Psychiatry & Psychotherapy Podcast - Buprenorphine and Opioid Use Disorder Management with Dr. Neal Christopher

Episode Date: September 27, 2023

We are joined again by Dr. Neal Christopher, who is currently the Vice Chair and Associate Medical Director of Arrowhead Regional Medical Center and the Psychiatry and Addiction Consultant for the San Bernardino County Department of Public Health. Dr. Christopher has previously appeared on the Psychiatry and Psychotherapy Podcast in episode 063, "Interviewing Well For Psychiatry Residency & Beyond," and episode 103, "Acceptance and Commitment Therapy with Dr. Steven Hayes."  In this week's episode, Dr. Puder and Dr. Christopher discuss the recent elimination of the X-Waiver and what it means for providers, the mechanism and efficacy of buprenorphine, and practical tips for prescribing buprenorphine and supporting patients on their road to recovery from opioid use disorder. This episode continues our podcast series on addiction, designed to meet the one-time, 8-hour training requirement introduced by the Consolidated Appropriations Act of 2023. This mandate applies to all providers registered with the Drug Enforcement Administration (DEA), and our series primarily focuses on the treatment and management of patients with substance use disorders. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome to the psychiatry and psychotherapy podcast. I'm your host, David Puter. This is your gateway to the intriguing world of mental health. As one listener put it, this is the podcast that your psychiatrist listens to. And we're incredibly proud of that endorsement. Whether you're a loyal, active listener who's been kind enough to reach out, maybe send an email at DM or put in a review, or you're new to this community. We have an exceptional opportunity for you, not only to learn, but to also, earn continued medical education credits with each episode. Our credits are meticulously designed to empower you in your field, demystify complex mental health topics, and transform your learning journey into a truly rewarding experience. To access this and more, just visit Psychiatrypodcast.com. We're grateful to our valued subscribers who are already reaping the benefits of these credits. Your support is instrumental in allowing us to devote time each week to curate. this podcast, sharing cutting-edge insights, featuring top professionals, and exploring the latest

research. Whether you're here to learn, earn credits, or both, we're thrilled to have you with us. Get ready to deepen your understanding of psychiatry and psychotherapy, one enlightening episode at a time. All right, welcome back to the podcast. I am joined today with Neil Christopher. He is a physician, psychiatrist, prior guest of the podcast. He was on Acceptance Commitment. therapy. We did an episode on preparing for the interview season for future psychiatry residents. He is the vice chair, associate medical director of Arrowhead Regional Medical Center. This is the county to all San Bernardino County, one of the biggest counties in L.A. He does that four days a week. The other two days a week, he is a psych, he is the psychiatry and addiction consultant to the county

department of public health. I say that right. Yeah, that's perfect. And he has no conflicts of interest. No conflicts of interest. And my opinions are mine. They don't represent any of the agencies. So, you know, just me. And so today we are going to talk about buprenorphine. We are going to educate people because this is something that you feel passionate about. This has been something that's been deregulated. There's no longer an X waiver. And so we'll get into that. We'll get to a lot of the practical aspects I'm hoping. So like super, super practical. Like, if you were to prescribe this, you should know this stuff.

And it's good to have you on. Thanks. It's good to be back. You've done a lot with this podcast and this audience. I know I think we talked about this when I was interviewing for residency. And I know I helped you get started. I've done some consulting for other podcasts, at least on getting going. But what you've done with it and the audience,

built is very, very good for the profession. It's very good for the patients. And I just am glad to be on. And thank you so much for what you're doing on an ongoing basis. Yeah, little known fact, Dr. Christopher would have been the first episode I would have ever produced if I had hit the record button. Rookie error. You move well beyond that now. I remember when we recorded the acceptance commitment therapy one and my power died like once the once our interview was done and I had this like freak out moment of like oh no happened again what if it didn't record you know because I didn't know how Zoom if Zoom stored it on their database or if it's you know how it worked so luckily that was not destroyed that was a long session so

I can understand why it was like two hours plus with like Stephen Hayes like how often do you get two hours of Stephen Hayes. Okay, let's jump into this. So first, let's talk about the removal of the X waiver and what that means. Yeah, so there was a thing called the Data 2000 waiver. So the Drug Addiction Treatment Act of 2000 created a process for physicians who had met certain qualifications. to be able to prescribe not only buprenorphine, but other Schedule 3, 4, and 5 narcotic medications in a setting other than an opioid treatment program. So prior to this waiver, it was illegal federally to prescribe opioids to someone with an opioid use disorder outside of an opioid treatment program, which is a special designation that you have to get from

various agencies or, you know, you would get shut down and criminally prosecuted. So this did open up the ability to prescribe outside of that. Now, you know, doesn't affect methadone because methadone was a schedule two. And so that's, and that remains the case to this day. So we won't be talking about methadone today. It has an important place in opioid use disorder treatment, but today we're going to stay focused on the buprenorphine medications. And so with this waiver, if you create, if you completed certain requirements, which came to be known as this eight-hour requirement, then you could be wavered in order to prescribe an opioid to a patient with the opioid use. disorder outside of one of these special programs. So it did increase access and it definitely had

its place. But one of the things that happened is none of us could anticipate what the third wave of the opioid use disorder was going to be with the misuse of synthetic opioids, particularly with fentanyl. And what has happened in this third wave is that it is, it is, it. It's just overwhelming our patients. It's causing deaths at unprecedented levels. And because the additional requirements for the waiver, many physicians and other providers were hesitant to get it and get involved. They made it seem, you know, risky and different. And so, you know, a patient may be going in for treatment for a physician that could, you know,

let's say in primary care could treat everything except opioid use disorder. And so it really became confusing and then limited access. And so in an effort to increase access, they created the Consolidate Appropriations Act of 23, which was designed to basically get rid of the waiver and increase access of medications for opioid use disorder, in particular, removing the limitation. So now anyone who is a provider in the United States, we're talking on the U.S. here today, with a DEA registration number for prescribing any of the controlled substances can now prescribe this. Now, it does add some additional requirements, which are since June 27th of this year,

2023, if you're going to get a new DEA or you're going to renew your DEA after that date, which will be all of us at this point, then you would have to complete this one-time requirement. Now, in the interim period, which is elapsed now, we didn't know exactly what this meant. I thought they would cut it down a little bit, maybe four hours of training. But they didn't. They actually just said, now you have to do a one-time eight-hour training, which is, essentially the same as what it was, but now everyone has to do it in order to get a new DA or renew. And so the other two options that would also meet the requirement is if you are board certified

in addiction medicine or addiction psychiatry. So if you're board certified, then you are assumed to have met the minimum of that eight-hour requirement. And then the final way to meet the requirement is if you have graduated from a school, medical school, advanced practice, nursing, physician assistant school, and your school will attest that they gave you at least eight hours of this type of training during your program, then you could submit that. And that would mean you had satisfied the requirement. And you have to do that one time. And that's my understanding and reading of it, is that's all you would have to do. Yeah. And that's why I'm doing episodes on opiates and I've read the fine language for like what types of things are required in these types of educational things. You have to use basically, you have to, the eight hours have to include the treatment of any substance use disorder, any drugs approved for substance use disorder by the FDA. And so we've slowly been covering things with Dr. Cummings on like alcohol use disorder. opioid use disorder. And this one will also apply.

