Substance and Opioid Use Disorder Basics

Pamela Baston, MPA, MCAP, CPPTechnical Expert Lead (TEL)

October 9, 2019

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Learning Objectives• Understand the stages of substance use in the

development of a substance use disorder (SUD), including opioid use disorder (OUD).

• Understand the role genetics, the environment, and the brain play in developing and contributing to substance use disorder and associated problems.

• Identify the most common drugs of abuse, including the various opioids.

• Review a day in the life of a person misusing substances, especially opioids, and how parental use affects children in the home.

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Stages of substance use disorder (SUD), including

opioid use disorder (OUD).

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Stages of SUD

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With opioids, overdose or death can occur at any stage

1st

UseCont. Use

Tolerance Dependence SUD

ContinuumSubstance use (alcohol and drug) occurs on a continuum from no or low risk to substance use disorders. Effective interventions are available at all points on the continuum. Risky use (consumption of

amounts that increase likelihood of family and health consequences).

SUD

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Developmental Disease: SUD Starts Early!

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1. First Use

Commonly includes:• Experimentation with alcohol or

drugs (e.g., sense of adventure, peer pressure)

• Taking medication that a physician prescribed for a specific issue (e.g., medical necessity)

• Coercion (e.g., from parents, perpetrators, and IPV partners)

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With some opioids, first use could be last.

2. Continued Use

Commonly includes:• Liking how the drug makes them

feel.• Continued need to use the meds

per medical requirements.• For some, prescription meds can

include misuse.• Can include beginning of problems.

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With some opioids, continued use could be last.

3. Tolerance

Commonly includes:• After a period of continued use, and

dependent upon the duration and substances being used, the brain and body have adjusted to the drug and now require a greater amount to feel the effects (tolerance).

• Tolerance to a prescription painkiller may mean that over time, the same dosage no longer takes care of the pain.

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With some opioids, tolerance issues can lead to overdose.

Tolerance• As with all chronic diseases, there are variations within

the stages unique to every individual.

• A heavy drinker with tolerance to alcohol might never develop dependence or addiction.

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4. Dependence (Physical/Psychological)

If dependence develops:• The brain has become accustomed

to the substance and doesn’t function well without it.

• The individual doesn’t feel “normal” if they’re not using.

• A person could become physically ill without the substance, perhaps even developing serious withdrawal symptoms.

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With some opioids, continued use could be last.

Withdrawal• Withdrawal describes the

various symptoms that occur after a person abruptly reduces or stops long-term use of a drug.

• Length of withdrawal and symptoms vary with the type of drug and it can be very unpleasant and even fatal without medical assistance.

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Withdrawal• For example, physical symptoms of heroin withdrawal may

include restlessness, muscle and bone pain, insomnia, diarrhea, vomiting, and cold flashes.

• Symptoms of withdrawal from meth include depression, anxiety, fatigue, and an intense craving for the drug.

• In the case of opioids, as soon as the person uses again, the withdrawal symptoms immediately stop.

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5. Substance Use Disorder (SUD)

Various severities of SUD based on 11 criteria:• 0-1 = No diagnosis• 2-3 = Mild substance use disorder• 4-5 = Moderate substance use

disorder• 6-11 = Severe substance use

disorder

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With opioid misuse at any severity level, OD risk is present.

SUD Disorder1. Use in larger amounts or longer than intended

2. Desire or unsuccessful effort to cut down

3. Great deal of time using or recovering

4. Craving or strong urge to use

5. Role obligation failure

6. Continued use despite social/interpersonal problems

7. Sacrificing activities to use or because of use

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SUD Disorder8. Use in situations where it

is hazardous 9. Continued use despite

knowledge of having a physical or psychological problem caused or exacerbated by use

10.Tolerance11.Withdrawal

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Questions?

The role of genetics, the environment, and the

brain in SUD.

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No one wakes up one day and says … “today feels like a great day to develop an addiction to drugs so bad that I will risk my health, my family, my job, my future, my freedom and possibly even my life.”

