The Zac Clark Show - Should You Take Drugs in Recovery? A Top Addiction Doctor Explains

Episode Date: January 20, 2026

In this episode, Zac sits down with Release Recovery’s Chief Medical Officer, Dr. Michael McCormick, for a candid, nuanced conversation about one of the most controversial questions in recovery: can drugs ever help sobriety?Together, they break down three major categories of medications – benzodiazepines, stimulants, and opioid medications like Suboxone, methadone, and Vivitrol – and explain how each works in the brain, why they can be both lifesaving and dangerous, and how clinicians decide, case by case, when medication is part of recovery and when it becomes a risk.Dr. McCormick challenges black-and-white thinking about “being sober,” addresses the stigma many people face in the rooms of recovery, and shares how careful monitoring, individualized care, and real behavioral change are essential if medication is used at all.This is not a pro-drug or anti-drug episode – it’s an honest, clinically grounded exploration of the gray area where medicine, addiction, and recovery meet.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 Recovery:[phone] releaserecovery.com@releaserecovery

All right, so we're joined once again by Release, Recoveries, Chief Medical Officer, Dr. Michael McCormick. And we're going to launch into a conversation today that focuses on medication, the role that medication plays in behavioral health care, specifically substance abuse and mental health. And the reason we have doc here today is because whenever I talk about medication assisted treatment and really, focus on that A, which is my belief that medications can play a role in someone's recovery so long as it is not the only thing they are doing. Right. So we're going to have this conversation. It's meant to be informative.

We're going to speak as if the listeners know nothing about medication and the roles that they play in someone's life. And it's meant to start a conversation. Great. down? I am. I'm ready. I'm ready. I know you are. So the thing I want to say is all of these, a lot of these medications are controlled substances. They are. They can also be someone's drug of choice. And this conversation, you know, there's parts of it that may even be confusing. So let's start with benzodiazepine.

What is a Benzo and what medications fall into that category? So first, I just want to say you're 100% right about the A and that medication assisted treatment. That was a really good point of yours. It's not medication as treatment, which we know, right? It's a combination of good therapy, good treatment, 12-step recovery. So I really appreciate that. There's not a medication, unfortunately, that can just take care. of the problem itself. So that that's actually a really good point that you made. With regard to the

benzodiazepines, they're under the class of sedatives, hypnotics, anxiolyics. And basically it's, it's an anti-anxiety medication. You know, it was originally developed to be used in short bursts or short periods of time, two to four weeks. And what, so just so we know, like, this is clonopin. Yep. So it's clonopin. It's Xanax. It's Ativan. It's the old Valium, right, which is still used. They're the most common that we see, you know, and unfortunately they are very commonly abused. You know, certainly in combination with alcohol or, you know, the thought is to extend the effects of opiates. So it's used with opiates, which we always worry about respiratory depression, combining the benzodiazepines with alcohol and or opiates.

That's when you hear about people dying in their sleep, right? That's it. Yeah. That's it. And so a benzodiazepine, just to be clear, Clonopin, Ativan, Ativan, Valium, Xanax, yep. They do what now? Yeah, they're, they're prescribed you someone who, when used correctly.

Use correctly as an anti-anxiety medication, typically in short bursts because they have a quick onset of action. You know, maybe it's, you know, 10 to 30 minutes. It's pretty quick. so someone that may need that in that burst that gets those panic attacks or has those severe episodes that are able to take it do some people also take it you know as a night time for a sleep aid yes they do um do we see many patients that are on it twice or three times a day and have been prescribed it for five 10 15 years unfortunately yes yeah and it's not really a medication that's that's that's supposed to be administered that way you know which is one of the problems that we have

The truth is the medicine works. Those medicines work. And people will tell you that. So that's why they're prescribed very easily. The other problem with them, though, Zach, is the tolerance that develops. And we see that just like tolerance in anything is, you know, your family practitioner, you know, may start you on a point five of clonopin or Xanax, whatever it is. And then over time, unfortunately, you're going to require more. And when did this medication come on the scene?

Like when was the pop? Yeah, so the Valium was the big one, right? Was the 70s and 80s. You know, and it's the housewife. Here's the Valium, the happy pill. This will take care of all of your problems and stresses. So that was really the start of it. And at the time it was, I don't want to use the whole GLP1 thing,

but there's this pop right now happening around some of the peptides. Was it similar? This is like the magic pill when this thing was first? There are studies in business school, I think about the marketing of Valium. That's exactly right. Like it was marketed as that and yet just was described as, you know, no problems. And this is going to help you through your day.

