August 4, 2025 • 43 mins
Dr. Amy Swift, Deputy Chief Medical Officer and addiction psychiatrist, shares insights on creating healthcare systems that better serve patients with addiction through reduced stigma, trauma-informed approaches, and greater accessibility. She brings a unique perspective as someone who oversees medical care while remaining deeply connected to patients' experiences, emphasizing the need to understand addiction as a brain disease rather than a moral failing.
• Psychiatry and addiction have historically been separated, with mental health providers often telling patients to "get sober first"
• Understanding executive functioning challenges in addiction helps create more flexible, accommodating healthcare systems
• Stigma against addiction is pervasive in healthcare and actively prevents people from seeking life-saving treatment
• Person-first language and creating welcoming environments are crucial steps in reducing stigma
• Virtually all patients with addiction have experienced trauma, requiring trauma-informed approaches to treatment
• Different trauma responses can drive different patterns of substance use – numbness often leads to stimulant use while hyperarousal leads to depressant use
• Family involvement and education are essential components of effective addiction treatment
• Youth education and prevention efforts are critical, particularly around cannabis and newer substances perceived as harmless
• Healthcare leaders must recognize addiction as a brain disease requiring the same compassion and quality of care as other medical conditions
If you're interested in improving addiction care in your healthcare system or community, focus on reducing stigma, implementing trauma-informed approaches, and creating flexible systems that accommodate the unique challenges faced by those with addiction.
To contact Dr. Grover: ammadeeasy@fastmail.com
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:00):
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is an interviewwith Dr Amy Swift, who is an
(00:44):
addiction psychiatrist on theEast Coast of the United States
and, in addition to taking careof patients with addiction
herself, she's also a deputychief medical officer, meaning
that she oversees the medicalcare of the patients in her
health system.
She and I had a greatconversation on how to improve
healthcare for patients withaddiction, as in how can we make
(01:07):
healthcare more accessible andfriendly for people with
addiction, and, given her rolesupervising a healthcare system
as a deputy chief medicalofficer, she had a lot of great
insights.
I am hoping that healthcareexecutives could take a listen
to this episode, as she has alot of great insight to share
and it sounds like theinstitution that she has a lot
of great insight to share and itsounds like the institution
(01:28):
that she works at is doing greatwork With that let's get
started, all right.
Well, good morning my time,good afternoon your time.
Why don't we start by havingyou tell us who you are and what
you do?
Speaker 2 (01:43):
Thanks so much.
I am Dr Amy Swift.
I am Deputy Chief medicalofficer of a freestanding
psychiatric hospital in NewCanaan, connecticut, called
Silver Hill Hospital.
How did you get into that role?
Services at Mount Sinai and Ilived out here and so I
approached them, I told themwhat I do and they created a
(02:13):
position for me to help create adedicated effort of treating
addiction on this campus in bothour inpatient and residential
settings.
Speaker 1 (02:18):
So I tend to focus on the micro stuff, because I'm a
doc seeing patients in clinicand you're zooming out and
seeing more of the system andyou've obviously practiced
before.
Which do you like better Bootson the ground or seeing the
whole system?
Speaker 2 (02:28):
Well, that's.
The thing is that I am somebodythat sits above the system and
sees all the boots on the ground.
So if you ask me how manypatients are assigned to me
today, I'll say zero.
If you ask me how many patientsI've seen today, I'll say 10 to
15.
It is the idea that you can'tmake changes in a hospital
system without knowing who's inyour hospital.
Speaker 1 (02:47):
So I go to the patients.
Speaker 2 (02:49):
I see them, I do it all.
Speaker 1 (02:50):
Do you want a job in California?
I like your approach already.
Speaker 2 (02:54):
Listen, I'll talk to my family about it.
Speaker 1 (02:56):
Yeah, yeah, Okay, we talked a little bit before we
got started.
I got a bone to pick withpsychiatry and I'm going to pick
on you and it's obviously notyou.
I'm trying to be funny.
My daughter is, I'm sure,rolling her eyes because of my
bad dad humor, but I'm reallycurious.
A lot of times my patients goto get mental health services
and they get told get sober andthen I'll see you.
(03:16):
And as an addiction doc it'sall mushed together and I don't
get a chance to pull it apartand a lot of what I do as an
addiction doc is a mix ofpharmacology and psychiatry.
Do you have a sense of wherethat history comes from of
mental health services sayingget sober and then I'll see you?
Speaker 2 (03:34):
I think it is a discomfort with understanding
what addiction does to ourmental health and it is the
reason I got into addictionoriginally is I never wanted to
be somebody that said go dosomething else with someone else
until I can treat you.
If you don't know how to treataddiction, then you can't be a
comprehensive psychiatristbecause they are intermingled.
(03:54):
So I think it's just a historicdiscomfort with the stigma that
rests with addiction.
Speaker 1 (04:00):
Yeah, I have a number of therapists locally that I
refer to and they tell me whoa,we don't do addiction and I'm
thinking I'll manage theiralcohol use disorder, but minus
prescribing medications I can'tfix their PTSD.
You do the PTSD part, I'll takethe rest and actually I'm
really grateful they're going tohost me for an in-service so I
can do some education on that.
But yeah, it's a frustratingproblem.
(04:22):
What was your experience inyour psychiatry residency around
addiction?
Speaker 2 (04:28):
acute and the patients that were really
suffering.
So I learned early on how tomanage acute agitation,
(04:52):
withdrawal, post-acutewithdrawal, all the things that
come up for patients that arestruggling with addictive
disorders, and so it wasingrained into how I practice
psychiatry in general.
So that's where the trajectorystarted.
But I do as I became further inmy career and I was actually
the program director for theAddiction Psychiatry Fellowship
I learned as I took fellows fromother places.
Some residents had zeroexposure and knew nothing.
So it really varies across thecountry in how psychiatrists are
(05:12):
trained to manage addictivedisorders.
Speaker 1 (05:15):
Do you think your residency training is what
pushed you into doing afellowship in addiction
psychiatry?
Speaker 2 (05:20):
Absolutely Many people go into addiction because
they had personal experiencewith it or a family member.
I went into it because it washard and I was going to do the
hard thing.
It was the patients that causedthe most kind of ruckus.
They were the most complex,they were the hardest to
navigate.
The personality constructs, theirritability, that stuff.
And that's the thing that Ithink really allowed me to
(05:41):
pursue the field is beingexposed to it and then feeling
like I could master this.
Speaker 1 (05:46):
Yeah, I think the other thing that makes people
pull away from treating patientswith addiction is I've learned
to think of addiction as adisease of executive functioning
right.
It's managing a calendar, it'sshowing up on time, it's
deciding to buy groceries orwhatever substance.
And I have to say some of mypatients are really frustrating
(06:08):
because they're always late orthey always get the wrong day.
In fact, the other addictiondoctor in the practice, the very
beautiful Dr Reb Close, who ismy spouse, she just does
walk-ins on Mondays, like that'sall she does.
Come sometime on Monday andI'll see you, and it actually
works fairly well.
What has your experience beenaround people being frustrated
by the lack of executivefunctioning in patients with
(06:30):
addiction?
Speaker 2 (06:30):
manage the rigid requirements for the reasons you
described.
So that's why we see theattrition rate.
But the other thing is thereason that I describe to
(06:51):
patients about why I recommendrehab is because their
decision-making is coming from adifferent part of their brain
due to the use of substances,and I tell them that we need to
get a break from that part ofthe brain driving the car so I
can get it back to the frontpart that actually drives the
car with executive function.
So I think that both parts areimportant to understand from our
provider perspective, but alsofrom the patient perspective.
Speaker 1 (07:09):
I'm going to try to be funny again here.
I mentioned I have bad dadhumor.
I keep thinking, wow, dr Swiftreally knows what's going on in
addiction.
As we're talking and I realized, yes, you're an addiction
psychiatrist, of course you knowwhat's going on, anyways.
Okay, so now tell me what wasit like transitioning to a
leadership role?
How did you have to zoom outand see the system?
Speaker 2 (07:30):
The thing that I think is most important about
seeing a system is being able tounderstand what the problems
that different people will havewithin the system.