Quote by No One

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Brain Science • We talked about some of the common pathways to substance use and the development of SUDs, now let’s turn our attention to what is going on in the brain during use.

• As a result of scientific research, we know that addiction is a disease that affects both the brain and behavior.

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Brain Science and Behavior

• Many individuals who work with individuals with SUD have not received training about how it disrupts an individual’s neurocircuitry affecting their ability to prioritize beneficial behaviors over destructive ones and their ability to exert control over these behaviors even when associated with catastrophic consequences.

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Brain Science and OUD

• The SUD-related compulsive behavior must be managed over time and for OUD, Medication Assisted Treatment (MAT) is the standard of care.

• “…With the medications, you’re creating stability in the brain, and that helps recondition it to respond to everyday pleasures again.” Nora Volkow (Director of NIDA, 7.8.19)

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Brain Science and SUD/OUD

• While the initial decision to use substances is often voluntary,* the brain changes that occur over time challenge a person’s self-control and ability to resist intense impulses urging them to continue using substances.

* Coercion is often a factor.

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Dopamine• Different drugs affect the brain

differently, but a common factor is that they all raise the level of the chemical dopamine in the brain that controls reward and pleasure.

• Drugs, unfortunately, are able to hijack this process.

• Drug use has compromised the very parts of the brain that make it possible to “say no.”

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Dopamine• Methamphetamine

abuse greatly reduces the binding of dopamine to dopamine transporters (highlighted red/ green) in the striatum, a brain area important in memory and movement.

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Multiple Risk Factors• As with any other disease, vulnerability to addiction differs

from person to person and no single factor determines whether a person will become addicted to a particular substance.

• However, in general, the more risk factors for substance use and disorders, the greater chance that taking drugs will lead to substance use problems and disorders.

• Risk factors can be environmental or biological.

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Effects on the Individual

• The individuals often have significant and complex histories of physical and sexual abuse, abandonment, loss, and associated trauma (for Native populations, historical trauma) adversely affecting their ability to engage in/comply with programming.

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Genetics

Dr. George Uhl and colleagues at NIDA's Intramural Research Program (IRP) in Baltimore, Maryland, found that, using a powerful new technique for identifying genes that are associated with diseases, they have linked at least 89 genes to drug abuse and dependence.

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Genetic Variables• Studies have shown that

40-60 percent of the predisposition to addiction can be attributed to genetics.

• What do grantees know about the family history of the caregivers they are working with?

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Genetic Variables (and Good News)• Research evidence suggests that the genetic risk for

addiction can be neutralized by involved and supportive parenting.

• One study involved teens who all had a particular genetic risk factor for addiction but different levels of parental support.

• Those who lacked involved and supportive parents had three times higher rates of drug use than those with high levels of parental support.

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Stigma

Despite the brain science, SUDs and particularly OUD are among the most stigmatized conditions in the world due to two main factors:

• Perceived control that a person has over the condition.• Perceived fault in acquiring the condition.

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• People who experience stigma are less likely to seek out treatment services and access those services.

• When they do, people who experience stigma are more likely to drop out of care earlier.

• Both of these factors compound and lead to worse outcomes overall.

Stigma Trumps Science

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Stigma Shouldn’t Trump Science

• Effectively treating people with histories of abuse, abandonment, loss, and associated trauma requires a time-involved process of testing and engagement (these behaviors should be expected as confirmation of their disorder, yet they can nonetheless be challenging for programs).

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Co-Occurring Substance and Mental Health Disorders• Because SUDs often co-occur with other mental illnesses,

clients presenting with one condition should be assessed for the other(s).

• Anxiety disorders are the most common type of mental disorder, followed by depressive disorders. Based on the significance of trauma among child welfare-involved families, trauma and stressor-related disorders are also common as they are among DV and incarcerated populations.

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Effects on the Individual

• The individuals often have complex family dynamics (multigenerational SUD/OUD, multi-age sibling groups who themselves are adversely affected from parental use, drug-using partners who can sabotage recovery efforts, etc.).

