This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through all CEUs. Register at allceus.com slash counselor toolbox. Okay, so I'd like to welcome everybody to today's presentation on medication-assisted therapies for addiction.  You know, that's cool. If you are working with someone who is in recovery from addiction or on medication-assisted therapies, it's helpful to know what meds they might be on and how that might be impacting their mood as well as some of the contraindications you might want to be aware of so you know when your patient is getting into a position where they might be in jeopardy of harming themselves. We're going to discuss the purpose of long-term pharmacotherapy. And when we talk about long-term, it's not necessarily forever and always, but we're really looking at several years as opposed to six months. We'll identify pharmacotherapies for smoking, alcohol, and opioids for the most part. We're also going to talk about some of those other drugs that don't have medication-assisted therapies identified for them. So why do we use them? In early recovery, we want to help people reduce cravings. When possible, and medication-assisted therapies that are so labeled are designed to assist patients in not having as many cravings. So the medication-assisted therapies can help reduce their desire, their compulsion, their obsession to go back out and use in order to feel that feeling again. It provides increased self-efficacy and a greater sense of control when clients can go in and say, all right, I'm taking this. It's going to help me not have cravings. Well, we know part of it's going to be placebo effect. That's okay. I don't care where the effect's coming from. If it's a positive effect, I'm pretty darn happy. So we want to look at what is this helping the client with? And obviously, if you're giving somebody a medication that doesn't do anything at all or a sugar pill or something, you're probably going to have different results. So I don't want to trick the clients, but I do want to help them see ways that the medications they're taking might help them in early recovery. Medication-assisted therapy can help reduce anxiety in a lot of our clients because a lot of clients come in and they've relapsed before and they're trying it again and they're afraid they're going to fail again or they haven't relapsed, but they're going to go to jail if they relapse or they're going to lose their kids. There's a lot of, there's a lot at stake on this. So there's a lot of anxiety about if I relapse. How am I going to deal with the feelings and the cravings and the yada, yada, yada, so I don't relapse and they just focus on all of the what ifs. Medication-assisted therapy can help patients have something to focus on to say, okay, I've got this tool. Now, we're not necessarily talking about a tool forever, but we're talking about a tool to help them climb the mountain. Think about those little poles that people use when they're climbing the mountain. That's kind of what we're thinking about with medication-assisted therapy. It's helping people maintain their footing while they're climbing to the apex of recovery, if you will. It also may improve depressive symptoms by enhancing hope and a sense of empowerment. Remember, depression goes with hopelessness and helplessness. So if we can encourage them to focus on the fact, well, this medication-assisted therapy may help you not have the cravings. It may make it easier to get through this early recovery period so you can master the skills and tools you need to live a sober lifestyle. That gives me hope when I say it. So I'm hoping it'll give the clients hope when they hear it and it gives them a sense of empowerment because it says you have control over this. We're giving you some tools. We're giving you those little walking poles to help you keep going forward. It's not going to be easy. We're not saying it's going to be easy, but we're going to try to help bolster you along the way. And certain medication-assisted therapies have pharmacological effects that will help alleviate depression and anxiety. So that's a nice sort of side effect if you want to look at it that way. If you're using it to reduce cravings, but it also is anti-depressant, well then bonus, we want to reduce co-occurring issues. We know that people who come into detox, if you've worked in a detox facility or even in a crisis stabilization unit and a little story here that will ring true with a couple of you, the last place I worked, well, a couple places, it was a big facility and we had a crisis stabilization unit and we had a detox unit. Now, I was over the detox unit and we would have clients come in and they would be in crisis. They may be actively psychotic, but they would also be stoned out of their minds. So the crisis unit didn't want them because they're like, well, we can't handle monitoring detox and we didn't want to take them because we didn't have the staffing to monitor and handle the psychoses. We didn't have a psychiatrist on our facility. So every time one of those clients would come in, we'd end up with this hot potato and they'd be calling the supervisors at home going, who gets them? And really it would end up with an evaluation of what is that person's psychiatric stability and how can we cooperate? Thankfully, we were on the same campus. So if the person had to stay over at the crisis stabilization unit, then our nurse would go over and do the periodic checks to make sure that they were doing okay, do the seawalls, whatever they needed to do. If the person was stable enough or they could get them to the point where they weren't actively psychotic and a danger to themselves or others, then they could come over to the detox unit where my staff would monitor their detox protocol. So it was, unfortunately, when you've got people with co-occurring issues, it's really a struggle and most people in early recovery have co-occurring issues. Now they may not be floridly psychotic, but they are probably going to have some pretty significant depression or anxiety. I mean, just because of the neurotransmitter imbalance, remember we've talked before about how when addictive behaviors are used, the brain is flooded with whatever that chemical is and that chemical recedes. If you want to think about ebb and flow, that chemical recedes just as quickly pretty much as it went in and a little bit different than that, but a lot quicker than the body can catch up. So it goes away and there's not that counter-balancing chemical in the right levels to help the person feel normal and you're burning through, if you will, a lot more neurotransmitters. So there's going to be neurotransmitter imbalance. People are going to feel crappy and when they feel discomfort and I use that term very generally because the discomfort they're feeling is palpable. I mean, it is really crushing sometimes, anxiety and depression. They need that to go away. They're like, I cannot survive feeling this way. So what is the response? A lot of times go out and use again. So in early recovery, we really need to help people get to the point where their neurotransmitters are stabilized enough where they're not feeling like they have to escape where they're not feeling like they can't breathe because of the anxiety and the depression and they're not craving the drug, which is a whole different ballgame. But this is what we're heading towards. We need to identify and address vulnerabilities and you know, medication assisted therapy, giving them medication or them taking medication, however you want to look at it is one aspect. Just giving them a pill is not going to fix everything. It helps them stabilize. So they have the energy and the clear headedness hopefully to participate in their recovery process. And then we start identifying and addressing their vulnerabilities. If they're homeless, if they're not eating enough, if they've got hepatitis C, if they've got anything else going on that might be contributing to their stress, their pain, and their neurotransmitter imbalance. So we help them improve overall health, education, nutrition, energy, help them maintain abstinence. Most of the time what we're talking about here, most of the drugs, well, the drugs we're talking about, people can abstain from.  