So, exactly like you're saying,in terms of looking at it from
the scheduling perspective.
So the person that's getting thecall from the person looking
for a service that they say,okay, I'm going to come in for
detox at 9 am we now have toknow that that detox that's
(07:50):
scheduled at 9 am is going toshow up somewhere between 9 and
12.
We have to account for that,right, and so we have to put
systems in place to be flexibleto accommodate these patients.
But also I then have to go tothe person that's going to see
the patient and give them somekind of scenarios If this person
shows up intoxicated.
Here's our two options, right,so it's being able to lay
frameworks for people thataren't as skilled in knowing
(08:12):
what addictive disorders can doto the presenting patient, to
give them a narrative on how tomanage it, how to interact with
an intoxicated patient thatcomes in and is incredibly high
on opiates, or if they're usingTrank and they just look so
sedated they're nodding, tellingthem how to manage that so that
it doesn't become a panic andthen a triage to some other
(08:32):
setting that maybe we could havemanaged them here.
Speaker 1 (08:36):
Yeah, so my first career was in emergency medicine
, so I have to keep thingsreally simple, because that's
how my ER doc brain was trainedto work.
So what I'm getting from you isyou're trying to make addiction
care more patient-friendly.
Does that sound right?
Speaker 2 (08:50):
Yes, it does.
Speaker 1 (08:51):
So you mentioned scheduling and protocols when
someone comes in intoxicated.
What else can we do to makeaddiction care more friendly?
Speaker 2 (08:59):
I think that also de-stigmatizing it.
When I tell somebody thatthey're considering what to come
in for, I give them personalkind of anecdotes about what
they might experience when theycome in and how it applies to
the person in front of me.
So, for example, here in oursetting we're in the middle of a
very affluent community andnobody realizes it, but I detox
(09:22):
so many moms from our communityand they are.
Every time one sits in front ofme we have some of the same
conversations how am I going togo back to the community and
everyone's going to be having awine at lunch and I'm not?
How do I?
Where do I tell them?
I am for four to seven days,and so when I'm talking to
somebody about what addictiontreatment looks like, I explain
to them that it's not just thediscrete episode of coming in,
(09:45):
it's how to navigate everythingafter, because you're starting a
new journey, you're starting anew path and I don't want them
to villainize this one episodeand keep it secret, because all
it does is a trickle-down effectof nobody else feeling
comfortable coming in.
I think that the idea thataddiction affects a person that
is defective in some other wayhas to be dispelled, and it has
(10:06):
to be dispelled on multipledifferent fronts.
Speaker 1 (10:10):
So let's put a quick pause in stigma because there is
so much there.
So I mentioned the otheraddiction doctor in the practice
is my spouse.
We actually just recruited twoadditional doctors so we just
doubled our workforce over herein California doctors, so we
just doubled our workforce overhere in California.
But my colleague and spouse, drReb Close.
She practices addictionmedicine on the street, in the
jail, in juvenile hall and thenshe also has a clinic practice.
(10:36):
The executive functioning andlived experience of somebody
who's been incarcerated orunhoused is very different than
a suburban mom in an affluentarea.
How do you approach those twopatients differently?
Speaker 2 (10:44):
So the first one you described was the bulk of my
career before this, and now Iwork with a pretty different
population and all the sameprinciples apply.
Every single one can berelevant to each other.
The difference is how long ittakes for the addiction to push
them into treatment.
The unhoused person gets pickedup a lot quicker.
The suburban mom I'm seeing herwhen her kids go to college
(11:07):
Interesting.
And when she no longer has theability to hide behind the tasks
and everything comes out.
So the difference between theirdisorders is when they present
to treatment and when there's alot going on in the background
they can hide.
When there's not much, itreally pushes them into
treatment earlier.
But what I will say, thedifference for me is on the
(11:28):
backside In New York City, inthe middle of New York City,
with a population that had lessresources.
It was a lot harder for me toput things in place, the
guardrails, to achieve sobrietyhere.
If people have means andmotivation, there's a lot we can
do to get them a path that willhopefully work more
(11:49):
successfully.
Speaker 1 (11:51):
Makes perfect sense.
Coming back to stigma, so Ilecture professionally on stigma
.
So a few years back we weretrying to do a hospital
initiative around addiction andone of the goals was to do
education on stigma.
And we reached out to ournational speaker provider I
guess it's like a speaker bureauand there was no one to lecture
(12:11):
on stigma.
So they said hey, grover, youdo it.
There was no one to lecture onstigma.
So they said hey, grover, youdo it.
So I've learned through theNational Library of Medicine and
reviewing articles on the topic.
I think, based on what I'velearned, stigma affects
addiction more than any otherillness, fully being aware that
stigma casts a very wide netepilepsy, urinary incontinence,
(12:33):
psoriasis, depression but Ithink addiction is the most
stigmatized and you and I bothknow that in the setting of
addiction, stigma kills.
In fact, my lovely bride andcolleague, dr Reb Close.
She and I had a gentleman wewere working with at a syringe
exchange and he was injectingand he got a fever and called Dr
(12:54):
Close and she's oh my gosh,injection, drugs and a fever.
You got to go to the hospitaland he said no, they're going to
judge me.
And he died of stigma, with asecondary cause of death being
sepsis, and so it's somethingwe've done a lot of work on in
our community.
But I'm curious, since you andI talked about wanting to bring
this up as a topic how does one,from the top down, work on
(13:17):
stigma?
Speaker 2 (13:19):
I think there are a couple of ways that we can
really do it.
One is a community presencewhere we comfortably are able to
talk about these disorders in away where we are approachable,
we are not whispering it.
I had a patient actually comeup to me on the campus.
I was walking the other day andshe came up to me.
She had been deciding betweentwo of our residential programs
(13:40):
and I had told her I thought sheshould go to our one for
substance use and she had chosenthe one for personality
disorders.
And it was really interestingbecause she came up to me on the
campus she said, dr Swift, Iwant to go to the one for to
Scavetta, the one for substanceuse.
And I asked her, I said why.
And she said she whispered tome she goes.
Well, I'm borderline and I waslike you don't have to whisper
it, we don't hide diagnoses here.
(14:01):
But it was interesting becauseshe was actually attaching more
to the substance use piece andhiding the personality component
more.
And I think it's because of theway we have it on our campus.
It's we don't do that withpersonality disorders but we're
(14:26):
so open and accepting ofsubstance use disorders that she
wanted to be part of thatpopulation.
She saw that house and saw howconnected they were and she's
like're not going to judge you,they're not going to stigmatize
you.
You are actually part of agroup that is welcoming as
opposed to isolating, and that'sthe message that we have to say
is that when you realize thatthere are people out there that
understand you, you won't feelas alone.
(14:46):
But what I will say is that wecome up against.
People do stupid things whenthey're intoxicated, and so we
have to separate the idea thatthat is a known effect of the
drug as opposed to acharacteristic of the person,
and that's where we can do moreseparate stigma.
Speaker 1 (15:05):
Yeah, what we ended up doing is a person-first
language campaign and a push toban terms that have inherent
judgment, particularly dirtyurine it just drives me freaking
nuts, they're not dirty.
So, yeah, we tried to do aperson with opioid use disorder,
a person with diabetes, aperson with asthma.
And then the one that reallygets me is when psychiatrists
(15:25):
call people crazy.
Oh, that really makes me upset.
Give the diagnosis Crazy isjust a judgmental term.
The other thing we did and it'sa podcast episode I've recorded
but I haven't had a chance toedit and release yet but in
addition to practicing medicine,I also help run a nonprofit and
the executive director of ournonprofit is a gentleman named
(15:46):
Jesse and there's a firefighteron Jesse's crew named Evan,
because Jesse's a firefighterand Evan got addicted to opioids
while he was a firefighter andactually Evan came on my podcast
and told his story, which iswhy I can speak about it.
And Evan's this big, burlyfirefighter, big old handle
mustache, and I'm 6'1 and I workout all the time and Evan has
(16:08):
PTSD and is in recovery fromopioid addiction and I have PTSD
from the ER and I had anorexia,bulimia, and I engaged in
self-harm when I was in collegeand what we've tried to do is go
into communities and educate asleaders, only to reveal our own
vulnerabilities once thesession begins.
