol and, um, opioid use disorder, MAT. So,
- These are medications that assist with the use of the combination of counseling and behavioral therapies
- to provide that whole patient approach to treatment of substance use disorder. So yeah, we're gonna
- focus on opioid use disorder, MAT, alcohol use disorder, MAT. What I will say is you're gonna hear,
- we love to change up verbiage. I feel like personally, it's like to age,
- the documents we have, like if you see chemical dependency, you know that was probably written in the
- eighties or nineties, right? So instead of saying OUDMAT, which is a mouthful, you're gonna hear,
- what is it? MOUD, medication for opiate use disorder. MOUD is what you're hearing more frequently now.
- So we're gonna start with opioid use disorder.
- or MOUD. And if you think about it in these three buckets, it's helpful. Again, I'm a visual person.
- If you're not, this may not be as helpful, but you have the methadone bucket, you have the buprenorphine
- bucket. There's a lot of stuff in this buprenorphine bucket. I feel like this bucket, every time I turn
- around, this bucket's growing with different things that they have, different options of buprenorphine
- products. Then you have like the Naltrexone slash Vivitrol bucket.
- So when you're looking at those, you have methadone, which is an agonist, and on the flip side, you
- have naltrexone or Vivitrol, which is an antagonist. So it completely blocks the opioid receptor. Now,
- buprenorphine is kind of in the middle of those two. It's a partial agonist, which means it blocks the
- opioid receptor, but it excites it. So there's still some dopamine release, which is why they have street value.
- right, because you hear about people getting suboxone on the streets. This is part of the reason why.
- So let's dive into each one of these. So methadone, what's really interesting, and I have to say, I'll
- be honest, because I think that's important. As I've been in this field, my views on medicated assisted
- treatment have drastically changed. Based on increasing my knowledge,
- as well as seeing this play out in people's lives. Methadone, I'm gonna just say this, a lot of what
- you know about methadone may be completely untrue, because that was the case for me. So with methadone,
- it has been around the longest. It's frequently referred to as the gold standard for opiate use disorder.
- It has the most research behind it, but out of these three buckets we just talked about, this is the
- most stigmatized one.
- And I think it's stigmatized mostly because of a lot of false information that people have about this.
- So you've all heard of methadone clinics. We don't even call them methadone clinics anymore because
- that word is so stigmatized. You hear them called OTPs, opioid treatment programs. So in the state of
- Indiana, I can't speak to outside of Indiana, but in the state of Indiana,
- opioid treatment programs do not give people pill forms of methadone. They don't. It's liquid.
- And in fact, when you're learning about all these different ones, this is the hardest medication to
- divert. What does diversion mean? Like to pretend like I'm taking, but not really, and then give it
- to somebody else or store a whole bunch of it for myself and take a whole bunch at one time. It's liquid.
- And in fact, it's mostly like a reddish liquid unless somebody has an allergy to that, in which case
- it might actually be clear if they're allergic to that, whatever that red dye is that they use in there.
- So and a lot of times people that are on methadone, I want you to think about this. So how many of you
- guys take medicine every day?
- you know, whether it's an antidepressant, blood pressure, cholesterol medication, think about this.
- To get your medication to feel okay for the day, you had to drive to a place every single morning, regardless
- of you're sick, your kid's sick, there's a blizzard, there's a tornado, you know, whatever, every single
- day. That's what these people do.
- And it's a lot of work. And at least in the state of Indiana, you have to be doing that for an entire
- year with no negative, no positive drug screens, not even just for marijuana, no positive drug screens
- at all to get a take home so that maybe you don't have to go on Saturday and Sunday to get that.
- That's a lot of work. And there's not enough OTPs. And so there's some people that are driving an hour
- and a half one way to get that medicine and get back. How much would that impede your ability to do
- your regular life massively, right? So just something to think about.
- Also, when you're looking at this, because I feel like this is part of the reason why a lot of people
- are like, methadone is horrible. It's just substituting one substance for another. So looking at methadone
- compared to heroin, methadone, you only need to take once every 24 to 36 hours. Whereas heroin, you
- have to be taking it every four to six hours to not be sick, right? Heroin, you have a really high
- overdose potential, methadone you don't. And like you get, in fact, let me just go to the next thing.
