 Hi everybody and welcome to today's presentation on medication assisted therapy for alcohol and opiates. So I know this is just a riveting topic that we all can't wait to talk about, but we'll get through it and we'll see if we can't make it as interesting as possible. I learned a few new things. So and this seems kind of interestingly on point since the woman who inspired President Obama's war on drugs to make it less criminal and more of a disease sort of thing passed away from an overdose. So we'll talk about why that happened, what that looks like and you know maybe look at some of the issues with medication assisted therapy when it is not implemented properly. So we're going to review some myths about medication assisted treatment because there is a lot of stigma that surrounds it not only in the rooms if you will, but also among providers at treatment centers. The clinic I used to work at in Florida while I was there we opened a methadone clinic as one of our programs and the amount of resistance we got from the staff was just mind boggling. So we're going to talk about that some because there's love misconceptions but then there's a lot of you know rose colored glasses by the people who support methadone. So I mean there's pros and cons to everything. Identify medications used to treat opiate dependence and to treat alcohol dependent interestingly a lot of times there's some overlap here because we're working with that dopamine system again. We're going to discuss the mechanisms of action and evaluate the pros and cons of each kind of medication. So one of the first myths is that medication is a crutch and you know when I think of crutches I think of something that holds people up until their body is healed and they can bear weight on their leg again or do something again. So you know I don't really like this term. I think a lot of people overuse it to say that people are using medication assisted therapy instead of comprehensive treatment and I don't believe that's true in the majority of cases when medication assisted therapy is implemented correctly. Yes medications involved but there is also a psychosocial component. It's important to remember that we do what's more rewarding and if somebody is in early recovery and they have like zero dopamine action on their own their serotonin system is all out of whack it's barely tolerable to get out of bed in the morning. Figure it thinking about life from their point of view it might be helpful in early recovery to keep them from wanting to try to numb all that out because I wouldn't want to live through that. It might be helpful to work with them to give them the tools they need to get the energy and motivation remember dopamine is our motivation chemical energy and motivation to get up off the couch let's get up off the couch and do what we need to do. Now it is not the be all end all I mean think about just think about depression for a minute if you give somebody an antidepressant does it make them undepressed not usually does it help does it take the edge off does it rebalance some neurotransmitters sure does it help them sing maybe with a little more color if you will sure I've heard those things however if they still have that negative cognitive pattern if they still have the stinking thinking if they still have the stress in their life they are going to be feeling exhausted hopeless and helpless so it's not medication is not just a magic bullet we can't give somebody a pill and voila make it go away it's not the flu. So medications make sobriety feel better by addressing the underlying neurochemical imbalances so we're saying you know sobriety really isn't that bad when people are coming out of detox they all feel so good and I had a client come to me one time and you know my half non-profit agency there were a lot of us we had a big load you know we can make all the excuses in the world but when it comes down to it we were models of what sobriety was like and one of my clients came up to me one day he's like nobody around here looks happy if that's what sobriety is I don't want it and I said oh you know that kind of hit home with me so of course you know my staff suddenly had to sprout some rose colored glasses but we actually did start to feel a lot better as a staff and start looking forward to coming to work more when we started but loosening up a little bit so medications give people the ability to start feeling some happiness feeling some activate some of those dopamine receptors medications can also remove the rewards from use by making it either unpleasant or removing or capping the high so you're not getting wasted at best you're getting a little buzzed and yes that's not ideal in recovery but you know we're thinking harm reduction we're thinking of keeping from people re keeping from relapsing in early early recovery and suboxone does both it has the high that it has buprenorphine which has a ceiling effect you can only get so much of a buzz if you will off of the buprenorphine but if you take too much it's actually going to induce a um opiate detox and it's going to do it rapidly and it's very unpleasant from what I've been told so recovery is more than just not using we need to help people get the energy and the desire to develop skills and tools to maintain this drug-free lifestyle medications can in some cases help ease the transition until the brain has time has had time to rebalance and their