And in terms of the work that we do, benzodiazepines, how, what role could they play, again, being a controlled substance, knowing that they can be abused, knowing that it may be someone's drug of choice, what role could a benzo play in someone who is actively seeking substance abuse recovery, if taken correctly? Yeah, I think that if for a short-acting, you know, immediate release, anxiety medication, it's going to do the job. And I think that if prescribed correctly, monitored, and taken the appropriate way,

then that's really what we would want in a patient. We obviously have a lot of fears in our patient population because of the tolerance that can build up and the increased amounts and looking to get more of it in other places. And that's because of where it lights up in the midbrain, you know, and we don't want it to activate anything where your threshold is lowered to, hey, maybe I can take a drink. Or maybe I overreacted to the opiates that I had, the problem that I had. And so that's our biggest fear. So the fear someone comes into your office, they're working on their recovery or their sobriety, they present a picture to you where they've been sober for 45 or 60 days. Their drug of choice is, you know, call it alcohol and marijuana. And they are also experiencing crippling panic attacks, crippling anxiety, can't get out of bed, can't show up to group, can't show up to life.

And they're looking for some relief. Your fear in prescribing a benzo to that. patient is that it will activate a part of their brain, which will then crave more of that medication. More of that medication. And we worry about the other medications because they hit, especially the alcohol and benzodiazepines, hit in really almost the exact same place in the brain. And so will that light that person up, you know, and will that lead then to problems in

their recovery? And so while we are cautious in prescribing this medication class to someone who's in recovery, we take the necessary steps. There is a world where someone can be deemed sober and in recovery and prescribed this medication. I want to make that very clear. I would agree with you, yes. And we have patients in our care that you and I take care of that are on these medications

and there's more awareness and a higher attentiveness to those patients and to watch them. But, you know, in our setting, it's monitored, right? It's controlled. It's locked up. It's given at certain times. You know, we have a nice control, and we hope that over time, the patients will learn those behaviors. And then when they leave our care, three months, six months a year later, they'll be able to continue to take that medication safely. Some, you know, interestingly, Zach, some with time start to realize while with us that they don't need it quite as much.

So it actually goes the opposite way, the use patterns, which, you know, we love. Yeah, they get motivated to not want to be on any medications. That's right. We see that a lot, right? Like they, they, I mean, I was the same. You know, I was prescribed Suboxone in treatment and, and I was on Vivitrol coming out of treatment, which we'll get to, medications. And I made the decision, uh, that I didn't want to be on any meds. Right. And so, yeah, that's very interesting. Um, and I would say that benzodiazinez, they can be abused, right? So to talk a little bit about that doubling doses, snorting it, sniffing it, smoking it. Yeah, that's it, right? vaping it you know we've had people that vape it all different forms you you hit it around the head but

they certainly can be abused absolutely and and that's what our fear is right is taking more and the drug itself lends to having to take more because of the tolerance profile and how that physiology works but it's um that that's probably our biggest fear you know is that the doses keep going and going going and you know part of the things that we see is in those high doses a lot of people you know, forget that they take their dose. I mean, we're talking about a lot of our patients that come in on these big doses. They don't remember that they took their midday dose and then they take another dose. And it's just a, it's a setup for disaster at times.

Right. So the conclusion here is you monitor like any medication. Sure. It's meant to be taken as prescribed. We try to, I think, avoid prescribing an alcoholic, someone with a drinking problem that is. has been diagnosed Benzos because it mimics some of the same feelings and lights up some of the similar parts of the brain. And also, the doctors treating the person should probably end up

being the person who makes the decision. Right. Yeah, I think it's a whole team approach. And that's what we do. And I think that's the safest way. We're not a no certain facilities, no, you know, no judgment or whatever it is. Some are they won't take controlled substances. I appreciate our mindness and that's why I appreciate us talking about this today to look at each person individually. Yeah. Yeah. I think that's important. Yeah. Yeah. I mean, the three questions that I continue to ask people that I, that I work with are coming to my life is do you have purpose? Is your life getting better? Yeah. You know, and do you have community? That's right. And if those, the answer to those three questions are yes, and I think we're doing a good job. Yeah. I agree. All right, moving on,

stimulants. Yes. So what is a stimulant? Yes. Stimulant. Yes. Stimulant. This is a hot topic one. And we deal with this on a near daily basis here. So stimulant, right, is primarily prescribed for ADHD, attentive, you know. Attention deficit disorder. And whether that's, you know, hyperactivity or hyperactivity, whatever that may be, or if it's in attention, it's a tough one. Similarly, it's going to act and, you know, it's going to hit in that midbrain as well.