To help people realize thateven the people that look
(16:29):
successful can have theirvulnerabilities too, and that
was sorry go ahead.
Speaker 2 (16:33):
I was going to say.
I think that what people don'tunderstand is that people aren't
seeking these substances to gethigh.
They're seeking it to removenegative emotional states.
So they are trying to come infrom their cold.
They're not on the top of theski mountain and enjoying the
ride down.
They're skiing in shorts and at-shirt and they're desperate
and they want to get in andthey're uncomfortable and they
(16:54):
can't stand the state they're inright now.
So they're really just tryingto distract.
It really is a maladaptivecoping mechanism and many of
them and I sit there and I talkabout.
I talked about it with thisyoung girl.
She was probably like 24.
She had an opiate use disorderand I said to her I was like you
just can't sit with thethoughts in your head and she's
I really can't, I really can't.
She had a traumatic upbringing.
She's like all the things thatcome into my head, I just I
(17:17):
can't tolerate them, I don'twant to think about it, and I
was like, listen, I.
So we have to do two things wehave to help you manage how you
triage those thoughts anddiscount the impact that they
can have on you right now.
And we got to work on thisopiate use disorder.
Right, we got to cover thosereceptors.
Physiologically your brain isfiring in a way, saying you need
this, but psychologically yourbrain is crying, saying don't
(17:38):
expose me to that.
And so it really has to be atwo-pronged approach for people
that have trauma, which honestly, by and large, is most of our
patients that seek substances.
Speaker 1 (17:46):
All of them, yeah.
The point I was making aboutthe firefighter and I, though,
is that we're trying to usepeople who seem like successful
leaders, and when we show ourvulnerabilities, it breaks down
some of that stigma, becausepeople don't look at me and see
an eating disorder, and when Ireveal it, they will think
differently about an eatingdisorder.
Haven't gotten to know me, sothat's one thing we've been
(18:06):
trying to do just to break downstigma.
But, to your point, explainingto people how their brain works,
to realize that, no, addictionis not a moral failing and no,
you're not a bad person.
I say this all the time to mypatients.
Let's say I'm seeing Bill.
This is not a Bill problem,this is a human problem that
Bill has.
We do this all day long, and,to your point about trying to
(18:27):
make addiction care reallywelcoming, we have peer support
specialists in our practice, andit just.
People come in and they gethugs and high fives and smiles,
and even if they've had arelapse, let's come on, come in
and see me, you're not introuble.
Let's get this figured out, andwe've really tried to create a
welcoming space, and I'll havesome patients just honestly come
hang out with us for the day.
Speaker 2 (18:48):
It's something that we have talked about a lot here.
Is that the impact of havingalumni, like you're saying,
people that have successfullyrecovered from a low point in
their life or some illnesswhether it be, like you said,
eating disorders, addiction,even acute mental health crisis,
right Anything to see that theyeven they, will tell you when
they were in that low point thatthey did not think that they
(19:10):
were going to get to where theyare today, and being able to
come back and say, hey, like I'msitting where you were, I was
sitting where you were sitting.
I never thought that I wouldcome out the other side.
It's inspiring.
I mean, we had this one patient.
He literally went to 50 rehabsand then he's been sober for 10
years.
And I said to him I was like Ireally want you to come back and
talk to our patients, becausewhen they tell me I'm not going
(19:32):
to go to rehab again for thethird time, I want to say any
time can be the last time.
It doesn't matter if it's threeor 50.
The opportunity is alwaysavailable.
Speaker 1 (19:40):
How long did it take you to create a culture where
the patients felt more safe,sharing their addiction history
more than their mental healthhistory?
That's pretty exceptional.
Speaker 2 (19:51):
I think that it honestly has been.
It was born here before I washere.
This hospital is rooted ingiving addiction treatment.
Some people thought it wasprimarily an addiction hospital
and they don't realize weactually do primarily mental
health.
But we just are reallyaddiction friendly, meaning that
we intermingle people.
When you detox, you're on apsychiatric unit, so you're on a
unit with everybody else.
You're on a unit with doctors,lawyers, whoever else may be
(20:13):
here for other things witheverybody else.
You're on a unit with doctors,lawyers, whoever else may be
here for other things.
But it really creates a culturewhere people feel comfortable
actually saying both.
So mental health getsstigmatized too.
So it has the dual function ofthe people that are here for a
near lethal suicide attempt cansay that, along with the mom
that told everybody she wasgoing to some spa and she's here
detoxing.
So I think we've just createdthis culture of being able to
(20:36):
allow people the space to be whothey are, without any apologies
.
Speaker 1 (20:40):
Do you guys have a particular approach to language
or who you hire, or you want tohire people in recovery?
Do you have a sense of what'sthe secret sauce?
Speaker 2 (20:48):
I don't.
I mean people in recoverydefinitely seek us for jobs.
I will say that, but what we dois we try to have this approach
of, when we do hire people,that we start, we introduce them
to what is our Silver Hillculture, meaning that there is
no judgment here.
Right, when you've walked onthis campus, even if you have
your personal preconditions ofwhat you think is right or wrong
(21:09):
, that needs to stay outside.
Here we are an environmentwhere everybody is coming to us
for help, and it doesn't matterwhat we assess of the situation
they're in.
We need to provide a measuredtreatment for the symptom that's
bothering them.
It becomes tough, though, whenyou see somebody that's of
(21:29):
privilege and is coming in andthey've got three kids at home
and they've got two nannies, andsomebody else is essentially
raising their kid, but theystill can't be present.
Addiction has taken over theirlife, for example, and they're
still not there to do the funthings, to go to the games and
these things.
You have to really find anunderstanding and sometimes
(21:49):
explain to staff that this is abrain disease.
They're not choosing this.
They don't want to be the momthat missed their kid's soccer
game because she was drunk anddidn't get to the 7 pm start.
That's not who they want to be.
But for people that don't haveaddiction training, sometimes
it's things you have toexplicitly say and huddle the
team together and say, hey,listen, we call it in psychiatry
our countertransference.
(22:10):
The countertransference to thispatient may bring up some stuff
.
It's like when you see apregnant patient in detox.
You sometimes huddle the staffand say, listen, mom didn't
choose to be this way, shewouldn't knowingly harm her baby
.
Speaker 1 (22:25):
The way I explain it is.
I go to a lot of schools toeducate kids about drugs and
alcohol use.
I ask those kids what they wantto be when they grow up.
None of them say addicted.
So what do you think yourexperience would be like as a
deputy medical officer at ageneral hospital, as opposed to
your specialty hospital aroundaddiction, stigma against
addiction and access toaddiction care?
Speaker 2 (22:44):
So when I was medical director at Sinai in the city,
we were a general hospital, wehad psychiatry and we had
addiction, but my interfaceended up with touch points in
our med-surg service and ED andI got into a lot of fights with
people about the way that everypatient deserved equal
opportunity and they weren'tcontentious fights, but I
(23:06):
definitely had to go to bat.
I did a lot of grand rounds forthe med-surg department on how
to approach the addicted patient.
One of my grand rounds wasentitled Is this Bad Behavior?
Because it looks just likethey're the addicted patient.
A lot of one of my grand roundswas entitled is this bad
behavior?
Because it looks just likethey're a difficult patient.
It looks like they are, youknow, medication seeking or they
are being disregarding therules, things of that nature,
(23:27):
and so a lot of it was aroundtraining other providers how to
manage these patients in anequitable way where everybody
got the opportunities to beafforded the same level of care,
regardless of the contributingfactors to why they were there.
Speaker 1 (23:41):
How many patients in America with addiction do you
think actually get discriminatedagainst because of their
addiction when they seek medicalcare?
Speaker 2 (23:47):
At some point, 100% I would agree.
I mean, I don't think that youcould find somebody that said
that they have had anoverwhelmingly welcome response
every time they've sought carefor addiction or have had
addiction brought up in theircare.