new coping skills and new support systems and new lifestyle is in full swing another myth is that using medication goes against the 12-step philosophy this is one that is rampant through a lot of meetings not all um but there are many clients who either a use this is an excuse so they don't quote have to go to 12-step meetings or um the reality is there are many meetings where people have said if you're taking medication you're not clean you're not welcome here so let's talk about that um the big book states that and I'm going to paraphrase you can read this but don't hesitate to take your health problems to your provider and remember that their services are often indispensable in treating a newcomer and following his case afterwards the big book recognizes that in some cases um recovery and sobriety and long-term happiness and wellness and all that stuff may be comprehensive it's not just going to meetings it's not just not using it's not just working the steps in some cases there are some biological um underpinnings that you know the psychiatrist or the doctor may have to address and I can hear you know in my mind some people saying well that's fine psychotropics are totally different than methadone and we'll get to that so what are the pros medications can increase energy and motivation while the person's brain and body are recovering remember our talk about neurotransmitters norepinephrine is your get it up and go chemical so it's glutamate and dopamine is your motivation chemical it's the one that says this is rewarding we're going to do this some more so as we try to basically artificially enhance those systems until the body can kick it in on its own we're helping people feel a little better some of the drugs can remove some of the reinforcing effects of the illegal drugs or the drugs that are being abused so you're not feeling the high you're not feeling good from it you may not feel anything from it at all and it's like what's the point in taking this it may prevent relapse by making relapse very very unpleasant so people may think twice you know especially if they're on something like ant abuse before they drink because it's like yeah do i want to drink that bad to be driving the porcelain bus for the next three hours it may reduce the intensity of co-occurring disorders so some medications that we're going to talk about actually address some of the physiological reasons that people may be using whether it be a neurochemical imbalance or chronic pain neurological pain something like that it can reduce conflict and improve social support now you're thinking what how does that happen are we giving the drugs to the other people too no but when you're patient when the person with the addiction is feeling less stressed is feeling a little happier is feeling less icky they're probably going to be less argumentative they're probably going to be easier to get along with less depressed which means it's easier on the people around them is it a walk in the park probably not because they're still not going to be walking on sunshine but it can help reduce conflict some of these things like the ant abuse if the significant others are aware that the person is taking it then it's almost like the safety if you will that the significant others are aware that they know with confidence that the person is not drinking because they're not puking their guts out there's some false negatives to that but we'll talk about that in a minute and reduced absenteeism from work if their energy's up their motivation's up their mood's a little bit better they're not relapsing guess what they're probably going to be able to get to work hey how cool is that which supports that whole new lifestyle that they're working toward downsides to medication some physicians are not educated or not sympathetic or both to the biopsychosocial model of treatment of addiction now i worked with a psychiatrist early early early in my career you know this we're talking back in the nineties who was very adamant that people had to have six months clean before he would prescribe them any sort of psychotropics antidepressants anything and you know now that as as a community we've really embraced the co-occurring disorders philosophy you know we can see where that's probably not going to be the most helpful because then we ended up with a lot of people who were clean but were depressed as all get out and suicidal and anxious and they just couldn't make it through that period until their brain kind of kicked it into the gear and normalized again the other thing is having physicians who are sympathetic to the issue and understand what needs to be done when we had people who had to go in for surgery or something like that and they actually didn't have to have opiate based medications or benzos for some reason there was always a safety system they were never given a bottle of pills and allowed to walk out of the hospital especially if they were returning to treatment with us but we would educate the physicians in the community that you know somebody else has to be responsible for this person's medications and in the case of the woman who just passed away she evidently had hip surgery and allegedly the doctors were aware that she had an addiction was in recovery um and allegedly because you know we're just dealing with initial information now she was given a bottle of 50 oxycodone and given that to take home by herself and I'm