So just to be clear, stimulants are adderol. Adderall, ridolin, you know, it's the amphetamine, dextra amphetamine, and then the long-acting ones like vivance, you know, that's a very common one that we see. Focalin, you know, patients have been exposed to these at young ages, right? So kids, you know, adolescents are diagnosed with ADHD and are prescribed these medications. You know, the biggest concern that we have is untreated ADHD and are we doing them a disservice? Do they have the inability to sit in group and process and retain what's being shared with them and then get the benefits, right? So just taking these medications away, you know, are we actually hurting them at times?

That's really what our discussion point is when we individually, look at each patient and whether they're on this medication or not. Right. And the abuse, right, the wide known abuse of stimulants, if you look at college campuses, you look on Wall Street and high achieving environments, is that, again, to your point, the drug works. You know, it is a miraculous drug. Whether you're prescribed it or not, you take it and you are laser focused.

Agree 100%. You've said, like I say that to the patients. I'm like, I know, because that was part of, you know, my thing, among other things, was the stimulus. They work. You know, and when we say they work, they give us energy, they give us focus, they give us attention, and they're the things. Now, you know, typically in a patient that has ADHD, when you give them these medications,

it actually brings them down and kind of smooths it out, right? So it allows them to receive what they're hearing. You know, in a patient that doesn't have ADHD, you know, someone that's, working on Wall Street or someone like myself, you know, it just gives us energy and focus and helps with mood and go, go, go. There's, you know, we feel, you know, like there's nothing you can't do. So yeah, those drugs work. That's part of the problem of them. And the side effects of stimulant abuse is obviously lack of sleep, which can lead to paranoia or psychotic breaks, right? Yeah, we've seen that. Unfortunately, we've seen that. We've seen increased anxiety with that.

insomnia is a big one you're you're 100% right um you know you're going to see weight loss in those patients and some take it for weight loss they come into us on that and it's just obviously not that's not the indication um and and some mood fluctuations and then when those patients come off those medications if you take them away they're going to sleep for two to four days you know and then they'll wake up that's kind of the detox yeah that's the detox and so a patient who into your care, maybe at 10, 11, 12 years old, they end up in a child psychiatrist's office. They're prescribed the stimulant. They're on that stimulant for the next five or six years. At some point, they start to abuse that stimulant, right? They then end up in a treatment center.

Right. And during that treatment stay, it is suggested that they might need to continue to be on a low-dose stimulant, are there alternatives or for that person who is truly ADHD and does need some medication assistance, right, to focus and to show up in life, what are we looking at? Yeah, so it's a great question. So when we, the problem is, is when you describe that patient, there are, you know, many patients that we take care of that have abused that psychostimuline. And so, you know, five and eight years ago, I used to have the thought of, and it may not be accurate or incorrect is like you've lost your privilege to use that medication, you know,

because you've misused it before. So that's always, so again, it's an individualized patient-by-patient decision. With regards to medications, the two most common ones that we use are Guanfacine and Stratera, and they're non-stimulent medications that will help with ADHD symptoms. Not narcotic. Not controlled. No street value. Can't get high. Can't get a bump. can't do any of that from it. And it's interesting to watch. So many patients of ours who were trying to get off of the psychostimulants or they've been taken off of it at a treatment center before getting gnaz because of misuse, they'll tell me those meds don't work. Those meds don't work. You have to give those meds medications time to work. So that's a lot of motivational interviewing,

a lot of support for myself and the therapy staff in giving them the confidence. Like, let's give it time. And it's interesting. Some, just like you talked about, who progressed through, this recovery and figure this thing out, they do give it a shot. And they do help. Are they as good as the Ritalins, the Adderals, the Vivances? They're not. But they work and they help. You know, some of the other things, non-medicinal is, you know, neurofeedback. And that's a whole different segment of things that we can, you know, we can work with. As a doctor in recovery, have you been able to educate the recovery community at large around the dangers of of someone in a 12-set fellowship,

turning to a newly sober person who may be prescribed by their doctor stimulants and telling them that they are not sober. Because we see that and that's where there's a lot of danger in that. Because if you tell someone who's newly sober and yes, they're on stimulants for ADHD, that they are not sober, why are they gonna stay? Yeah, they're gonna be very disheartened by that.

