[00:10] Mark: Welcome to the Rehab on the Mental Health News Radio Network. I am Dr. Mark Leeds and I will be your host. Join me in exploring the world of addiction treatment. How can we improve the ways that we help individuals to overcome addiction? The goal of treatment is to save lives and help people to get back on track to a path towards success and happiness in life. Adam Bisaga is an addiction psychiatrist, clinician, researcher, and professor of psychiatry at Columbia University. He conducts research on new treatments for opioid addiction and oversees a national program that mentors physicians treating opioid addictions. He is a UN expert involved in international addiction training and program development. Doctor Bisaga, thank you for joining me and welcome to the Rehab podcast.

[01:06] Adam:  Well thank you, Mark, for inviting me. I’m happy to be here and speak with you.

[01:11] Mark: Today we’re going to be talking about your new book which is coming out soon Overcoming Opioid Addiction the Authoritative Medical Guide for patients families, doctors and therapists and I just completed the book and I really loved it/ This is a book that I believe should be in the hands of definitely every doctor and maybe not just doctors who are currently treating opioid use disorder but doctors who are considering it pretty much everybody across the board. In fact I was going to ask you about something a few years ago actually 2007 so about eleven years ago I received a book in the mail that was called responsible opioid prescribing and it had been sent out by the Federation of Boards or actually the Federation of State Medical Boards it was by Dr. Scott Fishman and at that time it was just, it was great that they paid for that and sent that book out to us. It was a nice reference to have. I feel like this they should do that with this book, I mean whether it’s a Federation of State Medical Boards or some other organization I mean if this book could be put in the hands of every doctor in the country it would be really excellent. I think every doctor really needs to read this.

[02:21] Adam: Well I’m glad to hear that and there was an old definitely one of the intentions I had when thinking and then writing the book was that there is really a lack of knowledge and for a variety of reasons that we could discuss later that the education about addiction has been really removed out of that medical school education and then the doctors were expected to deal with patients who had this issue. So how they were able to do that if no one really taught them so they relied on the kind of common understanding of addictions that is shared by many people in the society which I think was very very limiting and it I think in some way contributed to this problem that we have. Which the problem that I recognize is a treatment gap that there are so many people that have a problem and we have effective treatments but we are unable to deliver treatment to people. So definitely my book was kind of in some way trying to fill the gap of knowledge but I think that much more had to be done to actually change that. But I’m glad that I did, you kind of noticed that and I appreciate your support.

[03:35] Mark: I was wondering also was there ever a consideration of actually making this three or four different books or maybe smaller pamphlet versions, for example, I would love for my patients to have this book. In fact, I may even make it a requirement and the family members also separately. I just imagine of course I will tell them to get the book or I will give them the book and say read section four if you’re patient… section three I think it is, if you’re a family member. Did you ever consider that having actually four separate books?

[04:07] Adam: Right, no I, we certainly, I did consider that but then again I thought that the book is really based on my experience working with patients and their families and what I’ve noticed over the years I end up telling the families and the patients all parts of the story. I tell them about how some people develop their problems because of again kind of overprescribing in the medical setting without paying attention to the potential of some of those medications to become addictive and then I tell, definitely tell how to educate patients in their families. While in their case the response to the drugs was different than in people many other people who got you to know painkillers but never developed an addiction. How then the medical treatments are able to help overcome some of those vulnerabilities in their brain that caused them to have an addiction.

I certainly talk a lot to families about what’s the best way for them to deal with having a loved one affected by this problem. How to protect themselves and also how to be most helpful and I certainly tell the families and the patients a lot about how to go through the necessary processes of stabilizing on medication and being able then to overcome the problem. So at the end I decided that I think there is something from all this perspective that could be useful to the families and the patients but then it could also be useful to professionals because professionals need to know how to advise the families and how to help patients go through the process of stabilizing on medication which they may not know what it’s like to be a patient in the grips of dealing with this kind of very intense physical and emotional experiences when they give up drugs. So I decided that in some way it could be actually useful for as you’re saying primarily read the chapter assigned for them but also to have access to the other perspectives and I would definitely if they’re ready to encourage them to read about the other perspectives to have a more kind of complete pictures and that’s why we decided to have it all in one book.

[06:18] Mark: It seems like the main underlying message of the book is that medication must be a part of the treatment of opioid use disorder and it must be part of the treatment of that chronic disease long term.

[06:31] Adam: Right, you know that the medical perspective is really necessary to be at the centre of treatment definitely at the beginning of treatment and again for some people, it may need to be a part of the long-term treatment. Others may be able to move beyond the medical stabilization and maybe have the rest of their life in a more kind of non-medical treatment focus on recovery work but that at the beginning of treatment is absolutely necessary because it the disease so deadly right and unless we provide the medical stabilization we really don’t give patients, we give them less of a chance to come to kind of compare it to come out of it. No different than from other serious medical disorder be cancer or some other heart attack that at the beginning of treatment is really important to have a kind of stabilized constrained effect of the disorder on the brain using medical interventions and then over time we can focus on the lifestyle changes, spiritual changes. You know other support changes and kind of less so of a medical focus because patients are actually way beyond the most acute phase. So that’s, that’s exactly as you were saying that the medical model at the centre of treatment and definitely the beginning of treatment for everybody with this disorder.

[07:56] Mark: And as far as the medications there are three medications you describe. Basically, for the treatment of opioid use disorder, we have three medications available methadone, buprenorphine and now naltrexone. Now some things I learned some new things about methadone. I kind of have always had a negative view of methadone and I didn’t realize it’s considered to be the gold standard of treatment and has a 75% success rate which is well above the 50% success rate of buprenorphine and now naltrexone for people who can get on those medications and it seems like for some people that may be the answer someone just cannot get to the point of and I had a patient in the situation he couldn’t get through the twelve to sixteen hours to get on to the buprenorphine and that may be the right option for a lot of people is to get started by going to a methadone program.

