Hi, I'm Susie Newell. I'm a DMP CRNA. I received my DMP from the University of Cincinnati and currently serve as adjunct faculty there. I'm also on the board of the Ohio State Association of Nurse Anesthetists and I am the PAC chair, so I am encouraging you to give money to your PAC as always. My DMP project from the University of Cincinnati focused on substance use disorder and coping mechanisms for women and I have no conflicts to disclose. These are the learner outcomes. Develop a professional understanding of how substance use disorder fits into the disease model and apply that understanding to perioperative care. Identify resources available to the patient with substance use disorder and identify important drug interactions of illicit drugs and medication-assisted therapy drugs. So why am I here? Why am I doing this lecture? Despite what I have done with my research, there was a whole life ahead of that before I started doing this work and on January 3rd in 2017, in a motel somewhere in California, my sister Kathy overdosed and died at the age of 53. Her daughter Shannon, who was five months pregnant with her first child, called me from Minnesota at 3 a.m. crying. She didn't have to tell me what happened. I knew when I saw Shannon's name through half-open, bleary eyes why she was calling. Kathy just couldn't or wouldn't get sober. She didn't see herself as someone with substance use disorder. With her master's in education, her three college-graduated children, she spent so much time trying to look normal. She lived in constant, deep shame of the horrifying fact that she was addicted to pills. Her shame, in my opinion, was what kept her from getting sober. She just couldn't be honest about her disease and therefore she couldn't take the necessary steps to heal. This is why I'm here. This is why I'm having this conversation with you. It's that shame that pervades every aspect of working with patients with substance use disorder that prevents us as providers and them as patients from getting healthy. My first shift back at the hospital after the funeral, I had placed epidurals in three patients in active heroin abuse. This actually isn't rare in Mansfield, Ohio. I work as a CRNA on an obstetric unit there where the substance use disorder rate is close to 20%. Prior to Kathy's death, I couldn't see a path to create the change that I wanted to see in the world of addiction. I wanted to create a world where the response to a positive toxicity screen from the provider would sound something like this. I see you have a high level of alcohol or heroin or amphetamines or cocaine in your blood. Substance use disorder is a disease and we have many treatment options. We have consulted addiction medicine and social services to review your treatment. In my family, it's quickest to say who doesn't have issues with addiction. I have a grandma and aunt who weren't alcoholics. That's it. I got sober so long ago that I have never been forced to share my disease in healthcare. I have chosen not to share this information because of the stigma associated with substance use disorder. This event changed my mind. Jack Stem is a retired CRNA, a chemical dependency counselor, and the chair of Ohio's Peer Assistance Committee. He said to me, Suzy, people need to know that long-term recovery from substance use disorder is achievable. I said, do you really think people need to know that I got sober young and relapsed after 10 years briefly and dramatically in my 30s just to make sure that I was good and truly addicted and then stayed sober for another close to 17 years? He said yes. I started working on my obstetrics unit for mothers with substance use disorder and began researching the world I already knew so much about. Because of my unique background, working with peer support groups in my personal life, I was able to start a group called Moms Getting Sober. My goal was to try to help beat down that stigma on my unit and perhaps guide some women into recovery from the disease. I also wanted to introduce the concept of substance use disorder as a disease to anyone and everyone. Not just the way we say, yes, I know it's a disease, but introduce the concept of treating it as a disease as a healthcare system. Enough of the mushy stuff. Let's get to the grit. This is a fascinating map showing death by overdose rates across the country. You will know it if you work anywhere in about a five-state area of Ohio, you are in the epicenter of the drug crisis. We really need to understand how to combat this stuff. Incidentally, death by overdose is largely a narcotic or opioid metric because that's where we see the most death by overdose. Statistically, methamphetamine is on the rise again, particularly out west. There's different hotspots all over the country for different drugs. Death by overdose in my area in particular is off the charts. The ignorance about how bad it is was really brought home to me. After this point with my sister, when I started doing this work, I was out at a conference, a society for obstetric anesthesia and perinatology conference, the eggheads who decide all the things we do in obstetric anesthesia. I was attending a lecture about substance use disorder in the obstetric patient. I remember it really clearly because I had my suitcase there. It was the last lecture I could attend to make my flight on time. I remember it really clearly being really excited about hearing what they're going to say. What are we doing as a country to combat this stuff? This gentleman gets up there and