Place your title on this first slide and include any subtitle. DO NOT CHANGE THE FORMAT OF THIS TEMPLATE. If you are creating ATTC-branded slides, you must use this template. If you move around boxes, make sure to check the reading order. If you widen any boxes they must not overlap any other box. IF YOU ADD ANY GRAPHICS, you will need to add ALT TEXT and check READING ORDER. (If the notes on ALT TEXT and READING ORDER do not make sense to you, please let the ATTC National Coordinating Office know to help with remediation.) This product was funded under a cooperative agreement from the Substance Abuse and Mental Health Services Administration (SAMHSA) Center for Substance Abuse Treatment (CSAT) (Grant Number TI-080200). All material, except that taken directly from copyrighted sources, is in the public domain and may be used and reprinted for training purposes without special permission. However, any content used should be attributed to the Mountain Plains Addiction Technology Transfer Center.

Substance Use Disorder: A Chronic, Relapsing Brain Disease Prepared by Mountain Plains ATTC University of North Dakota Grand Forks, ND 58202 701-777-4520 Place your title on this first slide and include any subtitle. DO NOT CHANGE THE FORMAT OF THIS TEMPLATE. If you are creating ATTC-branded slides, you must use this template. If you move around boxes, make sure to check the reading order. If you widen any boxes they must not overlap any other box. IF YOU ADD ANY GRAPHICS, you will need to add ALT TEXT and check READING ORDER. (If the notes on ALT TEXT and READING ORDER do not make sense to you, please let the ATTC National Coordinating Office know to help with remediation.)

Objectives: After completing this presentation, participants will: Reflect on their own thoughts/biases related to addiction. Review the brain reward system associated with addiction  Acknowledge that addiction is a chronic, relapsing disease

Drugs Affect the Reward Pathway to the Brain Evidence that addiction is a chronic brain disease is NOT NEW – in fact ASAM and AMA clarified it as a disease in 2011. The basis for this is really about the effect drugs have on the reward pathway in the brain..  In a nutshell: our brains signal pleasure by releasing dopamine. Dopamine release feels good. This release is essential for survival. It remembers that things feel good: eating, sex, music  - things meant for basic survival of species. Drugs of misuse also trigger release of Dopamine – in many cases (like with heroin) it floods your brain. IT feels REALLY good... National Institute on Drug Abuse, 2018

Comparisons of Dopamine Release Comparison by activity of how much dopamine is released after certain activities and drug use. Opiates, including heroin, are up there with other drugs listed. The brain actually responds to this constant “flood” of dopamine by decreasing the number of receptors for dopamine … so it becomes more and more difficult to feel even baseline without flooding your brain (with drug use). Other activities don’t come close to replicating this feeling AND your brain remembers what felt good. Patients start to feel lousy Ferguson, 2018

Change in Brain Chemistry “..persons with addiction often become less motivated by everyday stimuli (e.g. relationships and activities) that they had previously found to be motivating and rewarding. “Again, it is important to note that these changes become deeply ingrained and cannot be immediately reversed through the simple termination of drug use (e.g., detoxification).” (Volkow, Koob & McLellan, 2018) “Every day feels like the second Tuesday in February.” Over time, this use changes brain chemistry. The brain adapts and it takes more and more drug to get an effect. People actually move from getting a "high" to needing the drug simply to not feel horrible (withdrawal symptoms). The seeking behaviors that we might see are so often r/t seeing somebody in withdrawal or single minded in preventing feeling the withdrawal symptom. This process/feeling is not quickly resolved by simply detoxing from the drug. Your brain has fewer receptors as a result of use, you’re not using drug after detox period. It is more difficult to even feel at your baseline….. One person described it as “every day feels like the second Tuesday in February”

Addiction “Chronic, relapsing disorder characterized by compulsive drug seeking, continued use despite harmful consequences, and long- lasting changes in the brain. It is considered both a complex brain disorder and a mental illness. “Addiction is the most severe form of a full spectrum of substance use disorders, and is a medical illness caused by repeated misuse of a substance or substances.” (NIDA, 2018) Because of the altered brain chemistry, and the need to avoid withdrawal (not feel lousy), people may be willing to try other drugs, different forms (IV), smoking, sharing. People may put themselves into more dangerous situations to access drugs. And/or start missing out on family, work and social obligations to get drugs. The ASAM definition of addiction speaks to this behavior “Continued use despite harmful consequences” If left untreated over time, addiction becomes more severe, disabling and life threatening.