It's not like telling somebody they can't ever have food again. So we want to look at this and go during this period of early recovery, how can we help you maintain abstinence so your body can rest, recover and rebalance. And that's kind of a hot button topic. Whether you say you've got to abstain forever or you approach it from during this period of early recovery. I have found and from a motivational perspective, I have found that in early recovery, there's still a little bit of ambivalence. Clients can't imagine going the rest of their life without cocaine, without a drink, without this or that. And if I start talking about forever, it freaks them out. So we talk about how can you maintain abstinence right now because you're here, what are your goals and how can I help you achieve those goals? One of them is to help you reduce the cravings, improve your mood, improve your health, and let's see where you want to go from there. If a relapse occurs, medication-assisted therapy often reduces the intensity of the relapse. So that's something to kind of bear in mind.  Or they've already blocked some of the receptors. So when you use the street drug, you don't get the same high and it's just like, eh, whatever. Part of a comprehensive plan that addresses recovery involves us helping people deal with their emotional, cognitive, physical, social, occupational, and environmental issues. So we're going to look at that. But remember, people are not going to be able to maintain housing if they're spending all their money on dope. People are not going to maintain a job if they can't get there because they're too hungover or strung out. So medication-assisted therapy plays a critical, pivotal role in early recovery, helping people start re-establishing a new drug-free life. It's not a substitute for counseling. We're not saying give them a pill. It's going to make everything better and they can go on their merry way. And that is a misconception a lot of people have about methadone clinics. And we'll talk about methadone a lot towards the end of the presentation. But it's important that medication-assisted therapy is a tool. You have that person climbing the mountain and, okay, they know how to use these walking sticks and there's probably a different word for them, but we'll call them walking sticks. But they need to know how to adjust their breathing when the oxygen starts to get thinner. They need to know how to handle it if all of a sudden the snowstorm comes up. They need to know how to handle it if some other obstacle comes in their way. That's what counseling does. Counseling helps educate people about how to get to the top of the mountain and stay there and thrive instead of falling back down. The co-occurring model of addiction. Now, I want you to just kind of remember this as we're talking says that co-occurring disorders are the expectation. The person may not have been depressed, anxious, whatever before they started using. They may not have even been symptomatic for bipolar or schizophrenia, but the stress of the addictive behaviors and the stress on their body can trigger the psychosis or the bipolar disorder to kind of show its head. So it's important to understand that people may not have initially started out self-medicating. They may have started out using just recreationally and then something happened and they used a little bit more. And as they used more, their brain chemicals got progressively out of whack and then they started needing to use to feel normal. So by the time they get into active addiction, they've either created a mental health issue, neurotransmitter imbalance, or, you know, that one that was still there, they're self-medicating. Either way, in early recovery, I haven't ever met anyone who didn't have some level of co-occurring issues and that's okay, but they need to understand how that mood issue impacts or plays into the recovery process. Relapse begins when thoughts, urges or behaviors return to that addictive mindset. So again, we need to look at if somebody starts relapsing, their depression starts increasing again. If their depressive thoughts start increasing again, then those thoughts of suicidality and wanting to escape and making it stop are going to come back in and we see an addiction relapse after that. Addictive behaviors were learned as a way to stop distress and learned behaviors cannot be unlearned. So some people talk about a disease concept. I really talk about learned behaviors. Think about a salesman. A salesman may be great at selling, let's say cars, and then they decide one day, you know what? I don't want to sell cars anymore. This isn't fulfilling. I want to be a plumber and they learn how to be a plumber and they're good at that. But then all of a sudden the something happens and they can't be a plumber anymore. The plumbing is not paying their bills, but they know they can go back and be a good salesman. This is kind of what we're talking about with addictive behaviors. When the good coping skills, when the healthy coping skills, when the sober way of life quits working for some reason, one option is not the only option, but one option is to go back to those addictive behaviors that made the pain stop. We want to help people learn alternate behaviors and their consequences which are more rewarding than the addictive behaviors and our consequences. Addictive behaviors may have really awesome short-term consequences makes the pain stop. But in the long term, not so much. It's more punishment than positive reward. Our recovery behaviors in the short term may not feel so great. Distress tolerance does not feel near as good as numbing with opiates or something else. But does it help the person achieve their long-term goals? So when do we use drugs? Well, there is no pharmacotherapy for most abused drugs. Stimulants, which includes amphetamines and cocaine and Adderall and all those. Hallucinogens inhalants and marijuana. So and some of these they talk about having more psychological addictive behaviors than actual physiological addiction. Either way, if they're addicted, if they have withdrawal symptoms, we're going to have to address it at some point. So what I look at is what are the functions of these different behaviors? Since there's no drug out there that's specifically FDA labeled to address cravings. I say, well, why would the person use it? Let me see if I can get a clue as to their neurotransmitter imbalance. And one of them is we'll start with stimulants and cocaine. The sympramine is actually a tricyclic antidepressant and it was brought to my attention before this presentation. And it's actually a norepinephrine reuptake inhibitor with very little effect on serotonin. So let's think about this. Cocaine is a stimulant. All right, we got that. Norepinephrine is our get up and go and focus neurochemical, among others and glutamate and stuff. But if we increase the level of norepinephrine, we're increasing the energy level that the availability of focus and motivation, which is a little bit similar to what cocaine does. So and when we look at people who use cocaine, what are they wanting? They're wanting energy. They're wanting to feel good. They're wanting more dopamine. And, you know, some drugs, some pharmacological drugs can help them feel a little bit better. They can take the edge off that feeling flat and unfocused and unmotivated and I just can't do this. There was a study that was done and let me see if I can find it in addiction science and clinical practice in 2003 that showed that disempromine was actually somewhat effective at helping people in the study maintain drug-free urines. So that was kind of an interesting that was addiction science and clinical practice in 2003. That is not on your quiz. Just point of interest. So when you're dealing with stimulants, we know you're dealing with somebody who is trying to rev themselves up, which means they probably feel and they either feel unmotivated and depressed or no happiness and the dopamine is low. So we want to look at, you know, are there pharmacological interventions that a psychiatrist could help them with that might help rebalance some of that or help them address some of those symptoms of apathy or lack of pleasure. Lack of pleasure kind of as part and parcel of depression. So generally your docs are going to look at antidepressants first. Antidepressants and I'm going to go through the big five just because those are the ones that most people think five Zoloft tends to be pretty neutral as far as energy but it has shown a lot of effects for helping people with compulsive behaviors especially bulimia and compulsive gambling. So Zoloft is out there when we look at prozac prozac tends to be much more stimulating and can increase anxiety levels. But if you've got someone who's looking for more energy prozac might help them as you know are some other drugs. I'm just going over the older ones that we're talking about. Paxel on the other hand tends to slow people way down. It helps with anxiety so does Zoloft but Paxel tends to make people sleepier. So a lot of people who take Paxel take it at night. If you're you've got a patient who's really looking to wake up and get some motivation. Obviously it's between them and their doc but my experience over 20 years has told me that that patient is not going to be very happy on Paxel. So I guess those are the big three that I really wanted to talk about right now. Now hallucinogens you don't really think of those as drugs of abuse. You don't have somebody coming into detox for being addicted to LSD and but they do they are out there. Psychedelics and there I learned this during this presentation. There are three different types of hallucinogens. Psychedelics which act on the 5H2A receptor. You remember from Tuesday's presentation. 