 I am JoLinda LeClaire, Director of Drug Prevention Policy for Vermont. I oversee the Governor's Opioid Coordination Council, which Governor Phil Scott established by Executive Order in January 2017. Since then, the Council has focused on its mission to improve Vermont's response to our opioid challenges through prevention, treatment, recovery, and enforcement. This crisis touches everyone in our state. Many Vermonters have family members and loved ones who have become addicted after receiving opioid prescriptions for pain. Others were exposed to opioids and other drugs through friends, dealers, and traffickers. Regardless of how they were exposed, we know we have among us many who now have the chronic isolating and too often deadly disease of addiction. We are making progress. Treatment is available across the state through Vermont's nationally known hub and spoke system of treatment. Recovery centers in our communities are providing effective wraparound support to help people achieve long-term recovery. Many communities are building prevention coalitions to provide our children and families the tools they need to be resilient in the face of life's challenges and traumas. Vermont law enforcement has steadily worked to increase community safety and to decrease the supply of illegal drugs. They also work hard to support prevention strategies that will reduce the demand for opioids. There is more we can do and must do to turn the curve on Vermont's opioid challenges. Drug prevention education is a top priority for schools and communities. Increasing intervention opportunities in emergency rooms and other places will help more people enter treatment and recovery. Individuals and families in recovery need support to obtain jobs and rebuild their lives and support for harm reduction through safe and appropriate use and disposal of drugs and syringes will increase safety in homes and communities. Something we all can do to take every opportunity to raise awareness and reduce stigma by talking about addiction. To highlight the science of addiction as well as the cultural, social and economic challenges associated with addiction, the producers and hosts of Vermont Cable Access and the Opioid Coordination Council have created an eight-part series entitled Understanding Vermont's Opioid Crisis, Working Together to Create a More Resilient Community. This first segment in the series is about the science of the brain and addiction. Host Ed Baker and his guests discuss the changes that occur in the brain as the disease of addiction or substance use disorder develops and progresses. They explore what is required to treat those changes and begin the process of recovery, all a part of the Opioid Coordination Council's strategies. We hope that this knowledge will help to transform the stigma often associated with addiction. With compassion, long-term treatment and recovery supports, there is hope. Hi, everybody. I'm Ed Baker and I'm very happy to be here today with you. As Jolinda had mentioned in her introduction, this show is part of an eight-part series entitled Understanding Vermont's Opioid Crisis. This particular show's title is Science of the Brain and Addiction. We're going to go into an explanation of what addiction is as it impacts the human brain. In order to help us understand that, it's my pleasure and my honor to introduce our guest, Dr. Peter Jackson. Thanks for having me. I'm glad to be here. Thank you for being here, Doctor. Dr. Jackson completed medical school at the University of Utah and he completed his residency in psychiatry at the University of Michigan. He then completed fellowships in both child and adolescent psychiatry and addiction psychiatry at Massachusetts General Hospital and McLean Hospital, both affiliated with Harvard Medical School. He then joined the faculty at the University of Vermont-Larner College of Medicine, where he is an assistant professor in the psychiatry department. You're also engaged in a clinical practice with this particular population. Is that correct? People with opioid use disorder. Two days a week of my practice are pretty much exclusively focused on treating opioid use disorders. I guess, Dr. Jackson, where I'd like to begin is with a little bit of a personal question to you so the viewing audience can get an idea about what motivates you and what drew you into this specific specialty. What drew you into addiction psychiatry? Yeah. Well, thanks again for having me. I am happy to be here and happy to answer that question because I love it. When I started medical school, I don't think mental health treatment or substance use treatment was anywhere on my radar at all. And as I went through the first couple of years of medical school, as we began to learn in medical school about substance use disorders and addiction and mental health, I became very intrigued at the way that it impacts individuals and families and people who are connected to them. In medicine, we often talk about a biopsychosocial model, which is basically saying that we should care about not just how a disease impacts people's bodies and their biology, but also their emotional well-being and their functioning in the world. And I found that for me, it seems to me that nothing threatens all of those areas of well-being more than a substance use disorder. I met patients when I first was in my clinical years of medical school, one that I remember in particular in the