That's exactly right. And that's what we see. We have those conversations. with patients all the time. And what I say to patients is if you're taking that medication appropriately as it's prescribed and it's helping you, then you are sober. And again, I'm not the AA police, but that's my view on that. If you're snorting your riddling or you're snorting your Adderall, then yeah, we have a problem. You're not taking it as prescribed. Right. Doctor doesn't say, you know, do two lines of it a day or twice a day or whatever it may be,

right. So that's, that's really where we go through it. But, but we have that conversation that, you know, many times in the rooms, people do hear that from people, you're not sober, you're not that. If you're on an appropriate dose, a normal dose, you know, not a, not a terribly high dose, and it's helping you and you're taking it the right way, then I full, I 100% think that that's sobriety, definitely. Well, and I think we've seen cases too that, um, perhaps are, you know, shooting heroin or drinking a lot, maybe using cocaine, get into treatment. They do some neuro feedback stuff. Yeah.

Some testing. Yep. And it turns out that maybe they do have some ADHD. They do have some attention deficit. And the stimulant is introduced to help that person kind of stay in line. Yeah. I mean, to live a life that they deserve. And suddenly, maybe some of their cravings.

where they were self-medicating, go away. Yeah, I think that's it. And you bring up, there's multiple good points in that statement. And number one is that we typically, if a patient comes to us who has an ADHD diagnosis, they tell us, or it's on the chart, and they don't, and they're not on the psychostimulants, we really require, if they haven't had it in the recent past, we require that full neuropsychological testing. It's going to take a lot to prescribe to that person.

We do. We want it. So is part of that... I shouldn't even say a lot. It's just what medical professionals should do. We need it. I don't... I don't like the patient that's filled out like three little questionnaires at the primary

care and was given an ADHD diagnosis. So that's worrisome to me. So we fully want to have an appropriate diagnosis and this is what you truly have. And that's a full test. The other thing is the, you know, the fear that I have is when you talk about younger adults, it's a much bigger discussion, but like when we talk about the developing brain, right up through the age of 21 or 22, and that brain feeling and seeing and getting that psychostimulate, you know, how much is that affected?

And then likewise, when we get patients here who aren't necessarily on psychostimulants, but maybe could benefit from it, there's a lot of, and it's intentional sometimes, not intentional. There's a delay for me in like another week, another month that I'm allowing their brain to start healing. they're into the therapy, they're getting the 12-step meetings, they're doing the work with their therapist, they're in groups here, because we're allowing the brain to heal before we introduce that psychostimulant back into it. Yeah, I mean, I think of many cases over the years that there's been

a serious adder all addiction. It's being fueled by a desire to lose weight and look a certain way. It's being fueled by a desire to show up to work in a certain way. And ultimately, that patient ends up in a psychotic break because they don't sleep and they don't eat and their body essentially shuts down. Yeah. And then getting that person rehabbed and back to, you know, healthy weight and healthy sleep pattern. I mean, that can take, take a lot of time. And I think it would be safe to say that with that particular patient, we're going to look at some of the other kind of pathways to recovery until we go back to prescribing them.

That's right. Their drug of choice, essentially. That's right. And I can't tell you the exact time, and it's a great point. Like, that's the art of what we do. And that's the feel and that's as the recovery progresses. And I should say, like, this is not, it is an art. Like being a doctor is an art.

Yeah, especially this, what we do. Yeah, there's a lot of art to it, but that's, I think, where we really excel. And that's where I hope this conversation can just be helpful. And because I think our approach is helpful. Yeah, I do too. I think our approach is right or else it wouldn't be our approach. Yeah, I mean, I've seen the growth similar to me when I started this, the similar growth that I've seen in you in the open mind-in-ness. No, it's true.

And that's what I've seen, the open-mindedness to all these medications that we're talking about. Because there's not just one way to figure this thing out. You and I have come to that conclusion. Yeah, and my path is one of abstinence. And abstinence for me means I don't put any mood or mind-altering substances into my body. That does not mean the person sitting next to me can't have a different definition of, what abstinence is. And that's really, I think, the pinnacle of recovery is can you embrace your recovery, utilize it for your own benefit, spread that message to others, and also accept and

love that there are going to be people that do it a different way. I agree. And we're on the same page, you and I. We're 15, 14 years into this, both of us. We have not used mind-altering substances. That work for myself and for you, but we have enough open-mindedness to say, I mean, my truth is I'm terrified. You know, like, I mean, friends laugh at me sometimes I ask if the dessert is going to be cooked with with booze because I don't even the traces the trace amount of alcohol I'm terrified of finding its way into my body because at the end of the day I am convinced that I absolutely above anything else family life love job money love drugs and alcohol yeah and the second I get a taste of it

I would be terrified of where I end up right all right so the third class here that I want that So just a review for the listener, we have benzodiazepines, which are classically, I think, called like your downers, right? Yeah, yeah, exactly. Sedatives, yep. And then you got your uppers. Your uppers. Yep. And now we're going to talk about your blockers, right?

