Hello and welcome. I'm pleased that you are joining us for today's Opioid Response Network webinar, Stomping Out Addiction Stigma, Mindset is Everything. Funding for this initiative was made possible in part by a grant from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does the mention of trade names, commercial practices, or organizations imply endorsement by the government. Next, Today's webinar has been designated for one CME credit. Credit for participating in the webinar will be available in approximately 60 days. Next, please. Captioning is available for today's webinar. And if you look at the slide, you can see the box at the bottom of your screen. If you click on that, you will be able to get captions for the screen or a full transcript throughout the presentation. Next slide. Feel free to submit your questions throughout the presentation by typing them into the questionnaire found in the attendee control panel. Again, look at the bottom of our screen and the chat is the right connection. We will reserve 20 to 30 minutes at the end of the presentation for Q&A. I am Dr. John Renner. I am Professor of Psychiatry at Boston University and Associate Director of the Addiction Psychiatry Fellowship of the VA and Boston Medical Center. I will serve as a moderator for this session, and I'm happy to introduce our presenter, Dr. Alona Balasanova. Dr. Balasanova is an Associate Professor of Psychiatry at the University of Nebraska Medical Center and also holds an appointment in the College of Allied Health and Professions. She is duly board certified in general psychiatry and addiction medicine. She was the founding director of the Outpatient Addiction Psychiatry Clinic and also developed and now co-directs the Inpatient Addiction Psychiatry Consultation Liaison Service, both at the Nebraska Medical Center. Her professional interests lie at the intersection of medical education and stigma reduction. She has developed educational programs presented and published on addiction psychiatry education. With that, we will turn things over to Dr. Balasanova to begin her presentation. Thank you so much, Dr. Renner. So, I do not have any relevant financial relationships or disclosures to disclose. Our objectives today for our webinar, we'll first start by defining addiction and substance use disorder, and we'll review some related terminology. We'll describe stigma and its relationship to substance use disorder, and we will end by discussing interventions for reducing addiction stigma and providing evidence-based care. So, first things first, addiction, what is it? Well, it's a chronic brain disease that has the potential for both recurrence or relapse and recovery or remission. It's associated with uncontrolled or compulsive use of one or more substances, and it is also considered to be the most severe form of substance use disorder. So, really, the major salient points here are that it is chronic, it is not acute, and it does have the potential for long-term remission as well as recurrence. So, some consider it a chronic relapsing disease. Another salient point is that it is uncontrolled use despite negative consequences. Many times I've heard folks say, you know, well, why don't they just stop using if they're having such devastating life effects from it? Well, I think they would like to, but unfortunately, part of the disease itself is that they no longer have control over their ability to stop. So, as I said, the most severe form of substance use disorder is considered an addiction, and substance use disorder, according to our Surgeon General, is caused by repeated misuse of a substance. It does develop gradually over time, so using a substance one time will not necessarily lead to an addiction. The brain changes that occur do take some time and repeated use, and it does lead to those brain changes, which is why we end up with the uncontrolled use. So, substance misuse. I mentioned that repeated misuse can lead to a substance use disorder, so let's make sure we define substance misuse. So, substance misuse is the use of any substance in a way that can cause harm to the individual or those around them. For example, if it's a prescription substance that somebody has prescribed, if they are taking it not as prescribed, perhaps taking more, well, that is misusing that substance. Likewise, even substances that are perfectly legal, like alcohol, if you are out to dinner and you're 21 and older and choose to drink and have a glass of wine, that's not misuse. That's simply substance use, but it is appropriate, socially acceptable, and legal. However, if you were to have several glasses of wine and then get behind the wheel of a car, well, now that substance misuse because now you're using that substance in a way that can bring harm to yourself or others. So, there's an important point about dependence because we often hear this term, and what does dependence mean and how does it relate to substance use disorder? So, physical dependence, or some say physiological dependence, this is an ordinary biological consequence of taking certain medications or substances for weeks or years, and this includes opioids, even SSRIs. Some beta blockers can cause this. This really is a result of adaptations that occur physiologically, and that occurs naturally after a repeated exposure to the medication. So, our body and brain adjusts around it, basically. Now, these adaptations are distinct from the adaptations that result in addiction, the brain changes that I mentioned earlier. That really does refer exclusively to the loss of control over the intense urges to take the drug or substance, even at the expense of adverse consequences. So, while one may experience withdrawal effects due to physical dependence, that does not mean that they necessarily have a substance use disorder or an addiction. So, the neurocircuitry