intensive care unit at the VA hospital, who was there for cardiac problems related to a long-standing substance use problem. And I remember him saying to me, my heart is the least of my worries right now. And he went on to tell me about sort of the destruction that this challenge had left behind in his life, in his family, in his work, in his profession. And I remember that very well, him sort of saying that, yeah, this has impacted my body, but it's impacted my life so much in addition to that. And I just have felt an interest in working in that area. And I'm glad that you're doing the show and glad that we're here to talk about it. Yes, yes, yes. Thank you. Thank you for that, your candor and your genuineness that resonates with me. And I'm sure that that patient resonated with you. You know, more and more as as I asked that question to people I come into contact with in this particular field, I find that it's almost universal, that that's somewhere along the line, something resonated. And people choose this field, it's almost a calling that they care deeply about human suffering, they want to do something about it. So I want to I want to thank you for listening to that, that voice inside you that called you. Yeah. You know, the purpose of this show is to explain the science of the brain and addiction. But below that purpose is is really the purpose of this show in the whole eight part series. It's to dispel and contribute to the eventual eradication of stigma, the stigma associated specifically with with with opioid use disorder, all substance use disorder, but but specifically with opioid use disorder, because it's so urgent right now. Yeah, do you care to speak a little bit about about stigma? Sure. Yeah, I think we that's a huge problem. It's a huge problem. And people not being willing to seek treatment. We have millions of people struggling with this in this country, who aren't willing or or don't feel confident that they could go in and ask for help. And a lot of that's because of stigma. They're afraid that their their family would reject them or they would lose their job or they would be kicked out of social circles, because of this problem. I'm hopeful that that's moving in a positive direction overall, in our country. But it's something that we really need to address, not only in the in the community, but even in the medical profession, where we need we need to do a lot more work to train our our colleagues about about how these illnesses occur and what's going on for them. I think you and I talked a little bit about stigma around beginning stigma around the first time that someone ever used a substance and the stigma about continuing to use a substance. And so we can include that in our in our conversation as well. And and you know, bring some information that we ought to use to fight against the stigma. Absolutely. Both the beginning of a substance use disorder and the perpetuation of a substance use disorder. Absolutely. And I want to I want to just say something to the viewing audience says that, you know, we're all taught, you know, how to believe or taught how to think. And, you know, we we seem to have been taught as a culture that addiction somehow is some sort of moral failing or weakness or character flaw or choice. It's not it's not really our fault that we believe these things because you believe what you're taught. Yeah. So I think I think our role today, part of our role today is to teach the general public. What is addiction? What is substance use disorder? Not based on old, you know, beliefs that are inaccurate, but more based on current science, the science that's been engaged in by the medical profession over the last 30 years. So with that, I just like to bring up this concept of choice. A lot of people believe that addiction is a choice that someone actually chooses of their own free will to engage in behaviors that lead to addiction. So I guess I would like to address causality first. What do you see based in science as the causes of addiction? Sure. Yeah, so I mean, that's been part of my area of interest. That's why I did a fellowship in working with kids and adolescents. Because understanding the understanding the causes understanding the risk factors for addiction is something that can help us a lot as professionals, not only to be more empathic and to be less stigmatized and less biased when people come in to seek treatment, but also to educate educate the rest of our medical professional colleagues and understanding better some of the early risk factors. We are now starting to understand more and more through science, through imaging, taking pictures, understanding that there are many, many risk factors that contribute to the development of substance use disorders. First and foremost, genetic heritability, just like other illnesses can run in families. Substance use disorders can. The heritability, which means a rough estimate in what part of this illness do we feel like is related to your genes and what part do we feel like is related to your environment? Obviously, it's not just two categories of risk factors, but the heritability we think is about 50 percent. We know is about 50 percent a similar heritability to things like type 2 diabetes, prostate cancer. So nobody chooses to get prostate cancer. Nobody chooses to have that higher risk. So even just across the general public, we know that there's, due to our genes, there's already