So we talk about the opioid epidemic, which obviously took our nation by storm. And we started to lose people in the hundreds of thousands a year. Medication came on the scene. So there's really three groups. year. There's obviously there is the methadone. Yep. Right. Correct. Which is, we're going to talk about buprenorphine, which is your subutex and your suboxone. There's also injectables now. And then there's Neltrexone, right, which is your injectable vivitrol, which helps with some alcohol cravings, but also opioids. So when we talk about a blocker, can you talk about the, how a

blocker works and in a general way or do we need to just jump into each type? No, I love it. So that mu opioid receptor, right, you and I have talked before and you know that cup that sits on our brain, right? And so that's where the opiate comes in and attaches plants into that receptor. And that's where we get the euphoria, the pain relief, the sedative effect, whatever that may be. Just be clear, there's something on our brain. Yes. That the opioid travels in and it gets there.

And it attaches. And then that's when I start to feel all warm and fuzzy. Yeah. That's it. And in higher doses, you feel. Yeah. And the, you know, the interesting thing is that the brain starts to create as the disease is progressing, it creates more of those receptors because I like the way that makes me feel, right? So more receptors formed so the opiates can attach to more and get that effect. But then there's a down regulation. It's interesting the way that our brains are. And then it starts to get rid of some of those receptors. And that's where as the disease progresses for people, we see that an adonia with, I can't have enjoyment with anything, you know, when it's getting to the end with people. Because you're you you have all of this dopamine and all of these things floating around your brain, and you're not able to get the effects of them.

So to talk about the blockers, there's really three kind of buckets. That's how we like to describe it. And the first is methadone. So these are medications used to help treat an opioid use disorder. To you, exactly. M-O-U-D, exactly. That's exactly what medication-assisted treatment in that is described as. And so the first is the full agonist, which is methadone.

there's a subset of patients that need methadone. And that, when I say full agonist, it's not a negative thing about methadone, but it acts the same as heroin or oxycodone or Vicodon, meaning that it attaches to the receptor and you're going to get that same euphoria and pain relief, you know, those same feelings that you get. So it fully binds onto there and that's what happens there. So these are like the methadone clinics. Methadone clinics, exactly. And we've taken care of you and I patients that are on, you know, a relatively normal dose, I would say, of methadone that we've worked with at release and we've watched them come down on their dose with time. You know, the old teaching was these are, methadone is in that harm reduction class, right?

So decreased, you know, transmittability of disease and decreased crime and, you know, all of the things that go with that. But there are patients that need it. So I think the important thing in that is identifying which patient needs that. And there's overlap between the three. Now, a patient that needs methadone, we're not going to recommend that they get Vivitrol or Altrexone. They're the two ends of the spectrum. But are there some patients that maybe could benefit from buprenorphine versus methadone?

Yes. And are there some patients that maybe benefit from buprenorphine or Vivitrol or nitrachshone? The answer is yes. If that makes sense. Yes. Yeah. So methadone, can you get high?

Yes, you can get euphoria from that. No, but no, you can get, I understand that methadone can produce a high, but can you still go out and use your drug a choice and get high? Great question. Or is it blocked? Great question. So the theoretically, physiologically, it's supposed to attach to those receptors and block those effects of opiates. You know, in that patient population, sometimes what you see is the addition, right? So you're going to see the benzodiazepine use, you know, for that kind of extended effect.

but the goal is is to try to avoid patients from using heroin, oxycontin, oxycodone, you know, fentanyl, whatever it may be, yes. And there's a world where you have someone who's been using heroin for 25 years and they get on a methadone program and their life gets better. They start to be able to participate in their life, get a job, build a family. That's it. That's a win. That's it.

That's exactly right. That's a, I think of that as a win. 100%. 100%. Okay. So we have methadone and methadone. Methadone, I mean, the history there, I mean, it's been around forever. Forever, yeah, forever, yeah.

