Inside Addiction Medicine: What We've Learned

A little housekeeping , you've heard this before . Before we get started , I wanted to say thank you to Montage Health and the Montage Health Foundation for their support of my quest , as an addiction medicine doctor , to use this podcast to produce fun and engaging education for healthcare providers on addiction .

And if you're not a healthcare provider , well , I'm really glad that you stopped by to listen and I hope you find this podcast educational and useful as well . On to today's episode , I had the distinct pleasure recently of giving grand rounds at my hospital on the topic of the United States opioid epidemic and my approach to addiction medicine .

Well , it wasn't actually just my approach to addiction medicine I presented along with my addiction medicine colleague , Dr Reb Close . It was our approach to addiction medicine . We practiced medicine in the same office and worked together on quite a few patients .

During our talk we spoke about risk factors for addiction , how to talk to patients about their addictions and how to incorporate harm reduction into any medical practice .

The talk was actually an hour long and the first section was a discussion of the history of the opioid epidemic in the United States and some statistics as to what's going on with opioids here where we work on the central coast of California , and we've actually gone over those topics several times before on this podcast . So I edited that section out .

But Dr Close and I really felt that the talk about risk factors for addiction , how to talk to patients about their addictions and how to incorporate harm reduction into any medical practice was really impactful . We really enjoyed that part of the talk most , so I turned that part of our talk into the content of this episode .

Here we go and I hope you find it helpful .

And then , because of my work in the ER and face front , seeing what we were dealing with substance use and addiction and just the devastating loss , I actually started really focusing a lot of my efforts in treatment for people with addictions and so did a second training in addiction medicine , got our board certifications in that .

And then now I'm working in a private clinic just out in the community but where my heart is . I work in our street clinic and then in our jail . I don't work for Jail Medical . What I do is I go in and I do inReach to bring people into services when they're leaving .

Literally we've gotten to the point that we pick people up from the jail and drive them to their next destination if they need to go , pick up their phone or their wallet or whatever . It is to try to keep people from going right back to what got them there . So that's who I am . And then the lovely Dr Grover . Do you want me to do your intro ?

We're going to give you some history of how we got here and the why and how bad it is , unfortunately , but then what we want to do is to really have things that we take away so we can make change today , okay , and so the first is we need to talk about some risk factors . We've mentioned people with addiction and people in recovery .

We want to talk about risk factors that you can identify as a provider to help have that conversation with someone that they may be at risk and how you can mitigate that risk . We're also going to talk about how you improve your communication with your patients .

You're going to hear a lot of very respectful language , and that's incredibly deliberate , because my patients deserve respect , they deserve understanding and kindness , and that's what builds the trust for them to seek help .

Okay , so we're going to talk about that , and then we're going to talk about some strategies , and one strategy we talk a lot about is harm reduction , and there are things that people think about that historically , but we want to bring to the table all of the things that can be considered harm reduction . We can even brainstorm some additional ones .

So that's our plan , and all of this is to really prevent overdose , to prevent death and the devastating loss that we've had in our community .

And this is actually a painting of what he felt like living with addiction was like , and at the time I didn't know anything about addiction . In fact , between the two of us 15 years of medical education at UCLA and Stanford we got one entire hour between the two of us of training on addiction . So I met this young man .

It was like , if I buy you coffee , will you tell me about addiction . So we connected for three separate two-hour sessions where we drank coffee and he told me his life story and I started to understand more about addiction . And he died in 2019 of an overdose and I promised his family at the funeral that I would teach from his stories and his art .

The reason I bring this up is he was a nice guy . We'd go to coffee , he liked to skateboard , he liked YouTube . Addiction is a horrible disease that can happen to anyone , many of whom are wonderful people . I love my patients , they're so nice . Yeah , in honor of Paul , I always shared this painting .

We're going to get a little more clinical now . We're going to talk about some specific clinical things . The first is thinking about risk factors for addiction . There's essentially four major risk factors and whenever I work in the emergency department and someone may need an opioid , I actually ask them all four questions .