a risk there for a lot of individuals, much, much higher than others. And then we look at sort of, you know, the genetic influence and we look at the environmental influence and we're starting to see more and more through some big studies like the ACEs study, A-C-E-S, that's Adverse Childhood Experiences Study, where anything that you had happened to you in your childhood as a negative experience can make you at higher risk for a substance use disorder for other mental health challenges. I do believe, I believe there's actually a correlation between the number of adverse childhood experiences a child is exposed to and the likelihood of their developing substance use disorder later in life. Yeah. The more adverse childhood experiences, the more likely you are to develop. That's correct. Yeah, that's correct. So we're talking about things like any type of traumatic experience as a kid, major medical illness, physical abuse, sexual trauma, major accidents, witnessing violence in the home, witnessing substance use in the home, all of those things start to stack up and you see that there are many individuals out there who have so many risk factors piled up for developing a substance use disorder. I think one of the statistics that I recently came across was that a child who is exposed to six or more adverse childhood experiences is actually 46 times more likely to use injectable drugs. That's profound. It's amazing. Yeah, the risk factors are very powerful and can really be harmful. And again, that's not a choice. Yeah. Children don't choose what environment to be brought up in or what type of adverse experience they'll receive from a parent or a stranger. They don't choose that. So what you're saying is then is that there's like a genetic component to risk and an environmental component to risk. It's not a choice. Yeah, correct. What about let's continue on that line then. So that's causality. It's not, oh, that person chooses a life of addiction. You know, you made your bed, you sleep in it. I'm going to, if I'm going to help you to change your behavior, I'm going to help you change your behavior by punitive methods. What about continuation? What about the continuation of substance use? Is that a choice? Well, we're learning more and more that there are actual biological anatomical changes in the brain that make it increasingly difficult to have executive function, meaning sort of our controlling and our planning stage. And we can we can talk about that. I think that idea of you made your bed, so sleep in it, and the punitive idea, we've really seen that fail. Yeah, we've really seen that fail in treatment of substance use disorders, both literally because it's not helpful, but also empathically and that just perpetuates the bias that we talked about. Absolutely. So maybe, if it's okay, we could go take a look at a couple of slides. Yeah, absolutely, doctor. Okay. Yeah, so I'm going to pull up a couple of the slides here, and we'll look briefly at this picture. And I wanted to give some credit to my colleagues at the University of Vermont Medical Center, Dr. Michael Godie, in particular, who helped put together some of these slides. But briefly, we can go through and look and help the audience to see a little bit about what happens in our brain when we're motivated for something, when we're driven towards something. So everybody has probably heard about positive reinforcement. Basically, when we like something, our brain learns to do more of that whenever we feel good about something. So that comes from an area here down in the deeper part of the brain, the brainstem that releases dopamine, which is the main neuro chemical in charge of reward that passes along to the other parts of our brain involved in our action and our desires to lead us to like that thing and to want that thing, to seek it out and to do more of that. Then we have negative reinforcement, which is a little bit the opposite, where our brain learns that things that feel bad, we don't want to do those things, we don't want to experience those things. So cells in the amygdala down here, again, sort of a deeper part of our brain, are stimulated by adverse sensations, adverse thoughts, adverse memories, and we learn to experience anxiety, fear, distress, and then we tend to avoid those things that cause the anxiety and fear and stress, and we tend to want to do the things that relieve anxiety, fear and distress. This frontal part of our brain, kind of up in the front behind your forehead, is related to our attention, sort of our cognitions and thinking through things, judgment, planning, they call it the executive part of our brain in the prefrontal cortex. So this positive reinforcement center and this negative reinforcement center both have connections and messages here that our brain over time learns cues, learns things that are going to trigger those reward pathways. So the classic experiment with Pavlov's dogs, where the bell rings and they begin to salivate, that happens in human brains. And then over time, we see that change and strengthen so that those cues become even more salient. They respond more quickly, they trigger us more deeply. Right here, I just wanted to put in here the don't think but act part of things, and that brings up an important point where there are parts of our brain that we want to function automatically. If I were to go out with you on the highway and blindfold you and take you