The Zac Clark Show - Dr. Cara Poland: A National Voice for Mothers, Compassion, and the Fight for Better Addiction Care

Episode Date: April 15, 2025

This week on The Zac Clark Show, we’re joined by Dr. Cara Poland—an addiction medicine physician, educator, and national policy leader who’s been on the front lines of treating substance use disorder with science, compassion, and urgency. Dr. Poland works across every level of the system: running a clinic that supports pregnant and parenting people, training the next generation of doctors, and advising lawmakers on how to use opioid settlement funds to actually save lives.In this wide-ranging conversation, we cover:Why the language we use—addict vs. person with substance use disorder—can change how someone is treated, even by doctorsThe role of medication in stabilizing the brain so recovery can beginWhat actually works when supporting pregnant women with substance use disorderThe staggering lack of addiction training in medical schools—and how that’s changingHow stigma shows up everywhere—from hospitals to insurance companies to families—and what we can do about itThe story of Dr. Poland’s brother, whose death fuels her work every dayWhether you're in recovery, love someone who is, or just want to understand how we can do better as a society, this episode is for you. It’s about meeting people where they are, staying alive long enough to heal, and building a future where addiction is treated like the medical condition it is.Connect with Zachttps://www.instagram.com/zwclark/https://www.linkedin.com/in/zac-c-746b96254/https://www.tiktok.com/@zacwclarkhttps://www.strava.com/athletes/55697553https://twitter.com/zacwclarkIf you or anyone you know is struggling, please do not hesitate to contact Release:[phone]releaserecovery.com@releaserecovery

Welcome back to the Zach Clark Show. I am very excited about today's guest. Dr. Kara Polan does it all apparently, but she has really left her mark in the behavioral health care field. She is a board-certified addiction medicine specialist. She's a faculty at Michigan State, which we were just talking about. She's trained over 1,000 physicians through MI CARES or at Michigan care. Is it the MI is for Michigan? Yes. Yeah. And she's doing unbelievable ground breaking work supporting pregnant individuals with substance use disorders and I want to welcome first of all thank you it's great to be here how are you good thank you how about you you you flew in for us which I appreciate absolutely and I have permission to call you Kara yes okay

I want to start so when I read board certified addiction medicine I've been doing this for I just shared like you know 13 years working in behavioral health care and there is a there's a push right now around the language, right? So this word addiction, substance, how important is it? How important is the language? Does it matter? Does it matter? I go both ways, and I'm just curious.

I think the words we use matter, right? And so when we're talking to somebody who has a substance use disorder, what we know is that if I call them an addict, they feel stigmatized. If they, but they might use the word addict. And even if they say addict, still don't want me to say addict back to them, which is fascinating, right? So the way somebody self-identifies isn't necessarily how they want us to identify them as a provider. We also know that if we use the words substance abuse, which were old diagnostic terms that haven't existed in

over a decade, but still kind of come out from physicians and from other health care providers, that the public, so that loved one that might be with the patient, that the image that we have out in the community is that people believe that they are less worthy of treatment, less deserving of treatment, more likely to benefit from punishment. And we know that the opposite of addiction isn't punishment. The way to treat addiction is with kindness, compassion, and surrounding that person with support. And that's when we see recovery happen.

So I think that the words we use matter from that standpoint in terms of how the public perceives us, but they also matter in terms of how we communicate. within medicine. So we also know that if we give doctors to kind of written case studies about patients and they're the exact same except in one case we say substance abuse and in the other case we say it's a person with a substance use disorder that we provide higher quality care to that person with a substance use disorder. That's what we call implicit bias, right? That's what we call kind of unconscious bias. We don't know that we are doing it to our patients

because all we did was change the type of disease, the name of the disease, that the person had. Yeah. It's very interesting to me because my personal story, right, like I went to, I went to treatment for four and a half months. I was an IV heroin user. I got out of treatment. The program I went to was very 12-step-based.

I did use medication-assisted treatment by way of, you know, Suboxone to kind of get detox, and I was discharged on Vivitrol, which are medications if you don't know, and you're listening. And I found my way through a fellowship. I'll leave it there. And I think when I engage folks, they assume that I am going to force that one way onto them. And that's the only way. And I know that's not true.

And I think for me as someone who's watching your work and watching the work of so many smart people out there, it's always interesting to me when I see, you know, on the Internet or wherever it is, like the harm reduction community fighting with the 12-step community, which is fighting with the, you know, evidence like these communities are so prideful but like we can all work together oh i absolutely agree i think it's a continuum i'm actually writing an article on that premise um with a colleague of mine um who's a ethicist so this is like a key thing that i've been thinking about it's not either or harm reduction is an important part of a lot of medicine that we do so if somebody has diabetes and their blood triggers out of control i don't remove their insulin i don't not let them see the physician

I don't tell them that they're bad people and therefore, you know, come back in six months when you're ready for treatment for your diabetes. I try to engage them where they are and try to see what we can do to reduce the harms. I'm not going to send them to the eye doctor, the podiatrist, or any of the ancillary services that they might need, which are actually a direct consequence of their uncontrolled diabetes, right? And when I send them to the eye doctor or send them to the podiatrist, they're not going to say, Well, because you're here with it from the diabetes, we're going to, you know, tell you're a bad person and you should really take better care of your diabetes. No, they're going to treat that patient with kindness and compassion and address their other issue that is a consequence of their diabetes. But we don't do that in addiction. And I think a lot of that is a result of the fact that we were founded as a nation by a Puritan group.

And so there's this like value and judgment that we give to substances. But what we feel to remember is that we all fall prey to that. There is only one pleasure reward center. It is the same center in all of us. And so if I use a simple sugar, if I, you know, why is it easier to say yes to a donut than it is to say yes to a bowl of broccoli? Right. It's the same kind of idea.

But I really think that this is a continuum, right? We want to keep people alive by providing them with her. reduction resources. But the harm reduction services, in my personal opinion, should be well trained in basic counseling techniques like motivational interviewing to help try to work that person through stages of change into treatment. Yeah, I mean, I never thought of it this way, and you're like, you're blowing my mind right now because when I, so in the six months before I went to treatment, I was doing kind of like the daddy home rehab thing where my dad was. kind of doling out my suboxone and and you know you were getting $20 a day and like he was he

was putting these things in place that quite frankly now that I think about it like it was it was a little bit of harm reduction like he was he was just waiting for that moment which ultimately came and he's not a trained physician he was a businessman but it worked you know and it kept me alive and then then one day I was able to kind of like see the light or have that moment of clarity where I was like, okay, I'm ready to really look at this thing. Right. And we have to capture people when they're in that moment because that moment can sometimes be fleeting because these substances have such a powerful hold on the thinking

processes within our brain. So when somebody is ready for treatment, we need to meet them in that moment. You talk to my team. I am the sense of urgency, like when someone calls for help and I'm like, do not let them hang up like let's get in the car like and we mobilize that's what like I've built really a career on just answering the bell because I know if we don't get them in that in that hour in the next couple hours they might find you know a way to get high one more time which could lead to a thousand more times or in worst case that last high leads to their untimely death yeah

dr. Paul and can you just frame because Zach mentioned some stuff but you do a you do a lot of different things at the, you know, local state and even national. Can you just sort of frame like all the work that you're doing so that people really understand like you're involved and aware of a lot of different things happening in this space? So I like to kind of bucket my work into a few different buckets. I have a clinic where I treat pregnant and parenting women as well as other folks with substance use disorders that really focuses on how do we support that whole unit. We think of it as a family unit rather than just the pregnant and parenting people, because we all know that if you are in a relationship or you are living in a home with a parent or with a sibling