5HT is your serotonin receptor family and there are I believe 18 different types of serotonin receptors. 5H2A is just one of those. But your antidepressants work on different 5HT receptors. So each antidepressant may not work on 5H2A. So if you've got somebody who's using psychedelics and we're talking about your LSD PCP they're using them often to get that state of quote empathic well-being. They just kind of love everybody and the world is good and we're going to hold hands and sing kumbaya. Which would act I would want to say what is it when they're not on that you know what are they feeling when they're not on that that they really need a drug to help feel empathy and compassion and love for themselves and other people. I'm hearing anger maybe anxiety maybe maybe some depression but that would be talking with the client to figure out what's going on. But anyway 5H2A we know is a serotonin receptor so we want to look at a drug that's going to target 5H2A.  Now remember glutamate is the one that's secreted during the fight or flight response. So your dissociatives are probably going to be in people who have higher levels of anxiety. They have altered pain perception and it's a depressant. You know it's going to make them slow down. Respiration slows down that sort of thing.  Ketamine we talked about that on Tuesday but ketamine is a huge hallucinogen that is used to help people calm down in certain emergency situations it's actually a horse tranquilizer. But dextromethorphan is a big one that the youth of today are abusing and dextromethorphan can be bought over the counter it's a cough syrup you know you're probably familiar with it. But if you get it pure and not mixed with Gwey Fennison or one of those other things the youth are taking the pure dextromethorphan and using it rectally in order to get high. So being aware that that's an increasing problem. I digress. So if somebody's using a dissociative hallucinogen I might look at anxiety issues and try to figure out what's going on there. Delirians Benadryl and Dramamine now delirians are really dangerous because the level between recreational use and lethal is really really really small and is really easy to kill yourself. So okay that's fine whatever warning all over but the delirians reduce acetyl choline and we know that acetyl choline's involved a lot in schizophrenia and powerful dreaming and active mind and there's a reciprocal relationship between acetyl choline and serotonin ah see you know I was going to get somewhere that made sense as acetyl choline goes up serotonin goes down so if somebody's abusing acetyl choline we might look and say hmm I wonder what's going on their levels of serotonin are too high maybe they've got some anxiety going on what is it what is the benefit of this for them besides just you know the overall feeling but there are a lot of medications that they can look at the selective nor nor epinephrine reuptake inhibitors would be kind of tops on my list but again that would be between chiatrists the take-home messages hallucinogens can be used recreationally but if you've got someone who's addicted to them then there's some other reason some other thing that is keeping them coming back besides just you know a feeling because they're forgoing other activities in their life in order to use this substance it's almost intolerable to be without it your inhalants are depress so just like alcohol can be a depressant or is a depressant if somebody's using inhalants or alcohol I tend to look for high levels of anxiety and see what's going on there where the inhalants actually make them feel better and interestingly marijuana increases dopamine which helps it be relaxing or pain-relieving but I've heard a lot of people who've used marijuana really potent marijuana or the the new resin dots that have come out that have had really really bad trips spice was just new when I was leaving residential or not super new but it was new ish and I would regularly have clients go out on work phase and come back in they'd use spice and they're like well it's not going to show up on a drug test and it's legal so I can use it because that's the way the addictive mind thinks and on three occasions I can think of in the course of the year we had to call the ambulance out because the person's heart rate was it like 200 literally 200 and they were laying on their bed and they felt like they couldn't move their arms and legs were so heavy they felt paralyzed so marijuana is not always and obviously that was spice they were using the synthetic THC but the side effects can differ between people we want to look at why they're using it factors to consider when you're looking at do we consider pharmacotherapy cost now my little soapbox here if a patient needs medication many farm places that make the drugs will give out patient assistant programs or give out vouchers through their patient assistance programs AstraZeneca has a really good patient assistance program Eli Lilly so you find the manufacturer of the drug you go online and you Google that company's name plus patient assistance program the easiest way to do it and then it'll bring you to the page or close to the page for that pharmaceutical company that has the patient assistance program forms on it the forms are usually one page the doc fills it out faxes it in they make a determination and yada yada not every drug is covered on patient assistance programs but a lot are and there's also a lot of drugs the generics especially that are available on formularies the four dollar prescriptions or whatever through different pharmacies so in large part for many medications there is a way to get them affordably even if your patient doesn't have access to insurance for their prescriptions another thing to consider is availability can this drug be gotten easily methadone is a perfect example of that methadone clinics are not on every on every street corner and so if you're going to have your client start a methadone program they're going to have to go every single day seven days a week in order to get their meds because they're not allowed to take home any so do do you want them driving an hour and a half there and an hour and a half back every single morning in order to get dosed and are they going to do that are they going to stay compliant you want to consider the side effects you know if this person takes this medication what are the side effects and are those acceptable side effects in that person's purview we want to look at barriers workplace drug testing if they're working somewhere that prohibits the use of methadone and they may it would show up in a drug test and they may lose their job there is some argument about whether that's legal but you know let's let's be realistic here the time it would take to fight that out in court would be you know not good what other meds are they taking there are a lot of medication assisted therapies that don't play nice with other medications so we have to know that you a client beyond buprenorphine or methadone and be taking benzos so you know if they're going to continue to take their benzodiazepines they're going to not be eligible to take some others and incarceration with methadone with suboxone with buprenorphine with any of these meds actually I've found in the criminal justice system clients generally in the three states that I've worked and I'm not going to say this is everywhere when they go into jail they are taken off all medication and the only way they get put back on medication is if they are not manageable in the population now I could go off on a whole tangent about that and I I will refrain for right now but that means if they are on medication assisted therapies for addicted addictions the thought is going to be well they can't get the substance in here