and stand you in the middle of the highway and took off the blindfold and you saw a truck coming at you. You don't want to sit there and kind of think, should I run? Should I not run? You want something to kick in automatically and off you go and you run. So it's normal that we have some level of automatic occurrence in our brain. And so that's what happens here with with the anxiety and fear and distress signals is that often those sort of bypass the thinking and planning and executive part of our brain and create a behavior or a reaction or release of certain neurochemicals that make us do things. Well that is a really interesting description of this brain disease and opens the door to many avenues. So what I hear you saying is that there are actual neurotransmissions brain chemicals that are released in conjunction with the self-administration of drugs. And that process hijacks or subverts normal functioning. So that something that's been programmed through evolution and mother nature herself for survival becomes subjected to what we call addictive behaviors. So the memory of food would be replaced with the memory of the drug experience with the same kind of importance. I need food if I don't get food I'm going to starve to death. So the person with addiction has that same kind of feeling that same kind of emotion. I need drugs if I don't get drugs I'm going to die. How ironic that is. I like that word hijacked that you used and it's a very appropriate word because indeed these centers these reward centers these stress and anxiety centers definitely do get hijacked if we could look at one more slide to sort of show us some pictures. Let me pull this up and we'll talk a little bit about some pictures. I think sometimes we want to see something to believe something. And that's part of the bias I think that can happen in the field of addiction. If you break your arm and go into the doctor take an x-ray take a picture. Yep there it's broken. You know we see it we're ready to fix it. And so for a long long time we haven't been able to see anything. But that's not the case anymore. We're learning more and more through science through good research and we're able to see what's going on. So that's a little bit what I can show you in this in this slide. So this is a picture basically of the reward centers of the brain. Up here above the top one you can see sort of those darker orange sections down in the reward center of the brain. That's the that's them lighting up basically and responding regularly to rewards. When you see this bottom picture with the two yellow spots that's that's after somebody has had a prolonged period of chronic opioid use in this case chronic heroin use and you see it's a little bit cooler meaning that part of the brain is not lighting up as much. And so the reward center has actually been desensitized. It's been dampened. The things that should cause you joy don't cause you as much joy as they used to. And so your ability to seek out and find other healthy behaviors has literally become dampened it's happened it's happened in your brain. And then if you look if we look over here to the other side to the amygdala so the amygdala is one of the parts of our parts of our brain that's responsible for anxiety stress and fear. So this is a little bit of a double hit where you have the reward center that's desensitized and dampened and you have the stress and anxiety center that you can see here and you know these are these are difficult and I'm not an expert neuro neuroimaging person by any means but you can see the the white areas where that that part of the brain is lighting up for stress. You can see that it's lighting up flashing more in the case of again chronic opioid use. So if you can imagine having a combination of not being able to enjoy things that you wish you could enjoy or used to enjoy as much your reward center is dampened and then your stress center is active and bothered all of the time. It's it's a really unfortunate situation and and it's we can see it absolutely there absolutely and that's the the science that was speaking of that shows us that addiction or the continuation of addiction is not a choice it's a compulsion and the way you describe it is so impactful the double hit as you say the person is experiencing life life is gray life is no longer pleasurable yeah so they want to have that experience of pleasure again and the brain remembers drugs yep that's one very powerful motivation on the other side internally there's anxiety stress negative feelings caused by what you defined as the extended amygdala also pushing for relief so there's a drive toward positive reinforcement a drive toward negative reinforcement both very powerful yeah so if if I believe that addiction is a choice then I can look at what you just said and say okay so there's a double hit there's a very very powerful motivation for the person to reengage in the self administration of drugs if they don't want to do it why don't they just not do it yeah well that again that's been sort of a perpetuated a perpetuated feeling that leads to frustration that leads to discouragement at least the anger I think even people that work in the in the area of substance use treatment have those moments where we fall back to just stop you know what just say no yeah just say no but understanding this is important to to maintain our compassion to maintain our empathy and to fight back