• Failure to address these complex issues can result in treatment failure for the individual and missed opportunities to stabilize their family and environment.

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Intergenerational

• Substance use problems and disorders are an intergenerational problem. Can you see the parent in the same compassionate way you see their child(ren)? They were likely that child years ago…..

Substance Testing: What It Is/Is Not

• A drug test is NOT treatment. • Drug testing alone or with detox or a drug education

course will not address the underlying problems that created the drug problem in the first place.

• It is not reasonable to expect someone with a SUD/brain disease to attain recovery through drug testing and monitoring alone and sets them up to FAIL, which has tremendous adverse effects on their life and the lives of their child(ren).

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Substance Testing: What It Is/Is Not

• Not synonymous with a SUD diagnosis (or, if SUD, its severity)

• Not an indictment• A signal for discussion about options• Whether a child is safe• The parenting capacity and skills of the caregiver • ALL it tells you is whether the parent/caregiver has used a

tested substance within a detectable timeframe

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Spectrum of SUDs

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First-Time Use

Cont. Use/Tolerance

Dependence/Disorder

Questions?

Common drugs of abuse, including the various

opioids.

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Marijuana• Marijuana, often the most

common illicit drug used in the US. It looks similar to tobacco and is a dry, shredded green and brown mix of leaves, flowers, stems, with small hard round seeds from the hemp plant Cannabis sativa. The main psychoactive (mind-altering) chemical in marijuana is delta-9-tetrahydrocannabinol, or THC.

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Marijuana• Marijuana is usually smoked in

hand-rolled cigarettes (joints) or in pipes or water pipes (bongs). It is also smoked in blunts—cigars that have been emptied of tobacco and refilled with a mixture of marijuana and tobacco. Marijuana smoke has a pungent and distinctive, usually sweet-and-musty (skunk-like), odor.

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Marijuana Extracts

• Smoking THC-rich resins extracted from the marijuana plant (dabbing) is on the rise. Various extract forms:• Shatter—a hard, amber-colored solid• Wax or budder—a soft solid with a texture like lip balm• Hash oil or honey oil—a gooey liquid

Marijuana Edibles• Eating foods or drinking

beverages that contain marijuana have different risks than smoking marijuana, including a greater risk of poisoning. These “edibles” are products such as cookies, sodas, brownies, and candies that have been made with THC—the active ingredient in marijuana.

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Vaping Devices• Vape pens are a newer method

for vaporizing marijuana and are not well-studied. The first generation of vape pens are similar to e-cigarettes, designed to slowly heat oil cartridge contents to the point of vaporization. Marketed as convenient, safe, and affordable, they are unregulated and not very reliable.

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Synthetic Marijuana (Spice)

• Some Spice products are sold as “incense,” but they more closely resemble potpourri. Like marijuana, Spice is abused mainly by smoking. Sometimes Spice is mixed with marijuana or is prepared as an herbal infusion for drinking.

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Cocaine and Crack• Cocaine is a powerfully addictive

stimulant drug made from the leaves of the coca plant native to South America. It produces short-term euphoria, energy, and talkativeness in addition to potentially dangerous physical effects like raising heart rate and blood pressure.

• The powdered form of cocaine is either inhaled through the nose (snorted), where it is absorbed through the nasal tissue, or dissolved in water and injected into the bloodstream.

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Crack• Crack is a form of cocaine that has been

processed to make a rock crystal (“freebase cocaine”) that can be smoked. Crack provides an intense, short-lived euphoria followed by a “crash" that involves extreme fatigue, anxiety, depression, irritability, paranoia, and a craving for another high that can seriously disrupt normal daily living behavior for extended periods of time.

• If someone is making crack, it may smell like burning plastic (though some describe it as burning metal or glass) and there might be multiple boxes of baking soda by the stove and tiny cellophane bags. 52

Methamphetamine• Methamphetamine (a stimulant) is

taken orally, smoked, snorted, or dissolved in water or alcohol and injected. It can vary in color.

• Smoking or injecting the drug delivers it very quickly to the brain, where it produces an immediate, intense euphoria.