Now, one of the question that gets asked is, if I was previously ex-wavered, do I have to now do it again? And the answer is no. It is, you've been deemed that you satisfied that requirement one time. So you don't have to repeat it. So if you're already ex-wavored, if you were ex-wavored, you met the requirement. Okay, so let's get into the details. So talk to me about how you guys are. using this in the county currently and what you're excited about with the use of this?

Yeah, well, let's talk about a little bit about what buprenorphine is. I mean, there's multiple formulations of it, but one of the main ones that's being used is the combination of buprenorphine and naloxone in a sublingual formulation. And there's a film, there's a tablet that dissolves. There's two companies and a generic. So let's talk about the medication itself for a moment. Bupinorphine, you know, is a medication that it's actually a little bit more complex than initially thought. I think most people probably have realized that this is a partial agonist at the mu-opioid receptor, and which is typically the main one we think of and we think of maybe acute pain relief or

anti-noseception. And so it will occupy the receptor without fully activating that downstream pathway. And as is typical with the partial receptors, they tend to have higher binding affinities. And that's certainly true for buprenorphine. And so what's interesting about the medication chemically is that it binds so well it can displace and outcompete some of the other opioids, which is good in one sense because it makes it safer. The partial agonism means it's going to have a sealing effect.

So it's going to be much, much more difficult to overdose with this medication. It should start antagonizing itself is probably an easy way to think of it at a certain concentration for each patient. And so it's safer in that sense. And just getting people on this medication compared to other opioids is significantly safer. But the downside of that is that if a patient takes it too soon after another opioid. say, you know, more, you know, morphine or heroin or fentanyl, then it can and will knock those other chemicals off that muavoid receptor and cause an eatrogenic, meaning we did it in the healthcare system, precipitated withdrawal. And patients have done this to themselves, and that is a very

miserable experience for them, and if it's too severe of a reaction, as it often can be with comorbid fentanyl use, it will then reduce their desire to want to move forward in treatment. So timing of the medication is important based upon its activity. Now, it's also an antagonist at Kappa, Kappa opioid receptor. And so it's intriguing. It actually has effects further on more receptors than we initially thought. And so it is a complex medication, but the main action is that partial agonism at MU and in the main effects that you need to know about when you prescribe it. And so this would be, you know, compared to maybe now Trexone, which is an antagonist, which will then occupy that receptor without activating the downstream effects at all, which, you know, can be used. if a patient is completely off opioids for, you know, say a week to 10 days, and they're not going to get any withdrawal, it can be used for alcohol use disorder.

So, again, there's other medications that we're not talking about today, but that's the main way that the buprenorphine works. And then some of the formulations also include the naloxone. Now, you may, of course, know of naloxone as the rescue medication for an opioid overdose. to prevent sedation and death. And so naloxone can be that rescue medication. And if you think about how naloxone is given, we have an injection that paramedics can carry around. And then we have the intranasal that's become very popular for disseminating. And this medication does save lives.

But you think about the routes of administration that we're familiar with. There's a reason for that. And so naloxone is an antagonist that works very, very quickly, which is why it will work in overdose. But it doesn't really work. It's not bioavailable to a significant extent if it's taken in other routes. So if you try to just take a standard oral route or even sublingual, it's not bioavailable enough, which is why we have the injection in the intranasal. And so what we realized these companies that make these medications is that if they combine the two, then perhaps they would get the best of both worlds.

And if you take buprenorphine, which does need to be taken sublingually, then you really won't get any significant amounts of naloxone. But you do get the buprenorphine, so you get the impact. But if you were to try to liquefy this medication to inject it IV, or if you were to try to, you know, dry it out or crumble one of the pills and, you know, smoke it or something like that, then what's going to happen is you're going to get less of the buprenorphine and much more of the naloxone acting. And so you're going to block, you know, you're essentially going to block yourself with a rapid acting antagonist, which is safer. medically, but also a significant discouragement because it will put a patient into instant, or perhaps not a patient in this case, but put a misuser into instant withdrawal. So that is the medication and how it works when it's combined. Obviously, there's formulations that don't have the naloxone at all, and it's just the buprenorphine.

And so you wouldn't have that protection against misuse, but there's definitely patient populations that don't need the naloxone. So I hope that helps at least in understanding the medication. Yeah, I think it's good to reiterate. It's a partial opioid agonist of the mu receptor. It only partially stimulates the opioid receptor. I was thinking about how to give a good picture of this to someone, and it's kind of like you have a key that is going to go into the lock very tightly.

Right. So much more tightly than like fentanyl, right? So it's like you have this key, gets in there really tightly. It stays a long time in this lock. And every time you turn the key, though, it doesn't always open the door, right? So like unlike fentanyl, which is going to always open the door, it's only going to open the door sometimes. So you're not going to get the same level of like respiratory depression as something like fentanyl. Yeah, that's a very good and practical way, and that works.

You know, I was looking at one of the articles on, they've actually discovered in just in the last few years, two additional opioid receptors. So they're up to five now. And, you know, it's, of course, in the biochemical world, they're going to say, oh, it's much more complicated. But these analogies work really well for us to think about opening the door partway and a little bit more slowly for a partial versus opening the door rapidly all the way for a full agonel. versus an antagonist, which is kind of slams the door very quickly. Or just locks the door and doesn't allow it. It blocks the door. Yeah, locks the door and doesn't let anybody else in.

Yeah, yeah, yeah. So that does help, certainly helps me when we're trying to explain it to patients. And patients, by the way, like these explanations. Maybe not to this level of detail, but they will appreciate an analogy that helps them understand it. I just had a conversation with a patient a couple weeks ago and been on the medication for a and a half and he said no one had ever explained to how it works and it definitely increased his confidence in and staying staying on our on our agreement upon treatment plan yep and then once once it's

once the key is in there once it is connected to that receptor you know it stays there the half life of staying in that mu receptor is 166 minutes whereas with fentanyl at seven minutes and so it's like you have fentanyl hanging out there with this new key, right? And so fentanyl drops off half of it after seven minutes or whatnot. But once this one plugs in there, it just stays there for a super long time. So think about it like that too. Yeah, I try to give my patient's numbers that will make sense to them. I've settled on about 30 hours because one of the things they tend to have is this, you know, this negative anticipatory drive saying, oh, my gosh, I have to take this medication two times a day or three times a day or four times a day. And the reality is if they get,

you know, five good doses in their system, they can consolidate this medication to once a day. And I do tend to see a little bit more psychological resilience and a little bit reduction of that relapse risk in patients as they begin to consolidate. Now, consolidation immediately is not right for every patient, and some patients do have maybe comorbid significant pain, something causing pain for them, that they need to take it more than once a day in order to stay in treatment. But I do see less relapse in patients that have consolidated to once a day over time. And, And some patients go straight to it and they don't ever have any issues with it. But just consider how many times per day your patient may need it.

Or if you were maybe covering for a patient that's seeing addiction provider and they just are looking for a refill, it's definitely appropriate to be given more than once a day. It's also appropriate to give it once a day. But the patients definitely start to feel more comfortable once they understand that this medication can last. in a fairly consistent serum level for more than 24 hours after they've been on it for a while. And I think they start to relax and worry less about going into withdrawal or having cravings. And that is the way the medication works. And that's what keeps them in treatment. It's definitely beat out other options for treatment.