- So like this is heroin. So it, when you take it, it shoots you up into this really toxic area where
- you can get high. You go down, look how little time you're actually in a window of tolerance for heroin
- to where it like, once you cross this line, you're in
- overdose or overdose, I'm sorry, withdraw symptoms. This is where you're at risk for overdose. This
- is where you have withdrawal symptoms. Whereas methadone, it keeps you in this window of tolerance the
- entire time. Now, granted, you are going every day. So when you're starting, they're really monitoring
- things about how you're responding. So every single day, you could have things altered based on what's going on.
- Are there any questions about that I know I said I wouldn't stop for questions, but I feel like there's
- usually a lot of questions about methadone. Okay, all right, the other thing i'll just say really quick
- about methadone before we move on is in the state of indiana besides Center stone.
- and Pinnacle or Recovery Works in Martinsville, there is no place that regularly, because occasionally
- you hear of places doing a one-off, allow you to come to inpatient residential facility without completely
- stopping your methadone. And methadone is only helping with opioids, right? How many people do you know
- that only use one substance? You know, so a lot of times people are going to the
- OTPs to get their methadone dose, but they're still struggling with alcohol. They're still struggling
- with methamphetamine, whatever else. In the state of Indiana, they do not have regular places they can
- go to go inpatient facility. And that is not okay. It's not okay. Centerstone, we started doing that
- in 2021. We work with them. Is it a lot of work? Absolutely. Is it the right thing to do?
- Absolutely. And those people are so grateful for having access to the full continuum of SUD services
- because of that. So buprenorphine. So buprenorphine was approved by the FDA in 2002. And something to
- like know is Suboxone has buprenorphine and Naloxone. You're like Naloxone, I hear about that. Naloxone
- Narcan, that is part of what is in there. Now,
- At least in the state of Indiana, when people, when you're working with a woman who's on Suboxone and
- gets pregnant, they will frequently take her off of Suboxone and put her on a buprenorphine only medication.
- And part of that is there's just not a lot of research about Naloxone's impact in the pregnancy, because
- who wants to be like, I'll sign up to see if this messes my child up, right?
- There's a lot of times not a lot of research about pregnant women with certain medications and Naloxone
- is one of them. But in this bucket you have Sublicade, which is an injection that goes into your stomach
- by your belly button. This is really great when like somebody can't trust themselves, like Suboxone
- helps them with things, but they can't trust themselves to use it the way it's supposed to be used.
- Get an injection once a month if that's
- what's really helping you. There's also subsolve, there's subutex, there's a lot of different things.
- There's, I think it's called Rickzalti now where you can get an injection. This supplicates once a month.
- I think Rickzalti, you can do it once a month or you can do it like once a week or once every other
- week. I think there's different dosage that you can pick.
- And then we have naltrexone, vivitrol, and naloxone. So these medications completely block the activity
- of the opioid receptors in the brain. So when you're talking about naloxone, it's like you have your
- receptor and then you have like
- little opiate on it it just comes and like kicks that off and like sits on the receptor for a while.
- Now something to remember with Naloxone is people can re-overdose without taking more medication. So
- the Naloxone can wear off and they can re-overdose which is why it's really important for people that
- have overdosed to get medical treatment. Now they're not always willing but that's always the recommendation
- because of that because what they end up doing is getting an IV
- with Naloxone going into their system. So like they're able to keep Naloxone in their system until their
- body's processed whatever opioids or whatever else is in their system. Now, Naltrexone is a pill you
- take every day. So you could take a pill every day and that helps with opioid stuff. Or you can get
- instead, if you're like, I don't wanna have to take a pill every day, Vivitrol is an injection
- that is in your bottom. It's an inner muscular injection. So it's a pretty big needle. And I tell people
- if they're really scared, you shouldn't look at it. If that's not not your thing, and it gives you anxiety.