• Because the pleasure also fades quickly, users often take repeated doses, in a “binge and crash” pattern (similar to crack cocaine).

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Methamphetamine Production/Labs• Meth production involves a

number of very hazardous chemicals.

• It can be made in small, illegal laboratories, where its production endangers the people in the labs, neighbors, and the environment.

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Signs of a Meth Lab

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Opioids

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• Opioids are drugs that reduce the intensity of pain signals and include heroin and manmade opioids (synthetic) such as prescription painkillers (e.g., oxycodone)

• Opioid meds used to relieve pain are beneficial but can be overprescribed.

The Illicit Opioid…Heroin• Heroin, a highly addictive

opioid drug made from morphine, is a natural substance derived from the seed pod of opium poppy plants from Southeast and Southwest Asia, Mexico, and Colombia.

• Heroin can be a white or brown powder, or a black sticky substance known as black tar heroin.

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HEROIN HIGH

Opioids• In some cases the person will

demonstrate sluggish behavior and may even nod off. This can adversely impact a parent’s ability to appropriately supervise or protect their children. Overdose is also common (see photo right).

• Several states have reported “roll over” deaths involving parents high on prescription drugs who unintentionally roll over and suffocate their child.

Fentanyl• A powerful synthetic opioid

analgesic similar to morphine, typically administered by physicians via injection, transdermal patch, or in lozenges.

• 40-50 times more potent than heroin, and 50-100 times more potent than morphine.

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Fentanyl• Fentanyl is 40-50 times more

potent than heroin, and 50-100 times more potent than morphine.

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• Fentanyl can be mixed with other substances, injected, snorted/sniffed, smoked, taken orally by pill or tablet, or spiked onto blotter paper.

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Fentanyl

Carfentanil• A synthetic opioid 100 times more potent

than fentanyl, and 10,000 times more potent than morphine.

• A tranquilizing agent for elephants and other large mammals -- not approved for use in humans.

• Linked to a significant number of overdose deaths in various parts of the country.

• Improper handling of carfentanil, fentanyl, and other fentanyl-related compounds can have deadly consequences.

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OBVIOUS SIGNS: PARAPHERNALIA

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Questions?

A day in the life of a person misusing

substances/opioids.

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Opioid Use: What We Know• After an initial pleasurable

“rush,” people who use opioids may be verydrowsy for several hours, with clouded mental functioning.

• Repeated use often results in OUD (addiction) – where seeking and using the drug becomes the primary purpose in life.

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Parental Opioid Use and Daily Life

The examples provided in this presentation of opioid-affected daily life activities and conditions (e.g., withdrawal, preoccupation, diverted finances/resources, procurement, consumption, child exposure) are common to parents whose opioid use rises to the level of a diagnosable OUD but who are not in treatment.

While we will not cover it in its entirety today, we will also address how certain daily opioid life experiences can contribute to child safety risks (including toxic stress).

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Opioid Withdrawal• Excessive perspiration• Shaking and muscle spasms• Severe muscle and bone pain• Vomiting, nausea, and diarrhea• Irritability• Insomnia• Restlessness• Dilated pupils• Rapid heart rate/anxiety• Death is not likely from opioid

withdrawal, but people may feel like they’re dying

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Examples of Activities

Common to Parents with

OUD

Parental opioid withdrawal:Parent wakes up in the morning in pre-withdrawal/early withdrawal discomfort, experiencing flu-like symptoms and anxiety (“dope sick”).

Intimate partner power and control dynamics may be involved. That is, the survivor may be forced to rely on perpetrator for access to opioids or opioids are used by perpetrator as chemical tool for control.

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Examples of Activities Common to Parents with OUDParental opioid withdrawal:• Parent wakes up in the morning in pre-withdrawal/early

withdrawal discomfort, experiencing flu-like symptoms and anxiety (“dope sick”).

Intimate partner power and control dynamics may be involved. That is, the survivor may be forced to rely on perpetrator for access to opioids or opioids are used by perpetrator as chemical tool for control.