that bias and stigma I think we do need to be a little bit careful to make sure that we don't believe that this is so automatic that people can't change because that's one of the beautiful things we can talk more about is people can recover people can with treatment and help you know and one of the one of the other aspects so along along with this that idea of choice why doesn't the person just say no speak a little bit about prefrontal impairment like the person's inability to really say no you might have a person with this double hit that you've described that with every fiber of their being they don't want to go out and purchase a drug yeah and that their their brain is telling them no don't do it do something else yeah this is destroying your life what is it about this compulsion with the person actually does not have the neural transmissions to actually say no yeah yeah I imagine everybody could think back in their life to find a time where they did something that they didn't want to do mm-hmm and you're right about the prefrontal cortex so the frontal part of our brain that's kind of the executive part and the planning part in the decision-making part that we didn't we didn't bring that up on the neuro imaging slides but that part can actually be weakened to where literally the part of your brain that's that's helping you with inhibitory control that's helping you think twice about that decision that's helping you regulate your actions and behaviors because of the automaticity that that sort of nature of it of it continuing through a triangle and bypassing that part of the brain that it doesn't engage as well it's not as effective and so but again like we talked about it can become more effective again it will we'll see a little bit more as we talk that these parts of our brain can recover can heal with actual healing on on the level of like a neuronal level actually brain circuits healing yeah I've heard that described as like the double hit described as the go system go get that drug and then the prefrontal described as the stop system so there's an incredibly powerful go system and there's a literal breakdown in the stop system yeah so the person really against their own will will go out and continue to take drug because of actual measurable brain impairment it's not not a choice yeah I think that the people affected by substance use disorders are as surprised if not more surprised than their family members than their providers at this this at the lengths that they would go to to continue using a substance it seems baffling to us it's baffling to them at times they they they will have so much adverse experience they'll have so much so many consequences and and be frankly baffled that they'll continue to seek out that substance or seek out that behavior all the more reason for our compassion for our adequately funding early intervention and continuing care yeah the more the more we look at addiction today the more we realize it is a chronic brain disease it's not an acute occurrence like a broken arm you know where you go and get a set to get a painkiller you exercise your physical therapy and life is back to normal you don't have to worry about your broken arm ever again yeah that's acute chronic and with this disease model chronic disease model of addiction compassion calls for recovery supports over the lifespan yeah and sometimes extended treatment sometimes it takes a long time for a person's brain to actually heal so they can be safe yeah and not subjected to the recurrence of the self-administration of drugs yeah we want to talk a little bit about that about recovering about brain healing or treatment first treatment what kinds of treatment are available for people specifically with opioid use disorder yeah yeah there there are really effective treatments and we're learning more and more about them if you sort of overly simplify it you can identify it as therapeutic treatments individual therapy group therapy and those types of efforts and then there's also pharmacologic treatments medications that can be really helpful particularly for opioid use disorders there aren't medications that are helpful for every category of substance use disorders but for opioid use disorders in particular really there are benefits to the the medication treatments that are available you know viewers have likely heard of methadone or buprenorphine those are medications that are designed to target the similar the same receptors that the opioids hit buprenorphine in particular is a medication that's made to target those receptors sort of calm them in my mind to do a partial stimulating of those receptors but but can't sort of fully fully open the door basically it's kind of like partially opening the door so that the receptors can be sort of stabilized and and and it controls a little bit some of that automatic anxiety and distress that one is feeling when they're having a withdrawal okay experience all right and and and really stabilize them and again we're talking about biology we're talking about psychological and sociological factors to treatment and so I mentioned that biopsychosocial model that we talk about in medicine the treatment follows the same thing the biopsychosocial type of treatments and I talk with individuals often when they come in about that but we certainly have some good research and some good data about the biological treatment which we can do with medications