And even in many studies, has slightly higher. effectiveness than even methadone, which is our full agonist. Now, the reason for that may be that patients that have moved over to methadone have, you know, failed a lot of other treatment options. And so we are dealing with a little bit more, at least in California, we're dealing with a little bit more treatment-resistant population, with many more comorbidities oftentimes in patients that are in the methadone treatment clinics. but Suboxone has held its own and even beat out, even methadone in some of the studies. Yeah, I think that's good.

So, okay, so we're talking about, let's talk about the excretion of it. I think it's important to know that. So I was reading about 80% goes out by the feces, 20% by the kidneys, metabolized by CYP3A4 to nor buprenorphine, which has weak intrinsic activity. So the thing that it's metabolized to, if it is metabolized, right? Most is excreted by the feces unchanged. But if it is metabolized,

it's metabolized to something that's weak. So potentially if you block that metabolism, you'll have a little bit more longer. If you induce it, you'll have a little bit less. Things that block it could be like, you know, antifungals like ketoconazole, macrolide antibiotics, HIV protease inhibitors. So if you have a patient who's on an HIV cocktail, you might need to think like, okay, this person might need a lower dose. I don't know if you think about these kind of things.

I definitely think about them before I take a test. Exactly. Yeah, it's been a little while. So, you know, in my patient population, I don't see a lot of the medical comorbidities patients on too many of those medications, but it is important to know 3A4 and to look that up if you're starting a patient. So one of the key practical aspects is to – there's two aspects to the use disorders, right? And one is understanding that they have to develop an expert level of deception to stay in the use disorder for a long period of time. And they are very good at it, you know, the ability to maintain their job, maintain intimate relationships, family relationships, child relationships, to continue to get the resources to get access to drugs. As the use disorder progresses, they become better and better at deception. And so that we do see that as a practical aspect of getting patients into treatment and keeping them in treatment. But not in a punitive way, not punishing them the law enforcement strategy, for the most part for this have failed.

You know, obviously you can work with your law enforcement agencies and create a strategy that works, but just punishment has failed. And so it's important to kind of work with your patient to be aware that there may be deception and to be honest and develop a relationship with a patient where you can have honest, very honest discussions. The other aspect of it that is important is, though, is also not going to deception every time because that will take them right out of treatment with you and increase their risk of relapse. And what I mean by that is understanding that if a patient is saying that dose is

too low early on in treatment, it may be because they're on a medication that has induced 3 or reduced their effective dose or if they're feeling sedated, which has happened, it may be because they're taking more than they should, or taking something else that they're not telling you about. But it may also be because, you know, they've had some inhibition temporarily from a medication adjustment. And so this is something to definitely consider in the real world. And so I'm glad you brought that up. I think what you said is really important because it's like we're not incredibly afraid of giving them a little bit more, right, with this medication specifically. You don't have to be afraid based on the mechanism of action of giving them a little bit more,

especially if you have some relationship with them. I would say either they're early in treatment. They're probably going to need, it's very likely they may need a little bit more. A little bit more doesn't increase their risk of overdose. And, there's some exceptional reason. Many other medications or significant comorbidity or maybe respiratory problems or something like that. And so, yeah, we don't have to do it. And a little bit more will often keep them in treatment much longer. Caviot is always like mental status, right? So I remember one patient who was like literally falling asleep and like, I just need a little bit more. It's like, it's like, buddy.

No, you don't. No, you don't need a higher dose. Yeah, exactly. And so I think we definitely can transition into the practical realities in the clinic, and particularly in an outpatient clinic that's not, you know, necessarily in a specialty clinic just for substance use disorder. And so some of the things to consider. So here's what's going to happen. You're going to get a few kinds of patients.

One, you're going to get a patient that is made. been using heroin or been using, you know, using fentanyl. And they're ready to, you know, they moved from contemplation into action and they're ready to begin treatment. And you perhaps are the first provider that they've seen. And, you know, if it's been, you know, two to three days since last use and they're in active withdrawal to a moderate level, if you want to put a number on it, you could do the cows or clinical opiate withdrawal scale of, you know, say 10 to 12 or more somewhere in there, then it's probably safe to proceed with initiating one of the buprenorphine containing medications.

Now, I personally prefer Suboxone or the generic form of the buprenorphine naloxone sublingual film. I've just found that it has the lowest misuse potential. And so I do prefer. for that. Also in my patient population, in public health, in a county hospital, my patients don't really have access to any of the other formulations anyway. And so the brand name, Suboxone, or the generic film, is all they really have access to. So I certainly have the most experience with it. We do have one non-naloxone containing buprenorphine that we can prescribe as

well. And so, and get that covered. But how you would begin is to, you know, give them, basically two, four, or eight milligrams. And, you know, you can give that to them. Now, there was a treatment guide. It's available at SAMHSA. You can download the pocket card version, PDF, or the full guide. And it'll go through the kind of the older way of give two milligrams and wait a few hours and then give two more and then wait a few hours. And you keep checking the cow scale until it gets to zero. And then that's their dose, essentially. And you can put them on the beginnings of that maintenance treatment. The problem is most of us don't have a clinic that would support us in doing this. And so what we've learned from our emergency physician colleagues is that if you give a

patient up to 16 milligrams, once they're in moderate to severe withdrawal, it's also been proven to be safe, such so much so that they've created in California what's called the bridge programs, which is where patients can come into an emergency room and get started on buprenorphine and then get enough medication. They'll have a substance use navigator who will assist them in making sure they have an outpatient appointment and they'll get enough to make it to that appointment. And what they found in these programs is that 16 milligrams is their version of kind of this magic number. It's not so much that it's over-sedating for most people. It's not so little that they stay in withdrawal.

And so most of the patients here in Southern California from all the EDs have pretty much consolidated to that 16-millimeter dose. And so if you were calling me as one of the primary care providers at Department of Public Health and saying, you know, what should I do? I've got this patient. You know, I'd say if you don't have time or ability to think about anything else, just know there's thousands of emergency departments around the nation that are, you know, basically putting people on 16 milligrams, 8 BID of the buprenorphine by itself or buprenorphine naloxone combination. And so you're in very good company by doing that. Now they're watching them for a few hours before they release them to make sure that it's not too sedating. But the reality is it's not for most patients. Now, in the outpatient world, mild to moderate withdrawal, you may not need that much. So you may be more comfortable starting with two, four, or eight, and then having a follow-up in a few days to a week, maybe a phone call from nursing.

or maybe a seven-day, you know, once a week, follow up and go up on their dose if they're still experiencing symptoms. These patients will call you. They will call you and tell you if they're comfortable or uncomfortable. They'll call you and tell you if they're uncomfortable. And so, you know, I wouldn't worry too much about a dose that's 16 milligrams or lower. I know that scares a lot of people, say, oh, I don't want to go straight to 16. the reality is we can decrease that dose within the next couple weeks if they are sedated. But we do see pretty good effect out of that.

And I would say more often I increase by a little bit as a specialist than rather than decreasing by a little bit from what the EDs are doing. Occasionally they've gotten it wrong, but more often they get it right and it's close enough. And so I think that's a good number. So 2, 4, 8, you can go 1 and a half to 12 or 16 milligrams. And specifically we're talking about 16 is the total day dose, right? That's what you're saying? Total day dose. Yeah, exactly.