[08:53] Adam: Right, so you know as I’m trying to make the case over and over in this book that we have three very different medications that may actually offer something different for a patient and hopefully we will be able to find the best match for the given patient and a given time. It doesn’t mean that they have to stay with this medication for the rest of their life it means that when we are kind of trying to engage them and stabilize one medication may be more acceptable or as you’re saying easier to work with that than other medications. Once the patient is stable then we have options of either continuing on this medication or actually transitioning them to another medication. Methadone seems to be the one that we have the most experience with. We’ve had methadone since the late sixty’s. We had millions of people around the world treated with methadone.

We have a broad range of scientific literature showing you how to do this treatment properly and it appears to be when done really well it appears to be most effective defined as people who are able to have a stable life with the improvement of physical and mental health and improvement in well-being. Methadone seems to offer this to more people than other medication. You know that’s why it’s there, now, of course, methadone has a very tumultuous history in our society and many other societies and certainly, there is a lot to be talked about that why methadone has such a kind of bad reputation in some circles. But yeah definitely it’s a highly effective medication. It is very potent and very effective but it’s a difficult medication to use. There are a lot of restrictions and regulations which makes it, unlike any other treatment. The two other medications can be given pretty much in kind of most medical settings and also give most patients an option to use methadone. As you may know, it’s available in very few centres around the country primarily urban centres, methadone programs or opioid treatment programs as they are known these days are kind of very complicated to set up and run and therefore this medication may not be really available as widely as we would hope.

[11:15] Mark: And of course as I know my practice and my patients, of course, know buprenorphine works very well. Patients do very well on it and as you said, “it is possible to transition from methadone onto buprenorphine.” I think in the literature they recommend tapering down on the methadone to 30 milligrams first before going to buprenorphine. I’ve had some patients transition from a little bit higher because they were just determined they didn’t want to go to the methadone clinic anymore. It takes them a little while to get used to it they feel sick in a lot of cases for the whole first month but then they do really well after that. The buprenorphine is incredible and I think even described in the book as very rewarding for a doctor to see the change that happens and I sometimes don’t recognize my patients when they come back you after three or four weeks. I mean they look like completely different people sometimes walking in.

[12:09] Adam: Well that’s really interesting to hear that and that said, that’s certainly true that the change is pretty dramatic. Especially in people who are coming to using heroin every day and really have their life really completely wrecked. They’re in a severe depression, hopeless on the verge of thinking about ending their lives coming to you for help and then you start them on buprenorphine and it’s like in a few days they start kind of being amazed of how is it possible that they can feel so different so quickly. Then you see them every few weeks after that. They have even more and more of this kind of enthusiasm for life and of course often depression goes away. They start being hopeful. This may not last because then the reality of daily life hits them back but definitely, the change is pretty dramatic pretty powerful and very few treatments in psychiatry that we have that the change may be so quick.

So it’s extremely rewarding for the doctor and for therapies for someone else to see that patients can suddenly feel so well so quickly and you want to be a part of this right. You want to share this with the patient; you want to tell others about it. The patient wants to tell others about that and that’s why we are in helping professions to be a witness to this change. You’re absolutely right that wish more people had more doctors and therapy, same opportunity to witness that.

[13:36] Mark: In fact it works so well that It almost works too well and in some cases and I think you also describe this in the book that some patients feel they’re doing so well they feel like they’re cured and I’ve had this happen with patients where they try to quit their medication and they may if you feel fine for the next day after quitting it. Then they realize wait I’m getting sick again and then sometimes they even get upset like well you know now I have just traded one addiction for another. I am depending on something else and you go into this in the book you’re not really when you go from say heroin or oxycodone unto buprenorphine you are not really trading one addiction for another it’s not an addiction when you’re on medical treatment.

[14:15] Adam: Right, so I think it’s important because again the patients have these notions about what it should and should not be the part of treatment and they are strongly influenced by those notions. Many of them are not kind of accurate or to use the perspective that it’s not a medical perspective. So it doesn’t really match their experience but you’re absolutely right they are this notion that because you are taking medication every day and if you stop the medication you feel unwell that means that you’re addicted. You know, I can understand how people who have not been working with patients or actually addicted may feel that way but the patient cannot see that their friends from what’s like to be addicted where your mind is constantly preoccupied with getting the drug and doing whatever it takes destroying their lives to have a supply of the drug and a physical kind of discomfort because they don’t take medication every day and there is some physiological adaptation. While the families can maybe think that way oh they are taking medication that means that they’ve been taking painkillers now they’re taking this. It’s kind of the same but the patients I think would be easily taught or worked with to reframe how they are thinking about themselves that this is not really an addiction that they need a medication to have a stable life and they rely on medication. They are dependent on medication to have a stable life but they are certainly not addicted to the medication because they can have a normal life. They can devote their energy and time to pursue other things in life. Most of them don’t really think much about taking medication except that every morning when it is the time for next dose they think of how the medication and that’s about it. The rest of the day they are devoting to other pursuits in life. Which is very different from addiction right?

[16:06] Mark: And also, buprenorphine, people when they’re taking heroin and other opioids abusing them or misusing them are thinking is clouded. Of course, they’re also constantly thinking about how do I get the next dose and how do I keep from getting sick but they also because of the drug itself they’re not thinking clearly and people when they take buprenorphine they tend to their thinking clears up. They have clarity of thinking and they’re able to do their daily activities a lot better and function better.

[16:36] Adam: Right, absolutely so their mood is stable because there is no up and down of on and off the opioids. They are not sedated or in physical discomfort with the withdrawal which is a part of being on heroin and painkillers. They’re pretty much even stable throughout the day which is what medications do. They kind of stabilize the functioning of the opioid system. So, the most destructive for your brain is the kind of constant changes up and down which again have a negative impact on your cognition or your mood on your of course sleep and wake cycle, on your feelings and on your sex functioning. On everything else that we are about as human beings not having a stability kind of interferes with and then when you’re on medication Whether it is buprenorphine or naltrexone that keep the system on a kind of very constant level that allows the body to kind of reset the kind of normal physiological functioning in all those fears that you mentioned which again is very different than addiction. So those two points again it should make everybody realized that taking medication every day it’s not like an addiction to the medication. If you have a good response, of course, there are patients who don’t have a good response and that’s another story to discuss but 50% or more have an excellent response to medication and in those people, their life couldn’t be any different while on medication as compared to their life when they were addicted before they started medication.