he says, did you know that in some parts of the country, they are still prescribing opioids for vaginal deliveries? I thought, oh, dear God. I heard the woman next to me groan and just put her hand down. I looked over at her and I said, where are you from? She says, Ohio. We completely know this. We know the problem with prescription. We know the problem with these communities. We see it every day. We live it every day. I realized at that moment that nobody was going to take this bull by the horns and that we needed to start having a conversation ourselves in anesthesia about what can we do, at least in our little part, to make a difference. It's still a problem. Prior to when I first started working with this stuff openly, it was everywhere. You couldn't open the news channel without hearing something about the opioid crisis and how terrible everything was. Then, of course, something happened in 2020 that took away that news flash. However, the highest number of deaths by overdose recorded in the CDC's history was in 2020. This is a huge problem and probably worse than it was for reasons that we can all speculate on. There are a million ways to classify drugs. There are a million ways to classify what drugs do to you. Effects on the brain, morbidity and mortality, affinity, all of them have their validity. One of the current trends is to gauge substance use disorder not on days of abstinence from a substance, but to look at reintegration into a functioning life, to look at the reduction of harm in a person's life. Drug harms is the degree to which a psychoactive drug is harmful to a user and is measured in various ways, such as addictiveness and the potential for physical harm. This was basically a conference of top addiction medicine specialists in Australia using multiple criteria decision analysis to classify drugs based on these 16 categories. I love showing things like this. Don't think that just because it's Australia, it's so different in the United States because I could find some information about the United States, but this was so comprehensive. I wanted to share their particular study. Alcohol is always first and it's uncomfortable for people to hear that. Alcohol is a drug and it is our most destructive drug because of a million different reasons, but understand that when we talk about substance use disorder, the biggest problem we have in every single country in the Western world is alcohol. People who work in substance use disorder will always say, well, yeah, of course, I mean, everybody drinks. The harms overall assessment, of course, is huge, your injuries, your accidents, and it's the most recordable. That's just a little, guess what, alcohol is still a problem. The other thing that was interesting to me is that crystal meth was second. Crystal meth, like I said, is on the rise in the Western areas, but if you'll notice, heroin, fentanyl, methadone, prescription opioids all have separate categories here. I'm not sure how accurate the opioid crisis would be in comparison to crystal meth if you combine some of those. The other thing is the synth cannabis. This is such an interesting phenomena. Well, not interesting, sad, tragic, I'm not sure what you want to call it, but the synth cannabis is things like the bath salts that you hear about, these dramatic handmade cannabinoids and drugs. Really what it comes down to, I have had several meetings with the Mansfield Police Department because they have this great Richland County Opioid Council. The Mansfield Police Department will tell you unequivocally that if there's a big drug bus and they grab the drugs and those people tell you what drugs they are, they are inevitably not the drugs they said they were. Nobody on the street is getting the drugs they think they're getting. That's why we have all of these crazy incidents where there's carfentanil, there's things that are killing people flat out. We are in anesthesia, so we know that a heroin addict is not going to die from fentanyl, but they will die from carfentanil. The rest of people think, oh, fentanyl, but a heroin addict isn't going to die from fentanyl, they're going to die from an elephant tranquilizer. That's just a little clarification for us out there. There's so many additives in these drugs that people are getting that they don't even know what they are anymore. All right. What is your self-assessment here? What describes your attitude about those addicted to drugs? Is it a chronic relapsing disease? Is it a curable disease? Is addiction a weakness? Addiction is completely identifiable in your genetics. Some of you in your head are it's a weakness. I understand that. I do. I really do. It's a tough concept. It's a tough subject. If you said it was a chronic relapsing disease, you're right. I've been sober most of my adult life. That's a great fortune for me. I grew up in Minnesota, which is the home of Hazleton and all of these great treatment centers. They wrote the book, so I actually knew what treatment was in high school. They had a lot of access to that kind of information for me. When I did struggle, I was able to get help, and that is why. I did relapse in my 30s. I had that classic, they put me on a pill for a neck pain, and I just started chewing them down like candy. Back then, they handed them out like candy. I think I had 150 pills or something like that. By the time I was done with that bottle, I had a journey. My relapse almost destroyed me. It's definitely a chronic relapsing disease. It doesn't go away. We will talk more about