So it's 8 twice a day. So the first dose you give in the ER is 8. Is that correct? Depending on how they do it. But yeah, often in these bridge programs, they'll give a dose of 8. Now, it is important to note when you're looking at the combo formulation, it'll say 8 slash or dash. And so the first number is the buprenorphine milligram dosing. And the second number would be the naloxone milligram dosing.

And it's easier if we only talk about the buprenorphine number because the ratio doesn't change, right? It's always going to be the same. It is also important to note that there's a brand name that you may have if you're in an outpatient, patient clinic and taking commercial insurance, you may be using Subsolve, which is a different brand name. Some patients like it better. They like the taste better. Some of these films and tablets do not taste good. That's important to know to tell your patient after they've gotten used to it. They'll stop talking about it, but it is definitely something they'll talk about early on if they've not experienced it yet. But there is a brand name subsolve, and the dosing is

different with subsolve. So you do need to look at the chart. if your patients have access to coverage for that because there is greater bioavailability of that formulation. So the doses will be a little bit lower. But in the practical world, you don't have to worry about the dose of the naloxone because that's going to be fixed. So if you, you know, two milligrams will have 0.5 of naloxone and 8 milligrams will have the 2 milligrams of naloxone. So we're only talking about the buprenorphine number. And so, yes, in the ED, for instance, a patient may get eight milligrams is their first dose, eight milligrams is their second dose. They've been observed now for, you know, 20 hours, and the social worker or substance use navigator has established a specialty clinic appointment follow-up, and then they'll be released with, say, 10 days of 8 milligrams twice a day.

that would be a very common thing that we would see here in Southern California with a patient coming out of the ED. And so then I would receive them, say, in public health, with their first specialty appointment, you know, on the day before or the last day of their films. And then it would be time for me to evaluate whether or not that dose was appropriate, too much, too little, and continue their treatment. I'll be also testing their urine for other substances and seeing if there's other things that perhaps we need to talk about or work on in order to give them the best chance possible of staying in treatment and staying alive. And I have had patients that, I mean, unfortunately, this is real. We probably, is an addiction, probably losing more patients than certainly any other area related to psychiatry. Because fentanyl is just so deadly. It's just, and it's so hard to get off of.

So, you know, it holds the receptor longer. It holds it very strongly. I mean, we can knock it off, obviously, or we couldn't save them with the rescue medications. But that they're so afraid of precipitated withdrawal that they can't get off. And so we're having to come up with new and creative strategies to try to try, to try, to do that. And there's really two main options. Well, there's three options. One is go into full withdrawal, you know, or as some one addictionist said, have a family member lock them in the bathroom for three days. And because they're going to have the withdrawal, you know,

effects. They're going to have the gastric distress and the flu-like symptoms and they're going to have the, you know, the diarrhea and stuff like that. So just getting them all the way into withdrawal so that that first dose of buprenorphine helps them rather than making them worse. And that is really important for treatment. But that doesn't happen with the supply that's out there unless they run out and just don't have access because it's so available that they're able to stay in use. So the other options are to go straight to moderate to high-dose buprenorphine, and that's why the Emergency Department Bridge programs have been so successful,

is that 16-migram dose is enough for early or low-dose fentanyl misusers or heroin misusers. And so it does cover that. But as we're all aware, the receptors will adapt to whatever you throw at it exogenously. And so patients that are misusing fentanyl that are on high doses or for longer periods of time, you know, they need longer without the medication and they need much, much higher doses. And so what we're seeing is that these patients are not doing great with any dose of buprenorphine. In fact, we used to talk about things like of IV heroin users, about 50% of them will not be able to stay in treatment on buprenorphine, and they will need methadone because of the type of feelings they're used to having. And so they will need that methadone clinic. But with fentanyl, we're seeing perhaps even more than 50 percent if they're at high

doses or long-time users, you know, they're just going to require much higher doses. And so, you know, maybe that's the role of the specialist to come in there and do that. But if I'm called from on the inpatient side to advise on a patient maybe in the medical center or even in the inpatient psychiatric hospital. There's a couple of us that might be called for that, for that. And often it will simply be to increase the dose. So I do see 32, 40 milligrams needed sometimes to treat a patient as their daily dose. Now, you might not go straight there, but in relatively short period of time, getting them to a dose that before, or they're not going to be able to

to stay in treatment on this medication. And if that's not working, if you've exceeded 32 milligrams of a daily dose of Suboxone, you know, you may go to 40, you may go to 44, but the evidence really starts to run out at 32 milligrams. And so we see people reporting better pain control and pain perception that at those higher doses, but we do not see at this time more success at staying illicit opioid-free at higher than 32 milligrams.

And so I'll go a little bit above it for some patients, but not much higher. Now, having said that, I may go higher for a short period of time in an inpatient unit to get their fentanyl withdrawal under control and then back off to a dose that is high, but more appropriate for maybe outpatient prescribing. Oh, and then the third option is a low-dose initiation protocol. And this is a new approach that's being tried in different ways. And so sometimes you have to work with a pharmacist to maybe compound a low-dose buprenorphine formulation. And this is interesting because in this approach, you give such a low dose of the buprenorphine

that they continue to use fentanyl. And what you're doing is you're increasing that dose very slowly over time of the buprenorphine in such a small way and slow enough that they do not go into precipitated withdrawal. And you get their dose high enough that they can then begin to cut down on the fentanyl without going through moderate to severe withdrawal.

And so, you know, this is not dangerous medically, but it can be dangerous in terms of that precipitated withdrawal risk. Because if they speed up, if they cut the fentanyl too quickly, then they're going to go into that withdrawal. Once you get them to, we're seeing this in case studies. I've done it a couple times myself. It's hard to get right with the patient, because it's all under kind of their control and their understanding of your instructions.

And then, of course, their livers are different. You know, everybody's liver is different. So it's really difficult to get right. And quite frankly, the substance use supply is very commonly adulterated. So they may not know what they're taking. I routinely have patients that have been in treatment for, you know, two or more years. And occasionally, you know, we'll see something pop up, you know, in their, in their drug screen that they're not even aware of if, you know, if they were coming back

from a relapse or something like that. And so they don't always know what they're getting and what they're taking. And that's what makes all of this just so dangerous and so risky for our patients and our clients is that we're treating, you know, the disorder, but that disorder may have, may be complicated by substances that the patient's not aware of and we're not aware of. You know, and there's some other risk factors that we won't go into, you know, today, but the xylazine, which is another, yeah, tranquilizing medication is complicating the supply, particularly in the northeast. But it's moving its way throughout the country. And it's, you know, I think it's tripled in California,

even though it's at a low level, it has tripled in the last year in California of the supply that's been tested. So we don't always know what's in what's in there. And the highest risk of death right now that we see in most of the nation is the opioid misuse combined with stimulant misuse and particularly methamphetamine misuse. Those patients have the highest risk of death of the combinations that are out there at this time. Why do you think that's the case? Why do you think that's the case? Why do think that combination in particular? I think there's the factors related to the patient themselves. In some ways, they're using more at higher levels because you have polysubstance misuse,

which, you know, for diagnostic purposes, please don't use that F-19 codes anymore because you won't receive reimbursement for that code. So you do need to specify each substance. But, you know, but they're using more than one substance already. I think part of it is chemical in the sense of you're combining, you know, in the old terms, the upper and the downer, right? And so you have medical actions competing against each other. And I reviewed one case for the hospital where we had a patient come in and die very quickly.

and it was the ED, you know, it wasn't quite clear at that moment what was, what it caused the death. They really didn't have time to intervene. They did administer aneloxone, but the patient expired very quickly. And upon review, you know, my best guess was that this patient was on high doses of methamphetamine and high doses of fentanyl. And I think the, you know, this is kind of my guess in review, but I think the methamphetamine had, you know, kind of kept their heart rate and respiration up enough to keep them alive. And as the stimulant wore off, the opioids depressed them and killed them. And we didn't, you know, we didn't have enough time to get it right and figure out what was going on. you know, they're doing the best they can in the ED.