[18:08] Mark: Now with buprenorphine and the most common brand being suboxone effect a lot of people just call it suboxone. They call the doctors who prescribe the suboxone doctors and suboxone clinics. Suboxone or buprenorphine a common starting dose is for a lot of people I think is 16 milligrams a day and I just for example just say that you have a patient who stabilizes very early on at 16 milligrams a day. They have no problem with side effects. They’re functioning very well in their life and they kind of have earned a critical situation of that they have a job they can’t afford to lose it. They’re taking care of children and they’re doing really well. Is there any reason any physiological reason why the doctor should start pushing that patient at some point in the future and say well it’s time to start trying to cut back a little bit. We need to go down to maybe 12 then 8 milligrams and stabilize at the lowest effective dose because how do you know what the lowest effective dose is and maybe they’ll start having breakthrough cravings at some point?

[19:09] Adam: No, you are absolutely right that somehow people expect then that treatment with buprenorphine will be different than treatment with any other psychotropic medications. Right that somehow the goal should be to get people off medication as soon as possible as opposed to provide stability. So that is one kind of difference that I think it’s reflected by this tendency of the patient to lower the dose. Of course, we try to find the right dose which is that the most effective with the least of the problematic adverse or side effects and sometimes people do have side effects from higher doses right. They may be sedated although that’s rare.

Often, they may be sweating too much or they may have sexual problems or they may have swelling in their feet. Sometimes there are some side effects although there are rare and then we do try to lower the dose to try to kind of preserve the beneficial effect without the side effects and then lowering the dose is absolutely justified. People do want to see that they are making progress and people do want to see that they’re making progress towards that goal which in their mind is a life without the medication and I can certainly understand that who wants to take medication for years or for the rest of their life. That certainly could be indicated to think about to work with a patient on lowering the dose. My experience most patient’s kind of tends to over time lower the dose there are certainly a group of patients that want to just have a guarantee beneficial effects and they stay on the same dose. But many patients tend to gravitate to lower doses. So, patients will be on medication more than a year or two they tend to be closer to 8 milligrams rather than 16 and some people have been on medication for ten, fifteen years tend to be on very low doses. 1, 2 milligrams sometimes 4 milligrams and that’s certainly appropriate as long as they are open to monitoring how they’re feeling and how their life is going and making sure that they tolerate medication well.

So, I don’t think in other words that wouldn’t be any different from treating patients with any other psychotropic medication be it anti-depressant, stabilizer, anti-anxiety medications. When you would at first try to maintain the clinical response and then over time you do try to maybe, lower the kind of medication load with the idea that less medication is better for the body.

[21:35] Mark: But that’s not a definite protocol and I know that there’s no one size fits all but as far as like there’s no need to push the patient and say okay that’s your first month at 16 now we go to 12. Then we go to eight or maybe, not that fast. So, a person could, in theory, stay on say 16 milligrams for a long time and then when the patients ready and they’ve been while in counseling then we can ask the patient like do you feel like you’re ready? Do you want to try going back down a little bit?

[22:05] Adam: Right or listen to the patient because the patient may have an interest. Most patients do have interest to maybe, take again a little bit less of the medication and you help them get there. So, I think that the main problem we have is that patients come off medications too quickly. That’s the primary problem, most patients on average stay on [22:24 inaudible] from anywhere three to six months and that’s clearly not enough on average. It may be appropriate for some patients, but a majority of patients need to be a medication for at least longer so, most of the time we try to kind of encourage a patient to stay on medication rather than encourage him to come off. That’s how it should be, that’s what the evidence tells us now, of course, the practice may be very different, and you can certainly see the doctors who have a limited understanding of addiction. They haven’t had much experience working with these patients over a long time. They haven’t seen the devastating effect of relapses. They may feel like coming on medication should be one of the goals up on the list. I’m always saying that coming off medication should be one of your treatment goals but should be really very low on the list. On the top of the list should be of course to stay alive, to stay healthy. Be able to move on with your life have all the other things that addiction may prevent you from getting that we should be focusing on working in treatment and medication. Stopping medication should be really very low on the list. As it is with any other chronic medical illnesses right when you treat someone with diabetes you don’t really have coming off insulin as one of the primary goals of treatment. You have it, some patients are able to come off insulin or oral anti-diabetic medications when they have made all the other changes in their life but that is never on top of the list and somehow we want to have the same approach for treating of addiction.

[23:57] Mark: No, for example when it comes to vaccinating children sometimes people get confused because they look at stuff online and they see these anti-vaccinating movements where they say “Well vaccines are dangerous. They can cause further illness. It’s the drug companies are trying to make profits by selling these vaccines.” They have all these great sounding arguments against vaccines but the truth is vaccines are important for protecting the population and doctors are responsible for; the medical community is responsible to educate the public that vaccination is important. Now we have the same problem with the treatment of opioid use disorder or opioid addiction where we have people that are in a position of influence. People running treatment centres for addiction that are saying either medication should not be used at all or should only be used for a very short period of time may be one or two weeks or a month at the most. That’s a dangerous position and they’re the ones who are educating the public and so it’s almost like a minority of the medical profession is providing the correct information and in my case I’m completely in line with what you’re saying but I even feel that influence when patients say “I only want to take this for two weeks” and I start feeling guilty like who am I to tell them they have to be on this for years and years.

[25:12] Adam: No absolutely, you’re absolutely right and I think it is changing and we said certainly I hope that with this is a book and that the work that my colleagues and myself had been doing will help to provide the change faster but it is still the dominant model. It is a very traditional non-medical when the medication we’re always kind of used on layers and adjunct treatment for a very short time during the detox. That’s really how you know what the role for doctors in treating opioid addiction was only to provide some relief of withdrawal at the beginning of treatment before that real quote and quote real treatment could take place which the treatment of course done by peers that the behavioural treatment so with this kind of model still predominant in most of the treatment facilities. No wonder did you hear this kind of opinion as a primary one and the voice of the medical professionals, the scientist that people who have evidence behind them. It doesn’t you know is not heard as much. Now, this is changing a lot of leading addiction treatment programs like Hazel den Betty Ford have certainly been saying they change the view of the use of medication in the last few years. That’s very encouraging but it’s still a minority of the leading non-medical of physicians associated with programs or just the program leaders that are giving this new message.