that later. Here's the theoretical science behind it. I'm sure you've all heard about the brain disease model. This is the accepted disease, current disease model. Over time, continued use of mood-altering chemicals causes changes in the brain systems involved in reward, motivation, and memory. The brain tries to get back to a balanced state by minimizing its reaction to those rewarding chemicals or releasing stress hormones. As a result, a person may need to use increasing amounts of the substance just to feel closer to normal. There's a couple of things that help you kind of understand how this works. One of the things is, and I share this with addicts all of the time. If I use the term addict, I apologize because that is my vernacular, and I come from that world. I realize that there's a patient with substance use disorder, and I apologize if I'm doing that. The patient with substance use disorder comes to you, and they've had been addicted to opioids for some period of time. I like to say to them, hey, when you hit your shin, do you notice how much that hurts more? It's just so profound. they always say yes, and this is because the body uses pain as a protective mechanism. So when you are damping down that protective mechanism, if you're constantly taking something that is damping that, your body grows more pain receptors. It says, hey, you're not feeling pain. I need you to feel more pain. Here, let's grow more pain receptors. So what you find is people feel pain, actually feel pain more acutely when they are addicted to painkillers, any kind of painkillers, than people who aren't. And that's why we have such a difficult time catching that pain response with mu receptor drugs, because you can just keep giving it to them, and it's just not going to do anything for them. The flip side, or the other side of that, or the other part of this, is the same thing happens with your stress hormones. When you're constantly damping down your emotional response to things, your body creates these surges of hormones that respond to that damping down, same as with pain. So what happens is you take all those drugs away and those hormones go, and these people feel like they're dying. They're dying. They feel like they're dying. And it's not a fake thing. It's a real thing. They need that drug so badly just to feel normal, not to get high anymore, but just to feel normal. So that's the real speak about what the brain disease model is. Paired with ever-increasing image technology, researchers have been able to identify a number of consistent physical characteristics in the brain that support the concept of addiction as a brain disease. This is a neat little graph showing studies that have linked dopamine depletion to specific drugs. Again, look at alcohol there. Alcohol is a big depleter of dopamine. So that's kind of interesting. And here's some more evidence. And what I like about this is that we hear people kind of argue this brain disease model, and I'm going to talk about the healing from that. Here is direct evidence that after four months of cocaine use, your dopamine receptors are basically absent. Can you imagine how someone feels when they take the cocaine away, which is their substitution for their dopamine? They feel like they're going to die. If you have zero dopamine, how are you feeling? You feel like the four horsemen are upon your back. It's terrible. There's genetic research. So although we don't know the exact genetic markers, we are getting close to understanding how the genetics of substance use disorder work. The genetic connection was studied initially in the famous 1991 twin study at the University of Minnesota, where I graduated with my political science degree in 1991. So I remember this very clearly. You might not, but it was very fascinating. This is a study where the twins were separated at birth and not purposefully, but they were separated by birth and they went back and studied these people. We know from these studies that there are specific brain circuits that modulate well-defined higher order personality traits. And these traits have been inextricably linked to specific gene associations. So overall genes involved in the regulation of dopaminergic system have been found to be important for substance use disorder. It is known that substance use disorder exerts broad effects that extend to several neurobiological systems, including glutamate. So moreover, examining the role of peripheral systems like the brain gut interactions is an exciting new area. And that's a whole nother presentation. We have a saying in addiction that once you're a pickle, you can't be a cucumber again. And it's a fine line between addiction and problem drinking or abusive drinking. This helps explain what people like to call the genetic switch. Some people can party hard for more than a minute, but never actually become severely addicted. Once the brain starts to require that substance, like we talked about, that the four horsemen are upon my back just to feel normal, the patient will need full treatment. Ultimately, what we're fighting is the theory that people are weak because you have examples in your life. You know someone who just quit without any help. What is fascinating about that person is they're probably not truly severely addicted. In that state of the disease, the folks who develop things like the diagnostic and classification standards for the DSM-5 understand this and have staged the disease creatively titled at risk, mild, moderate, and severe. Classic addiction