or with anyone else who is using, trying to stay on the road of recovery is going to be that much harder. So we want to treat the support people around that pregnant and parenting person. I also run what we call a fellowship, which trains addiction specialty physicians that will be kind of the future workforce and they rotate through that kind of students in the house today right that's true one of my one of my lab students mandison walsh is here with us today what's up madison i'm good so i have to be here so i have students everything from medical students so future physicians to currently practicing residents as well as fellows and then um madison's an epidemiology students so i get them from i get students from all over so that leads me to kind of the next bucket

which is education and the Michigan CARES program was started to really focus on ensuring that there were addiction specialty physicians at each of the medical schools in Michigan so that we could train the future medical students because if you don't have the faculty member to train them in a kind destigmatized understanding manner of the principles of addiction, then you're not going to graduate doctors that are capable and competent at the time in 2018 when we were founded the average practicing physician had 10 hours of training and addiction across the about 10 years it takes to become a physician so it was it was dismal right like how can you know what to do just think about what the outcry would be if that's the amount of education and training that

somebody had to treat high blood pressure or asthma we wouldn't graduate those students so we started this program through a collaboration with the Michigan Department of Health and Human Services, trained the six docs. But as happens, in I think all fields, I'm sitting in my clinic, and I've got my colleague sitting next to me, and I'm getting special help to become boarded in addiction. My colleague wants that. So we went back to the state and said, hey, can we expand our purview and train other doctors? And they said yes. And then we got a call from somebody in Ohio, and I don't know if you know much about Michigan versus. versus Ohio, but I went back to the department and said, I know it's Ohio, but could we help this doc? Because Ohio also needs help. To date, now we've had over 18,000 people enroll in our program to get education and training on addiction. So it's pretty remarkable.

It struck me when you walked in with like, I thought it was just going to be you and literally one of your labs. So it's powerful. That was powerful. That was enough for me. I think this, she's doing it. thank you no it's it's it's about also inspiring the next generation so when you have opportunities to show them what their future could look like what why you do sort of the advocacy and the public facing work which is kind of my third bucket um i think it's important for them to get that exposure to be able to see what that looks like so that they can understand that well i can be a doc in an office treating patients and that's really important work on the one-to-one basis, but that there are these bigger, broader things that you can do depending on where your interests fall and your interests lie.

So that last bucket is advocacy. I'm the current chair of the Public Policy Committee for the American Society of Addiction Medicine. So I sort of lead the writing of the policy for the nation. Do you say that again? Because you like went way so fast. Oh, sorry. That's like huge.

No, I mean, no, that's huge. I just want people to really hear that. So I'm the chair. Yeah, I just was trying to give a pause. so that their cutting time would be easy. And I was flubbing over my words. So in my role in advocacy, I chair the public policy committee for the American Society of Addiction Medicine,

which is our largest physician-run organization in the United States. And so what I do in that role is I direct and lead the writing of public policy for the nation. And then those documents are kind of the documents that people can take to their local, legislators, their federal legislators, or even just their clinic manager and say, hey, we should probably think about doing this or doing that, or, you know, there's policy around how we could best support people in this space. And so that work to me is kind of that global big picture impact. At a state level, there's something called the opioid settlements, which has been a national a national effort to hold accountable pharmaceutical manufacturers, distributors, and developers

of opioids. Michigan is led to receive about $1.6 billion over the 15 years, and half of that goes directly to the counties, townships, and municipalities, and half of it goes to the state, and I chair the legislative commission, so it's in a nonpartisan portion of our legislature that advises the legislature on the appropriation of those dollars. So you're helping steward those funds. Are you, yeah, amazing. So I'm kind of making the recommendation to the legislature on how those funds can and should be used,

well, also really encouraging Michigan to up their game in terms of transparency and accountability on how they're using those funds because this is a once-in-a-lifetime opportunity to create infrastructure that will hopefully save lives not only in this current epidemic, but if we have the infrastructure, then as things evolve, because drugs evolve, right? We all know this. That's what's happened for thousands of years, right? So how can we make sure that there's some infrastructure built that can help us continue to address substance use longer term? Yeah, I mean, I just, I remember, you know, for, you know, we're, like, we're coming to, like, a gunfight with a knife to a certain degree. Like, I even share that,

you know, when I was in hospitals during my use, and even now when I, like, go into a hospital to speak, Like, typically they're sticking those people, the behavioral health care, like in the basement, like away from everyone else and the facilities are not. And that's not how we're going to cure this thing. So if we have the resources and they can be pointed in the right direction, that would be beautiful music to my ears. We've spoke to, I've ever done, you know, I've, being sober and through 12-step programs have, you know, gone into hospitals and told my story and basically had a 12-step meeting in there. with doctors watching as part of a program like, you know, med students, and, you know, just shocked at how little they understood about addiction, which is, you know, qualified as a disease. I mean, that's not debatable, is it?

It's not really debatable. Addiction is what we consider a chronic disease. When they've looked at kind of relapse rates in addiction and compared them to diabetes and hypertension, they're not different. So we don't talk about hypertension in terms of, oh, this person relapsed from their hypertension. You know, we don't talk about diabetes in the same way. And, you know, really working toward changing that language is really important because, you know, none of us are perfect, right?

I always tell people, if I go on the no chocolate cake diet, what's the one thing I'm going to want more than anything else in the world? Chocolate cake, right? And if you have a birthday party and you have a chocolate cake and you don't know that I've been on the no chocolate cake diet for the last 18 months, and you know that chocolate cake is kind of something that I really enjoyed or used in the past, you might offer it to me. And it's going to be that much harder for me to say no to my friend who's offering me this piece of chocolate cake out of the goodness of their heart, right, than it is, you know, to say no to something else, right? And so we kind of punish people in a way and have these very judgmental methods of treating them and talking to them that we don't

use in other areas of medicine. Look, we know that the weekend after Thanksgiving, like the Friday, Saturday after Thanksgiving, there are higher rates of things that are consequences of diabetes in the hospital because people are relapsing from their diabetes on Thanksgiving Day. Yeah, that's so interesting. Everyone needs to hear that. I, yeah. You've talked about the training that you've done and the lives that you've impacted. Your journey started with a very personal connection. My journey in behavioral health care started with my own recovery. Can you talk a little bit about your inspiration, which you've shared very openly about your brother

and how you've used that tragic loss to fuel your career and really be such an amazing inspiration to all of us? I think my personal journey keeps me grounded. I think I've heard that from you as well, that, you know, the why becomes very apparent when you have a very personal connection to a subject. And so for me, that connection is my younger brother. So when I was in my training, I was in my fellowship, kind of the final stages of addiction training, I was really close with my brother. And we had planned on him coming to celebrate the winter holidays. with Christmas coming up with my family. I had a 10-month-old baby at the time.

And so I had invited my brother to come to Boston, where we lived, bought him a plane ticket, and he didn't arrive for the holiday. And we ended up calling for a safety check, and the police went to his home. And a few hours later, I got the phone call that he had died of a self-inflicted gunshot wound related to kind of his depression

and his opioid use disorder. Oh, no, he had an alcohol use disorder. Let's try that again. I don't know how that came out. You needed to laugh in that moment. It's good. We can laugh, you know, seriously. I don't even know how that came out.