I think the traditional treatment industry still really is in the kind of process of changing how they see addiction. Not only about using the medication but also about using harm reduction strategies as a viable goal of treatment. Those are the two kinds of changes that we see that traditional programs are evolving and you do hear voices as you say. People saying oh addiction should not be treated with medication or if you really need medication you should really come off it as soon as possible.

What do we do when we hear these voices? Of course, we have to counteract those voices with a different, right opinion and it’s not an easy process because you don’t want to alienate the whole treatment industry. They have a lot to offer, they have a lot of experience working with this population using behavioral methods that can be all very valuable. To me it all has can have a value as long as people pay attention to the medical component. I don’t think that they have a value without the medical component because again they are sending and conflicting messages to the patients and patients who really don’t know much right.

Patients are only relying on their friends and families and they tend not to really differentiate why this doctor says to use medication for as long as possible. Why the other doctor says not to use the medications. They do get quite confused and that’s not fair to the patients.

[28:05] Mark: Yeah and hopefully like you said this book will get out there, get into the hands of doctors, patients, families, and therapist. The word will get out there and it’s another thing when we refer patients to a psychologist or to a drug counsellor. There’s always that fear, for example, there’s a psychologist I’ve referred some patients to it who has decades of experience certified in addiction treatment. He’s credentialed he has decades of experience and you know that I’m concerned what if he’s telling my patients that they shouldn’t be on medication. How do I know that when I’m doing all the right things of referring patients out to the therapist into the meetings that maybe they’re going to get the wrong message and just stop their medication not come back and maybe relapse. It’s a scary thing to even try to do the right thing and recommend patients you need to see your psychologist and develop a support network because those wrong messages can come from anywhere.

[29:01] Adam: Right, no absolutely and the part of my book The One Devoted to Families is how to find the right treatment provider or the right treatment program? What are the questions you really want to ask and when can you trust your loved ones or yourself to go to this provider what you know to go to risk provider and when you should look for someone else? You know that how to differentiate that and again it may be kind of complicated but guiding patients through this process is very important. As you were saying there is so much that patients can take advantage off from the traditional program, from the self-help groups and of course from the, even certified providers that use specific behavioural treatments that would be a shame to kind of completely separate them from the medical model of treatment. I really hope that those models can be integrated. But sometimes you have to say that’s not a good idea. A lot of as you know self-help groups especially the ones that grew out of the NA Narcotics Anonymous Movement far out reject the use of medications. They still hinder charter I think to reject the idea of medications as a part of treatment. They do not consider anybody who is taking medication as meeting the criteria for sobriety. I find that AA groups are a little bit more flexible because there are medications to treat alcohol have been around for a little bit longer or at least being present at the groups for longer. So, they’re a little bit more forgiving and but it’s a loss because and I think still has a lot of value. But yet people get confused when you say certified addiction treatment provider. You think that this person is using evidence-based latest rights treatment methods and you would trash the certification, but the reality is people get certified even though they do not believe what the science tells us about treatment.

They have an opposing view yet they get certified. That’s one of the many kinds of problems that we still have to solve. The same way treatment programs may be licensed to provide treatment yet they do not accept the use of medication but they are licensed by the state. How can you and they are licensed by the state to use public funds right to fund for treatment? How is it still possible? I think we have a lot longer to go. We are changing something beyond what it have been in the last years very dynamic efforts to change that but I think it’s not changing fast enough because to them it is ravaging the country and everybody knows it doesn’t seem to be slow in town if anything accelerating.

[31:39] Mark: Yeah and I was going to bring that up actually Narcotics Anonymous and for years I’ve loved NA and I thought it was the greatest thing ever and originally that was my goal. I first took the eight-hour course for buprenorphine prescribing and I think 2006 and I did some research and I came to the conclusion my goal should get everybody into NA. At that time they’re talking about tapering people off medication faster. I thought well that’s a goal get them in NA, get them a support group and working the steps and having a sponsor and they can be prepared for the coming off their medication quickly. More recently I’ve looked into it and NA has a document called Bulletin Twenty-Nine from 1996 where they talk about methadone being if you take methadone you’re not considered to be clean you can sit in on a meeting of course but you’re not clean. Twenty-years later in 2016 another document called NAN People and Medically assisted treatment where they specifically talk about buprenorphine again they say if you’re on what they call replacement medications you’re not considered to be clean you can sit in a meeting, you cannot participate, you can’t do service probably a sponsor is not going to work steps with you. I think later another document changed that where they said, “it’s up to the group if they want to allow you to share or not but you can’t go any further than that.”

[33:01] Adam: Right, so they’re evolving you know hopefully in the right direction but it is difficult because the whole identity right at the principles of the movements are based on the group confessional when you confess to your limitation and then in some way it kind of perpetuates a little bit of the of the moral view of addiction that you somehow responsible for. What’s happening to you, you have to take personal responsibility of course for the behaviours and then a lot of this is true but it kind of still reinforces the view that it is up to you and only up to you to change your ways and your behaviours and kind of revert the behaviours that are mark of addiction that could cause you to wreck your life as opposed to that there is a part of you should be taking care of and watching but there is a part that is just too difficult, impossible for most people to change. Now some people can do it but most cannot that has to really take advantage of all available treatments and now that we have a treatment you should get a little bit help because without it what we know what’s happening right? Untreated OP dependence is the most lethal of all psychiatric disorders you have 2% of people every year dying. It is indeed I think unethical to refuse or reject especially by the progress everybody has the right to do what they want to do of course. We live in a free country but if you’re going to really use the public funds and you’re going to really have kind of a regulatory oversight of the programs is unacceptable to still allow programs exist that refuse the evidence. I mean that’s at least my kind of view on that. It’s difficult, it’s difficult because very complicated kind of a multifaceted system and treatment system and a multifaceted problem that we deal with that opioid addiction is.