- And this can be really, really helpful. Now what I will say about Vivitol and Naltrexone is if they
- stop and go back to use, they're at higher risk of going like having an overdose, because
- It does not, they have no tolerance at all with that. Whereas with methadone or buprenorphine, you still
- have a little bit of tolerance. Therefore you're less likely to, if you stop and go to use, you're less
- likely to have an overdose. Okay. Alcohol use MAT. There's anabuse. Anabuse is a medication you take
- and it makes you super sick if you drink on top of that. My grandpa,
- My maternal grandpa got sober in like either the late 70s or early 80s using anabuse. And he actually
- continued taking anabuse for years after he had been in recovery because he was scared. He was scared
- that if he stopped taking it, he would convince himself he could have one drink again. And he knew he
- couldn't have one drink. That wasn't his thing. So he stayed on that for a pretty long time. Then you
- have Camprel.
- And that is something you take three times a day. So I don't know about you guys, but I would have a
- really hard time taking something three times a day. Your eyes do not deceive you. Naltrexone and Vivitrol
- are also in this category. Now, this doesn't make you sick like the anabuse does. What I've heard from
- people, and it wasn't as much Naltrexone, it was Vivitrol, is if they were to drink on top of it, they felt like
- like the euphoria and those positive things they would get from drinking were like turned down. Now
- what can make that dangerous is then they're like, well, I just have to drink that much more and I can
- override it, right? And you could have alcohol poisoning. So something to keep in mind with that. So
- some Medicaid assisted treatment truths. It's not trading one drug from another.
- When used as prescribed, MAT can help stabilize brain chemistry and reduce cravings. The non-MAT medications
- are short acting and create the euphoria. Methadone and buprenorphine are long lasting to treat symptoms
- of addiction cravings and the addiction withdraws, and they don't create that euphoria high. Now, what
- I will say to that is when somebody's starting MAT, they may look high.
- There's a lot of times I would start working with somebody in the jail. I knew what they looked like
- completely sober. They come to group and I'm like, did you start MAT or did you have a relapse? Like
- I can tell in your eyes, something's not right. It usually takes like a week, two weeks for things to
- like adjust, especially with the buprenorphine. Now with the methadone, they're going every single day.
- So things can be tweaked more frequently than the buprenorphine. Okay.
- MAT is well accepted as evidence-based treatment. MAT is not a crutch that prevents true recovery. Often
- it's a central component for successful long-term recovery for many people with opiate use disorder.
- It often makes recovery possible for individuals for the first time. I've worked with these people,
- they tried their hardest to do this and then MAT was the thing that
- was able for them to stay in recovery longer than they had when they had tried to do it without it.
- So best results occur when MAT is taken for as long as it provides a benefit. So SAMHSA treatment protocols
- advise against arbitrary time limits on the duration of treatment for opiate use disorder medication.
- Evidence show that tapering or discontinuing medication
- leads to very high rates of relapse and it also shows that research shows that somebody that's on MAT
- for at least one to two years has the greatest rates of long-term success. There's currently no evidence
- to support benefits from stopping MAT and if you think about when we're talking about withdrawal it
- can take your brain about one to two years to
- for the chemistry to get right back, right? And I worked with somebody who, he was taking 16 milligrams
- of buprenorphine, eight in the morning, eight in the evening. He'd been on it for a long time.
- And I was like, he's like, Ashley, I wanna try to stop. Now, I always train people, if somebody that
- you're working with wants to stop MAT, the first reason, like the first thing you should say is like,
- what's going on? Why? What's happening?
- Cause a lot of times people want to stop because somebody shaming them about it. And I know this sounds
- really dramatic, but shaming somebody about this could cause them to stop their MAT and go out and use
- and die. Um, and so be really careful about all of this. Cause again, that person that was on 16 milligrams,
- he, we had a whole plan. I had a plan with him. His prescriber had a plan with him. He got down to,
- from four milligrams to two milligrams and two milligrams wasn't enough. He started having really bad
- cravings, really bad withdrawal. And so he got bumps back up to four milligrams. But I was like, look
- at best though. Like that's an improvement. You now know you don't need 16 milligrams. You're okay with
- four milligrams a day. That's huge. And I'm like, that isn't
- loss like in terms of because I think he was really beating himself up like I'm a failure I can't do
- this I'm like again I'm gonna have to take antidepressants the rest of my life because of the trauma
- that changed my brain chemistry you might need to take four milligrams the rest of your life and there's
- nothing wrong with that. MAT does not increase overdose risk in fact research found that in comparison
- to those who didn't receive any MAT deaths from overdose were decreased by
- 38% in those taking buprenorphine and 59% in those receiving methadone. And long story short, there
- are many paths to recovery. Everyone has their own journey and it's not our place to judge what that
- journey is gonna look like. I wanted to talk just quickly about recovery meetings. Recovery meetings
- are imperative and what I love is there's so many different types of recovery meetings.