with absolute loss of control and hijacking of the brain doesn't happen until the severe stage. Until that point, people do have some choice over their actions. So you have an uncle who just quit or even more confusing. He only drinks occasionally now. That means he never flipped the switch. He never hit the brain hijack phase of the disease. He was never severely addicted because once you're a pickle, you can't be a cucumber again. Without a complete brain reboot and total abstinence, people who are severely addicted cannot make it. I had over 10 years of sobriety when I had that incident in my 30s. It was like not a day had gone by. My brain went and immediately was like, and I must have depleted those dopaminergic receptors like that. I think people who haven't had that process happen in their brain before probably don't struggle with those feelings, but I didn't. I went right back at it. It was like itching on the inside of my brain. I will never forget it. I'm so grateful that I was able to get through that period and continue forward because I had the information I needed to get out. Let's look at it in another way. Which disease does this describe? You subscribe to a lifestyle changes and get off medication or you require slight medication assistance or you require constant medication regulation and relapse prevention. Are we talking about substance use disorder or are we talking about diabetes? Someone who subscribes to lifestyle changes can lose a hundred pounds and get off medication completely, or maybe they lose 75 pounds and need or even lose a hundred pounds, but still need a little bit of medication assistance to regulate their insulin requirements or they can't lose the weight and they just require constant medication regulation and relapse prevention. What are we talking about here? Are we talking about substance use disorder or are we talking about diabetes? Thinking of the disease this way, I googled resources available for the patient with diabetes. The first thing that comes up on the list is the American Diabetic Association. This is an organizing medical body that sets up standards of care. It tells us how we should treat diabetics. Then you have the patient coming into the hospital. What happens when they come into the hospital? They have prompt diagnosis. They get immediate treatment for their blood sugar of 427. They have diabetic educators, dietary educators. We have diabetic navigator nurses. We have contacts for supplies. You can even get financial help to get those supplies. There is an endocrinologist that gets consulted once the diabetes is diagnosed. This is how we treat this chronic relapsing disease. Then I googled resources available for patients with substance use disorder. Somewhere after several money-making treatment centers, and mind you, I think treatment is important. I do. I think it's absolutely important. Somewhere after that was the Substance Abuse Mental Health Services Administration, which we all call SAMHSA. It is a very important resource for people who work with substance use disorder. It's a government body though. It's not a medical body. It doesn't create standards of care. It just has resources. The resources available in your hospital for someone with substance use disorder, maybe you have access in your community to a detox, but you probably don't have detox in your hospital unless you have a major center that has extra care for patients with substance use disorder. Overwhelmingly, most hospitals don't have a detox center, even though this is one of the most common diagnoses in our country, but we don't have detox centers. Maybe we don't even address the issue. Maybe we say, stitch up that patient in bay four, and then let's get out of here. He's an addict. I don't think people are intentionally cruel. I'm not saying that you all that are listening to this are this way. I'm saying as a community, we don't have the capacity to treat this diagnosis. It makes us uncomfortable and we don't know how to do it. That's why we're talking about it. Like I said, we do this poorly as a healthcare system. National Institute on Drug Abuse Statistics can tell us there's an astounding cost on healthcare and society. The most recent estimate states abuse of tobacco, alcohol, and illicit drugs is costly to our nation. It is annually $740 billion. Costs related to crime, loss in work productivity, and healthcare. Unbelievable. Yet most healthcare systems, little or no treatment options available for the substance use disorder patients. What are we doing? The trends right now, the huge buzzword is MAT. Medication Assisted Treatment. This is largely for the opioid crisis, but there are some alcohol related meds out there. Let's take a minute to review those drugs and drugs and what their effects are on anesthesia. First of all, I just want to point out that the AANA resources for analgesia and anesthesia for the substance use disorder patient is bang on. It is perfect. If you want this information, make sure to look that stuff up. It is exactly what you need to be doing and it is very current. Suboxone is buprenorphine and suboxone with naloxone is... Suboxone is buprenorphine with Narcan. It's subutex with Narcan is what suboxone is. Then buprenorphine by itself, we call subutex. We call these the subs. Suboxone, we don't want them to have a dose the day of surgery because it has Narcan in it. Good news though, intrathecal morphine can be used safely with both of these. In fact, if you think about it for a second, it actually