they don't need these cut them off cold turkey and that can get really ugly if they're on methadone or anything else and if they're incarcerated they're not going to be able to get the medications if you happen to work in a jail and finally what is their motivation are they willing to actually do the work so the medication assisted therapy can be successful because it only does part of it you know the person medication assisted therapy is only the walking sticks they have to use their own feet to move up the hill so we need to know are you willing to do the counseling to address the issues and make behavior and lifestyle changes to address the issues that made you want to use stigmatization why people may not want to use medication assisted therapy there are a lot of places many 12-step groups many treatment programs that are very very opposed to medication assisted therapy with the exception of interestingly enough nicotine replacement therapy so we want to look at the science versus the dogma and the science is really supportive of MAT in short to moderate term and like I said we're talking six months to maybe five or six years after that you know it gets questionable about whether there's any effect so we want to look at whether we're using it and we also want to look at whether we're using the medication assisted therapies in an evidence-based way or we're just handing it out as a alternative to street drug use and that's not helpful that's not medication assisted therapy that's just peddling like I said 12-step groups are generally pretty against it very vehemently against methadone and suboxone less opposed but still somewhat opposed to some of the antidepressants and things that are prescribed whether it's for mental health issues or to reduce cravings I found a lot of resistance and 12-step programs methadone anonymous is an alternative in some places though and it's really hard to find an MA group but if you can then that's wonderful not all counselors are open to medication-assisted therapy so people may have to shop around to find a counselor who can understand the purpose and embrace the use of it like I said there's a lot of counselors out there especially since you can get suboxone from your physician well from a physician on an outpatient basis there are a lot of counselors seeing clients for mental health reasons and those clients are on suboxone or buprenorphine and maybe even some on methadone but methadone clinics have their own counseling program so even as an LMHC or an LPC or a psychologist it's important to understand what these meds do and why a patient might be on them most payors interestingly require that medication-assisted therapy be considered when available so that actually shouldn't be on the barrier slide they're usually pretty open to paying for therapy as long as it's FDA approved for that reason the hiccup that I found or that I've experienced was when we were trying to get Medicaid to pay for Vivitrol injections for alcohol abuse so you want to check with the insurance company but a lot of times insurance companies are on board with medication-assisted therapy so what's the end point? like I said it's not forever if you want somebody to stay on methadone forever you actually have to get a waiver from the state pharmacy board or some state board in order to continue to prescribe after a certain point the goal is stabilization now somebody who is has mild depression and was abusing drugs for five years may stabilize a lot sooner than somebody who has schizophrenia bipolar disorder and was using and homeless for 25 years so this is why we say there's kind of a wide range of what stabilization is but we want to see them at the point where they're not going to relapse this treatment is individualized so you know what it could be for one person is six months another person is 26 months it does allow for relapse and what do I mean by that? I mean that medication assisted therapy in most cases sometimes it's up to the psychiatrist but in most cases medication assisted therapy says alright you were on this and you relapse let's look at your dosage let's look at what happened if you come back in and you say I relapsed now if you relapse and you continue to use or you start using other drugs now that's a big no-no you know if you drop dirty for cocaine at a methadone program you're probably going to be discharged but if you relapse on heroin or fentanyl or whatever your drug of choice was the doctor is likely going to look at it and go okay let's see what's going on here that would have precipitated this so on to our meds smoking cessation pharmacotherapy comes in patches gums, lozages and sprays the antidepressant Xiban has been effective has been shown to be effective for smoking cessation and verinocline or chantix has also been found to be somewhat effective now really quickly agonists are those drugs that they take that have roughly the same effect as the street drug they were taking or the nicotine partial agonists are ones that drugs that they can take or medication-assisted therapies they can take that activate those same neurons that in this case the nicotine does but only activates it a little bit more than halfway about 60% so instead of getting a wahoo they're getting a okay but it helps take the edge off so they're not feeling whatever this was down here they're up at a level where it's tolerable so partial agonists have been shown to be very effective NRTs should always be combined with a behavioral therapy program they've shown in the research over and over and over again that just replacing it is simply switching the method of method of access in many cases we need to look at two things with nicotine one why were they using you know let's address those neurotransmitter imbalances and the stressors physical cognitive emotional that were causing those neurotransmitter imbalances but also we need to address the habit because when people use especially cigarettes there's a lot of habitual there's a lot of ritual to it my mother was a multiple packet day smoker she would get up in the morning roll out a bed before she even had her feet on the ground she was lighting up her first cigarette and she changed smoke throughout the day it wasn't a do I need a cigarette right now it was I'm con conscious I need to be smoking and for her as she went through and stopped smoking part of it was to start addressing some of those habits now now she's on nicotine nicotine replacement therapy but I see that in many cases there's still a lot of habit to it you know harm reduction here I'm okay with it she's okay with it so you know whatever but behavior therapy addresses the habits and helps people break that either the hand-to-mouth habit or the I'm driving the car so I have to have a cigarette habit helps them learn distress tolerance surfing urges all that kind of stuff nicotine replacement therapy is expensive and expensive depends on the person but even the generics it's like 16 bucks for a box of the gum so it's not inexpensive many states cover this through the Medicaid program so if somebody's on medicaid they might be covered it I didn't finish my thought there you also want to look for smoking cessation programs in your state many state smoking cessation programs have free access or significantly discounted access to the nrt's many state government employees also qualify for free or extremely low-cost nrt's nrt's reduce the harmful effects of tobacco smoking they haven't been shown to be anywhere near as useful with people who dip and patients should not smoke while using it actually could precipitate a heart attack so let's not do it the nicotine patch has the highest success rate of available pharmacotherapies partly in my opinion because it scares the snot out of them if they know that if they smoke they might have a heart attack I've worked with clients before in other situations in other settings I have one client that I remember distinctly bless his heart he was very low-cognitive functioning schizophrenic but just the sweetheart and he relapsed on cocaine and I remember sitting in the nurse's office and I was talking to him and I'm like John I'm really worried about you because the medications you're on if you used when you're using cocaine that could really be really dangerous he goes oh don't worry Miss Dawn I stopped using my medications about three days before I went out and used because I didn't want to die okay you know I'm glad he didn't want to die and I'm glad he had that kind of forethought but so the addictive mind will is with the patch you know if it's on there it's kind of on there granted