Speaker 1 (24:03):
Yeah, we've had the same issue here is there's no
detox in our county, so none.
Send them to the ER and hope.
Speaker 2 (24:12):
Do they give them one dose and send them out?
Give them a banana bag?
Speaker 1 (24:15):
It depends.
It's a little bit of a.
If they're sick enough to havealcohol withdrawal, they'll get
admitted.
In my hospital we have onefamily practice doctor who is
board certified in addiction,who's been practicing addiction
medicine longer than I've beenalive, who occasionally admits.
But sometimes the hospital getsreally full and those
admissions get viewed as lessurgent, which I would disagree.
(24:37):
But and then we're told wecan't admit for those it's.
There's not a good system hereand the county to the east of us
has one tiny little hospital.
I am the first doctor ever topractice addiction medicine in
that county.
All of our residentialtreatment programs send people
to the ER just as like ascreening, just to make sure
their withdrawal is not too bad.
We struggle with access here,even though I've been practicing
(25:00):
medicine in this community forabout 11 years.
We just we don't have a lot ofresources for acute detox.
Speaker 2 (25:07):
When I was I don't know, I don't know how many
years, probably a decade ago Ihad a patient that came to our
unit and was detoxing on ourpsych unit.
We gave him 72 milligrams ofAtivan in.
I think it was maybe over 36hours or something.
So people got uncomfortable,sent him to the medical side.
They found out he had a pendingrape charge and they sent him
right back because they didn'tfeel comfortable with him on the
(25:29):
medical side and I said allright, you know what?
Who cares how many milligramsof Ativan this is.
We're still going to do it herebecause they're discounting his
need for medical treatmentbecause of the contributing
factors to something that mayhave actually honestly become a
product of intoxication.
He's out as a freestandingcitizen.
(25:51):
Some court has said that thisis fine for this man to be in
the community, so we're going totreat him.
But it spoke to the fact thatit didn't matter that the
medical necessity was there.
They didn't want to.
So we detoxed him on site andhe did fine.
Speaker 1 (26:01):
It's funny you mentioned that I mentioned my
lovely spouse and colleague, drClose.
Yesterday we were chatting.
She, as I mentioned, practicesmedicine in the jail and there
was a gentleman that she wasseeing and his attorney said do
you know what his charges are?
In this kind of menacing way,like he's such a bad guy and
she's like that's not mydepartment, that's yours, I do
the medical care, you do thelegal, and then ordered him some
(26:22):
buprenorphine.
Speaker 2 (26:27):
Oh, that's a whole other scenario.
Mat for opiate medication,assisted therapy for opiate use.
It sort of saves lives.
There's absolutely no reason torestrict it.
Zero, zero reason.
It's also cheap.
Speaker 1 (26:36):
Stigma.
Speaker 2 (26:37):
Yeah, but it's.
I mean, there really isn't.
I think that one of the thingsthat I have brought to this
hospital because Connecticut'sdefinitely different than New
York is the idea that Suboxoneshould be something that we
should consider.
For anyone that has everstruggled with kratom or opiate
use disorder, it is somethingthat saves lives.
It allows people to function.
(26:58):
I tell it to people.
I mean, I see you're wearingglasses, I wear contacts, I get
up and I put my contacts in myeyes every morning because I
want to see the world aparticular way.
Could in my eyes every morning,because I want to see the world
a particular way.
Could I function without them?
Sure, will it be hard,absolutely.
Is it safer for me to drive anddo other things with it?
Yes, the same thing forbuprenorphine.
If it's something that helpsyou function and it makes it
safer for you to be out andabout doing your things, do it.
(27:19):
There's really, honestly, thereshould not be stigma attached
to it, especially now that wehave injectable formulations
where you don't even have to betaking something.
Nobody has to know.
It's like getting an allergyshot once a month.
Speaker 1 (27:31):
So you had mentioned that many of our patients with
addiction have trauma.
I'm going to channel Dr GaborMate and say that everyone with
addiction has been traumatized.
So I came into addictionmedicine.
I went through the practicepathway.
I didn't do a fellowship and Iwas like, oh yeah, it's all
(27:51):
about penaltrexone and theacamprosate.
I was really med-focused and Ihave to say the single most
enlightening thing that happenedto me was to get diagnosed with
PTSD myself.
I had no idea the profoundchanges that my brain would go
through and it really helps meto understand what my patients
go through.
And I've started to try to makeeverything trauma-informed.
(28:12):
Like I have a CrossFit coachthat works with me and my family
.
She has been through a lotherself and I send my young
female sexual assault victims toher.
I call it trauma-informedfitness.
So how do we make addictioncare trauma-informed?
Speaker 2 (28:27):
So that's it's funny because we at our hospital we're
really a trauma-informedfitness.
So how do we make addictioncare trauma-informed?
So that's it's funny because weat our hospital we're really a
trauma-informed hospital becausewe have a trauma-based
residential program which is, Ithink, the only one in the
country.
But so it was already happeninghere.
But I was happy to see thatbecause it was really consistent
with the way that I practiceaddiction.
You cannot practice addictionwithout being trauma-informed,
because even if you hadn'tidentified what the direct or
(28:48):
indirect trauma was coming intoyour addiction, once you're
already using an addictivesubstance, the chances that
you've been in another traumaticinstance after that are, like
you're saying, 100%.
So even if you can't figure outwhat some indirect trauma was
coming into it, it's going to becompounding trauma.
You're now a vulnerablepopulation.
(29:09):
So I think that there are twothings that we really try and be
explicit about is notvillainizing people.
You can't blame the victim,right?
Many people are very shamefulabout the situations they've
been in when they've been usingsubstances, and we have to kick
that out the window.
But the other thing is, as Ispoke about before, is
(29:30):
identifying what are the keythings that are so hard to sit
with, because if we could tryand address some of that in a
therapeutic manner then thealcohol or whatever use could
diminish.
We had one patient that came in, went to our substance use
program, went out drank.
Went to another one of ourpsychodynamic programs, went out
, drank.
It wasn't until this person didthe trauma program that the
(29:52):
drinking stopped.
Because that's what it was.
We were seeing the tip of theiceberg, but it was just the
symptom that was visible.
All the other things we neededto address first to have that
iceberg go back under thesurface first to have that
iceberg go back under thesurface.
Speaker 1 (30:09):
So just to level set around who my audience is some
of them are healthcare providers, some of them are not.
Can you explain what atrauma-informed approach is and
then give me an example of,let's say, a program or a
modality that is nottrauma-informed and how you make
it trauma-informed?
Speaker 2 (30:23):
So one of the things that is really important first,
like first blush looking at apatient is that you have to
understand that asking somebodydirect assessment questions of
whether or not they've been avictim, have you ever been
sexually assaulted those sort ofthings People are going to tell
you no or they're going to tellyou yes, but it's not a way to
inspire conversation about howwe can address it.
So it has to be aconversational assessment to
(30:46):
begin with, about just towingthe water of have you felt
unsafe before?
I'm not validating whether ornot your assessment of your
safety was real.
I just need to know if you feellike you've been at risk before
of being vulnerable, becausethat's where the conversation
starts.
As we get to know people, we cansuss out a little bit more of
(31:06):
what it looks like to build ahistory of if they have some of
the symptoms that would beconsistent with, for example, a
PTSD.
We can ask about hypervigilance, we can ask about nightmares.
We can get some of thosecriteria met, but at the end of
the day, I actually don't needto know so much about the
specific trauma.
I need to know about yourresponse to it.
I need to know how it'simpacting your functioning today
(31:27):
.
And that's where when we saytrauma-informed care is that we
need to get a little bit of abase, but then watch and observe
the patient and see how we'reseeing it play out, because
that's where we can start tomake measured changes and
customize our approach to how weindividualize trauma-informed
care.
Speaker 1 (31:45):
Give me an example of a program that is not
trauma-informed, and then howyou make it trauma-informed.
Let's say, a residentialtreatment program.
Speaker 2 (31:51):
So all of ours here are trauma-informed.
I would say that, honestly, anysubstance use program, any
rehab that is not consideringhow to process trauma whether it
be from before a substance usestarted or during is not going
to approach.