[35:14] Mark: Just, for example, I had a patient who came in once and he was transferring from another doctor and I think he had been on buprenorphine I think it was at least two years. He was doing very well, his first visit with me I mentioned going to meetings and right away before I could finish my sentence he said, “I don’t go to meetings. I’m doing very well with my treatment.” I said, “I’m sorry,” and I never mentioned it again. I’m not going to get in the way of something that’s working but I know for other people meetings may be the best thing for them and everybody’s different. So, there’s no one size fits all therapy, you can’t really use a cookie cutter approach for every single patient.

[35:55] Adam: Right, but I think for those people that are really very connected to that twelve-step fellowship that really benefited from that. That really love the comradery and of course that kind of way of living in sobriety I think for those people maybe they’re not [36:14 inaudible] maybe there is not an attractive alternative right because I think most groups would be more forgiving when they see someone being maintained on naltrexone which is again non-opioid. It is an opioid but it doesn’t produce opioid effect. It is a medication that blocks opioid adjuvant system and it is not the replacement therapy or at least cannot be considered replacement or substitution therapy. It still helps with maintaining abstinence, preventing relapse decreasing craving and many people I’ve heard that are still much more comfortable themselves being in a group. Again not being on buprenorphine but rather being on naltrexone as a way to help them remain abstinent.

So that’s why I always suggest for people who you know that’s one of the decisions that we considered to be enough treatment. Which medication to go, do they want to be detox and be on naltrexone to prevent relapse or do they want to go on buprenorphine you know, that’s one of the things that we discuss when I try to talk to them about various options of getting help and to what are the differences?

[37:19] Mark: Yeah and naltrexone, is of the three medications. It is the only one that is not an opioid. It’s not controlled any doctor can prescribe it without any special training. In fact, a doctor who’s not even registered with the DEA could prescribe it. Any doctor can prescribe naltrexone.

[37:36] Adam: Right and it’s not quote, unquote cannot be abused. So quote unquote is not addictive. So it cannot really be misused and some people just like this idea a little bit more. I do not try to show patients that there is somewhat superior or kind of morally superior medication. I think they’re both equally good choices and should be equally good first-time treatments. You know for some patients those differences may be important, you’re absolutely right.

[38:07] Mark: If a patient comes in and you did discuss this in your book and I wasn’t sure about this before a patient comes in who’s abstinent. They’ve somehow whether by going to treatment or on their own they haven’t used any kind of opioid including buprenorphine for say two to four weeks or even longer and now they come in they’re concerned they want to be on some kind of medical treatment. Now suppose the first thing I would recommend would be naltrexone because they are abstinent. So why put them back on an opioid. Now suppose the patient says I have reasons not to take naltrexone. I didn’t respond to it well before. I don’t want to take it. I’d rather take buprenorphine. Now the patient has a negative drug urine screen. They admittedly have not been taking any opioid for at least weeks. Now I think in your book you do say that if the patient requests that we can put them on buprenorphine. Is that correct and how do we start that would be a lower dose?

[39:03] Adam: Right so you’re absolutely right that you know for methadone you’re right you cannot start methadone in someone really who is not physically dependent right. It’s pretty clear there are regulations how do you start methadone? What are the good candidates? And you would not put someone on methadone in that case. But for buprenorphine, there aren’t really any regulations or guidelines if they still have OP dependence then, of course, the fact that you’ve been abstinent for a few a weeks doesn’t mean that you got cured out of your opioid dependence.

We know that those patients will have cravings; urges will under stress will have an increased risk of relapse. We know that if you don’t treat them, a lot of them will relapse sooner or later. So if you can offer them medical treatment that will prevent it you know that is certainly a viable medical intervention and nothing really stops you from offering that. Of course, the patient has to understand that they will be with dependent physically again. Once, they start buprenorphine then you take it every day, you’re absolutely right the doses may be lower less than 8 milligrams maybe 2 maybe 4 milligrams. They probably wouldn’t need higher doses and then you’ll start induction like you would do and there is no physical dependence. So there’s really no waiting period you will just start prescribing the medication and try to find to keep them on a dose. Then hopefully help them stay with this for as long as possible. I mean it is absolutely for some groups of patients are at very high risk. The ones that you mention are of course people coming out of rehab or people coming out of prison right.

Those are the very high-risk groups we know that your risk of overdose goes up by eight times when you leaving those types of facilities because again you are returning to an environment where you’ll have all these cues and triggers and stressors that somehow maintain your addiction before. Of course, you have no tolerance to protect so your body has no defence to protect against overdose. So you have a double kind of whammy that puts you at the risk of relapse and overdose. It’s absolutely essential that people do understand those risks and do have a choice of restarting medication that will decrease those risks. That will decrease craving urges and they will protect them with a little bit of the blocking. Buprenorphine also can protect against overdose if people use it. Because it is very tightly bound to the receptors and it prevents heroin from getting out to those receptors.

So there is certainly a medical reason and as long as the patient fully understands the implications of starting this medication and you have a discussion. You check that they do

understand the risks and benefits. I think it’s fairly justifiable and I think most of the people who do this work would agree that this is a viable treatment option. Again it has changed, it hasn’t been seen like that maybe ten years ago maybe fifteen years ago when buprenorphine came to the market but right now with this opioid epidemic and the fentanyl overdose deaths. I think most of us would feel that this is a right medical decision.