it's helping it's transdermal it's kind of steady state whatever but I think there's also a certain amount of fear that goes along with that the gums require a correct chewing technique you're not supposed to chew it like regular gum and they tell you to chew regularly for the first month and then taper off over six months they found that people who chew a piece of gum every two to four hours and I don't remember what the number was instead of waiting till there was a craving had a higher success rate than those people who waited for a craving and the drink drinking coffee or acidic drinks while you're chewing the gum reduces the absorption of the nicotine so there's a lot of things to consider with the gum are you able to not drink coffee I know that would be a big deal for me and you know is this going to work for you with the gum it's easy to kind of forego it and go and you know I don't have a cigarette instead so they have to be super motivated lozenges suck on move it to the side till it dissolves there's no comparison studies of the effectiveness of lozenges versus the patch or the gum but some people prefer that if they've got like I do TMJ I can't chew gum so the lozenge might be effective but the nasal spray also might be it mimics the pleasurable effects of nicotine and has the highest risk for abuse if you're working with someone and I do want you to consider this if you're working with somebody who used to or continues to admit self-administer other kinds of illicit drugs through inhalation nasal sprays probably not a good way to go because that can be an easy easy trigger for relapse for other things the spray can only be used for up to three months so there are options for people if they're motivated to try to get off nicotine part of it is what they believe is going to work for them and won't what won't trigger other problems Zyban is again an antidepressant it works on the dopamine and norepinephrine receptors decrease withdrawal symptoms they say this needs to be started about two weeks before the quit quit date and then you kind of taper down to you take it daily for three days you can continue the pills for eight to twelve weeks so you're not going to be taking it forever side effects it could cause insomnia not so bad anxiety and not so great or seizures gives me pause but depends on the person if they've if they're not at risk procedures and if they've got concurrent depression this might be helpful for them the prescription includes a behavioral program to go with it shantix is a nicotine partial agonist so shantix is one of those that goes in and stimulus stimulates those receptors enough but not all the way again this is when you start before the quit date you increase your dose and it can be taken for 12 to 24 weeks and includes a behavioral program one thing they found with smoking is that people who are in recovery from abuse of other substances are at a much greater risk of relapse if they continue smoking one theory is because they are using a drug to moderate their moods through the nicotine and it serves as sort of a gateway drug but pharmacotherapy for alcohol dependence and to use camper all and the patrol and to use blocks a seat all a seat all hide the drug dehydrogen days basically it keeps enough alcohol in the system that you actually start suffering alcohol poisoning and it makes you vomit the reaction is flushing palpitations chest tightness nausea anxiety and headache if you drink while you're on this it does help people avoid slips or relapses but I do know addicts who've taken it who have taken it and just to see how bad the effect would be when they got it the intentionally went out and started drinking just to see how much they could drink and how bad it would be if they actually relapsed again so we want to look for somebody who's motivated it will affect the liver even without alcohol and has a ton of drug interactions so motivation is really necessary for a patient on an an abuse campbell or a campersate uses helps address the GABA and and mda receptors in the brain which can lead to alcohol dependency remember alcohol alcohol GABA is your natural anti-anxiety and and mda is responsible for learning and a lot of other things it's also involved in the flight response so campbell normal normalizes GABA and glutamate in the brain keeps that bath warm because GABA is made from glutamate it doesn't have any drug interactions to note minimal side effects and it can reduce the symptoms of protracted withdrawal so after somebody gets off detox they may have some ongoing foggy head post-acute withdrawal symptoms campbell has been shown to help with that but we're going to caution with it in suicidal patients and Revia blocks opioid receptors and pleasurable feelings from alcohol this is now Trekzone and we're going to talk about it on the next slide as Vivitrol reduces craving it comes in tablets or implantable pellets reduces alcohol slips and can be used for opioids and alcohol now it's blocking those opioid receptors so when somebody drinks which can be okay Vivitrol is an intramuscular injection of naltrexone which is given monthly the nice thing is it has to be done in a doctor's office but it's only once a month dosing it was recently approved for alcohol and but also requires patient motivation maintenance therapy for opioids and long-acting medication and a controlled setting is what we're looking for we want to make sure that people don't relapse because relapse on opioids is way deadlier in many cases than relapse on pretty much any other drug helps avoid withdrawal and craving reduces disease and crime and we want to look at it in terms of maintenance or detoxification so are we looking at it for an 18 month step down so they don't have to be on it for a couple of years while they learn other skills and yeah 18 months step down from heroin is not unheard of 18 months step down from methadone is also not unheard of methadone is a full agonist it's opioid substitution therapy highly regulated it has to be licensed has to be in a specific program you can't just get it at your doctor's office patients are regularly and treatment programs are required to provide counseling now these are going out pretty quickly I don't know if they're going to come back so I'm not going to spend a lot of time on them but just so you know and you can go back and look at this a little bit more closely later if you're interested but there are phases in opioid treatment methadone treatment initially they have to come in seven days a week to get their meds over the period of a year they start getting to the point where they can get up to three take home doses per week so they're still having to come in four days a week after three years in treatment they may be eligible for six take homes per week so they have to come in once a week provided that all of their their drug screens for the past year have been negative so there's a lot of drug testing a lot of counseling but in order to make it available and everything all of these regulations have to be in place controlled trials comparing medication and placebo show the superiority of agonists that full-scale methadone pharmacotherapy improve treatment retention eliminates the use of non-prescribed opioids because they're feeling they're not feeling the cravings decreased criminal activity reduced spread of HIV with pretty good results reduced mortality improved health and improved psychosocial functioning but can you get all of these from other drugs? Do we have to do a full opioid agonist? Not necessarily but methadone does not get you high because of its longer half-life methadone suppresses withdrawal and drug drug cravings for 24 to 36 hours at prescription doses now if you take three doses of methadone yeah you're probably pretty darn good or die but there's no real euphoria for people who are on methadone maintenance once they get used to it it causes sedation but not so much that they can't work or drive safely once they've kind of developed a tolerance and they're on a good good dose it is deadly if it's mixed with any kind of depressant including benzos and alcohol cognitive impairment may occur during induction or a change in dose or in combination with other drugs or medications including over the counter but like I said once they get used to it is totally safe some states restrict the amount of time people can be on methadone they need to be evaluated periodically to see if they can come off one of the benefits of methadone is for people who either are refusing to get off heroin or street opiates the hard way they want a kinder gentler detox or they