The first issue , or the first risk factor , is an active addiction . So if my patient is actively misusing opioids , using heroin , using fentanyl , that's probably not the best patient to give opioids to . Granted , in certain circumstances you have to severely painful condition .

Whatever , it's going to be A history of addiction to that substance or an active addiction to that substance . The next is an addiction to a different substance . So the classic story young man gets addicted to alcohol , teens and 20s , gets sober by 30 , needs a big surgery at 45 , gets painkillers afterwards .

Those same pathways around alcohol and opioids are connected and then it basically a new addiction surfaces to opioids . In fact , one of the folks we work with that was his story . He was a huge champion of Alcoholics Anonymous . He was all about I'm sober , got a surgery got opioids . Those same pathways connected .

So risk factor number two an addiction to something else . Risk factor number three is a family history of addiction . According to the American Society of Addiction Medicine , addiction is about 40 to 60 percent inheritable . Every one of my patients , when I do their intake , I ask them does addiction run in your family ?

I've only gotten one no answer and that was because the person was adopted and they didn't know . The last one is severe , untreated mental illness , which we'll talk about in a little bit of detail in a little bit , but I want to pivot to one thing that's on there , which are adverse childhood experiences , aces . This data comes out of Kaiser .

Kaiser likes to save money . I'm not going to say anything good or bad about Kaiser , but their model is about efficiency . They have a certain amount of money coming in . If they don't spend it because people are healthy , then they do well .

Okay , they wanted to see what makes people sick and what they actually found is a certain set of adverse childhood experiences were associated with heart disease , diabetes , high blood pressure , depression and depression Addiction , and these were adverse childhood experiences . Let me give you some examples .

A parent is incarcerated , domestic violence in the home , a parent with addiction , a parent with severe mental illness , a child experiencing sexual trauma , a child experiencing physical trauma , a child experiencing verbal abuse . There are these traumatic experiences . I think there's 11 of them , if I remember correctly , and in my life I can count one .

My dad died and got diagnosed with terminal cancer and died . He started dying in my teens and died in my early twenties . But I have one . Some of my patients have 10 . I have one individual . He's 15 and he lives in a different County and grew up homeless . Mom's forgive me a sex worker in Oakland . Dad was addicted . He's been incarcerated .

Dad's been incarcerated . Mom's been incarcerated . Dad has mental illness . He's been homeless before he was 12 . Yes , and by 13 , he was using methamphetamine , fentanyl and now he's doing great only on cannabis . I'm like I'll take that . But truly adverse childhood experiences are such an important part of the development of PTSD and anxiety .

I think we as healthcare providers often ask in a diagnosis-focused fashion what's wrong with you . But I'm going to ask a different question as it pertains to this what happened to you Story from the ER . So I'm working in the ER . I always remember what room they were in . It was room number 17 .

And there was a patient who was sent in from one of our local drug and alcohol treatment programs and she needed to be put on meds and cleared to go to the program . And they called ahead and say , okay , she uses opioids , she uses stimulants and she uses alcohol . I was like , great , okay , cool , hey , I'm Dr Grover . How can I help you today ?

This is what I know about you . Genesis House called . They said you're gonna need some help tonight . Just want to let you know you're in a safe place here . We're happy to help you . And I said , okay , they told me that you use opiates and you're on methadone , that you use stimulants and that you use alcohol . And she stops me .

She goes doctor , I do not use alcohol . My stepdad used to drink and then pee on us and beat us up . I can never , ever touch alcohol . And I remember going . I understand where you are , like think of the trauma that person lived through .

And so sometimes , when we have a really difficult patient , I will walk into the room and before I get there , I have to stop and take a deep breath and say I'm glad that I don't have to live this or remind myself to ask that question what happened to you . Many of our patients with addiction went through many of these childhood traumas .

Adverse childhood experiences because of the overall stress on the body don't just affect mental health and addiction . They also affect cardiovascular disease , diabetes , hypertension . They're really very pervasive in how a person's health is affected .

Okay , so those terms and I absolutely use these in various times in my education and in my career junkie , addict , dirty urine Okay , those sting hearing them at this point , because this is a person who is suffering with addiction , a person whose urine is positive for the substance of concern .