But if we don't get to them quick enough, that's why it's important to have some of these rescue medications available in the public. And in California, we now have it through our public health department. You can walk into almost any clinic and receive emergency naloxone. And so it is helpful. It does save lives. But so I think it's the combination of the risk factors from. polysubstance use, but also the chemistry, the biochemistry involved in combining those two. And the patient doesn't always know what's going on. And again, they don't always know what they've

taken. And then the rescue medication doesn't work for the other substances, right? It will only work for the muopioid receptor. So if your medication has been adulterated with xylosine, it will not rescue you from that. So there you're having a double depression, double respiratory depression that's occurring. And so while that rescue medication may work for the opioid, it will not work for the other substances. And so it may be too late at that point. Yep. Just to review, xylazine, trank, zombie drug, other names for it. It's like a clonidine analog. It's an alpha-2 adenergic agonist with effects on the central and peripheral nervous system. And it functions as a powerful, sedative, analgesic muscle relaxant

has long been used in veterinary medicine as a tranquilizer, you know, for these dogs, horses. Going into surgery, right? Or something like that. It's not FDA-approved for use in humans. And it's sold on the street, usually in combination with fentanyl,

and it supposedly gives fentanyl's legs, meaning it prolongs or enhances the effect. And the misuse is rising. So, you know, approximately 23% of fentanyl powders and 7% of fentanyl pills seized by the DEA contained xylosine. That was in 2003. So it's likely going to go up. I mean, it's like you don't know what you're getting often. And people who take fentanyl, it's like they don't know if there's xylosine and they're not likely.

And let's look at two potentials, combinations of problems. And again, this is important to educate the patients with the use disorder of their risk so that they understand. So if you were to say have fentanyl combined with a stimulant, you know, and let's say you've taken, you know, very high doses. And, you know, you get the rescue medication of naloxone to prevent the opioid overdose. So now what's happened is you, you know, all you have left is the stimulant. So that may, you know, run your heart rate too quick, you know, too fast, too rapid. And that could cause problems. And so, you know, you think about that possibility.

But then you say, okay, on the other end, you combine it with, you know, xylazine or some other strong, tranquilizing drug. And yes, you again can clear the fentanyl off the receptors, but then now you're left with another depressant. Well, now let's combine it all three together. And you've got your stimulant competing against your depressant with xylosine. And the body just doesn't know what to do. And so, I mean, you know, I hate to put it so simply, but it may just give up on you. And so, and so that's the risk of, you know, kind of continuing to use when the supply is adulterated. And, you know, we talk about, you know, anecdotally, I mean, I don't have any relationships with any dealers that I'm aware of, but we do talk about some of these, you know, it's a business

to them. And they like having a good supply that people talk about. And they're completely, they seem to be completely okay. with a certain percentage of their clients dying, because that means they have, quote, really good stuff. That was very counterintuitive when I heard that from a patient once, where they were like, actually, when someone dies, we try to go after that batch.

That's the batch we're trying to go after because it's very potent. And that, for me, was mind-blowing, like, what? And part of the disorder, we talked about deception being part of the disorder earlier. The other part of it is, I've done this before, I can survive that. I want to try that and see what happens. And so there's that craving as that frontal lobe loses its ability to say no over time, you know, the orbital frontal part of the brain, right?

You know, as we lose that ability to say no, they think more and more as they progress through the disorder. I want to try that. I've survived everything else I've done. I'll try that. That'll be fun. And unfortunately, it can lead you down to something that you can't do. And again, if you've gone into treatment and you've been off of perhaps your primary substance of misuse or you're switching substances of misuse, you're at very high risk of death. And in a very personal, you know, you talk to addiction specialists. And you talk to addiction specialists. You will find, first of all, the highest percentage of providers who perhaps have struggled with some sort of addiction. That may be a reason that they pursued that area.

If it's not them, it may be a, you know, a family member or friend that's been affected. So you do see this specialty being very personal. And I lost my brother to heroin and alcohol use. You know, he was in another state. He was pre-contemplative towards treatment until after 20-plus years of misuse. I do think an appropriately administered methadone clinic could have kept him alive longer, but even as a provider, when I looked at him, I was seeing very concerning use trying to repair my parents that, you know, I didn't predict that he would have much longer to live unless he got into treatment.

And he died from an accidental overdose immediately upon exiting a treatment program. Because his sensitivity had been reduced, he probably had been about eight weeks since he had used heroin. And so probably went back to what he thought was his standard dose. And it killed him. And so, you know, people will die from not doing this correctly. They'll die from things that they've done in the past that was successful for them. But as they change or as the supply gets further adulterated, some of these mistakes can be fatal. I had a patient that...

Can we, man, I think... think I never connected that your passion for this came out of that loss. That makes complete sense to me. I think it's like the hardest lessons are sometimes learned by pain. And feeling, you know, one of the motivations for learning is, you know, wanting to do better for others, you know. But as with so many things, whether it's diabetes or whether it's substance use, you know, you have to treat the patients where they are and offer them the options that they're willing to work with you on. And yet, we all can do better. You know, we all can learn more offering the medications. It's not just about medication, of course, as a specialist, making sure we're always

sharp on our motivational interviewing or MI skills. This is very important to overcoming ambivalence and what too many people call resistance is actually ambivalence towards aspects of treatment. But when you get below that, for every patient, there's often some reason to stop using. It may not be active enough in their mind to motivate them to move forward right now, but it can begin something. And so I had a patient that was lying to me for months, and it was obvious on the urine drug screen. And I began that conversation of, hey, we're going to do this, but I'm going to shorten the time that I see you. And hey, we're going to do this. And every month, it was the same.

You know, I don't know why this is there. I'm not using anything. And just visually, upon inspection of him entering the room, he looked worse over three months. And, you know, and finally the nurse comes in about the third or fourth month and says, oh, my gosh, he looks horrible today. And so I go in there. And it's so obvious that he is, he's relapsing on something. And we did have multiple positive substances in his urine throughout these months. It was not fentanyl, but it was other substances.

And so ultimately get to a conversation about what's missing in his life the most that he's running from. And it was basically, you know, psychiatry, right? It was a relationship with his mom, right? I mean, he lived in the house with his mom who had refused to speak to him for a year. And we finally got to that. He began to cry as he realized this was one of his highest values towards restoring this relationship that was very significantly damaged by substance use and his broken trust with his family, right? And he comes in, you know, we spent a significant amount of time talking about that. We activated that value and that drive for him. And he comes in

the next month. He admits that he's been lying, which of course I knew. And then I said, well, you know, I knew, but it wasn't helpful to you to bring up what I, you know, knew and suspected. And he says, well, I know that you know, but I need to tell you. And so that was a part of him moving forward. And he was just so thankful. And I said, what made the difference? You know, what made the difference? And he said, I knew you were about to, you know, send me out to another clinic. and I could not do this with another doctor. I could not start her over. I'm going to get better and I'm going to get better with you.