and then we add on those those other interventions like the therapeutic interventions and then other ways that people start to make changes in their life so so so the idea then with opioid use disorder would be to avoid withdrawal from opioids we know is incredibly uncomfortable muscle cramps, body cramps, nausea, shaking, sweating, chills so people are kind of driven to to continue their self-administration which is one of the double hits that you were talking about so the idea with medication then or guprenorphine and methadone in particular is to give the patient the exact dose of an opioid that would interact with the receptors in the brain that would prevent them or protect them from going into withdrawal while that same dose would be low enough to avoid what we call opioid intoxication the person would be stabilized yeah yeah and it's about the dose but it's also about the way the medicine's made it's not a medicine that can fully stimulate those receptors all the way like opioids can like heroin could it's a medication that can stabilize the receptors to a partial sort of activation guprenorphine guprenorphine yeah and then the person would engage in other related therapies if they needed them yeah yeah and I think you know there's one thing that's important about our field is as you look across the treatment recommendations the available forms of treatment there's not one sort of snapshot or there's not one cookie cutter model that's perfect for everybody but you look in those different categories and you decide with somebody what's right for them what's going to feel right for them but you mentioned opioids in particular in the withdrawal it's unique among substances for that more than any other substance out there is what happens when there's a physiological dependence is is such a horrendous experience in someone's body and that's why I think it's fantastic that we have now treatments that can help people stabilize through that part stabilize cravings and then be able to put in all those all those other things I had a patient in the office just this morning an individual who was in tears telling me about trying trying to stop and how horrendous how horrendous it is despite all the motivation despite all the desire despite how desperately that individual had wanted to stop and just the experience and how how sick that individual became and what a poignant example of exactly what we're talking about she's in your office crying wanting to stop so that front part of the brain is working I really want to stop doctor but those other that double hit is forcing her to continue and I think in part of your notes that I I reviewed you said that there are were approximately 23 million people in America with substance use disorder approximately 10 percent receiving treatment and all the more reason for our culture to grow compassion around this disease and get these people get these welcome these people into adequate adequate healthcare absolutely especially when you look at opioids and the the fatality or the morbidity yeah the people dying out there every day from from you know both illicit and illicit opioid opioid use didn't you did you have a slide on on on treatment yeah yep yeah let's take a look at that this is a little bit what we what we just talked about there's behavioral treatment if you lump that together kind of thinking about therapy the decisions that people are making learning new behaviors trying to manage their environment making changes that are likely to help them be successful that sometimes means changing some of your relationships some people try to change where they live and so we try to reinforce and help that executive part of the brain thinking planning and and working through it at the same time we're looking down here where we talked talked earlier in deeper parts of the brains where nobody can think themselves out of that type of withdrawal and so again this is this is imaging this is an image to help us understand the the efficacy of simultaneously including behavioral components of treatment and pharmacologic components of treatment and if we look if it's okay with you if we look at the next slide I love to see this picture because we actually can see again sometimes we want to see it to believe it we can sometimes see with these images that we can recover this brain can become healthy again so the first one again a normal brain with those darker orangeish red areas in the reward center firing normally at about one month of abstinence from an opioid use disorder still seeing those cool parts of the brain sort of not reacting normally and then in this last picture 14 months of abstinence so you mentioned the need to for long-term treatment this is 14 months so that's a long time but you can see that reward center in the brain lighting up again in those orange and red colors like it normally should so then so then doctor that this person whose brain we're looking at now at that 14-month mark where the dopamine receptors are in live and the brain is functioning relatively normally that person would begin to feel pleasure in life at the more healthy and natural rewards that life offers yeah all right yeah and over the over the course of life say maybe at an extinct because I know a lot of people in recovery I know people in recovery for 10, 20, 30, 40 years and these people there are healthy they don't ever really think of drugs anymore