like yeah um and she overdosed lots of things could have happened you know her tolerance probably went way down because she'd been clean for a while um the pain was probably excruciating and she had like access to a ton of her drug of choice so if you know worst case scenario you know the physician may have been uneducated as to what recovery means and how risky it was for her to have access to that kind of medication but we need to really work with um talking with physicians physicians are getting a little bit more educated about um addiction but not nearly as much as I would like to see um the some are awesome you know I have worked with some really amazing psychiatrists and physicians so I don't want to knock all of any group of people medications can give a false sense of security and provide false hope we're going to cover those same time there is still a significant proportion of people out there that think medications and magic bullet you give me a pill I'm going to be in recovery and I'm like no at best if you've got a pill you're not using your drug of choice that doesn't mean you're not going to find substitute addictions that doesn't mean you're not going to still be depressed that doesn't mean a whole lot of things all it means is you're not going to be using your drug of choice further you can still use your drug of choice it may be unpleasant you may not get the high so saying that because I'm on this medication I will never use again is a false sense of security given the right circumstances I think anybody connects even if they are on something like an abuse medications have side effects everything from extra pyramids and extra pyramids symptoms to um you know the side effects of an abuse and alcohol which is basically really bad flu like symptoms there is a stigma associated with the use of medication assisted therapy because there's a lot of misunderstandings about it and because there's a lot of lack of education about it people do think of it as substituting one addiction for another and at this point I usually find it helpful to educate people that addiction is using a substance to escape from pain and continuing to use it despite negative consequences that's where you run into your addiction if somebody is taking Zoloft in order to help them feel less depressed so they can get through therapy is that substituting addiction if somebody is taking even suboxone you know let's let's go with one of the drugs we're going to talk about if they are using it as prescribed and it is not causing them any problems in their life and it is helping them you know stay clean and do do the next right thing is it substituting an addiction I'm kind of putting that out there for you to chew on in your own in your own thought processes as to how you define what an addiction is and how it's relates to medication assisted therapy I will point out that if you look at just about any insurance company's level of care guidelines medication assisted therapy for substance abuse or mental health is recommended by every single insurance company out there just putting that out there medication does cost money yet another little soapbox if your patients cannot afford their medication go to the pharmaceutical company's website almost every pharmaceutical company if not everyone has a patient assistance program there's a most of the time one page sheet that you print out the doc fills it out takes less than five minutes signs it faxes it in and the patient can either get a waiver or can get low cost medications you know like four bucks a month or something so if a patient really needs medication I have yet to see one of those turned down if somebody is actually truly needy so do be aware that patients can get medication so let's talk about opiate dependence first neurotransmitters we're talking about it's mainly dopamine patients report when they take it it's pain and less anxiety so that tells us that there's dopamine and probably some GABA activation going on to medications for opiate dependence and like the other presentations there's a whole list of reps is that you can go look at more in depth at the end of this presentation but buprenorphine and methadone are two of the ones that we're going to talk about buprenorphine is well I'll get into it in a minute now trek zone and naloxone which is used for the opioid overdose and buprenorphine plus naloxone which is suboxone so buprenorphine is a partial opioid agonist it has a ceiling effect which means you can take you can take it and you can get a little bit of a high off of it but at a certain point it cuts off and no matter how much more you take you're not going to feel any higher you're not going to get any more of a buzz if you will now that's just if you're taking buprenorphine if you're mixing it with other drugs you can get high as a kite and our clients know this so but the medication itself um that does have a ceiling effect it can reduce the symptoms of withdrawal from misused opiates so it can be used to help taper somebody down in a safe and legal way because we're not obviously going to cut down their dose of heroin we're going to switch them over to something else and it's sort of a kinder gentler opiate withdrawal can be abused now kinder gentler opiate withdrawal another thing for you to think about and it's an ethical issue more than a legal issue if somebody detoxes from opiates which is rarely life-threatening