And he was smiling. He looked amazing. You know, he was clean. He was wearing nice clothes. I mean, he was ready for a job interview, you know, four weeks after, you know, three to four months of deterioration. So don't give up and keep working on the relationship with the patient. It can make a difference.

Yes, it may take a few minutes of extra time. It may take learning some skills from motivation. motivational interviewing or, you know, CBT or my particular style, it's a combination of motivational interviewing with acceptance of commitment therapy. And you can, you will know it. You will save lives with this medication and with your approach to the patient. Yeah. And I appreciate that about you. I mean, even when you were resident, you were diving into acceptance commitment therapy, which is why I had you on that episode to kind of help interview Steve Hayes

and you've always been passionate about psychotherapy. You've been passionate about connecting with clients. And, you know, I have watched you treat very difficult clients, you know, in resident psychotherapy clinic. I've observed you connecting with people who I had our time connecting with. So I was just going to say, lying is a doctor Tarwood.

always say, don't call it lying, call it degrees of revealingness. And it's always hard to reveal aspects of ourselves, which are shaming or things that we would not want others to know. So I pretty much, it's a given, right? In all relationships, there will be degrees of revealing this. There's social niceties, and we want to reduce shame. You know, it's like one thing I remember from reading William Miller's book on motivational interviewing when I was a medical student was a shame-induced treatment does not work. It actually pushes someone further into addiction, right?

Shame pushes further into addiction. It's like, it's actually, the motivational interviewing is a very kind, listening, connecting approach. And so I should want to put that out there. Yeah, it's the suck spiral of the disorder, right? So it becomes one more thing of another broken relationship. You know, they've damaged, you know, relationships at their work or maybe they've been fired from a couple places. They've damaged relationships with their, you know, their parents,

their intimate partners, their, you know, their siblings, their children. And so now they're damaging their relationship with their physician and that part of their brain just says, see, see, that's why you have to keep using. You can't handle the shame. You can't handle these emotions. I do like the degrees of revealing. I may start using that. I've been using, you know, these deceptive tendencies as a better word than lying.

You know, I'm wondering about your deceptive tendencies or something like that. And it's so funny that once they begun that process of engaging with you in treatment, the things they will be honest with you about. is, it can be a unique area of conversations. I mean, every specialty has that. But, I mean, it's quite amazing what they will open up to you about. And once they've begun treatment, they'll just tell you, they will tell you everything, how much they've used, where they use. I mean, and the more they reveal, the more likely they are to stay in treatment and get to, you know, two years, five plus years. since their last illicit use.

And, you know, for that matter, we could talk about what happens when the patient says, can I come off this medication? Can I stop it? And, you know, what I do see and what the evidence shows currently is that most patients will stop it too quickly. There's several reasons for that. One could just simply be adverse effects like constipation. It's not as bad as the full agonist, but it's still there.

So you do need to, you know, offer stool softener. and perhaps even something stronger. You know, I tend to go to Miralax. But there's multiple options. You guys probably know those just as well as I do. But make sure they have something. Ask them about, you know, bowel movements on a regular basis. So make sure that the reason they're not wanting to stop

is due to some adverse effect like sedation. And you could just reduce the dose. But often it will be family or friend pressure. You know, you are still using. You've replaced your addiction with another addiction. Now you're addicted to the prescription. And so this is something we have to work on and say, you know, that's a myth. You are in treatment.

This medication, you know, do you still have cravings? No, it ended my cravings. When was the last illicit use? Oh, it's been over a year since I've had illicit use. You know, and so that is treatment because you will see patients on the maintenance of these medications. whether it's buprenorphine or methadone or even naltrexone for that matter. And you will see the patients, you know, who will go, you know, months or years without relapse and they're able to now, you know, keep their family intact, restore some of those broken relationships, continue to gain trust over time, you know, get, not only keep their current job, but even get promotions and stuff like that as it, as they become more productive towards the things that. they wanting to do with their lives. And so that, you know, making sure, inviting them to bring the family member in. I've done phone calls. I've had family members come in and say, I want them off

this medication and say, I understand that. I want them to never relapse again. And I want them to stay alive for the rest of their life. And so let's combine these plans. Now, again, patient has the right to choose to take this medication. And, you know, unless it's court ordered, for some reason, which is pretty rare, but they have the right to choose to take this medication. And so ultimately, if they want to stop, you do need to work with them. I prefer a minimum of six months of illicit use and cravings before we even entertain that conversation. I even more prefer two years.

And so if we can get to two years of them restoring relationships, moving towards their own values, no illicit use, no triggers to use, or appropriately processed triggers to use. Like I had a patient say, oh, I just drove by what they call a trap house, which is a house where, one, you can get trapped into using, or two, the police know about, and they're just weighed, and occasionally they're going to, when they see a bunch of people, they'll just decide to go arrest. So anyway, trap house is like a known place where you can get a large supply for you. use. And so, you know, he had, he, the traffic was diverted and he had to drive down a different street. And, uh, but he'd been over a year. And he goes, I know I'm doing better because I didn't,

for a one second, I thought about stopping. And for the rest of the time, I thought about, I'll have to tell you about it. And I'll have to, I'll get busted. And then, you know, my family will know, and I'll be a disappointment to them again. And, and, and so, you know, yes, he had that. trigger to use, but he was able to appropriately process it. So that patient is moving perhaps closer and closer to being ready to cut down or discontinue his use. But the current evidence shows that the risk of relapse goes up when the patient stop these maintenance medications. Now, what we don't have are really long-term studies. We're just not there yet. Medication hasn't even been out for a long time. So we will stay open to that. If a patient,

though gets to five years of no cravings, no illicit use. And they want, you know, they want to go off. I'm willing to definitely partner with them and work with them. But I also remind them, you know, the risk of relapse does tend to go up based on our current evidence. And so there's no medical reason to go off of it if there's no adverse effects, no risk of falls, you know, no complications with other medications. But at the same time, I do want to support their goals. And as long as they're doing that for healthy reasons and they really don't think they're going to struggle anymore, we'll begin to taper them and then ultimately to do a trial off the medication. It is helpful if they're in some sort of group or therapy to do that because they tend to have the

best success. Patients that take themselves off of the medication in less than six months, they tend, the majority of them that I've seen do tend to have relapses. So how quick or how slowly do you taper someone off like when you decide to taper someone off? In the outpatient setting, yeah, I will taper them off typically one to two milligrams every one to two weeks. There is no risk in going even slower in going down one to two milligrams a month. So that might be a very slow way. They shouldn't feel much of anything. And how they would do it, again, we can use that.

We can use the length of the medication being in your system to our advantage here. And say, you know, you take, I don't know, let's say they're on 16 milligrams. So they're on, and they're taking two eight films, you know, at the same time every, every morning. Let's just say, okay. You know, I might have them take two films one day, and then the next day I might have them take one and a next day I might have them take one and a half or one in three quarters. These films can be cut. We haven't talked about that, but they can be cut. of the patients are used to that. So you can always prescribe, you know, the two milligram film

along with an aid or something and create your dose. But in our part of the country, there's a shortage. And so, and then other pharmacies just refuse to keep all different sizes. So lots of challenges in this area. And so a lot of times I've prescribed something and there's no pharmacy in the area that will carry that ability. So again, you have to work with the patients. on what you have available to them. So my patients know how to cut, cut their film to take the appropriately prescribed dose. So, so they, so in other words, every other day, or you could even go slower, every third day, you take the next step down dose of either one or two milligrams.