It's not trauma informed,because once you've been
intoxicated and do not have yourexecutive function intact, you
(32:14):
are potentially a victim.
You're vulnerable.
Things that happen during thattime A you might have not have
consolidated memory from whichis scary, or.
B you might have memories thatare kicking around in your mind
as bringing up negative emotions.
You don't like those emotions,you're scared of having them
again and you can't quit thesubstance.
(32:35):
So the potential that thosethings are going to happen again
is hanging over your headconstantly.
There is going to be ahyperarousal associated with
that.
So to just say no, no, no,let's talk about cues, let's
talk about triggers, let's talkabout relapse prevention that's
not going to work if you're notthinking about the things that
will amplify those cues.
Speaker 1 (32:55):
Let's weave our conversation together here.
How do you address stigmaagainst PTSD when people don't
understand what it is?
Speaker 2 (33:02):
Well, that's the thing is you have to identify it
first.
They don't even know what'shappening.
I've had patients say I just Ican't calm down and I was like,
oh, we have a name for that,it's called hyperarousal.
But they really don't evenunderstand that.
Not everybody's living likethat and there are papers
written about this.
But if there was a traumaticupbringing, these adverse
childhood experiences, if theywere like on edge all the time,
(33:24):
then they may have justfunctionally started to be quite
numb.
So as they felt very, very numband then got into this
adolescent age, they might seeksubstances that stimulate them,
that bring them to life, becausethey've spent a whole time
retreating back, that they don'treally feel like they're alive
until they bring something up.
So our stimulants, ourhallucinogens, things like that,
our stimulants, ourhallucinogens, things like that.
(33:48):
The other side is the peoplethat are constantly, constantly
so scared and that hyperarousalhas started early that they
cannot tolerate it.
They just want to break, theywant to come in from the cold.
So they seek the numbingsubstances.
They're looking at thesedatives, the opiates, alcohol,
things like that.
But when we remove those, theother state remains, and so that
can be traumatic in and ofitself.
Now you're being reminded ofthis mood state when something
(34:10):
bad was happening.
So now something bad happened.
You became numb.
You started using stimulantsand we tell you, it gets over.
You get sober, you're back tonumb, and now that's cuing you
of that time period where youneeded to be numb.
So we have to deal with it.
Speaker 1 (34:28):
It's how it all interconnects.
How about, in terms of stigma,when loved ones of a person
getting treatment don'tunderstand PTSD?
Speaker 2 (34:33):
So PTSD is something that you know because we've all
lived through some of the warsand things like that.
People really associate it withveterans.
By no means is itwholeheartedly associated with
veterans.
That is our poster child,because almost 100%, I would say
, of people that have servedhave some traumatic experience.
But that does not discount thatanybody walking around on the
(34:54):
street can have traumaticexperiences and it does not mean
that you're again a defectiveperson.
It means that the emotionsconnected with the event created
some disruption in your brainwhere it is no longer firing in
the way that it was before.
Whatever experience, it's not afault of yours.
It's literally a brain wiringthing where your brain is now
(35:16):
signaling be worried, be aware,let's not let this happen again.
Let me remind you about this itis not a choice to make this
thing impactful.
It is something that happenedin your brain when that thing or
situation or string ofsituations happened.
That now you cannot correctwithout a measured response to
it Therapy, sometimes somemedications, or just really
(35:39):
being mindful of how you areresponding to the intrusive
thoughts that are present withPTSD.
Speaker 1 (35:45):
I have to say, when I was diagnosed with PTSD I was
embarrassed.
I was afraid to share with mycolleagues.
It took me about four to fivemonths to finally get up the
nerve to tell my colleagues.
And then I realized I had toown it and if I was going to
break down some of the stigmaaround mental illness at my
institution I had to share it.
So I finally got up the nerveand I was chief of staff at the
(36:08):
time.
So I wrote my chief of staffletter to the board of trustees
in my hospital about my PTSDdiagnosis and I was really
pleased.
The board had a very favorableresponse.
They thanked me for sharing andthen I shared that same letter
with my emergency departmentgroup and I got a lot of
positive support.
But I still feel like a coupleof my colleagues are like yeah,
grover's a sissy.
So I don't know.
(36:30):
Personally I feel like now I'min a place where I can own my
diagnosis and I can talk freelyabout it.
But I was really scared when Ifirst got that diagnosis.
Speaker 2 (36:38):
Tough men don't get PTSD yeah.
Speaker 1 (36:40):
Yeah.
Speaker 2 (37:00):
I see you smiling to it.
It is not something again, likeyou said, nobody's going to
grow up and say I want thistraumatic event to impact me in
this way.
It is not a choice we made towallow in our sorrows of
something that has happened tous.
It is something that we cannotmanage the impact of, for
(37:23):
whatever reason.
The chemistry of our brain didnot allow us to manage it.
I think about a lot.
I don't know I forget if it wasa podcast or a documentary I
watched but about how you couldhave a bunch of people, for
example, in a bus crash, right,and everybody's experience or
impact of it is different.
And how do you predict whose iswhat?
Honestly, you can't.
You cannot predict who getswhat from that same event.
(37:46):
They all brought differentthings to it, they took
different things away from it.
But looking at it, that spaceand time you cannot point around
and say this person's going tohave a PTSD diagnosis in six
months from this.
It's just not predictable inthat way, because it doesn't
happen to people that haveidentified shared
characteristics.
Speaker 1 (38:02):
So we've talked about your work as a deputy chief
medical officer overseeingsubstance use treatment.
You try to make addiction caremore friendly, such as by
accommodating difficulties withscheduling when people are in
active addiction because ofdiminished executive function.
You talked about trying toreduce stigma.
You talked about beingtrauma-informed.
What else do you do to makeaddiction care better where you
(38:25):
work?
Speaker 2 (38:25):
informed.
What else do you do to makeaddiction care better where you
work?
We have to involve families.
We have to.
You can't do it without.
It's like fixing a car andsending it back to somebody that
doesn't know how to drive.
If the family around, orwhoever it doesn't have to be
family, the support systemdoesn't understand addiction.
It's very hard for the personwith the addictive disorder to
go back out and fend forthemselves.
It has to be a team effort.
(38:46):
When I meet with patients, Iactually I meet with patients
and I spend a ton of time withthe families because they have
questions.
I mean, I just did an opiatedetox for a gentleman and
probably spent I don't knowmaybe an hour and a half on the
phone with his wife because shehad so many questions.
He'd come by the prescription,honestly, but the way that it
affected his brain, he ended upwith an opiate use disorder and
(39:08):
so she really wanted to go fromthe beginning.
How did this happen?
How did this start?
When did you know?
Just, it was like having accessto somebody to ask the
questions was huge for her, andit made me realize how little
access some of the generalpopulation has to these
questions and they just don'thave the knowledge, and without
the knowledge it's hard todiscount the stigma that's
(39:29):
attached to it.
Speaker 1 (39:30):
It really is.
As we get to the end of ourtime here recording this episode
, what's next on your to-do listto improving addiction care at
your institution?
Speaker 2 (39:41):
Well, one of the big things and we're doing it this
year when I'm speaking at one ofthe high schools locally here
is we got to get it out to theyouth.
If we don't start this earlierand earlier, then it's harder
for me to treat it later andlater we're already in the
addiction field.
I don't know if you're seeingit too, dealing with the kind of
the baby boomers that they werethe 60s 70s.
Pot was not that dangerous thenas it is now.
They really have a differentrelationship with drugs and
alcohol than this populationhere.
(40:02):
But if we don't, youth does too.
They've stigmatized alcohol ina way that's a little bit newer.
But they're doing all kinds ofother what they think are clean
things that aren't.
Speaker 1 (40:10):
Like whippets.
Speaker 2 (40:17):
Exactly Like.
They think there's no lastingimpact of it.
So this is fine, but there islasting impact.
So one of the things that we'rereally and I'm really trying to
do is provide psychoeducationfor the dangers of cannabis use
in adolescents and whatconversations parents should be
having with their loved ones.
It's about being able to be theone to say no.