[42:15] Mark: That makes sense now another thing that has happened more than once with patients that have come in. A patient comes in and they have stopped taking heroin the day before. They knew they were coming in. They wanted to be prepared. They wanted to start treatment right away maybe a patient comes in with their husband or wife and they want to start right now. We do our evaluation and everything looks good and we give them the prescription to get the medication. Now that patient who is feeling very sick and just can’t wait to get started they go to the pharmacy and the insurance says you need a prior authorization. I think in 2008 with part of the Affordable Care Act was passed I think it’s called the Parity Act or has a longer name but there is a law of it that guarantees that everyone will get the same coverage for addiction and mental health conditions as it would get for any other condition. These patients who may have been able to get prescriptions for oxycodone paid for without a question are now the doctors are given long forms to fill out. The doctor fills out the form, I do them online. In fact for any doctor’s listening if you don’t use covermymeds.com it makes it very easy to get authorizations. So I go and cover my meds. I will fill out the form and then they start asking questions they want more information. Some insurance will just flat out, put up roadblocks. They make it very difficult and now the patient is sick and they’re calling and they’re saying what I do now. Do you know if there are any tricks to make these insurances do it?

[43:45] Adam: Yeah that’s absolutely right. Of course, I can hear the frustration from your voice and all we’ve been through that because we know how essential it is to provide this treatment as soon as possible. How great of a risk the patient is at if they don’t get treatment when they are ready. So it’s extremely frustrating the bureaucrats are making this decision and sometimes some of those pre-screening questions make completely no sense. I don’t want to waste time to give examples but tricks are two-fold. I do tell the patient that most likely the medication will be approved and you should probably ask pharmacists to give you a small supply of medication. You pay out of pocket you start treatment and once we get you approved you will then, insurance will reimburse you back. This has been a well-identified problem and many municipalities are kind of making sure that this doesn’t happen. So there is a law at the local level at the state level that prevents state and I know my state New York State has done this law that right now no insurance company can really ask or pre-authorization. That it’s illegal to do that because you’re right it should be consistent with a Parity Act but still, it was a widespread practice even though the Parity Act was on the books. So those are the, I think this is changing and I think what I tell patients again my trick is that they should really just buy two medications. You can get coupons many of the branded preparations offer you coupons to offset some of the costs in starting treatment that also could be helpful for some patients and again you’re hoping that most insurance will cover this. This is a very inexpensive medication as compared to many medications that they are paying for and it’s a life-saving medication. There is really no reason

we should be outraged if it’s going to be treated any other way. So, hopefully, that this will be less of an issue in the future and some of the legislation hopefully will counter that.

[45:49] Mark: I wanted to ask you about plain buprenorphine which a lot of people called subutex but I don’t think the brand subutex is around anymore. I think in some states there may even be laws about this or it may be more difficult but do you consider that acceptable in many cases if a patient can’t say they’re uninsured or they’re having difficulties with the insurance process to use buprenorphine as a cost-saving measure and it makes it accessible for the uninsured but then I know there’s a concern with not using the abuse-deterrent. This is present in Suboxone.

[46:23] Adam: Right so that’s a little bit complicated of course and it’s really a case by case basis. In principle, you would really want to use a combination product which is buprenorphine in a lump sum because it seems to have a little bit less of abuse ability. Of course, there is no absolute protection there, the combination product can also be misused and abused but certainly has a lower rate and then there is a perception the community that subutex is somehow more attractive medication because it doesn’t have the [46:58, inaudible] and as you’re saying. So it has a higher market value and again some people may be more readily if people are set on misusing the medication which some patients constantly are there may be more ready to do that with the product the subutex or the buprenorphine on the tablet.

So you have to be very careful about how do you work with patients who were treated with this medication. You probably want a little bit closer monitoring of this patient. We have ways of making sure that the patient takes medication properly, you can certainly give smaller doses you can have medication call-backs. You can even look at the blood level, urine level of buprenorphine and it’s metabolites to make sure that patient is taking medication, you know using the proper route. If that’s the only way the patient is going to have treatment, of course, you don’t hesitate to provide treatment. You will need to have a little bit closer monitoring at the same time buprenorphine product, of course, the preferred choice for pregnant women because there seems to be a little more concerned with teratogenicity of the naloxone on as opposed to buprenorphine.

So in this population, it is definitely medication of choice. In any other patient population, they should be offered a combination product. Unless as you’re saying it’s not feasible for them and there’s a lot of clinical issues how to manage patients. There are certainly, again for patients who don’t have the optimal response there are many ways that clinicians have developed how to deal with and help patients have a better treatment response. We don’t have time to go into that here but I just have to let people know that there is this mentoring support and training program PCS provide there’s clinical support system. That disclosure I’m a part of and that we do offer a lot of opportunities for physicians to get access to mentoring, to discussion list, to small group discussions, a lot of materials have been produced and are available for free that help physicians with all those clinical decisions that they have to make them feel more comfortable and supported when they decide to take on this treatment because as you probably know a lot of physicians are very uneasy when they do start offering this treatment to the patients. Most of them I have to say feel actually that this was a one of the best decision they’ve made after they’ve treated ten, twenty patients. They feel that there was really no reason why they were so hesitant and they like it but there is still a big I think the barrier to entering into the treatment. Unless we have more physicians offering this treatment we’re not going to really have any grip on the epidemic. I think that the best way to start combating the epidemic is to offer treatment which is the way that of course all Western countries and Western Europe were able to combat their epidemic. This is not the only epidemic of course that has happened in the past around the world. So we have models of how health care system and physicians responded to other epidemics and hopefully, we’ll have more physicians. Again my call is for more physicians to be open to provide this treatment. It’s no different any more difficult than prescribing painkillers. Which physicians seem to be very comfortable doing and I would encourage that physicians also get a chance and try offering this lifesaving treatment. Because as you’re saying it can be a very rewarding experience and of course it can be very helpful to the community that you are working with.

[50:47] Mark: And again you’re involved with PCSS and the website for that is pcssnow.org. I’ve been a member for I think the last three years at least and yeah I was introduced I went to, I think it was 2015. I went to an osteopath convention in Orlando. I spent my entire time in the addiction lectures and they introduced us to the program they gave us a literature and I went online signed up and got a mentor. It is all free, it doesn’t cost anything you can get your own personal mentor there’s no grading or anything. You don’t get graded by your mentors just somebody to ask questions and talk to. There’s tons of paperwork and information and a lot of education I mean everything you ever want to know about how to treat patients with buprenorphine with opioid use disorder. It is available at pcssnow.org. I highly recommend every doctor go look that up and get involved and sign up. Again it’s completely free doesn’t cost anything.