statistically shows that if you have a little bit of suboxone and use intrathecal morphine, you can have less itching. That's nice. It cuts down on puritis. Subutex, you don't have to do anything with that. It's really just a partial mu agonist. It's just another painkiller basically. It does not have any naloxone in it. It's important to consult with the patient's addiction professional and or MAT prescriber to determine if the patient should remain on the buprenorphine. Vivitrol, naltrexone is the latest and greatest. It is just a reversal agent. This shot that you get, Vivitrol shot, you need to be trained to give it. It's a big deal. This is why we're talking about training MAT providers all the time. It is really long acting, 30 days. You need to discontinue 30 days prior to surgery and start on oral naloxone or I'm going to say Vivitrol, oral Vivitrol for at least 72 hours before, or you need to start on oral naltrexone and then discontinue that 72 hours before elective surgery. It's pretty complex if you're going to have surgery and you're on Vivitrol. Patients should be off opioids for at least three to seven days before resuming therapy. Emergent procedures, you need to optimize non-opioid methods. All of our literature out there and all of the buzz about opioid-free anesthesia, that's where this is crucial, vital if you have someone with Vivitrol. I would argue that anybody that struggles with substance use disorder, particularly the opioid, you should be looking at using opioid-free anesthesia, not because they don't deserve opioids, but because if you think about the receptors, you want to hit receptors that aren't mu receptors. These guys, you are not going to catch these people with mu receptor drugs. You want to be looking at your ketamines. You want to be looking at Prozodex. You want to be looking at all of, of course, the anti-inflammatory drugs and COX-2 inhibitor. You want to make sure that you are catching them in places that aren't mu receptors. That's really important to look at because I think sometimes we're like, how do I treat them? I don't want to give them drugs. You absolutely want to give them drugs. You want to give them more drugs. You want to give them effective drugs. You want to try to prioritize non-mu receptor drugs. I think I talked about that later too. These are some of the older school drugs that we use that are medication assisted treatment. Methadone is a full-on opioid. It's thought to be an NMDA antagonist, so it blocks the icky feelings associated with withdrawal. It's very old school. It's a little out of favor since the advent of suboxone. Although the subs aren't the great savior they were originally billed to be, the strong mu receptor effect of methadone are still debated in the literature. Statistically, there doesn't appear to be a strict advantage of one over the other for days of sobriety while you're on them. So they consider you sober if you're not taking other drugs while you're on the program. But there may be an advantage of transition to long-term drug-free recovery. It's debatable, but in plain speak, what that means that if you're on methadone, you will stay upregulated or like they say in the biz, triggered for more severely than when you're on suboxone because methadone is a full on mu. I mean, it's a good drug, right? So they're going to stay a little bit triggered. They're going to kind of want that drug a little bit more than they will if they're on suboxone. So statistically, while they're on the drugs, they have the same success rate, but suboxone may be the choice for the person who really wants to get sober and wean off that kind of maintenance. And then I just want to take a second here to talk about how we can be a little bit judgy about maintenance drugs. And I certainly was victim of that. I was like, well, why are they on that? And the evidence is clear. People have your drug harms and your lifestyle can return to normal if you have medication maintenance, just like we shouldn't judge the person. I mean, we shouldn't judge, right? But just like we don't judge the person who is the diabetic, who has the need for maintenance. This is the same thing. Statistically, these people stay sober longer. They need this help. Let's help them. So that's my little say too about that. The other two, these are kind of entertaining. Acamprosate works to reduce alcohol craving and there's no alcohol consideration with this. It's stabilized, it's that same NMDA antagonist where it decreases those icky feelings of withdrawal. Disulfiram, this is anti-abuse. And I love this because my grandfather was on this. My grandmother who was born in 1903 gave this to my grandfather every morning at breakfast so that he wouldn't drink. It basically makes you allergic to alcohol if you take it and you puke your guts out and get super, super sick if you drink. So it's just a physical preventer. And I hope that we deal with some more of the issues now. So the drugs that we come into contact with and the things that we have to consider in anesthesia are the next few slides. Alcohol, something you don't consider, that liver disease can lead to some coagulation issues. We need to look for bleeding, bleeding, bleeding when we're talking about alcohol. That's a big one. The things that can help you anesthetically, you know, our Presidex, we love our Presidex. Lorazepam, halperidol and clonidine. Resistance to anesthesia is true probably with every drug. So just be aware that, you know, these patients are all upregulated and you have to