That respect just by realizing they are a person first and not a diagnosis or a name that helps us separate brings us into that trusting relationship . So , avoiding terms with judgment , like I said , it's not a dirty urine . Why is somebody clean and dirty ? What is that ? A urine that's positive , a urine that's negative ?

And getting back to what Casey was saying , another part of this is helping to understand the why Casey has experienced or has expressed the information on ACEs and that , that aspect of it . But the gentleman I was talking with about two hours ago was talking about okay , so I need to use meth for X ?

Okay , I've had a number of women that , specifically those that are unhoused they use meth so they can protect themselves at night .

Okay , if you don't get that information from them and it's just oh , you're an addict , you're a meth addict or a meth head , where do you start addressing how you help them if you don't understand what they're experiencing and what the drug does for them ? Okay , and this is my friend , mike , and he died of stigma .

Okay , mike worked with me at the syringe exchange . He saw patients with me every week , he took care of them , he brought them food , he'd get them socks , he'd get them hats and he was in and out of his own recovery . And Mike was developing a wound from injecting and he didn't even tell me . And I was there with him on Wednesday .

Okay , we're taking care of everybody else . And what I found out later is that Thursday night he started getting shaking chills , he was getting super sick and he was getting septic from his wound and he died because he refused to go to the hospital , because he had been treated like such garbage . And so he died of stigma .

And I pay tribute to him because I don't want anybody ever to die like that . That is preventable and it is something that our language and the way that we address our patients and our community can change .

I am very grateful to this institution for taking the lead on trying to educate about stigma . I apologize for the salty language on the slide , but I learned a lot from this paper . I think I mentioned a couple of you .

I have an addiction medicine podcast and there's a condition called cannabinoid hyperemesis syndrome , which is essentially where people get recurrent abdominal pain and vomiting from cannabis use and it's a real butting heads in the ER . The ER doc tells them it's the cannabis , the patient says it's not . They go back and forth .

Er docs are very frustrated with this condition because it's really hard to treat . Traditional nausea meds don't work that well . So I was like we've got to be able to do something . Maybe there's literature on this . So I go to PubMed and I love this title .

Sometimes people sneak funny things into the medical literature , but one of the things they talked about in this paper is nobody stopped to ask the patient why do you use cannabis , what does it do for you and what can we do to help you with that ? I'll give you an example . I can't sleep , so I use cannabis .

Well , that's easy , like why can't we just ask you if you tried some trazodone ? Pretty simple , I'm anxious , that's why I use cannabis . Great , let's have you see psychiatry or start you on an SSRI or on some hydroxyzine . The best question I can ask to help people know that I'm trying to understand them in addiction is what does the drug do for you ?

Nobody comes to my office addicted to penicillin or Prozac . Right , medicines cause short-term benefit and long-term benefit . Drugs and alcohol give people the perception of short-term benefit and they cause long-term harm . People always have a reason why they use and , as we get to know them , finding out that why is so helpful to understand how to treat them ?

Harm reduction . So harm reduction , I think , is a complicated topic . People think harm reduction and they think of supervised injection sites where they hear like liberal cities giving people heroin so they can inject . Harm reduction is . There's various approaches to this , but I'll give you our perspective .

I think when I look at all of medicine , I can think of three diseases that are most destructive Cancer , schizophrenia and addiction . They can affect people at any age . Schizophrenia and addiction tend to affect people at a younger age in life and with addiction a younger person is the harder to treat because their brains not fully developed .

Harm reduction is the idea that if I can't get them definitive treatment today , can I do anything today to make this illness hurt them less . Simple as that .

Okay , the best thing that I think we do is to have our patients trust us , because if you trust me and you're not ready today , when you're ready next week you're going to call me , and I think that's something that for even if , like my first four or five visits , all I do is just shoot the breeze and be nice to the person , that sixth visit that's the

one they're ready to accept the prescription , or that's the one they're ready to accept the prescription or that's the one they're at the ready to go to residential . So with harm reduction we really again we focus on a strong rapport and we focus on a stigma free environment , and the first one for harm reduction is really obvious To keep them alive .