- out there now. You know, we have like the traditional 12 step AA and A. I think there's like crystal
- meth anonymous. There's a lot of different anonymous meetings. We also have smart recovery now. Smart
- recovery is really great in terms of like, first of all, I'm a smart recovery facilitator. It's the
- best motivational interviewing training I've ever taken in my entire life. And I've taken a lot of those. So
- it that's really helpful. The other thing about smart recovery is they don't talk about higher power.
- I know sometimes people have had bad trauma with like church or other religious experiences and they're
- like, I just I have no tolerance for people to talk about God or higher power. They while they admit
- spirituality is a part of recovery, they're like, but we're just not going to talk about it in this
- meeting. So that's a really great meeting for somebody that's like really put off by
- that sort of thing. Then we have Recovery Out Loud, which was started by John Cunningham out in Columbus,
- Indiana. They are very much about nutrition and exercise. They also live stream their meetings.
- They're like, this isn't, I don't want to be anonymous. I want people to understand and be out there.
- There's also Celebrate Recovery. Now this is a very Christian based program. The cool thing about Celebrate
- Recovery is they don't just address substance use disorder, they address all behavioral addiction things.
- So codependency, if you have issues with like pornography or sex, or I mean, there's just a lot of things
- that they cover that a lot of these other ones
- don't. A traditional Celebrate Recovery Meeting is you meet for an hour for dinner, you have dinner
- together, you eat, and the first hour is the main topic everyone's at, and the third hour is you break
- up into groups. Most of the time it's women, men, and teens. So Recovery Meetings are really,
- really helpful, and this is where they can change their people, places, and things.
- And support, virtual support meetings, in the room app is really great. Any of the anonymous meetings,
- they have their own websites. You can look up and find different meetings, whether it's in person, virtual,
- all that. Facebook groups, especially with Recovery Out Loud, that would be a great place. That's where
- they stream their meetings. There's also YouTube. I always tell people, I was like, if it's 2 a.m. in
- the morning and you're really struggling,
- Go onto YouTube, there's all kinds of speaker videos on there. Also, I tell people, you know, there
- may be another English speaking stuff. You could, at 2 a.m., I don't know the exact time difference,
- but you could go to a meeting in Australia. They're up, it's not 2 a.m. in Australia. So there's a lot
- of different options. And I did wanna just real quick hit on,
- addiction as a family disease because we don't talk about this enough. It impacts everyone. I always
- joke with my clients saying, I can be just as crazy as somebody in active addiction, and I don't even
- have a substance to blame it on. When I'm in my Ashley control freak mode, it's not pretty. Again, this
- is not an exhaustive list by any means, but the whole entire family and their friends are impacted by
- the substance use themselves, maybe more than what they even know. And so those are some of the things
- that can happen. And we need our own support group. I personally myself have been going to Al-Anon for
- seven years. It's a game changer. And I know I will need Al-Anon the rest of my life. I pretty much
- needed to go straight from birth into an Al-Anon meeting, and that wasn't possible. But I know that
- These are my people. And then there's also Alateen, which is just a spinoff of Al-Anon for teens. There's
- some meetings that even have children there as young as like eight years old. There's a smart recovery
- friends and family piece as well, which I feel like is very similar to Al-Anon. I would say the biggest
- difference is because it's all motivational, entertaining based. There is a piece about how do you have
- a conversation with your loved one if you're wanting them to get into treatment. Apparently yelling
- and shaming doesn't work. I know because I've tried it. It actually has the opposite effect. There is
- also adult children, alcoholics and dysfunctional families. I kind of gave you the outline of celebrate
- recovery. That could be part of their recovery too with the family. There's also codependency anonymous.
- There's a lot of different things out there for people. And I have links.