be creative about how you give them treatment and how we treat pain. Same thing's true with alcohol. Here's some interesting things. I did not realize that cannabinoids, marijuana or cannabis leads to some baseline EKG changes. So if you want to take a look at that and see what that says, I thought that was kind of interesting. Upper airway irritability. Remember these guys are smokers. Like I love when people are like, I don't smoke, but I smoke pot every day. I'm like, you're a smoker. So you want to look at some decadron, maybe even lidocaine on induction for that. Cocaine, any of the amphetamines, cocaine, methamphetamines, any of the amphetamines, if we can cancel the case, cancel the case, because there's so much evidence that they have the potential to, you know, go flatline. So I think we all know that. That's something that we're all kind of freaked out about. Again, there's our Presidex. It's helpful with the hypertension and CNS excitability. So, you know, just be very aware that when you have these amphetamines that you're going to have to treat their heart rates. And no beta blockers, please, no beta blockers. Heroin, we've talked about this. Something to consider is their guts slow down to nothing. And remember, like, that's, you know, part of our ERAC protocols is we want to have gastric, improve gastric emptying. Well, these guys have trouble pooping like crazy. So they're going to have those issues. You have the same coagulopathies from the liver disease. You also have, you know, those hectic heroin addicts with their, you know, malnutrition issues. Again, we talked about the opioid sparing techniques and all of those non-mu receptor alternatives. Ketamine, this is on the rise, is my understanding. A lot of confusion there. A lot of horror feelings. And so you want to make sure to give some benzodiazepines and Haldol. MDMA, ecstasy. There's an interesting thing that can happen here is a serotonin syndrome. So that's a big thing with MDMA and they can go into severe serotonin syndrome, like pyrexia, overheating type of scenarios. And this one, if you can avoid doing anesthesia, please avoid doing anesthesia here. If they are positive for any MDMA or ecstasy or anything like this, do not give them anesthesia. If you have to, be aware that you are looking at the potential for rhabdomyolysis. Methamphetamines, same thing really as cocaine. Both with cocaine and methamphetamines, remember to watch your nasal tubes because you can go right up to the brain. I think we've all seen that picture of the nasal tube in the brain if they've destroyed their inner structure of their nose. Always heart attacks. These people are sick to begin with. So we have to just treat them as very sick, very high risk patients. Opioids, again, same thing. Gastric emptying, coagulopathy, liver disease. We use the opioid sparing techniques and the ketamine. So that's our kind of clinical side of what we do for anesthesia. What can we do to make a difference, right? What can we do with all this information? What are we not doing? First, you have to address the problem. If we're really going to make a dent in this disease, we need to treat it. We need to address it. High blood pressure equals treatment. High blood sugar equals treatment. Positive tox screen should also equal treatment. Sometimes this is tricky. I'm not asking people to become bedside counselors. I am saying that we are the ones who can take the stigma out of the conversation, take the shame out of the conversation. At the very least, a couple of screening questions can open the door to address the problem. Hey, I see you have a heroin problem. We treat substance use disorder as a disease here, and here are our treatment options. We have to know what those resources are though. And like we talked about, they may not be very available in our institution. This is where we can actually be the advocate. Find out what's available. Maybe have a pamphlet made up just for surgery. I guarantee you someone's trying to do something in your hospital. Find out who those people are. Make it cohesive. Don't reinvent the wheel. When I started this process in Mansfield, I found out there were things in our whole Ohio health system that were going on, and they were starting to have committees within my own hospital, and they didn't know what I was doing. I didn't know what they were doing. We didn't know what each other, and we found out we got this committee together, and we were able to kind of start to make a difference. And now we have an addiction medicine physician on staff, which you would think in a place like Mansfield that would be a no brainer, but of course you have to justify the cost and the need for it. So fortunately, the system is starting to recognize that we really need to treat addiction medicine as a valid concern for everybody. And so find out what's going on in your hospital. If you're not interested in substance use disorder, it's no big deal. You don't have to save the world. I'm not expecting everybody to do what I did. But just like any other disease, we are responsible to know how to turf it. Just like any other specialty, we aren't expected to be the experts, but you can get the ball rolling. The problem is with substance use disorder, unlike any other diagnosis, usually there's not an organized response system for this disease. Demand that surgery has a way to respond to it. Find out who in your institution can take the consult and make sure that's addressed. Sometimes there's a family practice doctor in the