Trauma Emotional abuse Physical abuse Sexual abuse Mother treated violently Household substance abuse Person struggling with mental health disorder Parental separation or divorce Criminal household member Emotional neglect Physical neglect https://attcnetwork.org/centers/mountain-plains-attc/trauma-informed-care Important to remember that “all behavior has meaning” and that really speaks to how trauma influences addiction. We know that childhood experiences can have both positive or negative impact on future behavior, victimization and lifelong health and opportunity. Much of the foundational research in this area is from the Adverse Childhood Experiences (ACEs) study. People who have experienced trauma such as emotional, physical, sexual abuse, mother treated violently, household substance abuse, familial mental illness , parental separation or divorce, neglect ….. are at risk. The link at the bottom of this slide is from the MPATTC website – there is a great video of our co-director and a national expert in trauma informed care discussing trauma

ACES Effects The Centers for Disease Control and Prevention, 2016 Children who experience abuse and neglect are at increased risk for smoking, alcoholism, and drug abuse as adults, as well as engaging in high-risk sexual behaviors. Women with a history of IPV are more likely to display behaviors that present further health risks (e.g., substance abuse, alcoholism, suicide attempts) than women without a history of IPV. Some researchers view risky behavior such as using harmful substances as both consequences of sexual violence and factors that increase a person’s likelihood to being victimized again in the future.24,28 The Centers for Disease Control and Prevention, 2016

Disease A condition characterized by specific signs and symptoms Caused by a combination of biologic, behavioral, and environmental factors Results in damage or change in function to body systems If untreated, can lead to loss of function or death Control versus cure Disease is characterized a variety of things. This is how we view Diabetes and cardiovascular disease. Certain symptoms that manifest. Caused by biologic, behavioral and environmental factors. Results in damage if not controlled. We view with a “control versus cure” way of thinking: minimizing symptoms, decreasing risk factors , monitoring and, keeping patients engaged. Finally a relapse of a chronic disease does not prevent treatment.

Chronic Disease and Addiction Specific signs and symptoms Compulsive drug seeking and continued use despite harmful consequences Cause is a combination of behavioral, environmental and biological factors Repeated use (behavioral), trauma (environmental), genetic predisposition (biological) Changes function/causes damage Causes long-lasting changes in the brain If left untreated can be disabling or life threatening Control versus cure

“Awareness without action is worthless.” Person centered language https://www.communitycatalyst.org/resources/2017-alerts/6-22/Guide-to-non-stigmatizing-languageFINAL.pdf Avoid “shame and blame” Screen for substance use and trauma Talk to people in recovery Know your referral sources

A Powerful Message from Family Madelyn Linsenmeier 1988 - 2018 https://www.sevendaysvt.com/vermont/madelyn-linsenmeir-1988-2018/Content?oid=21797604&fbclid=IwAR2fjyDwHDuJTyRtruJHqaoeSCAgDLiWkU9HvHdXVeLhVVEe7zch-3V1hgw

References Centers for Disease Control and Prevention (2016) About Adverse Childhood Experiences. https://www.cdc.gov/violenceprevention/acestudy/about_ace.html Ferguson, C.J. (2018) Debunking the Biggest Myths About Technology Addiction. Discover. http://blogs.discovermagazine.com/crux/2018/05/23/debunking-myths-technology- addiction/#.W9Z7OOJRfb1 National Institute on Drug Abuse (2018). Drugs, Brains, and Behavior: The Science of Addiction. https://www.drugabuse.gov/publications/drugs-brains-behavior-science- addiction/drugs-brain Volkow, N.D., Koob, G.F. & McLellan, T. (2016) Neurobiologic Advances from the Brain Disease Model of Addiction New England Journal of Medicine 374:363-317.