It's really hard in a group ofteenagers to say no and to be
comfortable saying no.
So doing that kind ofsupportive interventions in the
(40:39):
community studies show that ifyou target the most at-risk
youth, it has a herd effect andyou can disseminate it to other
people.
So being able to make an effort, knowing that, even if you
don't see it right now, that itwill be impactful later on.
Speaker 1 (40:53):
Well, if you need any slide decks, let me know.
I've been going to schools andtalking to students and parents
for about a decade.
Speaker 2 (40:59):
Amazing.
Well maybe I will hit you upfor that.
Speaker 1 (41:02):
It's actually one of the things I would encourage you
to do is walk into a smoke shop.
If you haven't done it already.
I've done a couple of episodeson Kratom and just seeing how
Kratom is sold and then takingsome photos of just how vapes
are sold and really targetedtowards kids, colors, flavors I
got plenty of slide decks, sowhen you're ready, reach out.
It's something we've beenworking on for quite a while
here in Monterey County.
(41:23):
As a deputy chief medicalofficer, what's the rest of your
day look like?
Speaker 2 (41:26):
I only got two more hours of the day, so I'm going
to go check on the detoxes weadmitted today to make sure
everybody is tucked in for theweekend, particularly the one
that was using Kratom, because,listen, you got to understand
what we're doing with theSuboxone that she doesn't think
she needs, but she definitelyneeds.
Speaker 1 (41:42):
I would agree.
So that's my day.
Okay, well, I have to say I, Iwould agree.
So that's my day.
Okay, well, I have to say I amso glad someone like yourself is
leading the ship at yourinstitution, because I can tell,
in speaking to you, yourpassion for your patients and
for what you do.
Thank you so much for joiningme.
I have learned a ton andappreciate the work that you do.
Speaker 2 (41:57):
Of course, it was lovely to meet you.
Speaker 1 (42:01):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
(42:24):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(42:47):
saves lives.
Welcome to the Addiction Medicine Made Easy
Podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:22):
For 14 years I worked in theemergency department, seeing
countless patients strugglingwith addiction.
Now I'm on the other side ofthe fight, helping people
rebuild their lives when drugsand alcohol take control.
Thanks for tuning in.
Let's get started.
Today's episode is an interviewwith Dr Amy Swift, who is an
(00:44):
addiction psychiatrist on theEast Coast of the United States
and, in addition to taking careof patients with addiction
herself, she's also a deputychief medical officer, meaning
that she oversees the medicalcare of the patients in her
health system.
She and I had a greatconversation on how to improve
healthcare for patients withaddiction, as in how can we make
(01:07):
healthcare more accessible andfriendly for people with
addiction, and, given her rolesupervising a healthcare system
as a deputy chief medicalofficer, she had a lot of great
insights.
I am hoping that healthcareexecutives could take a listen
to this episode, as she has alot of great insight to share
and it sounds like theinstitution that she has a lot
of great insight to share and itsounds like the institution
(01:28):
that she works at is doing greatwork With that let's get
started, all right.
Well, good morning my time,good afternoon your time.
Why don't we start by havingyou tell us who you are and what
you do?
Speaker 2 (01:43):
Thanks so much.
I am Dr Amy Swift.
I am Deputy Chief medicalofficer of a freestanding
psychiatric hospital in NewCanaan, connecticut, called
Silver Hill Hospital.
How did you get into that role?
Services at Mount Sinai and Ilived out here and so I
approached them, I told themwhat I do and they created a
(02:13):
position for me to help create adedicated effort of treating
addiction on this campus in bothour inpatient and residential
settings.
Speaker 1 (02:18):
So I tend to focus on the micro stuff, because I'm a
doc seeing patients in clinicand you're zooming out and
seeing more of the system andyou've obviously practiced
before.
Which do you like better Bootson the ground or seeing the
whole system?
Speaker 2 (02:28):
Well, that's.
The thing is that I am somebodythat sits above the system and
sees all the boots on the ground.
So if you ask me how manypatients are assigned to me
today, I'll say zero.
If you ask me how many patientsI've seen today, I'll say 10 to
15.
It is the idea that you can'tmake changes in a hospital
system without knowing who's inyour hospital.
Speaker 1 (02:47):
So I go to the patients.
Speaker 2 (02:49):
I see them, I do it all.
Speaker 1 (02:50):
Do you want a job in California?
I like your approach already.
Speaker 2 (02:54):
Listen, I'll talk to my family about it.
Speaker 1 (02:56):
Yeah, yeah, Okay, we talked a little bit before we
got started.
I got a bone to pick withpsychiatry and I'm going to pick
on you and it's obviously notyou.
I'm trying to be funny.
My daughter is, I'm sure,rolling her eyes because of my
bad dad humor, but I'm reallycurious.
A lot of times my patients goto get mental health services
and they get told get sober andthen I'll see you.
(03:16):
And as an addiction doc it'sall mushed together and I don't
get a chance to pull it apartand a lot of what I do as an
addiction doc is a mix ofpharmacology and psychiatry.
Do you have a sense of wherethat history comes from of
mental health services sayingget sober and then I'll see you?
Speaker 2 (03:34):
I think it is a discomfort with understanding
what addiction does to ourmental health and it is the
reason I got into addictionoriginally is I never wanted to
be somebody that said go dosomething else with someone else
until I can treat you.
If you don't know how to treataddiction, then you can't be a
comprehensive psychiatristbecause they are intermingled.
(03:54):
So I think it's just a historicdiscomfort with the stigma that
rests with addiction.
Speaker 1 (04:00):
Yeah, I have a number of therapists locally that I
refer to and they tell me whoa,we don't do addiction and I'm
thinking I'll manage theiralcohol use disorder, but minus
prescribing medications I can'tfix their PTSD.
You do the PTSD part, I'll takethe rest and actually I'm
really grateful they're going tohost me for an in-service so I
can do some education on that.
But yeah, it's a frustratingproblem.
(04:22):
What was your experience inyour psychiatry residency around
addiction?
Speaker 2 (04:28):
acute and the patients that were really
suffering.
So I learned early on how tomanage acute agitation,
(04:52):
withdrawal, post-acutewithdrawal, all the things that
come up for patients that arestruggling with addictive
disorders, and so it wasingrained into how I practice
psychiatry in general.
So that's where the trajectorystarted.
But I do as I became further inmy career and I was actually
the program director for theAddiction Psychiatry Fellowship
I learned as I took fellows fromother places.
Some residents had zeroexposure and knew nothing.
So it really varies across thecountry in how psychiatrists are
(05:12):
trained to manage addictivedisorders.
Speaker 1 (05:15):
Do you think your residency training is what
pushed you into doing afellowship in addiction
psychiatry?
Speaker 2 (05:20):
Absolutely Many people go into addiction because
they had personal experiencewith it or a family member.
I went into it because it washard and I was going to do the
hard thing.
It was the patients that causedthe most kind of ruckus.
They were the most complex,they were the hardest to
navigate.
The personality constructs, theirritability, that stuff.
And that's the thing that Ithink really allowed me to
(05:41):
pursue the field is beingexposed to it and then feeling
like I could master this.
Speaker 1 (05:46):
Yeah, I think the other thing that makes people
pull away from treating patientswith addiction is I've learned
to think of addiction as adisease of executive functioning
right.
It's managing a calendar, it'sshowing up on time, it's
deciding to buy groceries orwhatever substance.
And I have to say some of mypatients are really frustrating
(06:08):
because they're always late orthey always get the wrong day.
In fact, the other addictiondoctor in the practice, the very
beautiful Dr Reb Close, who ismy spouse, she just does
walk-ins on Mondays, like that'sall she does.
Come sometime on Monday andI'll see you, and it actually
works fairly well.
What has your experience beenaround people being frustrated
by the lack of executivefunctioning in patients with
(06:30):
addiction?
Speaker 2 (06:30):
manage the rigid requirements for the reasons you
described.
So that's why we see theattrition rate.
But the other thing is thereason that I describe to
(06:51):
patients about why I recommendrehab is because their
decision-making is coming from adifferent part of their brain
due to the use of substances,and I tell them that we need to
get a break from that part ofthe brain driving the car so I
can get it back to the frontpart that actually drives the
car with executive function.