changes, I had mentioned that there's brain changes that occur after repeated exposure to a substance when one develops a substance use disorder. So, the brain changes that occur result in impaired executive function. So, really, this prefrontal cortex area, which is what really, I think, defines us as humans, our ability to plan decisions and to execute those decisions. Ultimately, this causes problems with self-control, hence the problems over the uncontrolled use, and decision-making. So, we're not making the best decisions, despite efforts to do so and desire to do so. That prefrontal cortex is simply not functioning the way that it should be when our brain is hijacked, so to speak, by addiction. So, there's a continuum. We have substance use, which is simply using a substance, whether it's legal or not, which can lead to substance misuse, which, over time, repeated substance misuse can result in a substance use disorder, the most severe of which is then called an addiction. So, perhaps as important and maybe more important than what addiction is, let's talk about what addiction is not. It is not a moral failing. It is not a character deficit. It is not bad behavior, and it is not poor decision-making, although that may be a symptom. And, ultimately, it is not a voluntary choice. Part of the definition of addiction is that it is uncontrolled use. Once somebody develops an addiction, it is not a choice to be using that substance anymore, and now they've developed uncontrolled compulsive use. So, the language of addiction matters. We've gone through these definitions so that we understand what the clinically accurate terminology is. The language that we use when we talk about substance use disorders and any disorders is critically important, and, you know, language really is the fabric of our communities. It's how we communicate with one another, not only in medicine but in the world at large, so making sure that we're using the words that are as accurate as possible and as precise as possible to describe what we're talking about. So, the words we choose matter. Saying substance use disorder, substance misuse, really the continuum of the terms that I just mentioned, or a person with a substance use disorder, which is using person-first language. We should not be saying things like substance abuse or replacement therapy, which seems to suggest that we're replacing one addiction for another. We should not be labeling people as alcoholics or drug abusers or addicts, and instead using person-first language as a person with a substance use disorder. And now, why does this matter? Why does it matter to use these correct clinical terms? Well, because we are all biased as humans. As human beings, we all universally have unconscious bias. It's simply part of what makes us human, and this holds true even for the most highly trained and experienced health professionals. We all have unconscious bias, and so in clinical practice, this may ultimately impact the care that we provide. So, there was a study in 2016 of hospitalists or providers in taking care of hospitalized patients at Massachusetts General Hospital, and it was looking at attitudes and clinical practices of these individuals as it concerns substance use disorder care. So, 38% of those surveyed thought that substance use disorder is somehow different from other chronic conditions because those who use drugs or alcohol are making a choice, which, of course, we know is not true because once you have a substance use disorder, it is no longer a choice. 14% felt that medication treatment using opioid agonist is simply replacing one addiction for another, which is what the term replacement therapy seems to connote, even though we know that also is not accurate. And perhaps most chilling, 12% thought that somebody using drugs is committing a crime and deserves to be punished, which to me, I think about another chronic disease, say diabetes, and if somebody were eating a piece of cake, well, we would never say that they are committing a crime and deserve to be punished, and yet that also is a symptom, perhaps, of their disease. So, we do tend to look at addiction differently, even the most highly trained among us. And now language can also impact patient care. This was another study that was done looking at attitudes and implicit bias and how they might drive clinician behavior. So, this study looked at vignettes, which we'll see in a moment here, and it presented two vignettes, one of an individual who was called a substance abuser and another that was called a patient with a substance use disorder. And otherwise, everything else was the same. What they found was that clinicians were more likely to assign blame to the person, to agree with the need for punishment, and to view the individual named a substance abuser as less deserving of treatment than if the same person were described as a patient with a substance use disorder. And now these are the actual vignettes from the American Journal of Medicine. So, Mr. Williams in the first vignette is a substance abuser is how it starts. In the second one, it starts as Mr. Williams has a substance use disorder. The rest of it is the same except for when it's substance abuser in the first vignette, it is person with a substance use disorder in the second vignette. And that one change resulted in those differing attitudes by clinicians and how that person should be treated. So, part of this is due to stigma. And what is stigma? Well, according to the National Academy of Medicine, the stigma is really multifaceted. There's the attitudes, beliefs, behaviors, and structures that interact at different levels of society. So, there's individuals, groups, organizations, systems, and they manifest in prejudicial attitudes about and discriminatory practices against people. There's the cycle of stigma. We have public