can't imagine living without something so this kind of helps them but sort of buprenorphine and suboxone buprenorphine is an alternative to methadone it's a long-acting opioid agonist antagonist it has a ceiling it's only going to get you so far and then not so much so again like the other partial agonist it gets you from to okay but not all the way up to woo-hoo multiple forms it can be combined with naloxone which is called suboxone buprenorphine only is called subutex and when it's used for treatment of acute pain it can be called buprenix it buys to opioid receptors in the body and only activates them about 40% if somebody's already in withdrawal from opioids then activating those receptors 40% is pretty good it's going to take them from feeling like they've got a really bad case of the flu to okay I can survive the day if they're not in withdrawal then dropping from 100% to 40% it's going to make them feel pretty crappy so it's up to the doctor and the patient how they transition buprenorphine is less restricted than methadone you can get it from a pharmacy with refills for up to six months but outpatient physician visits for medication checks are needed addiction counseling is separate and the patient may be referred to another provider for this service again because it's an outpatient thing like suboxone so we're going to skip over that and move on to suboxone in the interest of time combination buprenorphine and naloxone they put those two together so that if somebody decides to either to try to inhale it or inject it then naloxone kicks in and it triggers an opiate withdrawal right away so you're not going to use you're not going to do that the short-term desirable effects of suboxone are a pain-relieving effect that's between 20 and 30 times more powerful than morphine and a mild euphoria that lasts for around eight hours a sense of calm and inflated well-being a perception of fewer worries and lower stress and increased relaxation it can be abused by individuals addicted to short-acting opioids like heroin because they'll use it between doses to keep withdrawal symptoms from occurring if they're it can also be abused by other people who are doubling up you know taking two or three suboxone at a time the naloxone only kicks in if the suboxone is altered and injected or snorted if a person who is not already tolerant to opiates uses suboxone the effect produces a mellow high but it's evidently a pretty pleasant feeling final thoughts like any other opioid tolerance develops quickly and goes away quickly there's a danger of overdose in patients who've tapered or stopped using opiate agonists who relapse because they often relapse expecting to be able to use as much as they were using before they stopped and that's not the case because of that Narcan which is the opiate reversal is available 35 states in at Walgreens and some other pharmacies but is available without a prescription and yes suboxone can be put on stamps it can be put on anything that can be licked so it is the preferred drug in many correctional institutions urine drug screening needs to be incorporated into all medication assisted therapy in order to help people stay safe make sure that the medication assisted therapy is doing its job and help us figure out what else we need to do if the person is relapsing obviously we're missing something and we don't want to just put them in a situation where they're where they're still in danger they're still suffering long-term pharmacotherapy is available and effective for several addictive substances medication plus counseling equals recovery medication alone won't do it and for some patients that period of time until their neurotransmitters stabilize and they can see colors again and they can feel feelings is so oppressive that without some sort of stabilizing pharmacotherapy counseling alone may not be enough so we need to consider the client nicotine replacement is available over the counter bupropion and various burn shantix are available by prescription for smoking cessation multiple medications are available by prescription for alcohol dependence including and abuse and Vivitrol methadone buprenorphine maintenance has been proven to reduce mortality crime and the spread of infection substitution therapy to eliminate withdrawal cravings and heroin effects so we're really using either a full or partial opiate agonist in order to help feel some of the benefits to address some of the reasons if you will that they started using the illicit substance in the first place all of these require an individualized dose because people are going to have different tolerances to opiates we are so excited to announce the launch of docsknife.com and its associated podcast happiness isn't brain surgery these resources are designed to provide practical tools and information to help people in need docknife.com contains solution focused goal sheets what we often call treatment plans videos informational texts workbooks and a variety of other resources that clients can use to enhance their counseling experience unlike other sites that just provide the worksheets docsknife.com provides text and video resources to walk people through using the tools the resources are ready made for you saving you the clinician loads of time for the actual counseling work during the first half of 2017 we're offering introductory memberships for $5 per month lock in your rate now annual memberships are also available at a discounted rate for organizations if you would like to use our resources with your clients but don't want to have them subscribe individually contact support at docsknife.com for pricing go to docsknife.com to learn more and join us each week for the facebook live broadcast recording of the podcast at docsknife.com facebook if you enjoy this podcast please like and subscribe either 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I want to now um summarize some of the problems with rendering for virtual reality and this may be um one of the most interesting parts of the lecture then for you um. I have mainly just been covering standard techniques from computer graphics which are used for rendering to a screen that is fixed in space where the viewpoint is fixed typically. So, let us look at problems with rendering for VR ok. So, let us go into the shading part right I gave various shading models um. One of the troubles is that the highlights or specularities need stereo perspective. So, you have to do twice the work there right. So, you have to take into account the left eye and right eye perspective I mentioned this already. If you do not do this it will not look right you know just the when the convergence will not look correct on the on the surface of the object um. Texture maps I just erased texture maps if I do texture mapping on a screen you know to some to some surface that is rendered on a screen and you are you are in the world looking at the screen it may seem fine.  So, you cannot really you do not really perceive the texture with all of its depth it just looks like a painting which is what would happen in the real world right.  It is much harder to see that on a fixed screen, but in virtual reality it is very easy to see that. So, it does not look right. So, texture maps look like painted cardboard or painted walls. So, you can tell the texture is artificial because you can change your view point you have stereo looks artificial ah bump maps and normal maps look fake.  