unless the person is pregnant um and then it's often only life-threatening to the fetus but if somebody basically goes cold turkey it is a miserable withdrawal no doubt but if i go through something that bad i'm going to be pretty certain i don't want to do that again and it's going to remind me not to do it again the kinder gentler opiate withdrawal the step down method doesn't have any bite to it so people do get off the medication but it's almost like well if i relapse i'll just step down again and that pretty much what some of my clients have told me um they only want to do the kinder gentler withdrawal because they don't like feeling pain i'm like well okay so is there are we setting patients up for relapse or making it um a little easier for them to relapse i don't want to say more likely um if they don't feel the full effects of an opiate withdrawal from a behavioral standpoint if we're strictly talking like skinner box behaviorism i'd say yes uh from an ethical standpoint do we want people to suffer that much for three to ten days yeah you know my compassion kicks in a little bit um so you know it's always a difficult difficult choice and obviously only one the patient and their doctor can make but methadone one of the most controversial drugs um there are a lot of places that are actually not a lot of states that are actually not allowing any more methadone clinics to be built because there are alternatives now in any event methadone is a full new opiate agonist it helps suppress some of the cravings for opiates but taking it high enough doses people can get high off of it it lessens the painful symptoms of opiate withdrawal just like the view from northing um and blocks the euphoric effects of the opiate drugs when taken as prescribed it's considered relatively safe during pregnancy and breastfeeding opiate withdrawal during pregnancy can trigger contractions and miscarriage um when the clinic the company that i worked for one of my units was a mother baby postpartum pregnancy postpartum unit the methadone clinic and then we had you know several other units but several of our mothers came to us and they were using or misusing opiates and the doctor moved them over to methadone detox them from the methadone once they gave birth to their child the children are born with methadone in their system and will experience a withdrawal that's just the way it is but they are generally carried as close to term as they would have been and there haven't been any noted significant negative effects long-term effects on the infant again this is a medical decision not a mental health decision but from our perspective if we have a client come to us who is shooting heroin and you know six months pregnant we may talk with them about options for protecting themselves and protecting the baby and one of them would be to get on methadone um i'm not sure about buprenorphine um in pregnancy but um anyway samsa tip 43 uh medication assisted therapy for opioid addiction is a really good in-depth text on methadone and buprenorphine it's an older text so it was written kind of when methadone clinics were really sprouting up everywhere and at their peak um so if you want to get more information about that that is a really good uh reference and it's free and online on the samsa website now trexone decreases the pleasurable effects of alcohol or opiates so now trexone can be used both places also known as vivitrol which you know we commonly think about vivitrol when we're talking about alcohol but decreases the pleasurable effects of alcohol or opiates by blocking opiate receptors so we're like okay well how does that work when the endogenous opioids or when the opioids are um enter into the bloodstream they cause um dopamine to be released so we block the opiates then the dopamine never gets released so there's no rewarding effect with now trexone alcohol abstinence is not required but opiate abstinence is it will kick in a uh opiate withdrawal independent users third party payer exemptance and the third party payer information i got from the nadac presentation on the couple of these medications um oral is covered by most major insurance carriers including medicare medicaid and the va now i added the oral part because my experience has been that vivitrol which is the long-term acting injectable is not covered in many cases by medicaid so it would be really important for your client to know which method would be accepted by their insurance company especially if finances are an issue vivitrol i've also not known the companies to be very giving of patient assistant programs for the vivitrol since the oral can be used basically in the same way naloxone blocks opioid receptors so again we're just blocking those opioid receptors to prevent the dopamine from going out to make it be less reinforcing it antagonizes which means it kind of shuts down um and and prevents the effectiveness of morphine and other opiates so it's a big bully it's going no you're not going to come in here you're not going to do your thing it prevents or reverses the effects of opioids including respiratory depression sedation and hypotension another one of the things that we have to remember when we look at some of these stats about the rapidly increasing deaths from opiate overdoses and i'm not saying it's not a problem in numbers you know i think there are a vast number of people who are picking this habit or addiction up