stigma, which can lead to discrimination, prejudice, and fear that can damage self-esteem. Then there's self-stigma, and you really internalize a lot of that shame, resulting in self-doubt, which then can result in not seeking care and dropping out of care and using the substance to suppress the negative feelings one experiences, which then of course lead to more stigma. So, it really is this vicious cycle. So, a stigma is also thought of as this overarching term. As I said, it was multifaceted that really is related to problems of knowledge, so ignorance, attitudes, so prejudice, and behaviors themselves, so discrimination. And stigma against those with substance use disorder is pretty prevalent, not only in society at large, but also in medicine. So, healthcare stigma, including physician misinformation and bias, is a significant driver of negative health outcomes of those with substance use disorder. You know, some healthcare providers may hold biased views or misinformed views that those who have substance use disorders are too complex to treat, or they're dangerous, or they're challenging, and they may not wish to work with such patients due to those biases, thereby preventing, you know, a good portion of patients from accessing needed care. And stigma does transcend. So, you know, stigmatizing language is not unique to people with substance use disorders, and we need to recognize the importance of culture and context and the experience and mitigation of stigma across cultures. So, it is critical for all people, not just those with substance use disorders. So, an important note is that not only does our unconscious bias impact patient care, it actually impacts us as clinicians. So, healthcare professionals generally hold negative attitudes towards patients with substance use disorders, and these attitudes are linked to lower levels of empathy and engagement with patients. Now, we know there's a burnout epidemic amongst healthcare professionals, and one of the hallmark elements of burnout is reduced empathy, reduced empathy for your patients. And this, of course, contributes to clinician burnout, which then results in worse patient outcomes. So, by continuing to use biased language and holding biased views, we're not only ultimately harming patients, we're actually harming ourselves as clinicians and can be contributing to burnout amongst us. So, changing gears a little bit, how common are substance use disorders? Well, they're pretty common. One in seven people will develop a substance use disorder at some point in their lives. Well, you would think that given the commonality, we would have a lot of treatment resources available and ready for these folks. However, only one in 10 will actually receive treatment. So that means that 90% of those that need help are not actually getting it. And I like to think, you know, how would we react if only 10% of patients with cancer received treatment? I mean, that's something that's unfathomable. We would never even think about that. And yeah, that is exactly what happens with patients who have substance use disorders. So part of this is due to this historical, traditional approach to treatment, which is really conceptualized well by this Peanuts cartoon. We have Lucy offering psychiatric help. We have Charlie Brown really offering his deepest feelings and sharing these really personal things like feeling depressed with Lucy and asking for help. What can I do about this? And she tells him to snap out of it and pay her some money. And that is historically how we have treated people with substance use disorders, right? We've had this traditional approach that substance use disorder is acute and curable, right? And that if only we separate the person from the substance, they'll snap out of it, they'll stop using and all will be well. And the priority was always to remove access to the offending drug. Abstinence historically was the only goal. And historically medications were not a part of the conversation. The services were also time limited. So typically it became a revolving door of time limited services. And historically the only really major service that was available was residential treatment, which colloquially is called rehab. And we know that with this one acute treatment, the chronic disease of addiction is not going to improve long-term. So what research has found is that over 66% of those who complete a one month residential program, so about 28 days typically, will return to use within weeks to months after if they don't have ongoing follow-up care. And over 85% will return to use within one year. So the great majority will return to use after this one acute treatment, which is why it leads to that revolving door if we don't change the way that we approach treatment. And for patients with alcohol use disorder, one study even found that 92% returned to use. So again, historically these residential programs didn't address other co-occurring psychiatric problems, which the majority of patients have. And fewer than 20% used FDA approved medications that exist for certain substance use disorders. And again, it's because we view addiction somehow differently than other chronic conditions. This is one of my favorite slides and it really presents a nice pictorial representation of hypertension and addiction and how we view them differently. So on the left, if somebody's blood pressure is high, that's their major symptom, before treatment it's going to be high. When you put them on a medication to reduce their blood pressure, and while they're taking that medication, their blood pressure is going to go down, right? Well, if you suddenly stop taking that medication, your blood pressure is going to go right back up again, isn't it? And that's exactly what happens when we treat addiction. Before you start treatment, your symptoms are high. You're