So I think that both parts areimportant to understand from our
provider perspective, but alsofrom the patient perspective.
Speaker 1 (07:09):
I'm going to try to be funny again here.
I mentioned I have bad dadhumor.
I keep thinking, wow, dr Swiftreally knows what's going on in
addiction.
As we're talking and I realized, yes, you're an addiction
psychiatrist, of course you knowwhat's going on, anyways.
Okay, so now tell me what wasit like transitioning to a
leadership role?
How did you have to zoom outand see the system?
Speaker 2 (07:30):
The thing that I think is most important about
seeing a system is being able tounderstand what the problems
that different people will havewithin the system.
So, exactly like you're saying,in terms of looking at it from
the scheduling perspective.
So the person that's getting thecall from the person looking
for a service that they say,okay, I'm going to come in for
detox at 9 am we now have toknow that that detox that's
(07:50):
scheduled at 9 am is going toshow up somewhere between 9 and
12.
We have to account for that,right, and so we have to put
systems in place to be flexibleto accommodate these patients.
But also I then have to go tothe person that's going to see
the patient and give them somekind of scenarios If this person
shows up intoxicated.
Here's our two options, right,so it's being able to lay
frameworks for people thataren't as skilled in knowing
(08:12):
what addictive disorders can doto the presenting patient, to
give them a narrative on how tomanage it, how to interact with
an intoxicated patient thatcomes in and is incredibly high
on opiates, or if they're usingTrank and they just look so
sedated they're nodding, tellingthem how to manage that so that
it doesn't become a panic andthen a triage to some other
(08:32):
setting that maybe we could havemanaged them here.
Speaker 1 (08:36):
Yeah, so my first career was in emergency medicine
, so I have to keep thingsreally simple, because that's
how my ER doc brain was trainedto work.
So what I'm getting from you isyou're trying to make addiction
care more patient-friendly.
Does that sound right?
Speaker 2 (08:50):
Yes, it does.
Speaker 1 (08:51):
So you mentioned scheduling and protocols when
someone comes in intoxicated.
What else can we do to makeaddiction care more friendly?
Speaker 2 (08:59):
I think that also de-stigmatizing it.
When I tell somebody thatthey're considering what to come
in for, I give them personalkind of anecdotes about what
they might experience when theycome in and how it applies to
the person in front of me.
So, for example, here in oursetting we're in the middle of a
very affluent community andnobody realizes it, but I detox
(09:22):
so many moms from our communityand they are.
Every time one sits in front ofme we have some of the same
conversations how am I going togo back to the community and
everyone's going to be having awine at lunch and I'm not?
How do I?
Where do I tell them?
I am for four to seven days,and so when I'm talking to
somebody about what addictiontreatment looks like, I explain
to them that it's not just thediscrete episode of coming in,
(09:45):
it's how to navigate everythingafter, because you're starting a
new journey, you're starting anew path and I don't want them
to villainize this one episodeand keep it secret, because all
it does is a trickle-down effectof nobody else feeling
comfortable coming in.
I think that the idea thataddiction affects a person that
is defective in some other wayhas to be dispelled, and it has
(10:06):
to be dispelled on multipledifferent fronts.
Speaker 1 (10:10):
So let's put a quick pause in stigma because there is
so much there.
So I mentioned the otheraddiction doctor in the practice
is my spouse.
We actually just recruited twoadditional doctors so we just
doubled our workforce over herein California doctors, so we
just doubled our workforce overhere in California.
But my colleague and spouse, drReb Close.
She practices addictionmedicine on the street, in the
jail, in juvenile hall and thenshe also has a clinic practice.
(10:36):
The executive functioning andlived experience of somebody
who's been incarcerated orunhoused is very different than
a suburban mom in an affluentarea.
How do you approach those twopatients differently?
Speaker 2 (10:44):
So the first one you described was the bulk of my
career before this, and now Iwork with a pretty different
population and all the sameprinciples apply.
Every single one can berelevant to each other.
The difference is how long ittakes for the addiction to push
them into treatment.
The unhoused person gets pickedup a lot quicker.
The suburban mom I'm seeing herwhen her kids go to college
(11:07):
Interesting.
And when she no longer has theability to hide behind the tasks
and everything comes out.
So the difference between theirdisorders is when they present
to treatment and when there's alot going on in the background
they can hide.
When there's not much, itreally pushes them into
treatment earlier.
But what I will say, thedifference for me is on the
(11:28):
backside In New York City, inthe middle of New York City,
with a population that had lessresources.
It was a lot harder for me toput things in place, the
guardrails, to achieve sobrietyhere.
If people have means andmotivation, there's a lot we can
do to get them a path that willhopefully work more
(11:49):
successfully.
Speaker 1 (11:51):
Makes perfect sense.
Coming back to stigma, so Ilecture professionally on stigma
.
So a few years back we weretrying to do a hospital
initiative around addiction andone of the goals was to do
education on stigma.
And we reached out to ournational speaker provider I
guess it's like a speaker bureauand there was no one to lecture
(12:11):
on stigma.
So they said hey, grover, youdo it.
There was no one to lecture onstigma.
So they said hey, grover, youdo it.
So I've learned through theNational Library of Medicine and
reviewing articles on the topic.
I think, based on what I'velearned, stigma affects
addiction more than any otherillness, fully being aware that
stigma casts a very wide netepilepsy, urinary incontinence,
(12:33):
psoriasis, depression but Ithink addiction is the most
stigmatized and you and I bothknow that in the setting of
addiction, stigma kills.
In fact, my lovely bride andcolleague, dr Reb Close.
She and I had a gentleman wewere working with at a syringe
exchange and he was injectingand he got a fever and called Dr
(12:54):
Close and she's oh my gosh,injection, drugs and a fever.
You got to go to the hospitaland he said no, they're going to
judge me.
And he died of stigma, with asecondary cause of death being
sepsis, and so it's somethingwe've done a lot of work on in
our community.
But I'm curious, since you andI talked about wanting to bring
this up as a topic how does one,from the top down, work on
(13:17):
stigma?
Speaker 2 (13:19):
I think there are a couple of ways that we can
really do it.
One is a community presencewhere we comfortably are able to
talk about these disorders in away where we are approachable,
we are not whispering it.
I had a patient actually comeup to me on the campus.
I was walking the other day andshe came up to me.
She had been deciding betweentwo of our residential programs
(13:40):
and I had told her I thought sheshould go to our one for
substance use and she had chosenthe one for personality
disorders.
And it was really interestingbecause she came up to me on the
campus she said, dr Swift, Iwant to go to the one for to
Scavetta, the one for substanceuse.
And I asked her, I said why.
And she said she whispered tome she goes.
Well, I'm borderline and I waslike you don't have to whisper
it, we don't hide diagnoses here.
(14:01):
But it was interesting becauseshe was actually attaching more
to the substance use piece andhiding the personality component
more.
And I think it's because of theway we have it on our campus.
It's we don't do that withpersonality disorders but we're
(14:26):
so open and accepting ofsubstance use disorders that she
wanted to be part of thatpopulation.
She saw that house and saw howconnected they were and she's
like're not going to judge you,they're not going to stigmatize
you.
You are actually part of agroup that is welcoming as
opposed to isolating, and that'sthe message that we have to say
is that when you realize thatthere are people out there that
understand you, you won't feelas alone.
(14:46):
But what I will say is that wecome up against.
People do stupid things whenthey're intoxicated, and so we
have to separate the idea thatthat is a known effect of the
drug as opposed to acharacteristic of the person,
and that's where we can do moreseparate stigma.
Speaker 1 (15:05):
Yeah, what we ended up doing is a person-first
language campaign and a push toban terms that have inherent
judgment, particularly dirtyurine it just drives me freaking
nuts, they're not dirty.
So, yeah, we tried to do aperson with opioid use disorder,
a person with diabetes, aperson with asthma.
And then the one that reallygets me is when psychiatrists
(15:25):
call people crazy.
Oh, that really makes me upset.