but remember that fentanyl is 30 to 50 times stronger and way way way way way cheaper to produce than heroin so a lot of people are getting heroin thinking it's pure it's cut with fentanyl and they're accidentally overdosing and killing themselves which is why it is really good to have naloxone on hand um because i think there are a lot of accidental overdoses that are occurring right now and it's not when we look at the overdose rates it's because the drug is back actually becoming more dangerous and more people a greater percentage of the people who use are actually dying all right so we're going to switch gears now that we end on a happy note uh neurotransmitters when we're talking about alcohol we're talking about dopamine which works on your motivation and pleasure endogenous opioids pain and euphoria glutamate which is your get up and go and GABA now think about alcohol when you drink at first you get you know kind of a little loopy if you will then you start to feel relaxed as the alcohol wears off some people start to feel anxious which causes them to pick up and drink again dopamine or not dopamine alcohol has sort of a too bimodal interaction it'll relax you but then the glutamate kicks in and the anxiety ramps up so uh it's it's a depressant but it's also an anxiety producer medications for alcohol dependence dysulfuram which you know i i tried i practiced on that one i still couldn't say it right which is an abuse naltrexone which the oral kind is known as revia blocks opioid receptors so the reward effects um are reduced because dopamine's not excreted vivitrol which is the extended release injectable naltrexone last time i checked the vivitrol injections were like 1200 bucks i don't know what they're running now um but it was really really expensive it wasn't something that the average person could afford if their insurance wasn't going to cover it a campersate or campral and newer medications which you know GABA penton is one of them and then these other two a campersate or campral reduces post acute withdrawal symptoms it up regulates the glutamate receptors you get up and go receptors which reduces the depression but you remember that GABA which is your relaxation anti-anxiety receptor is made from glutamate so if you've got too much glutamate not enough GABA you're going to feel a lot of anxiety in this case they're just like opening the faucet on the glutamate and the GABA's lagging behind there so it creates an imbalance which increases anxiety movability insomnia and trimmers there was a noted increase in adverse events of suicidal nature during clinical trials with a campersate they didn't go into detail about exactly why you know whether they thought it was because the anxiety was too much for people to deal with or there was another reason or the movability they just would go down into this deep deep depression and couldn't handle that or what happened but it is important to realize and when we don't get enough sleep that insomnia will kick in and kind of start impairing judgment as well so is this the best drug in the world in my opinion probably not but it's obviously still sold and obviously still used it helps with pause that's good if your person doesn't have a whole lot of underlying anxiety they may be able to tolerate it as you well know alcohol is one of the very few drugs that can have a life-threatening detox so you know it's really important that people be under medical supervision third-party payer acceptance it does qualify for patient assistant programs through forest laboratories who makes camperal it's also covered by most major insurance carriers including the VA if naltrexone is contraindicated so the VA obviously prefers naltrexone or revia. Dysulfuram, Antibuse, learned a few interesting things about this I mean I knew it was some nasty stuff but it makes patients physically sick if they drink okay you know we know that third-party payer acceptance it is insurer it is accepted by most or covered by most insurances that's great too how does it work in the liver alcohol is broken down into acetyl aldehyde acetyl aldehyde is converted by acetyl aldehyde dehydrogenase into acetic acid. Dysulfuram blocks acetyl acetyl aldehyde dehydrogenase which means the acetyl aldehyde accumulates in the blood to toxic levels so then basically the person's reacting to toxicity not a wonderful thing it makes them physically sick it makes them really really sick most of our patients know this okay so that's you know something they're aware of but what they're not aware of acute toxic reaction lasts about an hour but may linger while there is alcohol in the blood okay so good for them to know good for us to know if they're in detox and their puke and their guts out it can be triggered by alcohol containing products like cough syrup good to know a lot of patients once they get through detox and they're in treatment in iop and outpatient may be given an abuse it's important for them to understand that alcohol kind of lurks kind of like Tylenol it lurks in all the weirdest places so they really need to read the label before they ingest anything additionally how many alcoholic patients do you have that are painters you know just you may be like well three but that's still you know a fair amount if they're going to get physically sick patients taking this should not be exposed to ethylene di bromide or its vapors including paint fumes paint thinner