in residential treatment receiving care, then your symptoms are low during the treatment. But then if you are just dismissed or discharged and don't have any ongoing treatment, well, your symptoms are going to return again, just like they would if you stopped taking your blood pressure medication. It really is no different. So in order to best serve our patients, we really need to redefine the treatment paradigm and how we approach treatment for those who have substance use disorders. So this is another Peanuts cartoon that I think really nicely depicts this. So again, we have Lucy offering her psychiatric help, we have Snoopy coming by and setting up shop next door for friendly advice that is cheaper, two cents versus five cents, and calling himself the advisor as opposed to the doctor. So really in a friendly way, perhaps meeting people a little bit closer to where they're at. And we call this harm reduction. Harm reduction is a conceptual and clinical framework that is aimed to decrease the negative consequences of substance use without necessarily reducing the consumption of substances. Now it certainly can and does in many cases, but that is not necessarily the primary goal. And really the major tenants are respect, dignity of the individual, and showing compassion for our patients. This is an evidence-based public health approach that has been shown to save lives. It is strength-based, not one size fits all, and you meet the person where they're at and you stay with them. Your recovery is not defined by abstinence or arbitrary goals that are set by the clinician. It is not a circumscribed program, there's no progressive steps to complete, and it really is patient-driven. The interventions are personalized and unique to the individual. So for safer drug use, for example, there are syringe service programs, there's naloxone to help prevent overdoses, there's moderation management, controlled environment, medication treatment. And of course, abstinence is absolutely a potential goal, but only if it's the patient's goal. It shouldn't be our goal that we're putting onto the patient. So again, the major facet here is that goals do not necessarily include reducing the consumption of substances. Really what we're trying to focus on is functional impairment and not necessarily sobriety. We want these individuals to live their best life, to be functional members of society, contribute to their families, and whether or not they're sober isn't necessarily the goal. So one of the ways in which we use harm reduction is by looking at it through a lens of motivational interviewing and the stages of change, looking at where somebody is on their trajectory to want to make a behavior change. So we have pre-contemplation, where they're really not thinking about making a change. Contemplation, where they are aware that a problem exists, but haven't necessarily committed to making a change or an action, so are willing to listen. Preparation, where you're intent upon taking action and are taking steps to do so. Action, where you're actively modifying your behavior. Maintenance is when you have sustained change, so the new behavior replaces the old behavior. And then of course, as addiction is a chronic relapsing disease, you do ultimately have episodes of return to use where you fall into these old patterns of behavior. However, you can quickly then come right back around to maintenance because you know how to do that, right? A lapse here and there is bound to happen, and you can resume your treatment course relatively quickly thereafter. So motivational interviewing, when you're looking at the stages of change, is really a non-confrontational method. It's a little bit, I would say the opposite actually, of interventions, the type of show that they had on TV where you would confront people or families would confront people who had substance use disorders. So here we're really aiming to collaborate with the person, not necessarily confront them in an adversarial way. And we're accepting of the patient's objectives. We're not trying to convince them or convert them in any way. We also want to evoke from the patient instead of educate and lecture the patient. We want to elicit their values, their beliefs. What do they want to see for themselves? We don't want to instill or install our own goals as clinicians onto the patients. And also we respect the autonomy of the patient as well as the authority of the clinician. Historically, the authority of the clinician has often been given precedence, but here we are equals. And there's an expectation of personal responsibility on the part of the patient, but there's no pressure or persuasion on the part of the clinician. So a very important note on co-occurring disorders. So part of changing the way that we look at substance use disorders is making sure that we're looking at the whole person, looking at the person's objectives. And that also includes addressing their other psychiatric co-occurring issues. So in addition to their substance use disorder, they may have a personality disorder, other mood disorder, anxiety, psychosis. There may be a variety of other disorders. And we know now that integrated treatment for both substance use disorder and other psychiatric problems they may have, ideally by the same clinician or the same team of clinicians is gonna increase the likelihood of successful outcomes for all the conditions, right? We only have one brain. So treating things in isolation doesn't make a whole lot of sense when it's all intertwined. So again, evidence-based treatment, which can include the harm reduction framework, is typically a set of services that are individualized, but may include medication, psychotherapy, or counseling, and other supportive services that help to promote somebody's functionality. They really are meant to enable an individual to