they never have cravings maybe once in a while there'll be a mild craving because of some environmental cue or maybe a whiff of marijuana or they'll see bourbon or something there'll be an idea that there is no compulsion no strong drive whatsoever because is their brain is reorganized around life is that the case yeah yeah we have the science we have the information to sort of to back that up and to see it's delightful to see and to know and to talk with individuals about that all of those parts of our brain that we've talked about the deep parts of our brain the frontal kind of executive part of our brain they can recover and that the joy you speak of in my because I was a clinician for 30 years I've worked with this population and I understand that joy that you're talking about that the person is finally congruent I am living in line with the values that make me who I am I am no longer going against those values because I had addiction now I have the freedom really to make the kind of choices that I want to make in life yeah yeah I hear people use that word all the time freedom and they they can get there they can experience that freedom to enjoy the things that they want to enjoy freedom to use their time for productive healthy things yeah and there's a lot there's a lot of recovering people because of anonymity though we don't know who they are there are a lot of recovering people around who have become such contributors to this movement we see people in alcoholics synonymous yeah narcotics synonymous seven days a week supporting each other having meetings helping people find this one pathway into recovery recovery is a beautiful beautiful thing but very often it starts or and is not possible without without treatment yeah medical treatment yeah yeah now did you want to speak a little bit we have a few minutes left I know that you have training in adolescent psychiatry and also in addiction psychiatry yeah and from one of our conversations earlier I know the importance that you place on rightfully so on on adolescence as like a risk period in life do you want to talk a little bit about that yeah yeah yeah I do it's it's one of the areas where my sort of strongest passion lies so I'm glad glad to talk about that a little bit and something that I often feel like sort of shouting from the rooftops we'll look at a couple of slides but the earlier somebody is exposed to substances the higher the risk of developing a substance use disorder and there's a lot that we know about neurobiology about the anatomy of the brain that teaches us that so maybe I'll show another couple of slides I hope so this is a slide so synaptic pruning our brains when we're born have neurons that aren't as connected as they're going to be later in life and so if you think if you think about a new brain as as not very sort of connected and not wired to itself in as many ways children are starting to connect and attach to everything and so you see this brain at seven years of age it looks like a little bit like chaos you know things are just all the neurons want to talk to all the other neurons and then in our teenage years what happens is we start to prune if you think about sort of trimming back a tree we start to prune out what we're going to not need so we come primed as little kids ready to learn Japanese or learn English we learn we're ready to learn a bike we're ready to learn the trumpet or learn the violin and unfortunately in that way we're also more prone and more ready to reinforce or learn negative things in our life so the earlier that that exposure happens the more vulnerable the brain is this slide I'll explain very briefly but basically as the brain becomes more blue in this picture obviously our brains aren't blue but as it becomes more blue in this imaging picture that's just a more mature brain and you talked about stop and go teenagers go centers get efficient and get developed sooner than the stop centers and there are reasons for that teenagers don't just have you know broken adult brains or half-baked brains there there are reasons for that and but I see these as sort of amazingly vulnerable brains that are learning over time as they as the neurons develop the neurons can can pass signals a thousand times faster than they could when they were first developed and they can send the signal 300 times more often in their brain and so any young person their brain is basically developing and while it's developing it's a much much higher risk and so I'll show just a couple of these graphs here is a is a graph that shows sort of for those that went on later in life to develop a substance use disorder when that started and you see that happening in the in the mid to late teens and here just talking about prevalence of substance use disorders so look how big of an increase there is from you know middle school into high school and then by the end of high school is when substance use disorders are happening so lastly I guess I would just show that this immensely increased risk of developing a substance use disorder the earlier you start so if you if an individual is exposed to substances before 15 which sadly many of the people that we work with had been there's almost a 30 percent chance of developing a substance use disorder compared to a much much smaller chance of people never exposed or never experienced or are exposed to substances in their early life that's incredible so that's