- for other things. Oh, there we go. All right, let me stop. Do you guys have questions? That is a great
- question. How do we access that? If you guys are wanting the slide deck because of our whole registration
- process not working,
- I would go ahead and just stick your email in the chat and then I will make sure that you get a link
- to the slide deck as well as the recording of this. And then Lee, were you going to say something? Cause
- we also have cats. No, I was just going to address. I was going to ask about that. Yeah. Great. And
- I'll be sending out, if people need a proof that they attended, I'm collecting those emails. I will,
- if you email me, then I will send out something probably later tonight.
- Great, thank you for that, Lee. No questions at all? Everyone's like, I know that was a lot of information.
- So much information. I threw at you. Yeah, it's a lot to digest. Yeah. Yeah, I'll just put my email
- in the comments again. If you need any kind of proof,
- of attending, just email me. But for the slides and the recording, email, or Ashley will get your emails.
- And then this will be up on Cats at some point. They're so good about a pretty short turnaround time.
- So you should be able to find that on Cats pretty soon. And again, thanks for Cats for that. Kathleen.
- So you have people returning from treatment. And I'm assuming when you say that, is it like a 28 day
- stay? Is that what you're? Yes. Yeah. So it kind of depends on things. I feel like most of the time,
- I would say regardless, it's usually good to be in like some kind of like IOP, some kind of intensive
- thing that's like, you know, three times a week or so is usually really helpful.
- There are some times where there's people that have been in recovery for years, something happens, they
- return to use. They may not need something as intensive, but I would say for most people who've not
- had a lot of recovery time coming out of residential, the more intensive, the better because they can
- really struggle going from that 28 day where everything's happening right there where they're sleeping to then
- when they leave, they don't really have that external accountability as much. So providing that with
- as much structure as possible is usually a really positive thing. Is that helpful, Kathleen? Well,
- sort of. I have a mother who just was released yesterday, and we texted back and forth when she showed
- me her certificate. Then when I talked to her last night, I said, oh, I thought you were going to go
- to aftercare. And then
- They would help you find housing. They would help you find a job, all of that. She said, well, there
- was a girl in the program with me that I didn't really like, and she was scheduled to go to the same
- place I was going to go. And so I chose not to go. So again, we're back into excuses rather than really
- trying to deal with the situation. Yeah. And that's really common, Kathleen. I always tell people,
- I'm like, I don't know how many people are like, I did it. I did my 28 day stay.
- I'm done. I'm like, oh, yes, let's celebrate this accomplishment because this is an accomplishment.
- But you were at the beginning of your journey and to think that you go to 28 day things when you've
- had 15 years of a lifestyle, 28 day like isn't going to do it. You have to like start living it. You
- have to start intertwining that. And it's really easy to go to a 28 day program, get plopped right back
- in that same environment and go right back into like,
- Those old ways of doing things and thinking about things and everything. And yeah, there there's a lot
- of times where I'm like, there will be people you don't like everywhere. That doesn't mean that avoiding
- them is worth your recovery. Right. And I always tell people to, because you get a lot of people that are like.
- Well, my job is really important. And so I'm missing like my meetings and my treatment because I'm working
- 50, 60 hours. I had somebody tell me this, who was in a jail program treatment and he's, and he had
- graduated and was doing well. He's like, anything you put above your recovery, you're going to lose
- when you lose your recovery anyways. Whether that's your job, your kid, this relationship, whatever,
- you will lose it all anyways when you lose your recovery. And I think sometimes that helps in like,
- oh, I need a perspective shift, so to speak. Well, and that's good. And part of the reason she went
- to recovery when she did was because we're up to terminating her parental rights. So, okay, she needed
- to go to treatment, came out back with the guy who she was with beforehand,
- He came out of treatment as well. We'll see. Yeah, I'm skeptic. Yeah. And that's really hard. I worked
- for the Department of Child Services for five and a half years. And so I understand. And I think the
- piece that really sucks is because we want permanency for the kiddos. And the DCS timeline doesn't always
- jive up with a realistic recovery timeline. Right. And I always tell parents that
- that were going down that road, because I feel like that's the piece where it's really easy for them
- to just completely give up, right? Like, well, you're gonna terminate my parental rights. So like, what
- else do I have to live for, right? I'm like, regardless of your parental rights being terminated or
- not, your child will want to know you when they get older. And in every situation I've ever seen, regardless
- of how atrocious the abuse or neglect was, that kid wants to come back when they're 18
- to figure out what happens right they're trying to put all the pieces together and you need to be in
- a healthy place for that to happen, because no matter what something says on a legal piece of paper
- you're their biological parent forever you know. Well, thank you. yeah.