reduce or eliminate alcohol or other drug use, whatever their goals may be, to address the associated physical and or mental health problems that are sequelae of their substance use, and ultimately to restore the person to maximum functional capacity. It's not about sobriety. It's about the patient living their best life, living a safe life, and one in which they're maximally functional in society. So an important component of many people's treatment plan are medications for addiction treatment. Now, medications have been shown to keep patients in treatment longer, which of course increases their chances of a long-term recovery. The longer somebody's in treatment, the longer we know they're alive, and the longer we know that we're able to help them. Medications exist and are FDA-approved for opioid use disorder. There are three approved medications, and there's also three approved medications for alcohol use disorder, as well as several for tobacco use disorder. Medication for addiction treatment can truly save lives. They've done studies. One was of Medicaid enrollees who received abstinence-only opioid use disorder treatment, and those that received partial agonist maintenance treatment with buprenorphine, and what they found was that those who received the abstinence-only treatment had a 75% higher mortality than those that actually received the buprenorphine treatment. Now, 75% higher mortality is very high, and that is a lot of loss of life that could have potentially been prevented had those individuals received the medication treatment that they needed. So a note about peer recovery supports. Peer support workers are a wonderful addition to the substance use disorder workforce, and they can offer role model recovery and provide support across a continuum of care. These are individuals with lived experience who themselves are in recovery from substance use disorders or other mental health conditions, and they meet patients where they're at. This can also be in unexpected settings, like, for example, in the emergency department. When a patient comes in and perhaps they're in a crisis, talking to somebody in a white coat may be intimidating, but talking to somebody who looks like them, talks like them, walks like them, has really walked their walk, may be a little bit more conducive to you feeling comfortable at opening up, and again, that role model recovery offers insight not only to the patient, but very special insights to the peer support worker that can help them connect with that patient. So these are very essential workers that are a very useful addition to the workforce in substance use disorders. They are not professionals, however, so that's something important to keep note of, but that they are peer recovery supports. Also not professional are community mutual aid groups. So groups like Alcoholics Anonymous, Narcotics Anonymous, these are abstinence peer support groups that historically were considered part of treatment and in some places you are still court ordered to attend to some of these groups. However, these 12-step groups are not formal treatments, but they can be an incredibly useful adjunct to formal treatment, and the unique offering that they have is that they offer patients a camaraderie within a peer community that is supportive of their recovery, right? There are sober supports, so to speak, individuals that can help rally around you when you need that extra support, and that can be invaluable for a lot of people. Also notably, there's a subset of those with substance use disorders that may get well only through community mutual aid groups and without other services. So there is a subset of individuals like that, but it's something important to be aware of that this does exist, but it is not the only avenue and it is not the only option. So when we compare treatment of substance use disorders with treatment of other medical conditions, and we look at the relapse rates of those conditions, and now in this particular study, they defined relapse for the other conditions as either requiring another medication to be added to your medication regimen or requiring hospitalization for something like status asthmaticus. And what they found was with evidence-based treatment, the relapse rates for substance use disorders were actually better or lower than the relapse rates for some of these other chronic health conditions like hypertension and asthma. So it is treatable. Substance use disorder is a very treatable condition as long as we're approaching it in a comprehensive and individualized way. And when we do that, for every $1 that we spend on substance use disorder treatment, we actually save $4 in healthcare expenditures and $7 in criminal justice costs. But of course, that means that we have to actually put in that $1, and that can be difficult when there's financial problems and we're strapped for cash and budget concerns and state legislatures and things like that. And so sometimes it can be a little bit short-sighted, but if we do invest in a proactive way, we will have a wonderful return on investment by saving a lot of money down the road. So our take-home points are that stigma is universal and it impacts patient care or lack thereof. Meeting patients where they are on their recovery journey reduces harm and using nonjudgmental, clinically accurate language can help combat healthcare stigma. And with that, I thank you and offer my contact information. Dr. Valesnov, I want to thank you for a very enlightening presentation. It was a really excellent review of both the problem of stigma, but also I think gave the audience a very clear view of all the multiple resources that we can make available to someone who is going to be in a recovery program. This slide shows some of the resources that are available to help you. This comes from the Opioid Response Network. We