incredible so the message then and we all know it is that I mean because we've been adolescents the adults in the viewing audience know it is that adolescents is a very very difficult developmental time yeah to introduce the self administration of psychoactive chemicals during that time is extremely risky yeah and and I think we need to note that we're not talking really about opioids at this point now we're talking about tobacco yeah we're talking about vaping nicotine we're talking about beer yeah we're certainly talking about marijuana yes you know marijuana interferes with the endocannabinoid system which is responsible for connectivity during brain development yeah you know I mean we you know these drugs all these psychoactive chemicals and some of them would become kind of friendly with we don't think they're that dangerous they are dangerous so the parents you know in the audience really need to understand that prevention programs we need to put money into prevention programs yeah I can see that why that's your your burning desire and your your passion yeah there's so much opportunity there for for lasting success and preventive work yeah yeah yeah yeah we spend much much more money time and energy on treatment than we than we do on prevention and we've got to keep both in mind so you know we don't have we have only a few minutes left now I guess I'd like to just have one comment on you know you know we have the the medical profession and we have the counseling profession we have a prevention out there the the what what do you see is like the importance of the community really getting behind this now at this point in our history it seems like there really is a sea change occurring we're on tv talking about it mm-hmm the governor's council is studying it money is being poured into it we're doing something about it what do you see as the importance of community involvement regular regular people our viewing audience do you think that's important for them to support this yeah I absolutely do and we we talked about bias we talked about stigma individuals who have struggled with this need support they need support not just in a doctor's office but they need support in the community yeah I think I think we are seeing a sea change as you mentioned as you know coming through my training I feel like I feel optimistic at this time I feel like both public policy insurance coverage decrease in bias amongst medical professionals and amongst the community I feel like we're moving in a good direction and we just need to we just need to keep keep going I share that with you I'm so happy to be a part of this we had a recovery walk in Burlington this past summer mm-hmm and it was a bunch of recovering people I'm going to recover myself a bunch of recovering people we had our t-shirts on we were marching down Church Street and all the people shoppers tourists Vermonters passersby we're all screaming yay you know keep it up nice going and it was just a real cultural sea change that we need to really apply effort now to keep this moving in the right direction I agree with you 100% I guess in closing I'd like you to you know remark or just talk to the viewing audience what would you like to say in closing, Dr? I guess I'd I guess I'd like to say maybe I'll recount a story briefly when I started my clinical years of medical school literally the very first patient I saw the very first morning of my very first clinical day was an individual who'd been struggling with all kinds of infections all kinds of infections and nobody could figure out for a while what had been going on this person had been in the hospital many times and they were looking for autoimmune diseases etc etc and one morning when the nurse walked into the room they found the patient using an opioid illicitly and I saw the most disappointing and discouraging change come over the treatment team and the people interacting with that person where for some reason if this had been an autoimmune disorder we were going to rally to this person's support and we were going to we were going to fight with them and their family and then all of a sudden when it came to light that it was likely related to a substance use disorder people seemed to want to give up and get angry and be frustrated sure I feel like that was an interesting experience for me the individuals family member their spouse was one of the few people who to me didn't didn't turn and didn't didn't change their desire to stand by this person and work with them which I thought was remarkable and so I think the message that I that I would encourage us all is that these this is an illness this is a disease process it's something that we now we now can see that we're understanding better and better it's something that's treatable it's something that we should cheer for and cheer on and individuals should feel welcomed into treatment they shouldn't feel shunned when they disclose this to somebody and we should we should like like in that walk that you had we should be cheering this on like crazy because it can it can be so so destructive and when people recover it's an amazing thing to watch thank you I thank you and I would just like to invite the audience there are eight segments to this particular show and I want to I want to thank you from the bottom of my heart for being here today yeah and for your dedication yeah thank you for having me thank you it's been great to be here