varnish or shellac so anybody who works as a painter or works in furniture refinishing probably shouldn't be taking an abuse if your patient starts feeling really good buys a house decides he's going to remodel you know this is good because it keeps me away from you know bad people bad places bad things and it's a positive activity that's great just don't paint important to reinstall that in them because if they get sick doing something that is pro-social and positive it's going to be sort of a ding in the in the recovery armor they also need to exercise extreme caution when applying aftershave mouthwash lotions colognes rubbing alcohol and that antibacterial hand sanitizer now i know some of our clients in in residential we had to take the hand sanitizer down because they were drinking it but even just casual using it on the skin the amount that's absorbed through the skin may be enough evidently to trigger a reaction the other thing that the patient and the significant others need to know because remember i said significant others may be confident that as long as their person's not throwing up that they're they haven't relapsed and then their person comes home and starts picking their guts out and they're like you went out and drank and the patient's like no i didn't and they get into this argument and whatever it could happen if the person even if the person doesn't drink it also could happen if the patient takes anti-abuse and up to two weeks after the last dose of anti-abuse they ingest some form of alcohol or exposed or exposed to paint fumes paint thinner varnish or shellac it could make them very ill so can patients use this to try to explain away a relapse sure i didn't drink i took cough syrup yeah well you know they they already have probably researched this information but the thing about the lotions and the aftershave and and the fact that they can get sick for up to two weeks afterwards a lot of them don't know at least the ones that i've talked to so anti-abuse is still used it still has a lot of you know very useful purposes if you will remember when i was talking about the methadone being the kind or gentler withdrawal from opiates anti-abuse is kind of the cold turkey of alcohol withdrawal um you know they've withdrawn they're they're clean there's no alcohol in their system and if they use again it's going to be mighty unpleasant so they're probably going to think about it long and hard now trexone decreases the pleasurable effects of alcohol or opiates by blocking the opiate receptors you get the idea that all these drugs kind of work in the same way um let's see we already talked about uh third party payer acceptance remember now trexone can be used for both opiates and alcohol newer meds on den steron sold under the name zofran and works through the serotonin serotonin system especially in regard to serotonin three receptors and its effect on dopamine and there's a lot of text here but i think it's important because we're getting into psychopharm again in alcoholics they hypothesize that there's a heightened sensitivity of the serotonin three receptor which makes alcohol more rewarding we've heard people speculate about this before that sometimes maybe drugs are more rewarding for some people than others well some research has now indicated that that may be true some people may have an extra sensitive serotonin three receptor if this receptor is blocked then the person may have a decrease in alcohol induced dopamine release resulting in less pleasure from the alcohol which may produce a decrease in alcoholic drinking behavior now that's a whole lot of ifs and mays but if you have a highly motivated patient um this certainly may be something to for them to think about now the fiend is an opioid antagonist remember antagonists stop the pleasure similar to naltrexone without the risk of liver toxicity and it is longer acting than the oral naltrexone obviously vivitrile is an injectable and i think it lasts 30 days gabapentin is the one that i hadn't really thought about but it's being used for pain management and anxiety and insomnia which are all problems that are very common among alcohol and or opiate dependent patients so thinking about the patients that we have that are detoxing from opiates or alcohol in both um they talk about pain you know they took the opiates for pain um or when they took the opiates they felt less anxious when we think about our alcoholics a lot a lot of times they don't talk about pain but they do talk about anxiety or insomnia restlessness agitation the anger stress whatever they call it and they perceive that the alcohol helps calm them down so gabapentin has actually shown a fair amount of promise as an adjunct therapy with people that are in recovery for opiate and or alcohol disorders and then there's comorbid conditions you know we talk about addiction a lot of times like it's just this island out there and if we take care of the addiction then we'll take care of everything else and that's not really the case because there are comorbid conditions that either pre-existed or we were caused because of um overuse of the of the addictive substances or addictive behaviors so we need to look at helping people get through this early recovery period while their brains balance out interestingly anxiety insomnia depression and pain are the ones that come up most often PTSD is a whole other category obviously the uh uh neurochemical