encourage you to utilize the ORN consultant by accessing submit a request form on their website. Another friendly reminder, please submit your questions in the Q&A area of the attendee control panel, and we will try to address them for the remainder of our presentation. To start things off, I wanted to begin with a general question, or at least an observation. When we start with trainees who are exposed to people in recovery or in treatment programs for the first time, we meet a whole range of responses. Some of them are eager to work with the patients and anxious to learn how to do that, but there are always a few people who are nervous. They are, I think, uncomfortable working with the patients. They're not sure the treatment is going to work. They're not sure about their attitudes. And I'm particularly concerned about how we can work on stigma and the attitudes within the medical community to reverse those feelings. And I think the one observation that I would make is that I think stigma grows out of ignorance, and ignorance really is related to how little you know about the individual and their situation. And I think one of the wonderful things about treatment systems is that we can present opportunities where the caregivers can get to know the patients intimately. And I think one of the good things about mental health care is that it often permits that long-term relationship. But I wondered if you would have any thoughts about the value of long-term relationships in relationship to issues with stigma. Have you noticed anything that connects those two or see how they interact with each other? Yes, absolutely. Well, I can say that out of my own personal experience in residency, being in a longitudinal integrated clinic that addressed both psychiatric conditions and substance use disorders, and being able to work with patients longitudinally in the outpatient setting over two years, really allowed me to, like I said in one of my slides, to meet the patients where they were at and to stay with them, right, throughout that whole journey. And I will say it was, I was one of those that was nervous and maybe a little not excited to work with folks with substance use disorders when I was a resident. And then over time, you know, in working with these individuals for, you know, after about the first year, I started to realize that, wait a minute, these folks actually get better. They get better, they put their lives back together, and it was so beautiful to be a part of that with them. And I think I wouldn't have come to that conclusion had I not been exposed for so long in working with these patients. But also, I might add, if I didn't have the role models that I did, including yourself, Dr. Renner, you know, the role models who not only showed what it was like to treat patients with compassion, dignity, and respect, but who were also clinicians who, you know, had also done residency, who were working in the field. I mean, there's more than just the peer recovery supports that can role model recovery for patients. But I think on the education side, our senior attendings, even senior residents can role model what it's like to not treat patients in a stigmatizing way. And a very simple way is just through language and the words that you use to describe the patients. I think many trainees are eager at first, but that quickly become disillusioned when some of their seniors, their senior colleagues, perhaps, you know, diminish their excitement through using terms that are negative and through, you know, maybe making offhand comments about patients being frequent flyers and sort of this dismissiveness. But I think having that role model, clinician role modeling of how to treat these patients was absolutely critical. Yeah. Well, I think we have to take responsibility as medical educators for creating those opportunities for trainees to do that. Because for many, many years, I think people were often exposed to patients with substance use disorders in the worst possible situations. They meet them in the emergency room or they meet them in some acute care setting where the focus may be on providing needed medical care immediately and not on really getting to know the patient. And I think that one of the advantage of outpatient continuity clinics or certain CL operations is that the trainee can see the patient, can spend time with the patient, can talk to them in great detail. And I think that type of intimate knowledge of the individual is really going to be the most important factor in terms of changing stigma or reducing stigma. And I think in any kind of medical situation that will permit that type of longer term continuity exposure or care is really something that we need to build on and something that we need to make available for trainees if they are going to have an opportunity to work on their own stigma and to reverse that. Absolutely. We do have a question in the chat or in the Q&A. The question is, earlier you, Dr. B, stated that only one in 10 individuals are treated with substance use disorders while one in seven actually experience them. How can we as physicians make those with substance use disorders feel comfortable and safe enough to actually seek treatment? That is an amazing question, I will say. And I think my answer is going to come in multiple parts because I think there's a lot there. There's a lot of ways that we can address this. So, of course, there's this major mismatch, right, in the prevalence of disease and then those who actually receive treatment for that disease. There's also a great mismatch in the prevalence of disease and the clinicians who are equipped to handle that, right? So, we have a major workforce problem where we have insufficient addiction specialists and we have insufficient education of general clinicians, general psychiatrists, general physicians in how