Welcome to the RCG Family!

1. Welcome to the RCG Family! Welcome to the RCG Family!

2. Is there a difference? Physical dependence to opioids means that the body relies on an external source of opioids to prevent withdrawal. Addiction is a condition(disease) manifesting as uncontrollable cravings, inability to stop using a drug despite adverse social, psychological, and/or physical consequences. It is also accompanied by the need for an increased amount of a substance as times goes on to achieve the same desired effect. Opioid addiction is accompanied by tolerance, physical dependence, and withdrawal syndrome. Is there a difference? Physical dependence to opioids means that the body relies on an external source of opioids to prevent withdrawal. Addiction is a condition(disease) manifesting as uncontrollable cravings, inability to stop using a drug despite adverse social, psychological, and/or physical consequences. It is also accompanied by the need for an increased amount of a substance as times goes on to achieve the same desired effect. Opioid addiction is accompanied by tolerance, physical dependence, and withdrawal syndrome.

3. • The neuroanatomy of addiction and human subjects has documented metabolic changes noted on PET scan. • Addiction results in deeply ingrained memories capable of creating intense urges and patient exposure to triggers – emotional or sensory, after years of abstinence.

5. Brain Activity Brain Activity- -Non Addict Non Addict Brain Activity Brain Activity- -Addict Addict

7. • Drug addiction is a disease of the brain associated with abnormal behavior. We continue using the drug, despite doing significant social, physical and psychological harm to ourselves. • Drugs of abuse provide longer and larger highs • 5-10 times increases in dopamine to the brain than natural reinforcers as in food or sex. • Opioid Dependence is a Chronic Brain Disease shown to cause:1 – Pervasive changes in cognitive and drug-rewarding circuits1 – Significant altercations in the neurochemical, molecular and cellular levels1 – Changes to brain structure and function that persist long after the drug has ceased1

9. • What is Suboxone? – Combined buprenorphine and naloxone – sublingual film Buprenorphine – Has been used since early 1980’s in the United States for pain control known as Buprenex at 0.4mg IM or SQ. – Has been approved in 2000 for use in the treatment of opioid/opiate addiction, dependence. It has also been used to convert Methadone maintenance patients to eventually get them off Methadone completely. – Is a partial mu agonist. It also has some unclear action at the opioid kappa receptor. Buprenorphine – Is 25 times stronger than morphine. Analgesic does equivalence of buprenorphine to Morphine sulfate is 1/25. Meaning: 0.4mg buprenorphine will relieve pain equal to Morphine Sulfate 10mg. – Is partial agonist to the mu receptor, therefore, a ceiling effect. Meaning: if buprenorphine dose is increased to a certain point, there is NO increase in pain control or euphoric effect. – It is very long acting at the opioid mu receptor, up to 40 hours; usually about 28 hours in average. Meaning: less withdrawal when stopped taking. • •

10. • Buprenorphine – Has very strong affinity to the opioid mu receptor. Meaning: buprenorphine will displace other opioids/opiates from the mu receptor resulting in acute opioid withdrawal syndrome that will discourage addicts to use buprenorphine along with other opioid. • Also, from this strong opioid mu receptor affinity, buprenorphine will prevent other opioids from having any affect at all, therefore, discouraging using other opioids since the addict will not feel any effect of their drugs. • In case of emergency, when pain control is really needed, higher dose of full opioid mu agonist can be used to achieve adequate pain control. • There is clear federal guidelines for using buprenorphine in the detoxification and outpatient maintenance treatment for opioid and opiate addiction.

12. Opioid Buprenorphine Empty Receptor Opioid Receptor in the brain Withdrawal Pain Courtesy of NAABT, Inc. (naabt.org) Opioid receptor unsatisfied opioid receptors become less sensitive. More opioids are then required to produce the same effect. Once “physically dependent” the body can no longer manufacture enough natural opioids to keep up with this increased demand. Whenever there is an insufficient amount of opioid receptors activated, the body feels pain. This is withdrawal. Opioid receptor unsatisfied -- -- Withdrawal Withdrawal. As someone becomes “tolerant” to opioids their

13. Perfect Fit - Maximum Opioid Effect Empty Receptor No Withdrawal Euphoric Opioid Effect Pain Courtesy of NAABT, Inc. (naabt.org) Opioid receptor satisfied with a full stops the withdrawal for a period of time (4-24 hours). Initially, euphoric effects can be felt. However, after prolonged use, tolerance and physical dependence can develop. Now, instead of producing a euphoric effect, the opioids are primarily just preventing withdrawal symptoms. Opioid receptor satisfied with a full- -agonist opioid agonist opioid. The strong opioid effect of heroin and painkillers