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The caregiver is in withdrawal. Meanwhile, the child…

• May be left in a soiled diaper and in distress.

• May be having to take on responsibilities, including care for younger children, that may be beyond their developmental capacity (i.e., “parentified child”).

• May miss daycare or school.

And remember…this is not the flu. This “sickness” won’t go away in a few days!

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Opioid Preoccupation

“To my caseworker, I blame long hours at my job for my strange sleeping patterns and frequent absences, [but] I have no job. I’m just always on the hunt for more heroin. My opioid addiction has taken me over.”

“My life is broken down into four- to five-hour increments to get high, to put off feeling sick.”

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Examples of Activities Common to Parents with OUD

Opioid Preoccupation:• Preoccupation involves opioid seeking for next use. Considerable time

must often be spent setting up daily connections to procure opioids (e.g., multiple calls to multiple dealers, wrangling over money owed).

• Note: The strong physical dependence and compulsive use symptoms associated with regular opioid use render buying ahead and “stashing/rationing” nearly impossible (many parents will use ALL they have WHEN they have it). Therefore, many such individuals engage in daily transactions, increasing the potential harm to themselves and their children.

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The caregiver is obsessing about their next use.Meanwhile, the child…• May have an untreated ear infection or other

ailment that goes unnoticed to the caregiver• May be left in front of a TV or computer to

YouTube for the majority of their day while the caregiver works to obtain drugs

• May be at higher vulnerability to common dangers in the home (e.g., hot stoves, steep stairs, choking hazards, heavy dressers) because of caregiver’s distraction

• If older, may personally contact known dealers in attempt to satisfy a caregiver’s opioid needs

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Opioid Preoccupation • A parent with an OUD,

who is mood altered, preoccupied with getting high, or spending significant amounts of time recovering from the effects of substances, may miss the opportunities to foster healthy attachment with their child.

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Opioid Preoccupation (cont.)

• Parents with significant opioid-seeking preoccupation may have substantially less interaction with their child.

• Chronic neglect can lead to persistent activation of the stress response systems (toxic stress) in a young child that affects the architecture of their brain.

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Diverted Finances“I need heroin to feel normal. I don't love it anymore. Now I'm sick. I can't afford the heroin that I need. How did $10 used to get me high? Now I need $100.”

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Examples of Activities Common to Parents with OUDDiverted finances/resources: • Available money or resources are prioritized to support

opioid use. Users will also steal, pawn, sell things, trade sex, and become a dealer themselves to obtain drugs. Parents who use opioids multiple times daily may be unable to maintain employment, resulting in “sofa surfing” from loss of stable housing.

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The caregiver diverts finances. Meanwhile, the child…• May have inadequate food, poor

nutrition, lack of medical treatment or safe housing.

• May be exposed to a chaotic lifestyle (e.g., frequent moves, being temporarily placed with various family members, and/or in and out of different daycare centers - no baseline).

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The caregiver diverts finances Meanwhile, the child…

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• May experience loss of family and other supportive relationships as opioid use and associated behaviors (e.g., theft from family members) causes estrangement from once-supportive individuals and can lead to chronic anxiety and hypervigilance or contribute to developmental and cognitive delays in children.

• May be exploited for financial or sexual purposes.

Opioid Procurement “I grab my keys and head to my car, throw my kid in the back seat and off I go to the neighborhood I usually cop in. The drive always feels longer than it is when your withdrawals are kicking in again. I call my dealer and he says it’s going to be 10 minutes which I know isn’t true, I’m looking at around at least 45 minutes to an hour. I check my phone waiting for him to call, I’m starting to get dope sick again.”

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Examples of Activities Common to Parents with OUD

• Opioid procurement: • Obtaining opioids involves considerable time, commitment,

and risk. • Procurement is rarely timely (can involve significant delays).• Procurement may occur in neighborhoods that are unsafe.• Persons dealing drugs may be unsafe individuals.• Fentanyl can be knowingly or unknowingly included in the

opioid substance.