to manage substance use disorders and how to talk to patients about these things in a non-stigmatizing, non-judgmental way and how to treat with medications and other ways. And so, I think there's many things we can do. One is by starting education and training very early, incorporating substance use disorder education into medical school curricula, which even now is very few and far between. And so, incorporating it in a longitudinal fashion, having a component of substance use in every body block or every physiological block because substance use impacts every part of you. And so, there's something to be learned in all systems, in all body systems. So, I think, number one, incorporating it very early on into medical school and making sure that everybody who graduates from a residency of any specialty is equipped to address, at the very least, to screen for substance use disorders in a non-judgmental way and to provide treatment and or know who to refer to and what kind of services are available in their community for these patients. Another component that I will mention is that, you know, only one in 10 individuals are treated for substance use disorders. It's not that all nine of those individuals are seeking help and unable to get it. It's that some of them are not seeking help. And that, too, is part of that cycle of stigma that we talked about. They're not seeking help because of shame, because of judgment, because of how they've been made to feel by the healthcare system and by society at large, which then actually further fuels substance use as opposed to, you know, them wanting to get help. So, I think if we know how to address patients and know how to talk to them about these issues, again, in a way that we talk to them about wearing their seatbelts or wearing their bicycle helmet, you know, these are just routine conversations that we have. I think that we could get more people the help that they need. I'd be curious, Dr. Renner, to hear your thoughts. Well, I guess I would build on the comments that you have made, Dr. Balasanova. I think it's important to recognize that people with substance use problems often have had negative experiences with the treatment system or with caregiving systems. And they often begin with the question, you know, is this provider going to be nasty to me? Are they going to not hear what I'm saying? Are they going to refuse to treat my pain because they know I use substances and therefore I don't need medication for pain? They've learned lessons on their side which make it reasonable for them in some ways to hide and to be defensive and sometimes antagonistic. And I think that we have to help the caregivers understand that when they run into these behaviors that they shouldn't take it personally. The patient with a substance use disorder often is testing the waters. They want to see how they are treated. They are very attuned to the language you use, the attitude you express, how you treat them. Because you're going to give them signals about whether this is going to be a safe place or not. And they will respond in kind. And I also think that we have to look at the other options for reaching people who don't reach out in the beginning specifically focused on their substance use problem. I mean, for instance, people who are homeless or people who need other non-medical care per se, you know, can we treat them with respect? Can we be very helpful in meeting them where they are? If we can be very helpful to them in buying groceries, for instance, maybe they can learn that this might be a safe place and they can then test the relationship and permit you to get to know them and they will get to know you. And I think once that happens, the real story will come out. But it may not come out until there is some trust. And it is on our side as the caregivers to really nurture that trust and help it grow and not get defensive and not overreact and take people back no matter what's happened. Make them know that they're always welcome to return and we're always willing to try again. And I think if we have that approach to them, I think we'll do much better. Absolutely. I have another question from the audience. So this one is, could you comment on the use of psychedelics in the treatment of substance use disorder? That's an interesting question. I'll actually ask Dr. Renner his thoughts first. The use of psychedelics is still very controversial. There certainly is some evidence that under certain circumstances psychedelics may be helpful as treatment. But I've also seen patients who approach psychedelics the same way people with substance abuse problems approach any substance. And that is that if one is good, 10 are better. And they often end up abusing psychedelics like they abuse anything else. So I think you have to recognize we are just at the early stages of understandings how psychedelics can be used, how they can be used safely. The time and effort and energy that it takes on the part of providers to make them work successfully is really significant. It's not a quick, simple fix. And I think we have a long way to go before we understand fully how well they work and how best to use them. I definitely agree. And I will add that I think for so long we've had so few treatments available. Like I had mentioned, there's only three medications for opioid use disorder, three for alcohol use disorder, and just a handful for tobacco use disorder. I think there's just a lot of excitement by just the masses, the public at large. And even amongst clinicians, this idea that, wow, there could be this new amazing treatment is really exciting. It's been a while since we've had anything like that. Unfortunately, I think the excitement, we're getting a little ahead of ourselves because the excitement has gone ahead of the science. And we don't have the science yet to fully prove