14. Imperfect Fit – Limited Euphoric Opioid Effect Courtesy of NAABT, Inc. (naabt.org) Opioids replaced and blocked by buprenorphine. opioids for the receptor. Since buprenorphine has a higher affinity (stronger binding ability) it expels existing opioids and blocks others from attaching. As a partial agonist, the buprenorphine has a limited opioid effect, enough to stop withdrawal but not enough to cause intense euphoria. Opioids replaced and blocked by buprenorphine. Buprenorphine competes with the full agonist

15. Buprenorphine Still Blocks Opioids as It Dissipates Courtesy of NAABT, Inc. (naabt.org) Over time (24 opioid effect (enough to prevent withdrawal) and continues to block other opioids from attaching to the opioid receptors. Over time (24- -72 hours) buprenorphine dissipates, 72 hours) buprenorphine dissipates, but still creates a limited

16. Opioid Buprenorphine Perfect Fit - Maximum Opioid Effect Empty Receptor Empty Receptor Receptor Sends Pain Signal to the Euphoric Opioid Effect No Withdrawal Pain Withdrawal Pain Brain Buprenorphine Still Blocks Opioids as It Dissipates Imperfect Fit – Limited Euphoric Opioid Effect Courtesy of NAABT, Inc. (naabt.org)

17.  Medication assisted treatment is the treatment of addiction with the assistance of medication (  A multi  Individual counseling, group counseling, 12 support groups, accountability partners, spiritual groups/support are all very important components of successful treatment.  A common mistake during M.A.T. is to rely solely on the medication without addressing the underlying behavioral and cognitive issues associated with addiction.  Many people in M.A.T. assume that because they feel better and their life is “back on track” they don’t need to do any thing other than take the medication.  Attack the addiction from as many directions as possible! Medication assisted treatment is the treatment of addiction with the assistance of medication (Suboxone, A multi- -faceted approach is the best approach. Individual counseling, group counseling, 12- -step meetings, support groups, accountability partners, spiritual groups/support are all very important components of successful treatment. A common mistake during M.A.T. is to rely solely on the medication without addressing the underlying behavioral and cognitive issues associated with addiction. Many people in M.A.T. assume that because they feel better and their life is “back on track” they don’t need to do any thing other than take the medication. Attack the addiction from as many directions as possible! Suboxone, Vivitrol Vivitrol, methadone). , methadone). faceted approach is the best approach. step meetings,

18. As of now, or in the near future, there are five methods of Medication Assisted Treatment. 1) Overdose Prevention.( 2) 3) Buprenorphine implants. ( 4) 5) Oral administration of Buprenorphine. (Suboxone) As of now, or in the near future, there are five methods of Medication Assisted Treatment. 1) Overdose Prevention.(Narcan 2) Vivitrol 3) Buprenorphine implants. (Probuphine 4) Injectable 5) Oral administration of Buprenorphine. (Suboxone) Narcan) ) Vivitrol) ) Vivitrol injection. ( injection. (Vivitrol Probuphine) ) Injectable Buprenorphine. Buprenorphine.

19. 1) Injecting immediately reverses the effects of opiates, often times saving the users life. It can be administered by a pre nasal spray or the injects the medicine in the leg using a device much like an opiate antagonist, which is stronger than the agonist(heroin), therefore it binds to the receptors much quicker, overriding any effects from the 1) Injecting Naloxone immediately reverses the effects of opiates, often times saving the users life. It can be administered by a pre- -loaded nasal spray or the Evzio injects the medicine in the leg using a device much like an Epi opiate antagonist, which is stronger than the agonist(heroin), therefore it binds to the receptors much quicker, overriding any effects from the opitae Naloxone ( (Narcan Narcan). ). Narcan Narcan loaded injectable Evzio device, which injectable, , device, which Epi- -pen. pen. Narcan Narcan is an is an opitae. .