[51:50] Adam: Right so this has been available from early on from like early 2000 when there was a need to support providers to start prescribing buprenorphine. It was called PCSSD at the beginning and over the years the grant was renewed and it kind of the organization evolved and you know we myself and my colleagues from Columbia University came to this about six years ago, six, seven years ago. We’ve been an integral part of this since. Again trying to provide, develop educational materials trying to figure out what kind of support clinicians would benefit the most from offering, of course, buprenorphine waiver treatment, buprenorphine waiver courses that are necessary to have a DA approval to offer this medication. It again has been a very rewarding if I may say for myself equally rewarding to treating patients has been to convince physicians to take a leap of faith and start treating these patients with buprenorphine or even more so naltrexone because many people are very maybe familiar with buprenorphine but will be hesitant to offer naltrexone and then when they do offer [53:03 inaudible] which is now naltrexone they feel equally excited about the opportunity. So it’s been very also enjoyable for me to work with colleagues to again to expand access to treatment and I certainly thank you for encouraging people to check the PCSS. There are other support systems available also the AETC which is the educational network for aides. Also, offer some training and support for people prescribing with buprenorphine. So there are other support systems but I think PCSS is one of the largest and certainly worth checking.

[53:42] Mark: There’s also recently there’s been a movement of doctors. There’s a lot of talk about burnout in the community of physicians. Doctors are burning out their jobs they’re working for abusive healthcare systems, large hospitals what they call big box clinics. So there is now a movement where doctors want to get away from the burnout and there’s even an issue with physicians suicide. So doctors who feel overwhelmed with having to deal with the electronic health records and the bureaucracy they’re looking to drop out and start their own small practices. What generally were considered to be micro-practices where there maybe is just a doctor in a small clinic maybe one room and maybe a small staff or even no staff. One issue is that doctors they think, you know how is that going to work what is my business model going to be how do I take insurance? How do I get patients? How do I advertise? One easy way to start is just to if you want to become part of the micro practice movement also become part of the addiction treatment movement and establish a large part of your practice just to get started it’s fairly easy to get trained in how to provide treatment for opioid use disorder and make that an important part of your practice.

[54:58] Adam: Right and PCCS also support with the business plan and kind of thinking about kind of business aspects of running addiction treatment practices. So we can help you with logistics, regulatory aspect the same way as we can help you with the clinical aspects to do that. I think again you can practice alone or you can actually practice with addiction treatment program in your community that doesn’t have a medical provider. Most of those programs really crave for medical providers because they do know that offering medication and medical help can increase their success rate. So they do want to collaborate with a medical provider in the community. So reaching out to those programs and offering medical services can be also very rewarding and there are patients they’re ready for you to start seeing. You don’t have to really do your own looking for patients if you are concerned that you may not have enough patients to start with.

[56:00] Mark: In the book, you even describe what’s called the hub and spoke model. Where there’s an addiction treatment may be a large addiction treatment facility they see the patient, get them started on treatment and now they want to pass that patient long to this book which might be a small practice like me and I will continue the maintenance for the patient. If at some point if they need more intense treatment I can refer them back to the hub.

[56:23] Adam: Exactly, so one of the concerns you are right there doctors who don’t have experience is that those patients will be very difficult to manage and may have a bad outcome. So who wants to expose themselves to do that? So they haven’t spoken model offers a solution to that which is that as you’re saying and those programs actually have been very successful in Vermont, now in Baltimore and several other states are embracing this model because it’s much easier for the primary care provider who is even we’re not specialists to the practice in the community when they get stable patients from the hub and they just maintain stability. They always have a way to contact the colleagues at the hub to consult when the patient under some issues with the patient and where the patient is too difficult to manage they can refer patients back to the hub.

Then when the patient is stable again they can return to the practice and that way they can manage hundreds of patients up to 275 patients which are the maximum but that are plenty for most doctors and feel that this is manageable. So that’s another model you’re right to see where are the hubs in your community, with your state. There are other new efforts to expand access to treatment, states have received a lot of money recently to fund addiction treatment programs and they are very eager to give training and mentoring and maybe even financial help to doctors willing to treat those patients. So you should definitely call your state’s single aid agency for addiction treatment to see if they have any ways to help you get involved and be part of the system. A network of again providers in the state that can offer treatment so that could be another way for you to get involved if that’s what you feel like will be more rewarding to have more control over how you practice medicine.

[58:16] Mark: Yeah I’ve heard of several programs I think there’s one from YO university. I know this one here in Palm Beach County and I think in Mississippi there’s several where treatment is initiated in the emergency room. Then there’s an on-going program and patients are able to get their treatment completely paid for if they can’t afford it. If they’re uninsured and they get the full spectrum of treatment, the medication, the counselling, and the doctor’s visit all included and it starts in the emergency room.

[58:45] Adam: Right so there are many models, new models of providing treatment that people are trying starting in the emergency room are one of those models because that’s where patients often come in crisis. It’s easy to get them engaged they walk-in clinics, the kind of surgical type of model is another model that there is kind of low threshold of entry into treatment. Obviously, there is an opioid treatment program in your states patients can go there and get started and hopefully they don’t have to wait. Although some states there is a waitlist and so there are many ways to engage people in treatment. I strongly believe that once the patient is on medication their view of getting help changed pretty quickly. Many people are very ambivalent about stopping drugs because they fear what their life will be like without drugs.

That will be unmanageable because they no longer have this sure way off of dealing with the stress. Once they are taking the medication they’re thinking about themselves, about their lives, about the future it really rapidly changes. They are much more eager to accept treatment to believe their treatment is possible. That life without heroin is a real possibility. So getting people on medication as soon as possible of course safely is a priority and I strongly believe that the programs that allow patients to get started whenever they are ready are a solution to the problem. Patients should be able to walk into any emergency room at any time and ask for help and get started. Patient with overdose will be definitely brought to the emergency room right and treated for the acute overdose. The same should be the case for patients who want to stop using drugs that should be really no barriers for them to enter treatment get evaluated and started and of course, have free treatment. Especially at the beginning to allow them to do that because those are some of the barriers that we talked about right. Now providers, insurance barriers, you know many other barriers that keep people out of treatment whenever they are ready.