We're not taking any of that out. We should like be in the bloopers. It should be like in the bloopers. No, no, no, no. Should I start at the beginning? No, no, you're good. He had an alcohol use disorder, yes. Yes.

So he died of a self-inflicted gunshot wound related to his depression and his alcohol use disorder, and he'd been in and out of treatment. I was well aware of the medications that could support him. He was in law school. He had what from the outside looks like a pretty bright future, and I think that's something that happens, right? We never know what's going to flip the switch and, you know, talking to him prior to his death, I learned that he started drinking when he was about 14 years old, which is not uncommon.

The average age of first use is between 11 and 13 years old. So it's, you know, he was right in that space, and we know that when people are exposed at younger ages, they're more likely to develop a lifetime substance use disorder, which is why we always in the prevention world are trying to delay onset if we can and so that that kind of became the fire right the the why and and after my training when I moved to Michigan I learned that in Michigan there was no way for a physician to get reimbursed for an office visit to see a person with a substance use disorder and when the billing people at the organization you know told me that I frankly thought they were wrong because there is, from 2008, the Mental Health Parity and Addiction Equity Act at a federal level,

and I was like, well, this is clearly a violation of that, so how can you do this? And it was kind of a game of he said, she said, where in Michigan we have what they call a behavioral health carve out. So that is the carve out, they carve out the services for Medicaid recipients, and then we have kind of the rest of their health is through a more traditional HMO process. And both of those entities said it was the other person's responsibility. And it took seven years. And that's really how I got involved in advocacy is I just didn't stop talking about it.

And what I kept saying is like every day I wake up and there's a picture of my little brother in the bathroom where I get ready for work, right? Where I get dressed, where I, you know, brush my teeth. So I see him when I wake up and before I go to bed every single day. And that is my reminder that we fight for the right thing for the. the right people for the right reasons. And if I don't know, I have a moral, ethical responsibility to say, I don't know, I will try to figure that out for you, but I don't have that information. But for seven years, I would walk into these rooms, and I still say it today.

And, you know, I will always wonder if Max had been offered medications to treat his alcohol use disorder by a physician if he'd be alive today. Yeah, I mean, it's, um, it's tragic and I think anytime we lose someone I've you know clearly experienced a lot of loss and just doing this work and I'm sure you have after max and I want to hug you but you know we're sitting here um we always ask ourselves those questions you know we always ask ourselves and we've had grief experts on and it's just you know I don't I don't know but to your point Like, I don't have the answers.

Right. But how can we all work together to create a safer, healthier community so that other people don't have to suffer either, you know, a death like my brothers, but also just the devastation of those lost years to a substance use disorder, whether that's a person's own or somebody else's. One thing that I think is really cool about recovery is, for me, I think when I see my friends, my patients, the people that I know in recovery, I think they're like better, awesome, fitter, more amazing people because they had a

substance use disorder. Not to say that I wish a substance use disorder on anyone, but the outcome of somebody who's successfully been in treatment is often so cool because there's this new like passion drive and license on life that I don't know would have existed without that deep experience. Yeah, I mean, I feel very fortunate where I like, you know, dating, people worry about dating in early recovery. They worry about how you're going to tell your friends, how you're going to tell your family. And for me, I was just very straightforward because I don't know, and I don't know why I kind

of had this willingness and maybe it's how God is choosing to use me, but I would just tell people. and no one ever judged me and if they did it was you know outside of that conversation and maybe they ran back to a friend or someone like did you know about Zach but and the more I did that the more people were like that's really cool tell me about that you know like that so it's like this energy that we bring to it I'm like and that's why I asked the question about language because like I am a drug addict absolutely I love drugs I love alcohol typically when I do a lot of drugs and alcohol I get very anxious I get very depressed and I start to question my existence you know, and that's facts about my life.

Having had that experience, I am full of joy and happiness, and my life is so big and beautiful today. And I know that's because I'm a drug addict, to your point. Do you, so I'm just a lot of thoughts, but do you, why, I guess my first thing is, it's just, everything you're saying, it sounds like it's like it's a fight, right? It's just like a fight to make people at a, you know, governmental or policy level. recognize and understand like why is it is it is it because this isn't like a natural disorder or is it because there's just the stigma of well it must be a moral issue i mean like

why isn't it just recognized in the same lens as hypertension diabetes you know these kind of other chronic issues i think a huge part of it is judgment stigma and lack of understanding we spend as a physician between medical school four years residency three to as many as 10 years so we spend on average 16,000 hours in training and remember only 10 hours of that have historically been an addiction just think about that for a minute that's impossible and that's what the health care system is doing right that's what we're doing to train your doctors no we translate that to our government officials. We translate that to people on the hill and they only know what they've heard, what they've seen. I have a good colleague named Jonathan Stoltman who runs a program

called Reporting on Addiction where he works to train reporters on how to write these stories to be more humanistic, kind, compassionate. And he encourages them as part of this training to look at their own biases and examine where they might be coming from so that they can understand where those exist so that they can maybe avoid them, bring them to light so that it doesn't end up infiltrating, for lack of a better word, into their reporting, which is really cool, right? And so we do some of those types of trainings in the MyCare's program with medical students. So how does your personal bias, what baggage do you want to? walk into the room. And when I talk to residents, I will often ask them, you know, if you have two

patients, one with diabetes who appears uncontrolled and one whose diabetes appears under good control, which room do you, as the physician, have to take the deep breath before walking into? Right. Right? It's harder for us. We feel less effective when we're walking to a room with somebody who is an uncontrolled disease state. And what tends to happen in addiction is that a lot of times physicians, other healthcare people have only kind of seen visibly uncontrolled addiction. And so they haven't seen the people like Zach that are in recovery because there's so much stigma that not everybody is as brave as Zach is to be able to say, hey, I'm loud and proud and in recovery. And

that's a part of my health care and you need to be aware of it because there's this fear or there's also this idea that maybe it isn't part of their health care because we've had kind of I joke around that the neurologists have taken over the brain so I'm in the ether in addiction in some people's minds right like I'm in the I'm like the aura around the person which is kind of how a lot of people look at addiction in the health care systems and we've got to break that down and to me that's why I do the education stuff, because I want to prevent them from developing that judgment, prevent them from becoming stigmatizing when they go in there.

And if the only thing that is a positive outcome from that training is that when they walk into that clinical situation and they hear somebody say substance abuse, they think in their head, oh, that's not what Dr. Poland said. Dr. Poland said that we should be using these other words, then I feel like that's a win. Because we also know that if we use the word substance use disorder, we unconsciously provide better care.

So look, we're changing the health care system, just using the words that we say. I love that. I do think the language is important. And like I said, I've gone both ways with it. And this thing is so insidious. I mean, so as a business owner, you talk about stigma. I have two recent examples that I don't want to share with you

because I feel like we're on the same page. one is we went out and tried to get a line of credit with a bank or business and they came back oh no we wanted to accept ACH payments so we had to go through this process to be able to receive money in a certain way and they said sorry we can't we can't do that for you because your payers are unreliable right our payers our patients our clients are unreliable and I said to them are you looking at our books like For eight years, we've been a very good customer of this major bank. We've never been late with anything.

We've never overdrawn an account. We've always run a business. And our payments always come on time. And this, I mean, I got very animated and I tried to educate the person and it just wasn't going anywhere. We ended up going to another bank because it was just so frustrating. And then the second part is we're up for our insurance renewals and we employ about 100 people here. And a lot of us are in recovery, myself included. I've probably used my insurance three times in my recovery.