20. 2) 2) Vivitrol opiate antagonist. It is a long lasting dose that is injected intramuscularly once a month. This helps reduce cravings for opiates and also blocks opiates from binding to the receptors in the brain if taken. It was originally developed for alcoholism but was found to work well for opiate addiction. Vivitrol contains opiate antagonist. It is a long lasting dose that is injected intramuscularly once a month. This helps reduce cravings for opiates and also blocks opiates from binding to the receptors in the brain if taken. It was originally developed for alcoholism but was found to work well for opiate addiction. contains naloxone naloxone, which is an , which is an

21. 3) 3) Probuphine is implanted under the skin of the patients arm. The implant lasts for six months. This system cuts down on diversion and the possibility of a patient losing or forgetting to take their medicine. Probuphine. This is a delivery system that is implanted under the skin of the patients arm. The implant lasts for six months. This system cuts down on diversion and the possibility of a patient losing or forgetting to take their medicine. . This is a delivery system that

22. 4) This is not yet on the market, but will be soon. It is a monthly injection, much like Vivitrol is the active ingredient in Suboxone. It is a partial 4) This is not yet on the market, but will be soon. It is a monthly injection, much like Vivitrol, but contains Buprenorphine, which is the active ingredient in Suboxone. It is a partial- -opiate agonist. , but contains Buprenorphine, which opiate agonist.

23. 5) Oral administration of Buprenorphine. This includes Suboxone, These medicines all have buprenorphine and cases, which contains buprenorphine but not 5) Oral administration of Buprenorphine. This includes Suboxone, Zubsolv These medicines all have buprenorphine and naltraxone cases, which contains buprenorphine but not naltrexone Zubsolv and and Bunavail Bunavail. . naltraxone. . Subutex Subutex is also used in rare is also used in rare naltrexone. .

25. Create objectives(short term goals or methods which are measurable) that improve your chances for a successful treatment plan. Examples:  Occupational goals  Relationship goals  Hobbies (stay busy)  Exercise (releases  Debt cancellation  Buy/rent a house  Savings/ Checking account  Clean urine screens  Education goals School)  Taper medication Create objectives(short term goals or methods which are measurable) that improve your chances for a successful treatment plan. Examples: Occupational goals Relationship goals Hobbies (stay busy) Exercise (releases endorphines Debt cancellation Buy/rent a house Savings/ Checking account Clean urine screens Education goals ( Complete GED, Enroll/Re School) Taper medication endorphines) ) ( Complete GED, Enroll/Re- -enroll into College or Trade enroll into College or Trade

26. Create long term goals. Examples:  Get off of Suboxone or taper to sub  Career Goals  Financial Goals  Relationship/Family Goals  Long Term Educational Goals Create long term goals. Examples: Get off of Suboxone or taper to sub- -therapeutic dose Career Goals Financial Goals Relationship/Family Goals Long Term Educational Goals therapeutic dose

27.  Change PPT (People, Places and Things) People These may be long time friends, acquaintances or even family members that jeopardize the success of our recovery. Sometimes it may be extremely difficult to distance ourselves from these people. Places This may be a town, an area, residence, room or vehicle that you frequented or identified with during your active addiction. Things This could be a certain song, stress, item, time of day, or routine that identifies with using your drug of choice. Change PPT (People, Places and Things) People These may be long time friends, acquaintances or even family members that jeopardize the success of our recovery. Sometimes it may be extremely difficult to distance ourselves from these people. Places This may be a town, an area, residence, room or vehicle that you frequented or identified with during your active addiction. Things This could be a certain song, stress, item, time of day, or routine that identifies with using your drug of choice.    

28. Triggers: places and things. Everyone has their own triggers. The Behavior Chain Triggers Example: past.(This is the trigger). Bob thinks “man, this week has been crazy, I’d love to get high.”(The trigger initiates thinking.) Bob craves a shot of heroin. (The thinking initiates a feeling.) Bob turns into the house and buys a bag of dope. (The feeling initiates behavior.) Bob relapses. (The behavior has a consequence,)  Treatment, including counseling and meetings will teach you coping mechanisms to deal with these triggers.  Life happens! We are still going to have good days, bad days and stressors that we have to deal with. We must learn to deal with these events on OUR terms, not with drugs. Triggers: These can be any number of things involving people, places and things. Everyone has their own triggers. The Behavior Chain Triggers- -Thinking Example: Bob drives past a house where he bought dope in the past.(This is the trigger). Bob thinks “man, this week has been crazy, I’d love to get high.”(The trigger initiates thinking.) Bob craves a shot of heroin. (The thinking initiates a feeling.) Bob turns into the house and buys a bag of dope. (The feeling initiates behavior.) Bob relapses. (The behavior has a consequence,) Treatment, including counseling and meetings will teach you coping mechanisms to deal with these triggers. Life happens! We are still going to have good days, bad days and stressors that we have to deal with. We must learn to deal with these events on OUR terms, not with drugs. These can be any number of things involving people, Thinking- -Feeling Bob drives past a house where he bought dope in the Feeling- -Behavior Behavior- -Consequence Consequence