And if they're doing that, then they're not going to feel too much. And then you get down to every other day, and then you get down to every day. And again, you can go, this is not a great answer here because I'm customizing the plan for the patient. But that's what I do in real life. And so I've gone as fast as every other day. And then what will happen is the patients will decide themselves. And they're going to try something. They'll be like, oh, I went from two to one and a half and I just stuck on it.

And I had a bad day and a half, but then I just stuck on it. or I started to feel withdrawal and I took the one extra half back at my old dose one time and then that's all I needed and I was able to cut stay down. So they may go faster, but I would rather them be the one that's saying I wanted to go a little faster than your plan than me saying it and then being uncomfortable or starting to feel the effects of withdrawal or starting to feel, you know, triggered to use. And so I almost try to design a plan that's slow enough for what I know about that patient to where they're going to push it one level a little bit faster than me, but still be okay. That's actually my strategy. And again, it's not a great answer. But if you cut down, just as the principle of it, if you cut down if you're going faster up to every other day,

or if you just want to go in stepwise fashion, you could cut down two milligrams a week and in the outpatient environment that works okay. Now, if you've got a patient that's come in and was misusing and is not ready for treatment and their high risk and their polysubstance use and you're, you know, an inpatient setting, you can cut down, you know, 20 to 40 percent per day if you're just tapering them off and you're not going to be continuing them on medication. You can cut down 20 to 40 percent per day without. without too much misery.

And, of course, you can use supportive medications for that withdrawal. The clonidine can come in for, you know, supporting withdrawal. The peripheral, you know, opioid of the, what is it? Amodium is the brand name over the counter. I've forgotten the name of it. Anyway, it can be used for that diarrhea. And so, you know, you can use that in a supportive way that will help with some of these withdrawal symptoms if you're just tapering them off. Wow, yeah, this is really helpful.

It's a lot of practical stuff. Love it. Lopiramide. That's the name of Emodium, Lopiramide. Are there any other, like, as we seek to kind of like wrap up our conversation on this drug? It seemed to me, like, when I went through residency, the goal was to just, just detox them right right away, get them off of Suboxone five or six days. And I'm sensing that there's been a change in how addiction is managed.

Do you see that as the case? Like, do you see more people? Yeah, we do. I mean, we just have really, really good evidence of what prevents a relapse. And what prevents a relapse is controlling withdrawal. That anticipate the anticipation of withdrawal will keep a patient. misusing. And that's what we're seeing with fentanyl. Then we see increasing doses for longer periods of time, which results in death at some point, right? You can only tolerate so much, or you can only tolerate so much of

something added. And it may be intentional or it may be accidental, but, but, you know, it doesn't, it doesn't look like it's going to end well for our fentanyl patients. And eventually there'll be something stronger. There are, in fact, some of the other versions of, you know, car fentanyl, and there's another one out now coming in from somewhere around the world, and we're seeing even stronger medications become available in a limited way. So, so yes, we know from published studies, and we know, you'll know if you do this and treat a number of these patients directly, you will see what works and what doesn't very, very quickly. And my own experience has aligned almost perfectly with the published studies that says maintaining a patient on these medications is the

best chance to prevent relapse of the opioid use disorder. And it really helps with some of the comorbidities that tend to come in. And we haven't talked about the psychiatric comorbidities, but depression is the most common. And we see patients, depression scores. We're talking about 60% of patients with a depression diagnosed major depressive disorder. Their depression score will be half or go into complete remittance just with appropriate treatment and maintenance with buprenorphine. And so it's quite impressive, actually. Now, that may be that their depression was misdiagnosed or comorbid or caused by some secondary force, but we do see that.

I'm not suggesting this as a depression treatment, but I am simply saying that by maintaining a patient with comorbid significant depressive symptoms on buprenorphine, just track it. Do your ham D, do your madras, and prove me wrong because the evidence shows that it's the case. We do a PHQ9 at their public health clinics for every patient, every time they come in the door unless they refuse. And the scores go to zero for the vast majority of these patients. You know, that's really interesting because I've found that people on chronic opiates, they're more likely to get depressed. They're more likely to stay in their bed all day, not too much. Is that what you're seeing with Suboxone, or is it something different? Are you talking about misuse of suboxone?

You're talking about appropriate use of subpros? Appropriate use. Appropriate use. No, I don't see them depressed. We see them not depressed. And so that is a result, I think, of being in treatment and being free from looking for the medication from dangerous places, illicit places, and being comfortable enough to tell some of the people in their life about their treatment. and the freedom to move forward. I mean, you know, the opioid receptors affect the perception of pleasure, you know, pleasure

the opposite of pain. And so there's a reason people use, and some of the reasons people use is untreated mood symptoms at a severe level. They want to feel better, and they call it a high for a reason. And so while buprenorphine as a partial agonist does not create the same level of high, patients will often say once they're on the right dose, I feel nothing. And so we are not seeing the depressive symptoms and depressive scores at the same level. Now, you're patient with severe major depressive disorder, bipolar depressive disorder, notoriously hard to treat for all of us, right?

And so we don't, we're not, you know, they're still going to need depression treatment. But in your mild major depressions, in your depression that may be associated with, you know, prolonged pain. and then you might, in fact, you will probably see those types of depression symptoms be significantly reduced, if not go into remission from appropriate treatment with buprenorphine. Okay, very good. Let me ask you this question, because we watched a lot of video Continuous Case Conference, and I used to always try to convince residents, like, connection is important, connection is important. we'd watch these micro moments of connection disconnection.

How do you think that impacted your professional career? I think it made me a much better provider. So, you know, looking at my own skill set, you know, as all of us, we're good in certain areas, we're not as good in other areas. And, you know, some of the things you taught in the psychodynamic principles is, weren't my strength, quite frankly. I'm much better at the, you know, say the act, values, discovery, values activation. But it helped me to get better at some of the areas that I wasn't as good at.

And even in the act system, you look at acceptance, you look at self-as context. These are more closely related to some of the psychodynamic principles. And you look at mentalization-based therapy. which definitely draws from that psychodynamic world and requires really open, significant connection with a patient to make that work. And those are great skills to know about, you know, in addition to dialectical behavior therapy, you know, you can learn these mentalization skills for borderline personality disorder, which you will find in a number of substance use patients as being very comorbid. but just also in motivating your patients and connecting them to stay in treatment. And so I'll give an example from the last two weeks. I had a patient that had against my advice, but had achieved a minimum level of success over a year without illicit use.

And this patient took themselves off of maintenance treatment. They did do it with me. they just said they were going to do it. So then I helped them do it, but I made it clear that I wasn't my preferred path and had not seen the patient for many months. And they came back in. And I'm not great at hiding the emotions on my face. I'm not great at the classic perfectly neutral psychiatry look. And so I've had to learn to leverage that.

and the patient had just finished telling their spouse, whom I had never met, I heard them talking, saying positive things about me as I walked in the room, and I opened the door and I go in. And the interview turns, goes south very quickly because I can't hide my disappointment. Now, the patient had not relapsed, but the mental symptoms, the mental health comorbital. were all worse. And, you know, the patient starts yelling at me very quickly. I can tell you, you know, you're just looking at me with that judgy face. And now I regret even coming back. I told my spouse, you know, you were such a good doctor. And now I remember you're not.