imbalances are not going to cause PTSD and and there are other treatments and interventions needed there so we're just going to focus on these four but one of the commonalities you probably see as you scan this slide all four of them one of the first line response pharmacological responses for them are SSRIs so let's look at you know stimulating that serotonin system getting whatever's going on kind of back into balance it doesn't always work remember we've talked before about how too much serotonin can be as bad as too little serotonin insomnia you know with anxiety you've also got boost bar when treating comorbid conditions generally docs try to stay away from the highly addictive substances your typical barbiturates benzos and opiates so you're not going to see things like lunesta for insomnia you're going to see them looking towards SSRIs gabapentin or atypical antipsychotics generally um depression SSRIs atypical antipsychotics these medications the patients are not going to get high off of but it may give them the oomph that they need to get up and go when we talk about pain SSRIs are there too and you know if you didn't go to the class on on the neurotransmitters it's important to remember that a lot of our pain perception is controlled through serotonin and and our endogenous opioids but patients who have low serotonin have been found to have a much lower pain tolerance and are much more reactive to any sort of pain which you know when you're in pain you don't sleep well you tend to be grumpy when you tend to be grumpy and don't sleep well over time it just wears on you you know how that goes so we need to look at talking with our clients about these comorbid conditions talking with them about medication assisted therapy what can it do for them and what can't it do it's not a magic bullet but is it as scary as they think it is my uncle when he was in recovery would not take aspirin um he's passed away now so you know that's why i said when he was in recovery but he was so afraid of becoming dependent on taking a pill for everything that he just wouldn't he wouldn't take anything there are extremes obviously and sometimes some people need extremes but in many cases it helps if you want to talk about the kind or gentler it helps make sobriety and early recovery and that post-acute withdrawal phase um more tolerable more bearable is to remember in the addiction the dopamine system the the receptors there's so much dopamine in that synaptic space that the the receptors in the postsynaptic neuron start closing down some of the doors they're like we got to stop so much of this dopamine from going through and then when the person quits taking the cocaine or the opiates or whatever it is the brain doesn't automatically open those doors back up it doesn't realize that then it's not going to be flooded again so it keeps those doors closed for quite a while and whether it reopens the same doors or forms new doors we're not really sure yet but until that happens then the quote normal amount of dopamine normal amount of serotonin normal amount of whatever that goes into that space that's been blocked is not going to get through to the other side so the person's going to feel down it's going to feel slow it's going to feel less rewarded eventually the brain does start being becoming more reactive the other thing i can you know draw parallel with if you've ever been on steroids some people are on steroids for two three months after chemotherapy or for various reasons but then they have to be weaned off of them for the same exact reason because the body quits producing its own steroids because it's getting them artificially it doesn't need to and if the body produces that much its own steroids and then it's getting artificial steroids then it would be too much so the body says okay well if you're going to do that you know i need to maintain homeostasis i'm kind of ocd about that i need homeostasis so i'm going to quit producing mine you withdraw and it's not like the body goes oh okay the prescription ran out so i can start performing again now it takes a little while for the body to kick in and go oh i'm not getting enough now there's a deficit so i need to kick it into gear i'm hoping that makes sense um anyhow so both opiates and alcohol activate opiate receptors medication assisted therapy is used to make sobriety more rewarding and reduce relapse triggers in early recovery it's essential to address comorbid conditions in addition to the substance use you notice i didn't say substance dependence or addiction because medication assisted therapy is really only addressing the substance use itself it's not addressing all the underlying reasons why the person uses the substance or why the person might relapse so we need to make sure that we help them understand that so those relapses don't come from quote out of the blue hopefully they don't come at all are there any questions if there are questions feel free to send me a message at support at allceuse.com or um how often is ant abuse prescribed um quite honestly i can tell you in the nearly two decades that i've worked in community mental health i've only seen it prescribed a handful of times but i have only worked at a handful of clinics um that would be something that i will research and i will put in the notes in your classroom um because i don't know the answer to that off hand all right everybody have a great afternoon