Like literally. I go to the doctor, whatever. And again, sorry, we need to like jack your rates up because of the types of people that you have working for you. And I'm just like, and I sit there and I'm like, am I fighting this fight or not? Right, right. Well, I have two sticky notes that are on my monitor. at home. One says keep the passion, control

the emotion. And there are definitely moments that I'm walking into that room with that senator or walking into that room with that, you know, executive at my organization or at a local organization, but I am thinking in my head, keep the passion control

the emotion so that we can have a fruitful conversation. And then the other one says transformative change was never brought about by reasonable people. So it's kind of a balance. Both of those are like, hit me right, like, right here.

You need the sticky nose. You need the sticky notes. It's a great way to remind myself of kind of what those values are, right? And what is the North Star in terms of this work and the broader communities that we're serving. Yeah. Where do you want to go? Pregnant?

Yeah. How did you get there? I mean, we have a stat that. blows our mind in terms of 10% of all pregnant use illicit substances. So if I walk down the street and I see 10 pregnant women, one of those, please. And that's illicit substances, right? So that's one in 10 people use an illicit substance during pregnancy. That does not include alcohol. Right? So just think about what those numbers. actually are in the lack of compassionate care that these folks can find that lead to them hiding

their use, not telling people about their use, all of those things, which are so unfortunate when we look at the broader amount of care. What I love about treating pregnant people is I have yet to meet a pregnant person that doesn't do something during their pregnancy in terms of their own health care in order to improve the outcomes for that baby. I'll give you myself as an example. I have two children. I had fertility issues. So I spent two years trying to get pregnant. Then I got pregnant. Then I was breastfeeding. Then I got pregnant again. And then I was breastfeeding. So it was like six years of getting pregnant, pregnancy, breastfeeding. And I am one of those terrible, awful, evil women that is an overproducer of breast milk. So I had like gallons

of breast milk in my freezer. I know. I know. Everybody throw the eggs. Well, maybe not eggs, because that might be kind of expensive right now, but I'll address the hate mail when it comes. No, but so my daughter's, my daughter turned one, and according to the American Academy of Pediatrics, you're supposed to breastfeed for one year. Her birthday is February 1st. We had a birthday party on February 15th for her,

and the morning of the birthday party, when we're, you know, putting everything together, getting the house ready. I looked at my husband, and I said, I'm going to McDonald's. And he was like, what are you going to McDonald's? for to share. And I said, I am going to McDonald's to get a Diet Coke because I have been six years without a Diet Coke and she is kind of weaning from breast milk. There is plenty

in the freezer and I'm done breastfeeding and I want my body back. But I went out and got like the gold standard of Diet Coke. If anyone else is kind of a Coke product, drinker, affectionato. Amen. It's elite. It's the best, right? There's like a whole whole, like there's a whole theory behind it that I have. But anyway, okay, so there are five things with Diet Coke that make it, that from McDonald's that make it the best. They actually have a different ratio of syrup to carbonated water that they use it at McDonald's so that the flavor doesn't dilute as much as at other places.

They require the syrup to be climate controlled during transportation. And it's transported in stainless steel instead of in plastic. And so when they infuse it together because the stores are required to keep the syrup at that same temperature, most places it's kept at room temperature. So the coldness, it comes from the carbonated water. But at McDonald's it's actually the same. And then the final thing, which I think they've messed up recently is the straws are like a broader diameter. and that allows more bubbles to get in your mouth and burst in your mouth instead of in the straw.

We have a shape shop on this block, 19th Street, in Manhattan. They have these straws that are like, I swear, you're like, you're drinking the whole beverage and one kind of like suck. And it's like my favorite thing in the world, but I digress. There's like a whole thing. But anyway, like I was. I'll send you some, I'll barter for some of these straws and send you a couple. Yes. It's amazing, right?

When we think about it, like there I was, the pregnant and parenting person. who was like, all I want is a Diet Coke, right? And it was like perseverative at times where I was like, I just really miss Diet Coke or I'd see somebody drinking a Diet Coke and I'd be like, I can really want that. And what's your fear in those six years of having one Diet Coke?

Probably an unfounded fear that it was going to cause, you know, my child to spontaneously combust or something completely irrational. But it was like... If you were treating you as a doctor, would you say, have a Diet Coke? I would have totally said have a Diet Coke.

And I also would have said, like, your child is not going to be harmed if you have a diet coke, but also your child is not going to be harmed if they, if you are so nervous about having a diet Coke that you want all the Diet Coke and the caffeine and whatever chemicals out of your system and you decide you don't want to breastfeed for 24 hours after you have said Diet Coke if you give your child formula. Right?

So I was putting all of this on myself, right? And all this weight and all this pressure. And pregnant people do that. A lot of pregnant people do that. It's not, like, unique to me. It's not unique to the disease of addiction. So when I talk to people, I say, you know, just like I didn't drink Diet Coke when I was pregnant and breastfeeding and trying to conceive, my patients are just trying not to use

fentanyl or alcohol or whatever the substance is. It's the same thing. You don't have a substance use disorder, right? I don't have a substance use disorder. Okay, so that's, and I think that's where a lot of the stigma comes from, which is, unless you've experienced it or seen it a lot like you have in your work, it's very hard to understand what is actually happening right and it's this mind body kind of kind of thing right and the body the mind is like like it like has this ability like a sane decision versus an

insane decision and I remember and I've spoken to so many people like two three four days okay I'm living healthy I'm living healthy you get to that moment where you open the you see the thing and you say oh the mind starts like you don't have just one right it's going to be different this time you deserve this you put three days together of not drinking so naturally like if you have this one beer you're going to drink it and everything to be fine right i have that one beer and i am in handcuffs right within 12 hours right right well and that and that's kind of the power of the brain right like we know that the drive chemical is dopamine a lot of people talk about dopamine is the pleasure chemical it's not it's actually the drive chemical the dopamine

the chemical that causes us to feel pleasure is endorphins and endorphins chemically are opioids so opioids are what give us all pleasure it's what gives my children pleasure I don't think they've been exposed to opioids before but right it's it is the thing that gives pleasure is endorphins in our brain but that dopamine that drive to use comes from comes from kind of this area of the brain that we that we is a earlier more primitive area of the brain that we actually sometimes refer to it in medicine as the reptilian brain and and there's not like logic there right and so it sends that message forward to the frontal cortex which is our CEO it's our executive functioning is what we call it

and so it is the stop mechanism but we all know that sometimes stop doing something or changing the behavior is really hard and when we have substance use involved in that that dopamine signal is much stronger than it is in other spaces so if we look at kind of having the best meal of your life or the best sex of your life that pales into comparison to the amount of dopamine that is released with heroin with methamphetamine we've done the studies to know to know that so the drive is a remarkable And so we don't always have the brain capacity to turn that stop mechanism on.

And then we think about the fact that that executive area of the brain isn't fully developed until we're in our late 20s. And so if your brain is first exposed when you're an adolescent or a young child, look, one of the questions I ask my patients is, what's the first memory you have of using any type of substance, whether that's nicotine, alcohol, cannabis. Those are the big three that usually are given to young children. And it's not uncommon for me to hear ages like four, five, six years old.