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The caregiver is procuring opioids. Meanwhile, the child…• May be left with unknown and/or unsafe caregivers.• May be left home alone or strapped in a car seat for

hours or days at a time and potentially exposed to unsafe people while caregiver is procuring.

• May witness the caregiver’s frantic attempts to procure or steal opioids.

• May be at risk for car-related injuries/fatalities if caregiver uses right after procurement and has accident due to intoxicated state or leaves child in car exposed to extreme temperatures.

• If older, may be asked to drive the caregiver to obtain opioids in unsafe locations.

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Opioid Consumption

“My dealer gives me what I need, now I need to find a good bathroom; I can’t wait to get home to use. I find one of my favorites; single stalls give you more privacy and time. I park out front and walk straight to the back where the bathrooms are. I’m obsessed with the ritual of shooting up, the water, the mixing, the pop of my vein when the needle goes in. I release the belt and the heroin floods my brain. Wandering back out to my car I get some looks from customers like they know, but I really don’t care.”

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Examples of Activities Common to Parents with OUD

• Opioid consumption: • Depending on the type, strength, and amount of opioids

consumed, the duration of the parent’s “high” can vary considerably in length of time and the severity or the extent of associated behaviors (e.g., nodding out, disorientation).

• Overdose risk may be present.• Risks may be high for contracting infectious diseases

(e.g., HIV, hepatitis) through infected injection equipment and/or unprotected sex with an infected person.

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The caregiver is misusing opioids. Meanwhile, the child…

• May not be able to wake the caregiver or may witness the caregiver’s overdose (even a fatal one).

• May go without basic care like diaper changes, baths, or appropriate meals for hours or days.

• May not have a safe sleep environment (e.g., co-sleeping, loose blankets in the crib, unrelated men in the home, etc.).

• If older, may misuse opioids themselves with or without a caregiver’s permission.

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Other “Consumption” Factors• Parents who use opioids multiple times daily often lack hunger

cues/appetite, contributing to inconsistent meal schedules for their child. • A parent high on opioids may have reduced parental capacity to

respond to a child’s other cues and needs.• If older children observe/become aware of parental opioid use, it may

normalize such use and contribute to their access and/or other environmental reinforcement contributing to their use.

• Parent may have difficulty regulating emotions, contributing to physical or emotional abuse of children/other family members.

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Child Exposure to Opioids/Paraphernalia

Parents may expose children to opioids/paraphernalia, causing:• Poisoning from accidental ingestion

(e.g., pain meds look like candy to children).

• Harm to child from straight-edge razors used to “cut” heroin or pain meds for snorting or injecting.

• Exposure of child to infectious diseases (e.g., HIV, hepatitis) from contaminated syringe and needles.

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Child Exposure Examples (cont.)• Children are much more

susceptible to (and affected by) secondhand smoke (opioids can be smoked) at much lower dosages than adults (e.g., may experience a “contact high,” asthma, respiratory problems).

• Belts/laces/plastic tubing used to “tie off” for heroin injection could pose a strangulation hazard.

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Treating a Biobehavioral Disorder Must Go Beyond Just Fixing the Chemistry

We Need to Treat theWhole Person!

In Social Context

Pharmacological (medications) Behavioral Therapies

Medical and Social Services

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System Failure

“We are routinely placing individuals with high problem severity, complexity, and chronicity in treatment modalities whose low intensity and short duration offer little realistic hope for successful post-treatment recovery maintenance. For those with the most severe problems and the least recovery capital, this expectation is not a chance, but a set-up for failure—a systems failure masked as personal failure.” (Bill White, 2013)

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Various and Complex Pathways• Different and complex initiation

reasons• Missed opportunities to interrupt

trajectory• Multiple consequences (justice

system, family destruction, custody losses, poor health, and early death)

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Thank you for all you do to increase access to life-saving behavioral health care for

individuals and families in rural communities across America!

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Questions?

Thank youThe purpose of RCORP is to support treatment for and prevention of

substance use disorder, including opioid use disorder, in rural counties at the highest risk for substance use disorder.

Pam Baston, 828-817-0385pbaston@jbsinternational.com