29. Suboxone will take care of the physical need for opiates, but it will not prevent you from giving in to triggers or change existing behaviors. Determine what people, places and things make you vulnerable to relapse. Stay away from these triggers as much as possible. DO NOT let the trigger initiate old behavior. STOP and THINK. The following are some common INACCURATE thoughts.  It is not going to hurt.  No one is going to know.  I need to relax.  I’ll just do it once.  I have had a rough day, week, or month.  My friends want me to get high with them.  I never had a problem with weed, so it’s not really relapsing.  It’s the only way I can sleep.  I can do whatever I want  I am lonely. Drugs are no longer an option for me! Suboxone will take care of the physical need for opiates, but it will not prevent you from giving in to triggers or change existing behaviors. Determine what people, places and things make you vulnerable to relapse. Stay away from these triggers as much as possible. DO NOT let the trigger initiate old behavior. STOP and THINK. The following are some common INACCURATE thoughts. It is not going to hurt. No one is going to know. I need to relax. I’ll just do it once. I have had a rough day, week, or month. My friends want me to get high with them. I never had a problem with weed, so it’s not really relapsing. It’s the only way I can sleep. I can do whatever I want I am lonely. Drugs are no longer an option for me!

30. There are several ways to help yourself prevent relapsing.  Develop a daily relapse prevention plan(ask your counselor for assistance with this).  Have a strong social support system 1. Have an accountability partner 2. Parent or spouse 3. Sponsor 4. Physician 5. Counselor 6. Spiritual guide  Make a list of 10 reasons why you want to stay clean. Never forget those reasons. Read the list over and over to yourself.  Develop coping skills (again, ask your counselor if you need assistance). There are several ways to help yourself prevent relapsing. Develop a daily relapse prevention plan(ask your counselor for assistance with this). Have a strong social support system 1. Have an accountability partner 2. Parent or spouse 3. Sponsor 4. Physician 5. Counselor 6. Spiritual guide Make a list of 10 reasons why you want to stay clean. Never forget those reasons. Read the list over and over to yourself. Develop coping skills (again, ask your counselor if you need assistance).

31. The following page is a list of resources you can use to help you defeat your addiction. Use as many “weapons” as possible. Go to war with your addiction. You can do this. You will do this. Follow the advice of your Dr.’s, counselors and staff and you will be successful. The following page is a list of resources you can use to help you defeat your addiction. Use as many “weapons” as possible. Go to war with your addiction. You can do this. You will do this. Follow the advice of your Dr.’s, counselors and staff and you will be successful.

32. Websites  www.smartrecovery.org  www.NA.org  www.AA.org  www.celebraterecovery,com  www.SAMSHA.gov  www.recovery.com  www.thefix.com  www.recovery.org  www.reneweveryday.com  www.dailystrength.com  www.stepchat.com  www.intherooms.com  www.additionrecoveryguide.org  www.zubsolv.com  www.suboxone.com  www.bunavail.com www.helpguide.org/articles/addiction/overcoming  D.A.W.N  www.addictionsurvivors.com  http://www.addictionsurvivors.org/vbulletin/forumdisplay.php?f=45 Websites www.smartrecovery.org www.NA.org www.AA.org www.celebraterecovery,com www.SAMSHA.gov www.recovery.com www.thefix.com www.recovery.org www.reneweveryday.com www.dailystrength.com www.stepchat.com www.intherooms.com www.additionrecoveryguide.org(tips, guides, etc…) www.zubsolv.com www.suboxone.com www.bunavail.com www.helpguide.org/articles/addiction/overcoming- -drug D.A.W.N- -Drug Abuse Warning Network www.addictionsurvivors.com http://www.addictionsurvivors.org/vbulletin/forumdisplay.php?f=45 (Forums, tips, self- -help guides. Secular group) (find a meeting) (find a meeting) (Christian based recovery program. Local meetings.) (Government resources) (Forums, tips, etc…) (Excellent resources) (Videos, forums, blogs, stories, support groups) (motivational, information) (support groups, tips, advice) (on line meetings) (on line meeting) (tips, guides, etc…) ( (Zubsolv’s ( (Suboxone’s ( (Bunavail’s drug- -addiction.html Drug Abuse Warning Network There are specific forums for people taking Buprenorphine products (Forums, tips, self (find a meeting) (find a meeting) help guides. Secular group) (Christian based recovery program. Local meetings.) (Government resources) (Forums, tips, etc…) (Excellent resources) (Videos, forums, blogs, stories, support groups) (motivational, information) (support groups, tips, advice) (on line meetings) (on line meeting) Zubsolv’s home page) home page) Suboxone’s home page) Bunavail’s home page) addiction.html home page) home page) (articles) (articles)  There are specific forums for people taking Buprenorphine products