[1:00:51] Mark: There’s just so much here in this book that we couldn’t possibly cover at all. I mean for how families can deal with the addicted family member or loved one and how they don’t kick them out on the street, don’t do tough love doesn’t work. Not for the opioid disorder,

you want to get them medical treatment and don’t hold back your anger. You talk about motivational interviewing; oh I wanted to say you describe it in a way that makes it a lot easier.  I took a class that included motivational interviewing training but when I read the way you describe it makes perfect sense.

[1:01:25] Adam: Sure no thank you, thank you for that and again the book has a lot of like simple I was trying to make very simple tips and guide for their families because they are often so confused when they’re caught in this crisis, that constant crisis of offending an addictive family member. Then simple suggestions can be very helpful for some things to try many of them may not work but definitely, there are some better suggestions than others. The one that you mentioned the one that you often hear from the traditional treatment providers which is to kind of distance yourself from the patient until they are ready to come back to you. Maybe it is acceptable for other addiction but I strongly feel is unacceptable for opioid addiction because we know that many of those people will not come back because it will be that. You really cannot afford this kind of strategy. I don’t think it’s acceptable.

[1:02:19] Mark: And part of that also is the harm reduction you talk a lot about that. Providing clean needles if someone is just not going to stop using the heroin. Places where persons can go in certain communities to be monitored, where they will check the heroin and make sure that it’s not poisoned with fentanyl or car fentanyl whatever they put in it and they will make sure that the person doesn’t die and administer Narcan if necessary. I just don’t want to finish with the most important thing, Narcan. I mean we have fire extinguishers on the wall everywhere now we have automated defibrillators on the wall almost everywhere.

We should probably have Narcan on the wall everywhere and until then everybody can get a hold of Narcan and have it with them in the car, at home you know you can save a life. Naloxone, Narcan, reverse an overdose and save someone who’s turning blue and dying because they’re not breathing after using too much opioid.

[1:03:09] Adam: Oh that is a good suggestion I never had put it that way but I think it makes a lot of sense. I think it will be worth looking at how much it costs to have defibrillators everywhere and how much it cost to maintain them and how often you actually use them and what are again the costs of having the Narcan available which is extremely inexpensive or can be extremely inexpensive medication you know, should be extremely inexpensive medication. Let me put it this way and why not to have it available whenever there could be a medical emergency like in the public areas, airports, schools, universities, medical clinics where defibrillators are. I think that a very good point because you’re right we have to do everything Narcan, of course, is not going to cure opioid addiction whether it is overdose but unless you get someone into treatment they’re much more likely to have another overdose. Many of those people do eventually die the only way to prevent reduce the risk of death is to start them on medication as soon as possible but of course, Narcan will allow them to live to be able to do that. But unless Narcan reversal is followed by the medication I don’t think we’re there yet.  I would soon to see all the people who have Narcan at least be offered medication they may not, of course, take it. They may refuse it but they should be offered. You probably have seen yesterday in the paper that there was also a princess family is suing the hospital claiming that he was suing

for overdose. A week earlier in the hospital and they’re claiming that he was not offered evidence-based treatment. Now, of course, we don’t know what will happen but I think it just exemplifies and brings to people attention the fact that if you have someone who comes to the hospital with the overdose this is an amazing opportunity to have them started on to treatment to prevent the risk of overdoses in the future. Even though many people will refuse it and they have a right to refuse it and that’s really what we want. We want more and more people having accessible, available and effective treatment.

[1:05:23] Mark: And that’s something that these treatment centres should consider the residential treatment centres where they don’t believe in medication or just short-term use of buprenorphine that could become an issue for them long term liability. Maybe even and NA, NA world services organization with this document and I just read what it says. It says in NA addiction is treated by abstinence and through the application of spiritual principles. So they’re actually saying, NA is saying we treat addiction, we treat it with abstinence and it shouldn’t be providing any treatment for a medical condition.

[1:06:00] Adam: Right exactly, they do appear to families as if they provide treatment. No, they provide spiritual support and community and a lot of help but they do not provide treatment. What they offer is not compatible with the evidence-based treatment the way we want the rest of the medicine to be guided by the principles.  But they can provide a very useful additional service and the whole idea is how to bridge those two perspectives because again at the end we care about the patients rather than other organizations.

[1:06:35] Mark:  Again this book coming out soon Overcoming Opioid Addiction the Authoritative Medical Guide for Patients Families Doctors and Therapists and everybody in that group should get this book. Everybody, every doctor in the country should or in the world who has access to it read this book. Anybody who knows anybody as a loved one family member who’s addicted needs to read this therapist especially.

[1:07:00] Adam: It’s available actually now as of today I think it’s available on Amazon and should be hopefully available everywhere we put it down in paperback book so it’s inexpensive from the beginning and again we would like as many people to be able to have access to the information contained there as possible because I think that there is really a lack of reliable information on the market. You know, searching the internet can be helpful for many things but I don’t think it’s helpful to help you make decisions about what’s the right treatment. I think there’s too many confusing information on the internet about treatment.

So hopefully the book will fill the gap and thank you so much for inviting me and talking about this book and again for doing this work and educating others and bringing everybody else up with that progress in science because we’ve made a lot of progress that should really be trickled down to the patients and the communities.

[1:07:56] Mark: Get this book and thank you very much. Thank you for coming on I really appreciated. It was definitely a pleasure talking to you and thank you again.

[1:08:04] Adam: Oh likewise, likewise and keep up the good work with the podcast and all the best to you. Thank you, Mark.

[1:08:11] Mark: Thank you for joining us today on the Rehab on the Mental Health News Radio Network. I hope that you have found the show to be interesting and useful. If so, please subscribe to the Rehab podcast and share on social media. I appreciate you taking the time to listen to the Rehab.