So, so so it is very easy because you can easily change your view point it is easy to determine that um these are not done correctly. So, those are some challenges there is here some well known tricks and these um in virtual reality they do not work so well. So, what should we do that is for you to figure out um let us go to another problem aliasing excuse me a minute. So, we talked about aliasing this is the problem of not having enough resolution and we have already talked before about um number of photoreceptors that we have on the retina especially at the fovea we talked about putting the display in front of the eye and the problem of seeing the pixels right. So, it seems like we need higher resolution displays than ever before. So, aliasing is clearly going to be a problem um. So, so we need higher resolutions than before just because of the way that these the optical system is arranged. So, we need that and I think I am going to go over to the other board here getting too low ordinarily when you look at a surface and in in a rendered surface onto a display with pixels if there is not enough resolution you get some kind of staircase effect on the boundary right. So, that is something we are quite familiar with um well if what is being rendered here depends on how you are looking right which way your head is moving remember we have motion tracking occurring that was a couple of lectures ago we are putting all this together we are tracking your viewpoint that means that the particular stairs here if you call this a staircase effect right this looks like a sometimes called a staircase effect the particular stairs will look like they are moving up and down. If you are moving your head right even the smallest motions that you do will be very easy to see here as what looks like some kind of rippling or or changing of the stairs and because our eyes are very sensitive to motion we tend to focus on that. So, we notice these flaws very well. So, not only is everything somewhat zoomed in let us say to where we know we notice pixels, but in addition to that we see these jagged boundaries moving around. So, um so what I what I like to say is that the staircase becomes um an escalator. So, the fixed staircase that we see on a screen becomes like moving stairs and your eyes fixate on that. Now, it gets even worse because um we are really looking at this in stereo. So, that means I have I have two different views one for the left eye one for the right eye and in one eye view I guess I should make the staircases really look right here I guess. So, so I have one view for this eye and have another view here for the other eye right and the particular stairs do not match up exactly do they because it is a different perspective for each eye. So, not only do I have an escalator I have multiple escalators I have two different escalators one for each eye. So, they are moving up and down and I am trying to converge on a single edge. So, in the real world there is no escalator I converge my eyes together and I look at a perfect edge here I have moving escalators on both eyes and they do not match. So, I see this fuzzy sparkly kind of escalator pattern every time I look at a sharp edge. So, see if you can find that in some of the um in some of the demos that you are trying. So, stereo causes mismatched stairs or mismatched escalators um for every edge. Generally speaking the higher the amount of contrast between this side of the edge and that side of the edge the more you see this effect right. So, if there is a very bright if you have black on one side white on the other you will notice this. So, if you want to try to make a display or a project where you can highlight these effects then try to put black on white make it bright against dark and you will see these effects come out um very easily right. So, aliasing is really bad because of this. Questions about that? Sorry I do not have the solution. So, you have to just pointing out the problems. It is part of our jobs as researchers right is to um is to find the problems. And I think we are at a we are at a place in this field where there are many more problems to solve than we know what to do with. So, um so there is a lot of good activities for US as students and beginning researchers. Another problem is the render target. Normally the rendering is being sent to a rectangular screen. Now that might still be the case um if the rectangular screen is put inside of a head mounted display, but due to the way the optical system works only some part of that is actually visible. So, even though there might be a rectangular screen inside of your head mounted display although very soon these displays are going to be optimized. So, that perhaps there is one display for each eye and it may be shaped appropriately even it may not be a perfect square um things may be optimized in some way, but as it stands right now if you render to a display there is maybe one region that you can see for one eye and another region that you can see for the other eye. And the rest of it out here you might as well not even render anything to because you cannot even see it. So, that means the effective area which I will just shade in and yellow here. This is the place where you need to be rendering some kind of shape like that anything you do out here is just wasted work. So, that is a little bit of a difference not too hard to fix um. It turns out if you just use standard ah graphical processing unit GPU tricks you can use what is called the stencil buffer in the GPU to just deactivate all of the pixels that are outside of the actual field of view due to the optical system. So, you can just turn those pixels off using the stencil buffer setting the right flags and do that in one pass and then it will quickly skip over that the GPU will quickly skip over those pixels when you when you do your rendering. So, that is nice um the next problem you have to account for which I have talked about before and I am going to talk about it even more in just a little bit is you have to correct for optical distortion. This could correspond to the spherical aberrations of the lens could correspond to chromatic aberrations or other kinds of aberrations you have to correct for the optical distortion of the lenses which I have not talked about um yet in the context of um um rendering right I have mentioned it before in previous lectures. Questions about that? Two more problems ah latency. So, one fundamental issue is that GPUs the whole GPU pipeline of computation has been optimized optimized over the years for triangle throughput. In other words blasting as many triangles per second through the pipeline as possible ah not latency. So, if you waste a frame or two doing some kind of pre computation so, that you can get as many polygons as possible through the pipeline no problem right, but now if you waste a frame or two in virtual reality that introduces latency into the system that causes ah discomfort and possibly simulator sickness. So, GPUs need to be re-engineered to optimize for latency not necessarily blasting as many triangles as possible until you fix the latency problem you know if you get the latency down enough so, that you can go through at maybe 90 or 100 frames a second and there is no latency in the graphics pipeline ah beyond that you know you can render everything you need in one frame time will be in very good shape and then um only then I would say try to optimize the number of triangles that you can blast through the pipeline. If your geometry needs to be simpler because of that so, be it it will be a comfortable experience you do not need to have absolute photo realism to have a good VR experience, but you do need to have um the latency brought down as much as possible. So, I am going to talk about some latency compensation methods um in just a little bit. So, you can do um latency compensation the best way to do it is just to remove the latency in the whole rendering pipeline. There is not very much latency in the tracking part um it is mostly in the rendering part right now whatever little bit there is in the tracking part can be easily compensated for with prediction, but um um based on the momentum of your head and a little bit of prediction, but um the the latency part in the in the graphical rendering pipeline is large enough to where for a very complicated scene people right now are doing some kind of artificial tricks um one of them is post rendering post rendering image warp which I will talk about shortly. And you could also do additional prediction using your tracker if you do not have to predict too far into the future it will only compensate for part of the problem and if you know precisely when your rendering is going to be finished and you are actually going to be switching pixels. So, if you know when that time is going to be you could do some kind of prediction using your tracking algorithms, but the further you try to predict into the future the more you might introduce errors or instability into the into the system which are perceptible and that may be a problem. So, here is a couple of ways to help with this while we operate or we live in an era of high latency. Hopefully we can eventually have GPUs that are well optimized for latency and not worrying as much about blasting or maximizing the number of triangles um blasting as many triangles through the pipeline as possible um alright. One more topic and then I will get into um some of the ways to mitigate these problems, but um we are certainly not there across the boards um. So, there are in in the models that we use a lot of geometry errors geometry or geometric errors I guess I will say geometry errors. Thin objects it may be the case that um for example um the geometric model might have some leaves on a tree and these