Okay. And then so buprenorphine, which a lot of people know to be Suboxone or Subutac, in the last couple years, we've seen an injectable sublocade come onto the market. Yep. Can you talk a little bit about what buprenorphine is when it came onto the scene and how it's being used? Yeah, so initially was indicated actually as a pain medication. That was the initial indication for buprenorphine, which was, was great and it does help with pain. You know, we have some of our chronic pain patients on smaller doses more frequently throughout the day. You know, so maybe two milligrams, maybe four,

four times a day or six times a day, whatever it may be, uh, to help with pain. So that was the initial indication. And then in practice, when it started to be used, it was noticed that this is a partial agonist. So it partially attaches to that receptor. And there were good results certainly with opiate withdrawal and then in turn with trying to help what are we trying to do we're trying to decrease cravings and decrease withdrawal symptoms in our opiate patients and buprenorphine does a nice job of that so we use it a couple ways right so you know we use it as a detox medication and that's a five to six day or 10 day whatever that may be taper to get people off of opiates or cratum or whatever it may be that's where we love that medication that's how it was used for me

Basically, I was addicted to heroin. I entered into a detox program. They waited 36 hours, I think, before they introduced the Suboxone into my treatment. Yep. I started to feel really sick. And that was a good sign because the heroin was getting out of my system. It also told the professionals know that I was probably ready for my first dose, the first dose. The fear there is that if you introduce the buprenorphine too early, it can send the patient into a precipitated withdrawal.

which is you wouldn't wish on your on your worst enemy yeah maybe you do it to someone on purpose but and then and then I was on it I think for yeah seven eight nine 10 days in that range I traded me off and I was I never thought about it again that's it that's it so that's kind of like the one indication and you're exactly right to precipitate a withdrawal you would not wish upon and many of our patients with their experience and traveling you know around the world they they they know that and they're fearful of that. You know, over the last three to five years, our biggest concern with this is because fentanyl,

like fentanyl, although shorter acting than heroin, has a longer, really half-life in the sense of like staying in the system. So we have to wait even longer to start Suboxone on those patients to avoid precipitated withdrawal. So that's always an interesting thing. So the behavioral health care 101 half-life, if you're listening at home, is basically the amount of time that a certain drug will stay into your system, whether that's to pass or fail a drug test or to be able to introduce kind of medications

like this that are going to help, right? Yeah. And so the initial, exactly. And so that initial indication for us is as a withdrawal agent, but then the other place where we use Suboxone is as a maintenance drug. And we certainly have patients that come to us that are on buprenorphine maintenance, but we've introduced it to patients as well. And where I see, you know, a lot of value in that is that when we get back to it,

and I know you always love the nerding out and the science of it is when they're midbrain, the cravings are that much, the withdrawal is there, their brain is talking to them, their solution is an opiate to quiet that. So when we have someone that's here at day 10 with us or day 12, and they're just not able to engage in group, right? and it's whether it's the post-acute withdrawal that started or whatever it may be, we will have that conversation with them about adding in Suboxone. And part of that conversation, though, before we started is like,

my recommendation is going to be that if you go on this medication, it's typically going to be for a year. And then if we make the decision as a team, you, myself, whoever else is taking care of you, to come off of it, it's going to be another six to 12 months to wean off of it the right way. the least painful way that you continue with your recovery. So we like to have that conversation up front. And in a maintenance program, this is where I want to get into some of the specifics

of medication-assisted treatment. My fear with a maintenance program is that the medication becomes the entire treatment. Right. And then the person basically becomes dependent upon that to stay sober and they don't actually improve the quality of their life. So whenever we talk about someone being on a maintenance program And to be clear, this is not something we're doing regularly.

You know, we are doing it in certain circumstances. We want to make sure that there is some level of motivation or willingness for the patient to also participate in the rest of the treatment plan, which oftentimes means going to meetings of some sort and building community. It means, you know, eating healthy, drinking water, going to the gym, movement, meditation, volunteering, you know, all. these other things that we like to see when we build out a holistic treatment plan. And I understand that there may be cases where the medication is the only thing present in that plan. And I would have a

hard time believing that that person's life is getting that much better. Yeah. Yeah. And our patients are doing all of those things from the jump here. That's one of the things that I love about release. And that like we're hitting them with all of that. But if they're not, engaging and there is, you know, ongoing withdrawal. The cravings are too much and they're not able to hear that message, participate, do all that. That's when we have it. It's, that's not, that's correct. It's not a, you know, that's not the majority of our patients, but, but it is an option for us. And, okay, so that's Suboxone and Subutec. And Subutects, right? So the, the only other one that we do utilize, which we like is the Sublicade, which is the monthly injectable