community that really is connected with the substance use disorder community. Sometimes that can be, that alone can help channel people to the right place. I highly recommend finding out what the treatment centers offer or where the closest, at the very least where the closest detox center is and make sure that your system is responding to this disease as a disease. Here's the deal. We can't throw a pill at addiction medicine. So the current healthcare system is ill-equipped to really know how to deal with it. There's zero pharmacological cure for substance use disorder. Pharmacological management of substance use disorder is sometimes important, but really not effective if we don't address the whole problem. Here's what we know about substance use disorder. Peer support is imperative. And by this, we mean development of coping mechanisms and a support system. Attention to physical activity is important and it's part of the coping mechanisms. You have to develop these endorphins and the ever controversial mind-spirit connection, the brain reboot. First of all, this is my term, the brain reboot. I use this because of the intensive work that goes into the full recovery from substance use disorder. It's complicated. This is a place where we teach our brains different response pathways and we redevelop the ability to create endorphins that keep us functioning normally. This can be meditation, yoga, a spiritual path, religion. The point is it can't be just do it, just figure it out, which is kind of sometimes what we do right now as a society and as a healthcare system. There needs to be a government and a healthcare system. There needs to be a guiding principle that allows your brain to exercise a new pathway to do this hard reset. That's why things like AA work. That's why things like finding God works, religion works, meditation works for people who don't believe in any kind of thing, like meditation and counseling, that can be all you need. I often am entertained by the literature trying to quantify this process because serious research doesn't want to sound like they're talking about God. If a belief in God is what reboots Karen's brain, we don't care. It's my saying, I don't care how you get there, just get there. Peer support and the work done on rebooting the brain takes months and months and months of active participation in the recovery process. And I believe that science is way behind because we've treated the addict like a social service problem instead of a healthcare problem. Just like a stroke victim needs to retrain their brain, an addict requires the same attention and time. We are a little more complex than a PC. You can't just turn us off and reset us. It takes more than a minute. If you combine the dopamine depletion factor, there are weeks to months for a person to literally lift the haze off their brain and learn how to function clearly without drugs. The good news is there's a lot of science behind this. Studies, meta-analysis of peer support, and frankly, my own personal experience tells us that we can do this. I will direct you to my website and you can find a plethora of current research equating a mind-body-spirit approach to rebooting the brain to create positive mental health. Or like I like to say, positive health. It's just health. This is why I'm proud to be a nurse. There is no other specialty better equipped to handle this crisis than nursing. My goal is that facilitated peer support groups are in every hospital someday, that nurses will facilitate this group because healthcare will understand that this is actually the treatment. There will be substance use disorder nurse navigators, substance use disorder response teams, doctors, nurses, and nurses. And I'm sure there's a lot of people substance use disorder response teams, detox centers in every hospital, universal substance use disorder treatment pathways that don't just involve, here's a pill, because giving someone a pill can be helpful, but it's not the answer. When someone has a positive tox screen, we don't just go, hey, there's an addict in Bay 4. We say, we need a substance use disorder consult on Bay 4 and the wheels go in motion. Peer support itself has solid evidence as well. Last year, a Cochran meta-analysis study published that showed that peer support groups are as effective as inpatient treatment. In fact, they're more effective in keeping people sober over time. My work is based on several studies that show that facilitated peer support associated with mothers and pregnant women have higher success in both outcomes for mom and baby. Women are vulnerable at this time. It's a great place to introduce a peer support program. On a personal note, when working toward my doctorate at the University of Cincinnati, we had the revolutionary idea that my work with women with substance use disorder should be available to everyone. I had developed a program that focused on coping mechanisms for women. This work and my experience with peer support weren't exclusively for women with a diagnosis, but rather could apply to anyone. So I wrote the book. If you're looking for more resources and more information about the evidence-based practice behind MindBodySpirit Reboot, go to the path365.com and look under the research tab. I have lots and lots of articles there. And that's it. Thank you for your time. These are my references.

substance use disorder

opioid-free anesthesia

peer support

stigma reduction

holistic treatment

healthcare systems

evidence-based practice

recovery resources