leaves are very thin um you know leaves in the real world look very thin, but they may be so thin that they generally have a thickness that is much lower than the width of what a pixel would typically be right um in any kind of rendering that we do. So, that means that we want to make very thin objects and if you render them on a screen they might look fine, but if you put your face up to let us say a leaf and you look right down its edge it will look incorrect you know will not render properly it looks very fake. So, um so thin objects look fake or implausible when you combine that with aliasing problems it looks even worse. Try that out in some of the demos that you have in the lab take a look put your face up really close to leaves and start looking at them from different perspectives. Let me know if they look right they will also be texture mapped in many cases and then it will look like as if the leaf texture is just painted on to some surface that is way too thin. So, things just do not look right um what if you have holes in your surface. So, holes or isolated points like maybe there is just a point raised above the surface become more obvious. In other words whatever minor flaws you have in some surface now if you render this in a with a CAD tool or maybe you wrote some code that generated a perfect surface maybe it is going to be fine. What if you got the data using some kind of simultaneous localization and mapping method right you have some kind of depth cameras you are building some kind of view you have reconstructed this table that is in front of me for example it might look fine when you render it on a screen and you are just sitting in your office looking at it, but if you go put your face up to the model and you look you say oh look there is no data there oh I see a hole there is a mess there it is not done correctly. So, once you can move around through the space the data looks a lot worse. So, any kind of model that you might have generated automatically right may look worse. So, think about some kind of models that you might have generated from SLAM or simultaneous localization and mapping SLAM data or models. Questions about that and finally, you know one more bit about the geometry remember we have talked about this before what do you do if you come up to a wall and you put your face up to it. In fact, what if you want to just if I want to in in virtual reality just go right into the board in the in the real world my head hits the board and I am stopped was not completely comfortable, but it does not nauseate me. In the in the virtual world what happens when I come to the board do you want to just artificially stop the head motion that could cause a vestibular mismatch that is nauseating or you can poke your head completely through do you really want people doing that in your virtual world right maybe they poke their head all the way through and they start talking to people in the corridor outside right that is not what you intended.   So, you have to deal with these strange problems that people do not spend a lot of time talking about, but this is what happens when you try to build a VR experience. All right I am going to talk about a couple of I am going to talk about three different kinds of techniques to handle some of these issues, but they do not get us all the way there. So, I just want to talk about some of the state of the art techniques. First I will talk about anti aliasing. So, as I said we have these moving staircases or escalators one per eye and ends up being a big mess. So, anti aliasing is now more important than ever maybe there was some hope that aliasing issues were not a problem as the resolution of displays got higher and we can barely even see pixels anymore on any of our displays in the real world. Now in virtual reality we have problems with pixels again. So, anti aliasing or as people in the graphics industry like to say getting rid of the jaggies back in the 1980s especially people call this aliasing problems the jaggies jagged is what it comes from jagged lines. So, you have a bad case of the jaggies you need to fix it. So, the most common method is super sampling which is you know in the standard method we have a pixel I will just zoom in on the pixel and I have my triangular edge hitting here. So, this is the overlap that I have and remember I said we just sample at one place and determine is that does that fall inside or outside of the triangle in this case it is outside. So, we do not render that pixel according to this surface of the triangle here. If this point had fallen on the inside then we render it. So, it is a binary decision that is all we have inside or outside. So, another way to handle that by super sampling is we divide this pixel into sub pixels not doing a very good job here making it uniform. Well let us pretend I drew that in a uniform way and then we just sample each one of these. So, we pretend we have a much higher resolution and we sample points inside of here and again I have the edge slicing across in some way. So, in this particular case I may have found that these points fall on the inside of the surface here this is the the triangular surface right. So, these points these 1 2 3 4 5 6 are on the inside these 1 2 3 4 5 6 7 8 9 10 are on the outside. So, I can say that 6 out of 16 points are on this side. So, then I will do a kind of interpolation or I will average the values right. So, I will figure out maybe these points correspond to some other surface right behind that there may be another triangle or in front however it works let us say behind maybe another triangle because this is occluding some other maybe surface in the back. So, I will do some kind of averaging between the between whatever properties let us say RGB values that I would have for the surface behind and the surface in the foreground and I will make that ratio be 10 16ths for the background and 6 16ths for the front. So, I just do an interpolation. So, that is a way to assign this a kind of averaged value that will in some way smooth out the jaggies or the aliasing rather than making it all 1 surface or all the other surface which only amplifies this problem at the boundary. So, that is one way to fix that. So, you average the colors or RGB values or whatever else you are going to be using as attributes. You do not have to pick a regular pattern like that. In fact, that may cause trouble in a lot of cases. So, you could pick some kind of random pattern of samples right and then again figure out what fraction falls inside what fraction falls outside just from your samples. You could use random samples or you could use some kind of irregular deterministic sampling pattern such as a low discrepancy sample sequence. So, all sorts of ways to do this. What is the disadvantage of this? Now it looks like you have to essentially do these computations these shading computations at a much higher resolution than your image right. So, now it is very expensive. So, this may help with the aliasing problem, but you have now had to draw images as if you had a display that was much higher resolution. And so, if you already had trouble with latency then fixing the aliasing problem may give you even more latency. So, that is an unfortunate disadvantage of this is that it is relatively expensive. So, good, but expensive one way around this which is done in GPUs is to use what is called MSAA multi sample anti aliasing. And in this case this higher resolution sampling is only occurring for some of the attributes such as depth or whether or not you are on one side of or other of the triangle, but the more advanced shading calculations are not done for all the samples. And they try to put together a result that looks good enough and people accept that. So, there is some kind of let us say a hack that is done in GPUs using MSAA you can read about that if you like the more details of it various techniques for that. And it seems to provide reasonably good performance does it still look good enough for virtual reality? I do not know you know you have to do your own experiments and see. But this is some kind of let us say trade off that is done in GPUs. So, that you do not have to fully do all of the rendering calculations at a higher resolution, but just do some of them and hope for the best. Questions about that? So, I just want to say a little bit about how aliasing problems are handled, but it comes at a great expense or there is a kind of trade off that seems to give some of the benefits at a lower cost. Next problem is handling the distortion. Let me just cover the distortion due to spherical lens aberrations.