buprenorphine. And the patients that we've had on it have had good results. So what does that take away? Well, they don't have to take a tablet or a film on a daily basis. And for some people, there's a little psychological bump from that, meaning like they don't think, okay, I've still got to take this tablet. Like I used to take my tablets of Perkissette or whatever it is on a daily basis. They come in. There's, you know, we minimize the pain with that injection, truthfully. You know, we were very good at that. But it's, like a 10 or 15 minute visit, we do that and then it's again, you get the next injection the following month. And the difference between methadone and buprenorphine? Yeah. So with the methadone,

remember, that's that full agonist. You get that full euphoria. You're going to get that full pain relief. You're going to get all of that, that, ah, feeling with the buprenorphine. The patients that are on it are very honest. You may get a little bump in energy. And when you start it, you may get a little bump of euphoria. I had this conversation yesterday with the patient, but it is nothing like the opiates. They all say that universally because what's the argument that you and I hear all the time? We're substituting one for the other. Wait a minute.

My son or daughter, loved one, husband, wife came here and now they're on this other one. They're not really the same, meaning buprenorphine versus an opiate and unfortunately, methadone's in that because you can get up. It's also how you're taking it, right? Suboxone can be melted down and shot into. your veins, which, again, I would argue that melting your Suboxone down, putting it in a syringe, and shooting it is not sober behavior. Right.

However, taking two milligrams twice a day as prescribed by a doctor. And that's it, right? So I've had that conversation many times. If you're taking your buprenorphine tablets and crushing them and snorting them, now when you have the bup, the Suboxone with the Naloxone in it, you're probably only going to do that once or twice. You're only going to shoot that film you melded down once, because once you shoot that in the vein, that's it. But unfortunately, patients do that. So we have that conversation. If that's how you're taking it or we've written one tablet a day or one film a day and you're taking four a day,

then you're not, you're not take that's, yeah, that's a problem. And then lastly, which I think, and I don't want to speak for you, but we prefer or like is naltrexone. Yes. Because Because, like why? Talk me through what now Trexone is versus methadone and buprenorphine. I mean, there's no euphoria here, right? No euphoria. There's no, you know, no risk of any mind change or anything like that. You know, one thing that I would say is with buprenorphine, there have been reports from patients and it's been read that there is a little bump in mood in a positive way. So we would always take that. But now Trexone is, you know, it's that anti-exone. It's that antiportone. It's going to get on that receptor and it's going to block the opiate from attaching to that receptor.

If you're on naltrexone and this is the receptor. Yep. And the naltrexone is kind of blocking it and the heroin or the opioid comes in to try and get you high. It's kind of being pushed away. It's going to be pushed away. Yep. Can you, can you beat it? Can you do so much that you break through?

You can. There's that, right? and then there's that fear of the respiratory and overdose and respiratory depression. And then there's also the fear, unfortunately, because of how popular it is, but fentanyl and fentanyl getting through it, which is so hard. So that's why I think that when we make the decision with the patient and saying like this is the medication assisted treatment that we recommend for you, we take all of that into account, you know, because that's what the fear is. you know, obviously over the last five years, that's a fear on a daily basis for me, is that I know that fentanyl can break through that, and so that's scary. And naltrexone, Vivitral, these also help with alcohol cravings?

Why is that? Absolutely. So same thing, similar pathway initially indicated actually first, Vivitrol and Naltrexone for alcohol cravings. And it seems to, it certainly helps with the cravings for alcohol. You know, the question that comes up a lot that we get asked is, can I still get drunk on Naltrexone or Vivitrol? And you can, but it's a different level.

There's a different functionality of it when it happens. But we've also seen over and over again, especially in our patients who are trying to decrease their alcohol consumption, who maybe aren't quite ready to dive into the recovery, you know, that we've take care of as an outpatient, that it decreases the amount that they drink, which is great. I mean, sometimes these medications are the gateway or the entryway to opening someone's mind up to really living a life of sobriety and going to meetings and being a part of something. But if they never have a moment where they are not getting high or drunk, it's going to be impossible to. And I think Bill Wilson kind of talks about it in the big book.