- Okay, L Lopez. What, I think it depends on like what's going on, how much are they using? Can you tell
- me a little bit more info? Oh, I guess her or his microphone is not working. How much is drug use? I think it,
- It's hard for me to say generally, I think it requires assessing what's all going on. If they're regularly
- using, they need to be assessed for residential to go inpatient for a 28 day stay. They might, depending
- on what they're using, if they're using alcohol or benzos, they might need medical detoxification before
- they can go to residential. If
- you know, if maybe they've been sober for a long time and they went back to use, I think we could definitely
- plug them into some outpatient things and assess how that's going. Yeah. And, and I also want to say
- drug screenings, drug screens have typically been used as punishment. Right now, the drug supply is
- so tainted. I think of drug screening as
- a safety thing. Because a lot of times people don't know what they're using. We've had people come into
- a residential facility saying, I'm only using benzodiazepine. We drug screen them straight up fentanyl
- in their system. They're using things that look like benzodiazepine. They're pressed to make it look
- like that, but it's not. And so you absolutely, I think drug screens are really helpful. Like they may
- really think they're only using marijuana. They may think they're only using this one substance. And
- it turns out
- they're using significantly more than what they realize. Did that help? Yes, drug screens are helpful
- because that can also, you know,
- A lot of times they lie to you about how much they're using they're downplaying how much they're using
- so I do feel like drug screens sometimes give you a better picture of what of what's happening. And
- it can be very informative to them of what's actually in their system because they don't they don't
- know right now. you're welcome.
- had a question. Um, this was great. I, I oversee family preservation with my agency. So we're all we
- do home based with the families who have a lot of substance use referrals and domestic violence, I would
- say is probably what we see the most. But what curriculum I'm looking at adding some more evidence based
- curriculum for my therapist and skills coaches. What would you recommend because I know there's a lot
- out there, but a lot of it is for groups and we don't do groups. It's all just
- individual, either one parent or both parents. And sometimes we work with teenagers with SUD as well.
- But I didn't know what you have found to be helpful. We use we do have that like MI, we do CBT seeking
- safety, but I wasn't sure. Yeah. And, and this is generally used in a group setting, not that you couldn't
- use it otherwise. I really love Stephanie Covington stuff, because she intertwines that stuff with trauma.
- because trauma is almost always at the root of that. And I feel like there's a lot of curriculums that
- never get to the bottom of that. There's helping men recover and there's helping women recover. And
- those are amazing curriculum because it really digs into stuff. Now, you have to have people facilitating
- that whether you're doing it individually or in group that are gonna be okay talking about those things
- too. Because that's what I see a lot of times I'm like,
- I knew this one person, cause it goes over yourself, like relationships, spirituality and sexual out,
- like sexual stuff. That person would completely cut out the sexual stuff because they're like, we don't
- want to talk about that. That's too hard. Yeah. But you have to talk about it. You have to talk about
- it. I was like, so when I trained that now I'm like, you absolutely have to talk about this. And I always
- tell people, I'm like, if you're going to have,
- a client write a letter to their mom and share that and bear their soul, you should be willing to write
- a letter and share that with their peers. In fact, when I teach those curriculums here, I have them
- do that beforehand. I'm like, you're going to write a letter to your dad, you're going to write a letter
- to your mom, and you're going to share it. And if you can't share it, maybe you shouldn't facilitate
- this stuff because that's
- that's my number one rule as a clinician is I'm never going to ask somebody to do something that I haven't
- done myself. Yeah, absolutely. I jot it down. Thank you. Yeah, of course. Well, I think everyone's like
- maybe you have full bellies and you're ready to
- Take on your afternoon now. Well, thank you guys so much. Yeah, of course. Thanks for being here. Thanks
- for sharing all your knowledge and your wisdom. And thanks to everyone for being here and taking it
- in. And you know where to reach, Ashley. Yeah, and I'll stick my email in the chat. Great, great. I
- know it was on the thing, but you're very welcome. Great. Yeah, thanks again. Thanks, everyone.