And, you know, some family member thought it was funny to watch this child at a party get drunk. Right. Is dopamine, first of all, I'm thinking of a memory. I, you know, the first cigarette I ever smoked, I don't smoke cigarettes now, I was eight years old and I stole it from my uncle and I remember that my older cousin helps me plan to steal it and this was like a whole and it was the whole like chase it was the plan you know of executing this thing that was just as as as you know driving me as getting the cigarette I mean because when I smoked the cigarette it was disgusting but you going

back to dopamine as drive would you say that is dopamine the response from the drive or is it the drive itself because I'm just thinking about and you can discuss this like you know the rat park studies which you've spoken a lot about and you can tell us what they are how things changed when the social environment changed and so is there this thing where a lot of people may be predisposed because of a certain brain you know, chemistry to abuse or addiction, if not for their life sort of taking them into different social settings that allowed them to just use that drive or that, you know, that susceptibility in a more healthier way. Because you are a very passionate, you know, obviously

addiction runs in your family, you know, what, it seems like it's such a faint line about what's the difference, you know? well and I think we see a lot of people with this predisposition to addiction and we see it in recovery a lot too where we we are people that tend to extremes we are people who don't always do things in moderation I'm going to call you out for something that I've also done but not to the extent you have which is run marathons I was I mean I'm going to let you answer his question but I'm sitting here and I was going to be very honest about my relationship to running which I have to do keep an eye on because there is no doubt there are mornings when I wake up and I don't want to do life I don't want to get out of bed I don't want to see people in fact like I can't do any of those things until I go for my run and I get that high and then I'm able to walk into this office and CJ and Sarah and smile and I'm a better worker I'm a better like it's all the lies I told myself when I was using opioids you know it's like for many years I would say I have to

to get these pills because they make me a better employee, right? And so, like, now it's almost like, I have to go for this run. And we see it in the recovery community. And I'm curious what you're going to tell me. And I'm scared what you're going to tell me. But it's also, I've seen people become addicted to running and then they get injured. And those stories don't always end well. Right, right. Well, we have to keep an eye on anything that we tend to extremes. And I think that's part of the, like, addiction susceptible brain. I'm so nervous. Bring it on. Right. So I know that when I have a glass of alcohol, I like it too much. So to Jay's point, why did I go in one direction and not the other direction? I tell people I just had like a really healthy fear. So when all my like friends in undergrad were going to parties, I was going to the law library and studying. I graduated undergrad in five semesters. Not because I'm that's, I'm the smartest kid in the classroom, but because I was like, ooh, if I go to that frat party, it's going to be dangerous for me. If I go to, if I go to that thing or do that thing where there are substances, like, I know my brain just likes it too much.

And I had seen enough in my family of people, to your point, using unhealthily with substance use disorders to kind of want to be a little bit more cautious. I don't know why I was the lucky one, right? I tell people all the time, it's not like I was raised in the house and my brother was raised in the garage. We were raised in the same home. it just we had different experiences and that led us to different situations and you know one different step in the different direction and I would have been my brother and he would have been me I firmly believe that I don't know that I have like scientific proof of that but when we look at the rat park studies these were a series of experiments done in the 80s out in Vancouver by a gentleman named

dr. Bruce Alexander and essentially what he did was he took rats and he put them in cages and he gave them the choice between water that was adulterated with cocaine and water that was unadulterated, just plain water versus water with cocaine in it. And the rats used the water with cocaine in it obsessively until they overdosed and died, essentially. And then he said, well, one of the reasons that we use rats as kind of an analog for humans in studies is because rats are social creatures the way that humans are social creatures. So he put them in a cardboard box that ended up being labeled Rat Park. And Rat Park had all the things a rat could want.

Fluff to make bedding with, tubes to run in, other rats to play with, all the cheese that rat could desire, other rats to make families with. And he gave them the choice between cocaine, adultered water, and regular water. And some of the rats use the cocaine water, but a lot of the rats, Most of the rats tried the cocaine water and then preferentially went to the plain water. So what was different? The rat's social connection. So then he took it one step further and he took rats and he got them in isolation.

And he kind of produced a substance use disorder in the rat. So he kept them in isolation until they were using that cocaine regularly. And then he took those rats and he put them in rat park with some rats that had been raised in rat park. And what he found was that the most of them. majority of the rats recovered. The majority of the rats went from the cocaine adulterated water to the regular water. There were still some rats that had severe persistent substance use disorders, right? But the majority of the rats recovered, which is crazy. And so people say, well, those are rats. That's not

humans, right? And the human analog that I usually bring up is that during the Vietnam War, about 50% of all the soldiers used heroin in Vietnam. And when they came back, and to this day, the VA is the largest single provider of substance use disorder services in the United States. We thought there was going to be this huge epidemic. And so the VA was kind of gearing up to address this, right? And what they ended up finding out was that most of the people, when they came out of war, right, which is kind of isolating fear for your life every day, that 95% of them just stopped using because they got back into a safe, healthy community, right, for the most part.

And so what is the analog of, you know, what's the human analog of Rat Park? And, I mean, we could go down the social media, isolation, images that, you know, we're serving up our young children. And I'm sure we all have strong feelings there as well. I mean, you can apparently at age 13, you're competent to make a decision about whether or not you can join social media, which is not founded in any type of reality. That legislature originally said 16, and then it was reduced for no real great reason. But I digress.

So when we look at these kind of situations, how do we create kind of the human analog of Rat Park where there's human connection and social connection? And how do we do that in a safe, healthy way, especially for those of us that kind of tend to those extremes, right? So how do you make sure that your running stays in the healthy range and doesn't run into the unhealthy range? Because there's a line there where, you know, you mentioned injuries, but there's also just that general experience of, is this taking up more time than it should? Are you doing it to the detriment of other relationships? I mean, we can, we could pull out the substance use disorder diagnostic criteria. I'm bodily and mentally different than

and then a lot of my brothers and sisters. That is a fact I know about my existence and it's running and it's food and it's nicotine and it could be gambling or sex. Like thankfully I haven't tapped into, you know, but like I know. I know that and I'm very, very, very aware of it. And I oftentimes have this conversation with myself like, oh, I'm leaving a dinner party at 9.30 guys because I have a big workout in the morning. You know, like I have to go do my big work.

workout in the morning and like the truth is is like I'm obsessing over like I need eight hours of sleep I need time to get up I need to fuel properly I need to like so I can go do this run because if I don't do this run then I'm not going to feel good and I'm going to have a bad weekend right that sounds very similar to something else I know doesn't it yeah yeah yeah exactly so I want to I want to dig in because we're like we're we're talking about a lot of things. I want to hear a little bit more about the work you're doing with pregnant women because I think it's very powerful. Before we do that, you know, one of the things that I really try to make this podcast about is hope and solution. And hearing you talk about Rat Park and community,

when a patient comes under your care or someone presents with a, if you could tell them one thing, is it that? Is it to go find community above all else? Or what is your, what is your starting point? I take a medication-first approach when it comes to opioid use disorder, because what the data shows is that offering somebody, methadone or buprenorphine, reduces the outcome of death by 50%. And none of the other treatments have the ability to reduce the outcome of death like that. So that is square one. And really what that does to me is it stabilizes the brain structures so that it reduces, it doesn't necessarily eliminate, but it reduces the cravings. it reduces their kind of feeling of dysphoria. Again, it doesn't eliminate kind of that,

having the blas or the icks, but what it does eliminate is it does eliminate the withdrawal. It does eliminate that kind of drive and need to continue to get substances. And that's where I tell people is where the work really begins. And then it is kind of the idea of community and recovering. What does that mean for somebody, right? Do I talk to my patients about,

AANA, smart recovery, Dharma recovery, all the community-based support groups that are available. Do I talk to my patients about individualized counseling, intensive outpatient programming, where they go for counseling for three or four hours, three to five times a week, right? Do I offer all of the things? And then I tell people, like, I know the math data and science. I can tell you what I recommend, but if that's not going to actually work in your life, then I might as well talk to my shoe because it's not going to help you.