33. Smartphone Apps  InReach  NA Self Help  NA meeting finder  BetterHelp  No More!  Recovery Today  Recovery Box  Squirrel Recovery; Addiction  Addicaid  New2Recovery for Addictions  Drug Addiction *There are numerous apps for recovering addicts and more are created everyday. There are support groups, blogs, forums, meetings, tips, advice, clean applies to your Smartphone Apps InReach NA Self Help NA meeting finder BetterHelp No More! Recovery Today Recovery Box Squirrel Recovery; Addiction Addicaid- -Addict Support New2Recovery for Addictions Drug Addiction *There are numerous apps for recovering addicts and more are created everyday. There are support groups, blogs, forums, meetings, tips, advice, clean- -time clocks, etc… Just check the App Store that applies to your smartphone (Apple only) (Apple and Android) (Apple and Android) (Apple and Android) (Apple and Android) (Apple and Android) (Apple) (Android) (Android) (Android) (Android) (Apple only) (Apple and Android) (Apple and Android) (Apple and Android) (Apple and Android) (Apple and Android) (Apple) (Android) (Android) (Android) (Android) Addict Support time clocks, etc… Just check the App Store that smartphone. .

34. The Big Book of Alcoholics Anonymous The Big Book of Narcotics The Life Recovery Workbook: A Biblical Guide Through the Twelve Steps Dreamland Why Can’t SMART Recovery Handbook Clean: Overcoming Addiction and Ending America’s Greatest Tragedy Codependent No More: How to Stop Controlling Others and Start Caring for Yourself Melody Healing the Shame That Binds You How To Stop Time: Heroin From A to Jagged Little Edges: Life After Addiction Dope We All Fall Down: Living With Addiction Pill Head: The Secret Life of a Painkiller Addict Opiate Addiction **There are Thousands of books and memoirs on drug addiction and recovery. These are a few of the popular and best The Big Book of Alcoholics Anonymous The Big Book of Narcotics Annonymous The Life Recovery Workbook: A Biblical Guide Through the Twelve Steps Dreamland- - The True Tale of America’s Opiate Epidemic Why Can’t Jjohnny SMART Recovery Handbook Clean: Overcoming Addiction and Ending America’s Greatest Tragedy- - David Codependent No More: How to Stop Controlling Others and Start Caring for Yourself- - Melody Beattle Healing the Shame That Binds You- - John Bradshaw How To Stop Time: Heroin From A to Z Jagged Little Edges: Life After Addiction- - Lorelie Dope- - Sara Gran We All Fall Down: Living With Addiction – – Nic Pill Head: The Secret Life of a Painkiller Addict – – Joshua Lyon Opiate Addiction- -The Painkiller Addiction Epidemic, Heroin Addiction and the Way Out **There are Thousands of books and memoirs on drug addiction and recovery. These are a few of the popular and best- -ranked books on the subject.  Annonymous   The True Tale of America’s Opiate Epidemic- -Sam Quinones Jjohnny Just Quit Sam Quinones  Just Quit? Kyle Oh, M.D. ? Kyle Oh, M.D.   David Sheff Sheff   Beattle John Bradshaw Z - -Ann Marlowe Lorelie Rozzano  Ann Marlowe  Rozzano (several books in this series) (several books in this series)  Sara Gran  Nic Sheff Sheff  Joshua Lyon  The Painkiller Addiction Epidemic, Heroin Addiction and the Way Out- - Taite Taite Adams Adams  ranked books on the subject.

35.  Alcoholics Anonymous- www.aa.org Local meetings with over 58,000 locations in the USA  Narcotics Anonymous- www.na.org Local meetings held daily with several locations.  SMART Recovery- www.smartrecovery.org/meetings_db Secular organization which accepts MAT(Suboxone) as a viable type of recovery. They are primarily a web-based community, but there are actual meetings in and around central Ohio.  Celebrate Recovery- www.celebraterecovery.com Spiritual, church based program with several locations throughout Ohio and the USA.  Al-Anon- Al-anon and Alateen are both sub groups based off of the AA principles. These are primarily for families and teens dealing with addiction in their famiy. www.al-anon.org

36.  One Day at a Time  Always remind yourself that you’re an addict and always in a battle  Stay active in your recovery  Be selfish about your recovery(no one can do it but you)  In the words of the great comedian George Carlin…”just because you got the MONKEY off your back doesn’t mean the circus has left town.”  Good luck in your recovery!