He says there needs to be a period where we are kind of brought back to our baseline where like there are no drugs or alcohol. so that we can actually hear the message of AA, you know, and that's very similar if we bring it up to modern times, like, you know, we need to kind of get back to that baseline. And sometimes these medications can be helpful so that we can hear the message of therapy or AA or smart recovery or whatever it is that we're that we're using to kind of supplement the treatment. Yeah. And it's taking people out of their environment. You know, we talk about this a lot. And like physically removing them from those risks. Can you ever, you know, drop those risks to zero? Of course not. But taking someone out of their environment and allowing them to get better is what we, you know,

is what we need. And that's exactly what Bill Wilson's talking about. Like we just, yeah, you need to let your brain heal. We need some time here. Yeah. And with all these things, there's a, there's an expectation of hard work. There's an expectation of sacrifice. There's an expectation that, you know, regardless of what medication protocol you might be on. And there's a, there's an expectation of, that recovery, sobriety, mental health recovery, mental health coaching, recovery, this stuff requires work. Yeah. You know, to change these behaviors that we've been participating in for so many years.

And that's it. That's what you're trying to do is change those behaviors on a daily basis, day at a time, is make those changes so that we have sustained recovery for a lot of years. That's it. Yep. So there'll be a part two and three to this conversation. I think we will definitely sit back down and talk about antipsychotics and kind of mental health treatment. We will also sit back down and talk about the role that antidepressants, antidepressants take in one's recovery.

But just to wrap a bow on this one, you know, we talked about controlled substances. We talked about substances that can be used as someone's drug of choice. We see people end up in our care because they are abusing these medications. Right. And it's polarizing because these medications also can be helpful. Yeah. And that's where I think we lose the thread at times. And to your point, why we need to as behavioral health care professionals, I believe it's a case by case.

That's it. I think it's individualized for everyone. There's no solid in stone answer and people may argue that, but there's just isn't. Yeah, I mean, if I have my way with the methadone clinics, right? Like in an ideal world, the person would go get their methadone dose and then stay for treatment or stay for therapy or engage in some community before just grabbing their dose and heading off to work. That's it. Yep. And that's where the pivot really, really is.

And what would you say, what would you say to the person out there that for whatever reason will make it their job to let someone know that they are not. sober if they're on said medication and this person has no clinical or medical background. Yeah, I mean, I just, I think that unfortunately the statement that I heard early on was, well, that patient and it's dramatic, but will that person be at your funeral if you pass away? And that's really, really powerful. And what I took from that was like individually, it's your own thing. You know in your heart how you're taking that medication, how your recovery is progressing. and that's what's most important.

Because I have stories of that where people were shamed or made to feel a certain way and stopped taking their medication and it led back to relapses and they've gone on. And that's a sad story. Yeah, I mean, I'll close with this story.

I was talking to a guy who I love that got out of treatment, I don't know, two weeks ago. We met for coffee and he said, you know, I want to share something with you. I said, yeah, go ahead. He says, you know, I'm on Suboxone. Yeah, okay. Great.

And he said, well, I had a lot of fear around telling you that. I said, that's very interesting. Why? Is that because I know there's people out there that think I'm not sober? Yeah. And that, to me, is very sad. Yeah, it is. And this guy actually has a plan that he wants to stay on maintenance for a little bit

and then start to titrate down and ultimately get to this place where he's not actually on. any medication, but he also is willing to be patient and take the amount of time to do that. He's an IV fentanyl user. Exactly. He's an IV fentanyl user. He's doing the right thing. And in time, he'll come down off of that. And you know we always throw around these words, these buzzwords of non-judgmental and empathetic,

but that's how we live. And I'm glad that he felt that from you because I think that's what's most important. Yeah. And he, with that history, that's probably the right. right medication for him at this time because you and I both know people that have come off the box and we've watched them yeah over the course of a year year and a half two years yeah there's miracles out there and and that's not to say I haven't seen the nightmares yeah you know I've seen the nightmares and and this thing go a lot of a lot of different ways I think a lot of times what I see is

you know someone might be on a maintenance program and it keeps them around the rim long enough and then there's some period of maybe relapse or return to use and they show back up at our doorstep or at the doorsteps of recovery in general and they say, hey, I'm going to really try to do this in a different way and not use medication and really try to use some of the free tools that are available to me. And ultimately, it's all that body of work that gets them to a point where they are living the best version of their life for themselves. Yeah, that's it. Doc, I love you, dude. I appreciate you being here. I hope this was helpful. I hope people can appreciate our approach. And if they can't, that's all right, too. I'd say, okay. We're still going to

keep doing it.