So what we need to do is we need to partner together to figure out what does that recovery program look like for you. And we both need to understand that what we think today, what you tell me today might not be what's working in three months from now, three days from now. So it may be fluid, but it is about kind of building up that community around them. What was the quote you gave me about emotion and passion?

keep the passion control the emotion yeah i mean that's where that's where for me it gets hard because i have had my own personal experience uh getting getting well and when i see someone like you said who's either it really doesn't fit into their life or they just don't want it to fit into their life or whatever their reasoning is you know the emotions come out at some point if we're six, 12, 18 months into it, and it's just the same thing over and over. And that's where they probably need even more compassion and empathy and love to really be seen and heard. And that's what makes working in behavioral health care so hard. That emotion comes from a place of just, I'm scared. Right. I'm scared that something's

going to happen to you. And I say that. I say those words to a patient, right? Like we've been working together, you know, I'm concerned about you, you know, and part of that fear is, right, in this disease space, we're also worried that we're going to wake up one day. They're going to miss an appointment. And what's one of the places I search for my patients? Obituaries. That's the reality of this disease space. And, you know, I think that's one of the things that is really drawing to me for doing work with pregnant and parenting people is there is that drive to change their health care because of that pregnancy. And it was really kind of an accident of coincidence that led me to pregnant and parenting

people, which is that at the time there were three of us addiction specialty physicians at the organization. And one was an addiction psychiatrist, so he was taking care of all of the patients that had more significant mental illness that was outside of my wheelhouse as a. internal medicine physician. And then we had another physician who's an infectious disease doctor in addiction medicine. So he was treating the patients that had consequences like hepatitis C or HIV alongside their substance use disorder. And we were getting pregnant people. And it was kind of like, well, you're the only female. You're the only one of us that's been pregnant before. So I guess you

should do the pregnant people. And then the other thing that was really hard for me at that, time it was just a couple years after my brother had died and it was just I had kind of this feeling of I wanted to save people that reminded me of my brother so seeing somebody in their 20s who was male which is a large portion of our population was really hard for me and I started to question my ability to make good clinical decisions because I had a little bit of I wanted to save them because my brother wasn't saved so to speak baggage that was coming with me into those exam rooms. And so I started focusing on pregnant people

because it was kind of a safe space for me where I was able to make safe clinical decisions. Yeah, so I went to a treatment program, so I went to true, too. So in 2010 I went to a place called Seabork House, and they actually had a unit at the time. I think for women either with children or pregnant women could come in, you shared this stat, that 10% of, pregnant women are using some type of illicit substance and that excludes alcohol and then

the next line kind of in our in our notes here were that detoxes will oftentimes not treat pregnant women which to me is bizarre what is the reason for that are they scared that something might happen they're not capable of it they don't have the they don't have the team to do it What, what, how would you? I think it's that they're scared that something might happen. And there's a, but isn't that what we do? Like, aren't we scared? Like, isn't that like the risk I have here at release?

Like, something could happen, not going to at any moment. Right. I mean, I employ people in recovery. We house people in recovery. We treat people in recovery. Something could happen at any moment. I think with pregnant people, you know, we kind of talk about, you have two patients. you have the pregnancy and you have the person, right, that is holding the pregnancy.

And that, I think, sometimes scares people. There was also some old information that's, again, been debunked, that detox during pregnancy posed a risk to the pregnancy of miscarriage from, like, the 70s. It's not actually true, just to be very clear. But we still kind of see that just general fear. there are still places where you have to hospitalize somebody in order to get them on medication while they're pregnant, again, because of this unfounded fear, but it's just still there. Is Suboxone methadone safe to use while someone's pregnant? Suboxone and methadone are both not only safe to use while somebody's pregnant, but have better outcomes than not being on medication.

And when we think about it, we all know here on this podcast that when somebody is actively using some, substances, right? They're going in and out of withdrawal every day, right, likely multiple times in a single day. So to get somebody onto Suboxone, they often need to have an amount of withdrawal because the way the Suboxone works in order to feel better when you give them the Suboxone instead of feeling worse. I felt the other side of that. I don't wish it all my worst sound of me. It's horrible. So we can safely do that because they're doing it every day, right? And we know that they're not miscarrying in large numbers. I think one of the other barriers that's not always talked about is the fear of child protective services.

In some states, not where I am, which I'm very fortunate that Michigan is not a state where we have mandated reporting during pregnancy. But in some states, there can be mandated reporting to child protective services. and it can even in some areas be considered a crime to use while pregnant that can result in incarceration. Do most of these patients, I mean, I think I read something about you, you've seen kind of like 100 cases from start to completion, there's been healthy bursts. Do they, would you say that most of these women are coming to you and are already living with the substance use disorder?

Do some of them come, get pregnant in recovery and then kind of realize? or what is kind of the makeup of these folks that are coming? And how do they even come to you? How do they even know about you? And let's just go, it's called great, it's a great mom's program, right? Is there anything else, any other program like this in Michigan or anywhere else? There's a program similar to this at the University of Michigan in Ann Arbor. And then there are some packets of folks that, you know, there's an OB up in Traverse City,

which is kind of in the northwest part of the lower peninsula of Michigan. that where there's an OB who's boarded an addiction and kind of does a side of addiction, but more OB, GYN than addiction. So she takes care of some of these folks. And we sort of, I think in most communities it's like this. We kind of know where the other people are. So if I have somebody that's coming and they would be closer to Traverse City, I might say to them, hey, there's another dock.

If I have somebody who's coming up from Kalamazoo, which is an hour away, I might say, hey, there's another dock down there. So we kind of have like our own internal network that we kind of share across. And we, you know, those are the friends that I call, the colleagues that I call if I'm not sure where to go with a patient, right? I have a colleague at University of Michigan who's a psychiatrist. And so when I have somebody and I'm not sure where to go with psych medications, I might call her up and say, hey, Maria, you know, Dr. Music, can I, you know, pick your brain on this patient? And so, you know, I think because of the space we're in, we're all just like, there is plenty of work to get around.