We put it over at the Monterey Transit Center my gym has it . You walk in , you take your Narcan , you go about your business . Right , we need to keep people alive or they never get a chance to get their lives back .

And again , this isn't . And I will have my patients say to me oh , I don't need Narcan . Huh , how do you not need Narcan ? You're a human . We showed on that map where overdoses are happening . That's called everywhere . And so just reminding people , we've got to got to destigmatize Narcan . Even that simple to say , yeah , of course I have Narcan .

I asked my educators to put it right on their badge . It should be right there on your badge because when you respond to a kid that's overdosing , you're going to freak out and nobody's running to the office to get you anything . You need your Narcan . And then when you freak out and somebody comes after you because like why are you freaking out ?

And they see that someone's overdosed .

We have some that are like three and four years sober and we have come that are 12 months sober . We have some that are like three and four years sober and we have some that are 12 hours sober . One of my patients who's really struggling with alcohol comes to work out on the nights .

He works out , he doesn't drink and so if I can get you to the gym with me and that's a good night for you , that's some progress . Frank is amazing . He runs a gym called First City Fitness .

He used to be First City CrossFit and we approached him saying we'd like to put together a program for people with addiction and people who are allies to those with addiction , where you can come and work out in a welcoming space . It's so fun , it's my dopamine .

It's the absolute highlight of my week to go , and it just and I think this comes back to harm reduction right . Are we giving people drugs ? No , are we thinking outside the box and trying to make them feel welcomed and human ?

Anyway , I'll bring this giant tub of sunscreen out for people in the exchange . That's harm reduction , it's helping people know where to get help and that people care about them .

So literally a number of our community members will come up to where we are at the exchange and they'll bring tampons and socks and dog food and little things of soup and whatever you know , just letting people know that they care .

My goal is that I want you to be sober , and if today all I can get you is to put on some sunscreen so you don't get sunburned , I'll take that today and then , because you trust me , then I know I'll see you next week .

I was like because you matter , of course . Why am I here to come see you , right and checking in with him ? And I had to tell him I would so love to give you a hug right now , but I get in trouble for hugging inmates because you're not supposed to . But when I see them on the street I'm like hey , buddy , it's this , I care about you .

Wouldn't we all want that ?

There was a medication called buprenorphine , and when they began prescribing it liberally , their overdose death rates dropped by 79% . So we lose what like 110,000 Americans every year to drug overdose probably like 80,000 of which are on fentanyl . If we dropped overdose deaths by 80% , that's a lot of lives saved . That's incredible . Now here's the problem .

First , I wanna give kudos . Dr Meckel and Dr Gorman are two PCPs in Montage and , with the help of Ro and her team , we put together education for our doctors here by Montage doctors . For Montage doctors to start using more buprenorphine okay , here's the problem . Doctors to start using more buprenorphine Okay , here's the problem .

In America we restricted buprenorphine that only certain doctors could use it until 2023 , and then in 2023 they deregulated buprenorphine and any doctor , any PA , any nurse practitioner can now prescribe it , and prescribing has gone down . So we literally have a medication that drops overdose deaths by 80% and we're really not using it .

So that for us I still have people like my doctor said I had to see a specialist to get buprenorphine . I'm like , okay , at least you made it to me . Primary care has a huge opportunity here . In Dr Deldar's pain practice they use a lot of buprenorphine . It's a much safer medicine for pain , very effective for pain .

We have a huge opportunity here and we're certainly trying .

Bupe is an amazing pain med and I have said a number of times that if I need an opiate of any sort , that's the only one I will accept like end of story , because it is so safe and so effective . Deldar has taught us tons about how to use it for the pain patients and it's this beautiful medication that is actually so incredibly safe .

So just to put that out , there is my patient called me and this was such a tribute to her surgeon . I called the surgeon and I said , hey , can we use bup for her post-op pain ? And the surgeon was , yeah , talk to me about it . I'm like , and so we went through it . I explained what my rationale was .

I explained about adjunct therapies Can we do additional treatments ? What offering do we have ? And then I told her I'll run the bupe .