And why are you looking at it? And just uninterrupted yelling. Wow. And I was like, how in the world do I get out of this? And so I finally said, you know, I need you to take a breath so I can speak at some point. And so they did. And I said, I just want to apologize because I can't, you know, I can't hide my face. And what you may be picking up on is my disappointment that you are at such a state because this is not what I want for you. It's not what I want for any of my patients.

It's not what I want when I meet your spouse for the first time. And, yeah, I really wanted you to be at a better place. And I'm sorry that whatever I've contributed to your treatment plan didn't work for you. But it's because I care. I think you might be misperceiving. Is it possible that you're perceiving judgment when what I have is concern? And it flipped just as quickly as it came on, you know, it flipped back the other way and she's, you know, crying and apologizing. And, you know, the spouse has these giant eyes because I think they were fairly convinced I was going to call police and kick them out.

Wow. Okay. And they said afterwards, yeah, I've never seen that done like that before. And, you know, and again, that was, I think, paying attention not only to the patient's, you know, affect, but to my own affect and my response, and then figuring out how to leverage it. And I think, you know, what you teach about connection is the most elementary steps in learning how to do that. And so I've continued to try and develop them. You know, I'll never be a great psychodynamic psychotherapist, but I've learned what areas of connection I can be good at, and I've learned to leverage those for my patient,

and I think it's made a good difference for their lives. Yeah. Yeah. Well, I think you've learned how to exploit your strengths, your intellect, your your hard work, administrative, prowessness, you know, and good things to come, you know, already doing awesome. So, yeah, and let's say this is a last, let's say this is a last bit of advice. I, you know, there was a federal law, and it's still in place. So, so all of the agencies that govern this, you've got National Institute for Drug Abuse, you've got SAMHSA,

You've got the DA. You've got the FDA. So you've got at least four federal organizations involved in treating the opioid use disorder from different angles. And then, of course, there's state laws that are different, you know, in the requirements to prescribe, release all these medications, what an opioid treatment program is in that state. For instance, in California, methadone is only available as a liquid dispensed at the site. or unless you're in the hospital. And so it can vary from state to state. And under the federal laws that were in place,

referral to therapy was required, and it still reads that way. That goes against the current guidelines and against, in some degrees, the intent of the most recent act that ended the X waiver. But what I would say is that it's always a good idea. I'm not an attorney.

It may or may not still be against federal law to not do it. That part's a little unclear. But the current guidelines, what we're suggesting as specialist is we're saying that you should be in therapy, but if they're pre-contemplative towards therapy, we wouldn't withhold the other treatment. And so they are in treatment with medication. They are in treatment if they're in a group or therapy. and they're certainly in treatment if they're doing both. And so continue to make those referrals.

You will get better results. But sometimes the patients will not be ready to engage in either group or individual therapy, go to an N.A., get a sponsor unless their other symptoms are controlled and they start to see the benefit. And they can see that with this medication earlier than trying to do it on their own. But I'm definitely an advocate for continuing, you know, whether it's inpatient or outpatient. I love the population because it does allow me the most freedom to practice all the psychotherapy skills that I worked so hard to gain. And whereas, you know, with depression, if you're limited to a short appointment, I may not be able to do that. I may have to refer that out.

But I can do a little bit of work on triggers. to use, triggers to relapse, values towards staying in treatment. We can do a little bit of work, even if it's five to 15 minutes, pretty much every visit. And even in the initial visit, the initial, you know, addiction medicine evaluation can be a nice blend of, you know, removing cognitive distortions or identifying barriers. And so I do, I do. I do. strongly encourage that. And then, again, I'll close with this. You know, if they're not ready for any of this, do not forget about harm reduction. Harm reduction works, particularly with fentanyl, teaching patients how to use more safely when they're not ready to make any other change. Maybe the only thing that

keeps them alive. So they can cut down their own fentanyl use. They can use, you know, heroin with with clean needles. And while, you know, there's a large part of, I think, all of us that kind of reacts against the harm reduction education, because we would prefer it if our patients, you know, weren't using anymore, we'll never get that chance if they don't live long enough. And so harm reduction may be the techniques that they need to stay alive long enough to get to treatment. Yeah. Yeah, no, I think there may be an initial reaction, but I think when you look at the studies and the ability to stay connected with them,

I always am surprised when an addictionologist will stop or not see someone if they come back with a positive urine drug screen. It's like, no, continue to see them, build a relationship, do the motivational interviewing. Because it's a long game. and you're not going to like okay so i mean you could get fearful like oh this person could kill themselves if they continue to use and if i'm their doctor and they kill themselves that could be bad for me i could get sued it's like well but you could also potentially you know one year from now

six months from now finally get through to the patient and then they have a relationship with someone who cares about them so i'm i'm always in it with the long game i have some clients who, you know, regress or use intermittently, I'm not going to fire them. I'm going to continue to work with them. I don't know. Do you have any thoughts on that?

I know it's not a, like, what's the current standard? Because I've seen that from a couple people that have been surprised at it. Yeah, the current standard is understanding the illness, right? It's relapsing, remitting. Yes, the current standard

is understanding the illness. Relapse is part of the disorder. Right. And most patients will relapse, you know, seven to ten times before they no longer relapse. And that's when they get into treatment and stay in treatment. And so if there wasn't that relapse risk, I mean, it wouldn't really be a disorder. You know, this has affected their brain, their ability to say no, their ability to move forward with what they want in their life. What started out as a choice, becomes a disorder of the inability to choose. And so they do lose that ability to choose over time. That's what makes it a disorder. And so as much as they may want to not use, their brain is firing in such a way that perhaps we can't understand

if we've never had an addiction ourselves. They can't say no yet. But just as much as that much as that is true, it is that once they're in treatment long enough, you know, that brain will heal itself. Those pathways can rewire that reinforcement will reduce, you know, so that they do have, they regain the ability to say no. And so that, you know, that's what I would say is, is you've already said it, don't blame, don't shame, but accept it as part of the disorder and move forward to the next level of treatment. It does mean you may change, but I treat a lot of these patients, not as much as some that work full-time only in a specialty treatment center, but based on the inpatient and outpatient settings, I treat a lot. And I'm probably only

terminating from my treatment, probably only about three per year is what I average right now, out of all the patients I see. And those usually go with a referral to a methadone treatment center nearby. Occasionally, I come up with some other options, but that's usually how that will go. And again, it's not responding to treatment, continuing to misuse, continuing to, you know, exceed evidence-based guidelines. And I've even used the change of the waiver as part of my treatment in the sense of, you know, know, any provider with a DA can prescribe this medication now. And so, you know, my patients need to be able to be honest with me, work with me, and work together on a plan that keeps you moving toward, moving toward staying in treatment.

And so when a patient is making any positive steps, then I consider them to be staying in treatment. And yes, if they have a couple of relapses along the way, then that's part of the disorder. that I'm treating. When they're making no positive steps and they're regressing for multiple visits observed over time, or perhaps they're just trying to increase their supply to sell or trade or whatever, then those are the ones that that I'm going to terminate. But it's much less than what I thought it was going to be. as a

before I began to really focus on this area. Awesome. Hey, thank you so much. Neil Christopher coming on, Dr. Christopher, I look forward to more in the future and we'll leave it there for today. I think so much.