How can we figure out what the right place is for a patient? And I think we're relatively lucky in Michigan that there's a grouping of us, and we're all collegial. We're all friends with each other. And I can feel like I can call them up at 8 o'clock at night and run a patient versus, you know, having to schedule a time, so to speak. I don't know that all states have that sort of, you know, know, network within the systems. But I think that that's really powerful because sometimes we all

need to phone a friend, right? When I talk to my trainees, I always tell them, the most important thing for you to learn, you know, is what the boundaries of your knowledge are, so you know when to phone a friend. Because whether you're an epidemiologist or you're a physician, you need to make sure that the information that you're putting out there is accurate and complete. So if you don't know where your knowledge ends, you could cause harm. And so that's, you know, developing those inside networks around individuals is really, is really important so that we can make sure we're taking the best possible care of the people that we serve. So like, what, like, Zach, was like the question, like, what's the profile? Like how, what typically, you know, is the kind of person that

comes to you for, for help? We see, we pretty much see it all. We see people who are actively using. We see people who have been in recovery for 10 years. We see people who have been in recovery and then return to using either before or during their pregnancy. We see people that come in and they just got that pregnancy test and they're, you know, eight weeks pregnant and we see people who come in at, you know, 34, 36 weeks pregnant because they were scared to come for prenatal care in the past. We see people that come to the hospital and the first prenatal care is at their delivery. So we kind of see it all. You offer dual care. You offer prenatal care and you know through and the the drug treatment as well. Yeah we try yeah yes so we offer kind of the

general OB care and then we also offer the addiction care. So we work as a collaborative team to make sure that people get that care and we do it in one location and one place because that way they can come and get all their care at once. What we found when we first decided to create this clinic was that we were being very health care centric, which probably comes as no surprise. And what we found was that we could be asking a pregnant person to do as many as four different things in a week. And that's practically impossible for anyone to do.

So we brought all the players to the table and figured out where was the most logical place to house a clinic that would be able to provide as many of these services as possible in one location all at once for that patient. sometimes we tell them like when they have their anatomy ultrasound which tends to take about an hour you may be here for a couple hours we've got snacks you can bring your own snacks right because you might be here for two or three hours and but then you don't have to come two or three times for an appointment look I saw my doctor yesterday and I from when I got to the office till I left the office it was over an hour right I mean that's just what happens and that doesn't even include

the transit time to get there because there's, you know, wait times in health care and it's not probably the most efficient system we could have, but how could we increase the efficiency from that patient's perspective? And that's kind of how we looked at it and how we've been able to kind of keep the focus on what is going to support our patients the most. And we have a remarkable recovery coach, and he connects with a patient, talks to the patients, helps them make sure they have transportation to get to the clinic, helps support them in exploring things like WIC, women, infants, and children. So other social supports as well, helps them get connected to other services, ensures that

if something comes up and they can't get to the clinic, that they don't lapse on their medications, right? Because these are life-sustaining medications that we're prescribing. And so it takes that whole team to come around that individual and that family unit. And so we do take care of them from pregnancy. We've had an occasional kind of I'm thinking about getting pregnant and I'm in recovery person that comes in for kind of a pre-pregnancy session, which is fantastic. But those don't happen super often.

Pregnancy, postpartum, generally speaking in the OBGYN world, people tend to come to tend to come between around 12 weeks to see the OB for the first time by the time they figure out that they're pregnant and all that kind of stuff. and then they keep them through six weeks postpartum, but we keep our patients at least for a year. And some patients at six weeks are like, I have my physician that I had been seeing before you guys. I saw them for eight years, peace out.

And some of them, you know, we're kind of navigating when is the right time for them to transition. Because as a person who's had children, that first year is really hard. And you're not getting sleep, and you're not getting the self-careful. that maybe you should because you've got a little human and they have their own needs and they're not really rational beings yet, right?

Women in general are underserved in this world. I mean, I always share like when I visit treatment programs across this country, it's four or five guys to every one girl on those campuses for whatever reason. You know, women just don't get access to treatment or don't show up in treatment as as frequently as men do. And I just, I'm sitting here listening to you and I can't help but think about statement, think about the person who might say like, well, you have a child in your stomach.

That's not enough for you to stop, you know, doing drugs. And like, I actually get that. Like, there's nothing that is going to, like, when I want to get high, there's nothing that's going to stop me. It doesn't matter if my parents are in the room with me. It doesn't matter if I'm carrying a child. it really doesn't matter. And that's where the compassion and the kindness and the work that you're doing

just becomes so important because that person, trust me, feels bad enough. Oh, my gosh. I can't tell you the number of times I've said to a patient who's had a relapse or has been using an episodic use or has been using is not currently engaged in kind of a recovery program and is actively using how many times I've said to them. So have you beaten yourself up enough about that? that? And the answer is always yes. And then the question I always ask is, is there anything I could say that would make you feel worse? And the answer is always no. So I don't need to

beat you up. Let's talk about how we're going to move forward together. And I always tell people, if somebody is still using an active disease, but they're showing up to see the addiction physician, there's some part of them that wants something different. Or they wouldn't be coming in for that appointment. And so my job then becomes to support them and how, help them figure out what is that driving force? What is what are the things that are barriers in their life to what their goals are? And their goals might not be freedom from substance use disease, right? Like their goals might be to use safer, right? And so I'm going to have that conversation with that patient to try to keep them safe. Yeah. Make sure they have

access to harm reduction services. Make sure they know where to go in our community for those services hand them a box of naloxone if I need to if they don't have that right like how what are the things that we can do to support them here and now just so that we can establish that trust because maybe one day they'll wake up and they'll have a different thought and if I have alienated them by saying something like well why didn't you just stop don't you know you're pregnant well yeah they do and for whatever reason they're not in a place where it's feasible for them to stop what's the demographic is their typical demographic of woman that comes to the clinic? Not really.

I mean, addiction doesn't have boundaries, right? I've seen people who have come to me from affluent areas of our community, from not-so-affluent areas of our community, on commercial insurance, on Medicaid, you know, all different skin tones, all different educational backgrounds. Our biggest referral source, which I'm really proud of, is not from other health care providers, it's word of mouth, which I think, hopefully to me at least, means that we've established trust within our community that former patients of mine will say to their friend, hey, you should go see Dr. Poland. And I think that that's really cool.

It's incredible. It's incredible in the work you're doing. What is next for you? where is this all going in the world with Dr. Carapol and yeah talk can you talk about like what you're doing on the trying to do at the national level and then also like you know not to get political but just to talk about how your work is being impacted by you know what you know some some decisions being made and so from a national standpoint we're really pushing for access to medications. So right now there are conversations. It was being worked on in the last Congress, but modernizing opioid treatment and accountability act or moda, which would allow addiction specialty physicians to prescribe methadone. So giving access to medications

to all individuals, right? Methadone clinics were created in the 1950s when it was predominantly heroin in large cities. And it was actually created and marketed on a probation or parole type of model. So asking people to come in every day to get dosed six or seven days a week, really kind of punitive in terms of how they addressed substance use. And those regulations were relatively recently changed in the last couple of years to make it a little bit less punitive. But it still access is a huge issue for methadone across the nation so that that is a really big push is to try to make methodome more accessible by allowing physicians who are boarded in addiction, either addiction medicine or addiction psychiatry,

to prescribe it from their office the same way we prescribe buprenorphine, the same way we prescribe any other controlled substance. So that is kind of a really big push because, again, if we can provide people with an opioid use disorder medication, we reduce the outcome of death by 50%, which is, you know, if there was something that reduced, you know, left small toe amputation and diabetes by 50%, everybody with diabetes would be offered that medication, right? And so we need to do the same in the world of addiction. That's a really, really big push. Pay parity is a huge concern. The proportion of people with a substance use disorder that are underinsured or insured by public insurance like Medicaid is higher than

in other disease spaces, and we know that generally speaking pays less. So we are trying to engage in conversations around parity for payment. That would be really changing in terms of kind of this idea that, you know, behavioral health is sometimes shoved in the oldest building in the corner with the mill-duty carpet, which is very common, right? We want to create open, welcoming spaces, right? there's a big heart institute in Grand Rapids that's like 10 stories and it's got this beautiful silver building and we've got like an old converted you know shack in the back right right that's

kind of what it is right but it's you know so how can we elevate those types of images across across the nation is a big part it's good kind of fake it to you make it with that stuff for me like why not put these people in a really nice environment so that they can actually see and feel like what life is available to them. Right, right. So that was part of why we put the Great Mons Clinic initially in the maternal fetal medicine office because it was like bright and shiny and there's ultrasound machines right there in the suite, right?