that these psychedelics are safe and effective and don't come with their own slew of problems. So I think it's still so early in stages of science and research and having any kind of definitive answers that I think this is much more of an excitement at this stage than it is actual clinical utility. Yeah, I would underline that. And I think that both do we have to be cautious as we approach the use of psychedelics, but I also recognize that we do have treatments that work. And I think you covered all of that very well today. And I think if we can really learn how to utilize what is currently available, what we know is safe, what we know is effective, we're going to go a long way to getting these problems resolved. So I think rather than looking for something that we don't fully understand, I think we really need to make sure that we are making good use of all the options that have been proven effective and safe. Well, we have about eight minutes remaining and we've gone through our participant questions. So Dr. Renner, if you have any additional questions for Dr. Balasanova, that'd be fantastic. Okay. Well, I would go back to our original focus and that is that the personal relationship with the patient is absolutely critical. Getting to know them, getting to know what is going on in their life, getting to know their family situation, getting to know their challenges, getting to know their strengths, and that takes time and effort and energy. And unfortunately, we often work in medical systems that, you know, place great reward on rapid turnover of patient care where it does not permit you to really spend the time that the patients require to get to know them well and to deal with these problems. So I would hope that everyone will make an effort to take the time to know their patients, to treat them with respect, and to help them utilize the resources that are available because we have better treatments for substance abuse problems than many other areas of medicine, yet we don't use them. And it's very critical to recognize that these are chronic relapsing diseases and what that means is that recovery is not like flipping a switch and all of a sudden people are better. Recovery is like learning how to ride a bicycle, you know, it will take time, you may fall off several times, it's important that you get back on and that we help you keep going. So getting people back into recovery quickly, trying to limit relapses to make them as short as possible, is really critical no matter what treatment you are engaging in. It's important to keep the patient in the treatment to recognize that recovery may take years to fully blossom, if you will. You can see wonderful responses within the first few months, but long-term recovery really takes time and effort. And I think you have to be patient and I think you have to commit yourself to your patients and I think that means that you are going to give them long-term care, that you're going to take them back no matter what happens, and that they are going to be welcome no matter where their disease is and how it progresses, that they always will have a safe place to return and that treatment is possible. No, absolutely. I actually just noticed another question from the chat that said, I think you mentioned that in addiction there were changes to the frontal cortex leading to impaired executive function. Do you know if any of the physiological changes that occur can be reversed with abstinence or even decreased substance use? That's an excellent question. And I know there's Nora Volkow, who is the director of NIDA, has done extensive research into medications for opioid use disorder, particularly buprenorphine, as well as methadone. And one of the things that she has found and written about is that in the brain disease model of addiction is that when you have, say, an opioid use disorder and you are treated with one of the treatments being a medication such as buprenorphine or methadone, that does allow the brain to heal or those connections to be restored for you to be able to engage in other therapeutic endeavors in psychotherapy or in whatever other modality you're engaging in. So when you are in treatment, particularly with medication treatment for some disorders, those physiological changes do normalize over time. And so that was something that was exciting and a really big positive that, you know, even if you develop a substance use disorder, it's treatable, right? Like you can get better. Like Dr. Renner said, you can get better and live a very lengthy and fulfilling life with minimal returns to use if you have the right treatment for you and you have clinicians who are with you along the way. Dr. Malazanova, that's really a wonderful statement to end our talk today. I want to thank you again for a really wonderful presentation. I want to thank all of our audience for joining us today. This recorded webinar will be posted to the APA Learning Center in approximately a week. Please send any questions that you have regarding continuing medical education credits to learningcenteratpsych.org. Again, thank you very much. This is our last ORN presentation for the year, and we want to wish you well for the future. Thank you. Thank you, Dr. Renner, and thank you, Dr. Malazanova. We do want to encourage you all also to access our APA Learning Center or some of our other initiatives. We have two virtual learning cooperatives running currently under this grant, so please check those out as well. Thank you again, Dr. B. Thank you. For the questions in the chat, the slides will be posted in our APA Learning Center, so the contact information will be posted in those slides.

Addiction Stigma

Substance Use Disorders

Non-Stigmatizing Language

Harm Reduction

Integrated Treatment

Patient-Centered Care

Healthcare Provider Training

Peer Support

Compassionate Care