Like there were all these like little perks that we could give our patients because we were in this fancier building, right? Downstairs was a kudoba and a Starbucks, right? And so they could come and get their Starbucks, you know, on their way up, right? Like it just made it feel a little different than it does in other, than it does in other spaces. That's always, you know, a fun, a fun thing to be able to have or to offer patient a voucher for Starbucks if we're running behind,

you know, so just again, being respectful of them as individuals. But how do we do that on a national scale and build that infrastructure or something that I'm really passionate about and think about in terms of Congress? Look, there is no bound. to addiction. Addiction affects everyone. It doesn't matter what your political party is. It doesn't matter who your family is. Addiction can be a part of your life story. We know that one in seven people in the United States has a substance use disorder if we take out nicotine. So just think about

that. If we include nicotine, it becomes one in four. So it's amazing the number of people that are affected by it. So we can't go anywhere without seeing people affected by a substance use disorder. So how do we create that rat park on a national level? The American Society of Addiction Medicine just last month, we came up with a public policy statement on housing for people with a substance use disorder. What business does a health care group of physicians sitting around a table have talking about housing?

I've been in housing my whole career. And it's, you know, we are high. High-end, highly structured, so a certain population can afford our services. I'm happy to show you one of the properties upstairs when we're done here. And people always ask you why it's so expensive. Well, it is expensive. And part of that reason is to really do housing right, like to really do it right, it's expensive to have the staff, to have the support,

to have the people there to help monitor some of the medications and the drug testing and the things that go into really running a safe home probably isn't going to be $300 a month. No, it's not. And insurance doesn't Will not recognize it as a, so that's my soapbox. No, I, well, we can, you might have, I might shove you over on that soapbox to climb up with you. I often tell people that my soapbox just got so high

that I'm going to have to be careful climbing off of it because I might break my femur. So it's, right, like, but these are, these are the conversations that need to be had. And look, no one person, no one party, gets to own the rights to addiction, right? Because it affects everyone. And when we look at the way addiction has historically been funded,

which is some of what this current administration is looking at doing more broadly, it's by something called block grants. And the problem with funding things through block grants is anytime there's a grant, it's time limited. So every time I get a grant to provide a service to my patients, I have to be thinking ahead two or three years to how am I going to sustain that service? And if I don't get additional funding to sustain it,

then that service falls away, right? My recovery coach is currently funded by a grant, and it is in the back of my head, like, how do I care for this population? How do I continue to provide that, like, feeling of safety and somebody who's relatable in a very different level than I am with my, you know, starched white coat that I don't wear, by the way,

but you know what I'm trying to say. compare you know in the power differential because I I always hold the power of the prescription right and for somebody who's on Suboxone and it's a life-sustaining medication they're always going to be wondering if they say something wrong might I stop that prescription no matter how much I try to reassure them that no I'm not going to it's always going to be there because I have I'm in that position of power in that situation right so how do we how do we work across the aisle you know right now some of of my programs, very frankly, are in threat, right? And a lot of my work is workforce education that is funded through, funded through like NIH grants and SAMH grants, but I haven't been able to

hire a program manager for one of my grants because I have to get approval from SAMHSA on their CV. And this person's been waiting since October to start a job. I can't continue to ask him to wait for somebody to check a box. And this is a guy who's, who has his master's in public health and has worked for eight years in workforce development in substance use disorders. He's overqualified for the job.

He just wants to work with me, and so that's why he's waiting for this job. He could get... I want to work with you too. Next will be my grant. I want to ask one last question here, and I could talk to you all day, and I'm sure Jay's got a laundry list of things

that he's wanting to ask, but the clock is running, unfortunately. So you've talked a lot about the value in Suboxone and Methadone and the 50% reduction in death. There is a large conglomerate of folks who are, who I have compassion for because I can't expect them to have my experience working in behavioral health care. They're not a trained physician. They just don't know. But they will turn to that person and say, well, you're not in recovery if you're taking suboxone or you're not in recovery if you're taking methadone. And they probably don't understand how much damage they're doing with those words to the person who is trying.

How do you navigate those conversations with that person? Because it's something we see and it's hard. I try to empower my patients to know why they're on the medication. And so I usually tell people that what we're doing with the medications is stabilizing your brain so that you can do the hard work that is recovery. So what we're trying to do is we're supporting you in that space. And we know with something like major depression disorder, when somebody has a first episode of depression, we don't want to start medication for thus than one year.

And one year we might talk to them about possibly tapering that medication. do they need it around the clock every day, 365 days a year, or was that an episode of depression that was isolated? But once somebody has two or three major depressive episodes, then we know that that person's brain just needs to be on that medication because their brain needs it for that physical support. We also know that if somebody has high blood pressure and we start them on medication, we also talk to them about a low-salt diet, about, you know,

know, maybe losing some weight if they are overweight. And if they come back and they see their primary care doctor and they've lost 100 pounds and now they come in and they say, you know, sometimes when I get out of bed, I feel a little dizzy and lightheaded, we check their blood pressure laying down and sitting up. And if we find out that their blood pressure is going down when they sit up or they're having these dizzy episodes, we don't tell them on your way home, go grab a box of Oreos. You should probably gain some of that weight back. We adjust their medications.

Yeah. And we should be doing that in addiction, and everybody's brain is a little different. And some people, I think, and this is just a Dr. Poland hypothesis, that some people, part of what drives them to substance use is that their brain is natural opioid deficient, just like some people who kind of edge toward depression, they go on a medication called selective serotonin re-uptake inhibitors. And what that does is it increases the amount of serotonin available to the brain. So are there maybe some people who are endogenous naturally occurring opioid deficient that need the Suboxone, need the methadone to support their brain so that they can live life on life's terms and do it in a way that is safe and feels good for them? Absolutely.

And who am I to judge if you are struggling with weight loss and that's part of why you have hypertension any more than I am to judge somebody with a substance use disorder who's taking medication. So I try to empower my patients to kind of be able to have a version of that conversation with other folks so that they can put into terms that maybe that person can understand from their own personal experience. Because if we can ground it in their personal experience, then it's easier for them to understand how that might look and feel for somebody with a substance use disorder. no i love dr poland this was really good i appreciate you jay should deserve some credit here because he was the one that like was stalking you and like we have to talk to her because she's the work she's doing is so

incredible so kudos to jay thank you for glad we got you here thank you yeah and uh we'll have to connect offline on some of this stuff you guys are going to have to thank miss madison because i had With all due respect, I had no idea who you were. That's fine. I didn't even know what The Bachelor was. That's good. And she was like, no, no, this is like legit. Because I was like, I don't know.

Is this legit? Like I showed her the email and I was like from Jay. And I was like, is this like legit or do you think this is like some sort of weird spammy thing? And she's like, no, no, no, this is real. I know who he is. Thank you, Madison. There we go. I appreciate you, Madison.

And that's a whole other episode, the, the collateral benefits of, well, you know. It's been a wild ride, and I'm here having conversations that I want to be having, and that's most important. Thank you. That's it. Thank you.