Give the diagnosis Crazy isjust a judgmental term.
The other thing we did and it'sa podcast episode I've recorded
but I haven't had a chance toedit and release yet but in
addition to practicing medicine,I also help run a nonprofit and
the executive director of ournonprofit is a gentleman named
(15:46):
Jesse and there's a firefighteron Jesse's crew named Evan,
because Jesse's a firefighterand Evan got addicted to opioids
while he was a firefighter andactually Evan came on my podcast
and told his story, which iswhy I can speak about it.
And Evan's this big, burlyfirefighter, big old handle
mustache, and I'm 6'1 and I workout all the time and Evan has
(16:08):
PTSD and is in recovery fromopioid addiction and I have PTSD
from the ER and I had anorexia,bulimia, and I engaged in
self-harm when I was in collegeand what we've tried to do is go
into communities and educate asleaders, only to reveal our own
vulnerabilities once thesession begins.
To help people realize thateven the people that look
(16:29):
successful can have theirvulnerabilities too, and that
was sorry go ahead.
Speaker 2 (16:33):
I was going to say.
I think that what people don'tunderstand is that people aren't
seeking these substances to gethigh.
They're seeking it to removenegative emotional states.
So they are trying to come infrom their cold.
They're not on the top of theski mountain and enjoying the
ride down.
They're skiing in shorts and at-shirt and they're desperate
and they want to get in andthey're uncomfortable and they
(16:54):
can't stand the state they're inright now.
So they're really just tryingto distract.
It really is a maladaptivecoping mechanism and many of
them and I sit there and I talkabout.
I talked about it with thisyoung girl.
She was probably like 24.
She had an opiate use disorderand I said to her I was like you
just can't sit with thethoughts in your head and she's
I really can't, I really can't.
She had a traumatic upbringing.
She's like all the things thatcome into my head, I just I
(17:17):
can't tolerate them, I don'twant to think about it, and I
was like, listen, I.
So we have to do two things wehave to help you manage how you
triage those thoughts anddiscount the impact that they
can have on you right now.
And we got to work on thisopiate use disorder.
Right, we got to cover thosereceptors.
Physiologically your brain isfiring in a way, saying you need
this, but psychologically yourbrain is crying, saying don't
(17:38):
expose me to that.
And so it really has to be atwo-pronged approach for people
that have trauma, which honestly, by and large, is most of our
patients that seek substances.
Speaker 1 (17:46):
All of them, yeah.
The point I was making aboutthe firefighter and I, though,
is that we're trying to usepeople who seem like successful
leaders, and when we show ourvulnerabilities, it breaks down
some of that stigma, becausepeople don't look at me and see
an eating disorder, and when Ireveal it, they will think
differently about an eatingdisorder.
Haven't gotten to know me, sothat's one thing we've been
(18:06):
trying to do just to break downstigma.
But, to your point, explainingto people how their brain works,
to realize that, no, addictionis not a moral failing and no,
you're not a bad person.
I say this all the time to mypatients.
Let's say I'm seeing Bill.
This is not a Bill problem,this is a human problem that
Bill has.
We do this all day long, and,to your point about trying to
(18:27):
make addiction care reallywelcoming, we have peer support
specialists in our practice, andit just.
People come in and they gethugs and high fives and smiles,
and even if they've had arelapse, let's come on, come in
and see me, you're not introuble.
Let's get this figured out, andwe've really tried to create a
welcoming space, and I'll havesome patients just honestly come
hang out with us for the day.
Speaker 2 (18:48):
It's something that we have talked about a lot here.
Is that the impact of havingalumni, like you're saying,
people that have successfullyrecovered from a low point in
their life or some illnesswhether it be, like you said,
eating disorders, addiction,even acute mental health crisis,
right Anything to see that theyeven they, will tell you when
they were in that low point thatthey did not think that they
(19:10):
were going to get to where theyare today, and being able to
come back and say, hey, like I'msitting where you were, I was
sitting where you were sitting.
I never thought that I wouldcome out the other side.
It's inspiring.
I mean, we had this one patient.
He literally went to 50 rehabsand then he's been sober for 10
years.
And I said to him I was like Ireally want you to come back and
talk to our patients, becausewhen they tell me I'm not going
(19:32):
to go to rehab again for thethird time, I want to say any
time can be the last time.
It doesn't matter if it's threeor 50.
The opportunity is alwaysavailable.
Speaker 1 (19:40):
How long did it take you to create a culture where
the patients felt more safe,sharing their addiction history
more than their mental healthhistory?
That's pretty exceptional.
Speaker 2 (19:51):
I think that it honestly has been.
It was born here before I washere.
This hospital is rooted ingiving addiction treatment.
Some people thought it wasprimarily an addiction hospital
and they don't realize weactually do primarily mental
health.
But we just are reallyaddiction friendly, meaning that
we intermingle people.
When you detox, you're on apsychiatric unit, so you're on a
unit with everybody else.
You're on a unit with doctors,lawyers, whoever else may be
(20:13):
here for other things witheverybody else.
You're on a unit with doctors,lawyers, whoever else may be
here for other things.
But it really creates a culturewhere people feel comfortable
actually saying both.
So mental health getsstigmatized too.
So it has the dual function ofthe people that are here for a
near lethal suicide attempt cansay that, along with the mom
that told everybody she wasgoing to some spa and she's here
detoxing.
So I think we've just createdthis culture of being able to
(20:36):
allow people the space to be whothey are, without any apologies
.
Speaker 1 (20:40):
Do you guys have a particular approach to language
or who you hire, or you want tohire people in recovery?
Do you have a sense of what'sthe secret sauce?
Speaker 2 (20:48):
I don't.
I mean people in recoverydefinitely seek us for jobs.
I will say that, but what we dois we try to have this approach
of, when we do hire people,that we start, we introduce them
to what is our Silver Hillculture, meaning that there is
no judgment here.
Right, when you've walked onthis campus, even if you have
your personal preconditions ofwhat you think is right or wrong
(21:09):
, that needs to stay outside.
Here we are an environmentwhere everybody is coming to us
for help, and it doesn't matterwhat we assess of the situation
they're in.
We need to provide a measuredtreatment for the symptom that's
bothering them.
It becomes tough, though, whenyou see somebody that's of
(21:29):
privilege and is coming in andthey've got three kids at home
and they've got two nannies, andsomebody else is essentially
raising their kid, but theystill can't be present.
Addiction has taken over theirlife, for example, and they're
still not there to do the funthings, to go to the games and
these things.
You have to really find anunderstanding and sometimes
(21:49):
explain to staff that this is abrain disease.
They're not choosing this.
They don't want to be the momthat missed their kid's soccer
game because she was drunk anddidn't get to the 7 pm start.
That's not who they want to be.
But for people that don't haveaddiction training, sometimes
it's things you have toexplicitly say and huddle the
team together and say, hey,listen, we call it in psychiatry
our countertransference.
(22:10):
The countertransference to thispatient may bring up some stuff
.
It's like when you see apregnant patient in detox.
You sometimes huddle the staffand say, listen, mom didn't
choose to be this way, shewouldn't knowingly harm her baby
.
Speaker 1 (22:25):
The way I explain it is.
I go to a lot of schools toeducate kids about drugs and
alcohol use.
I ask those kids what they wantto be when they grow up.
None of them say addicted.
So what do you think yourexperience would be like as a
deputy medical officer at ageneral hospital, as opposed to
your specialty hospital aroundaddiction, stigma against
addiction and access toaddiction care?
Speaker 2 (22:44):
So when I was medical director at Sinai in the city,
we were a general hospital, wehad psychiatry and we had
addiction, but my interfaceended up with touch points in
our med-surg service and ED andI got into a lot of fights with
people about the way that everypatient deserved equal
opportunity and they weren'tcontentious fights, but I
(23:06):
definitely had to go to bat.
I did a lot of grand rounds forthe med-surg department on how
to approach the addicted patient.
One of my grand rounds wasentitled Is this Bad Behavior?
Because it looks just likethey're the addicted patient.
A lot of one of my grand roundswas entitled is this bad
behavior?
Because it looks just likethey're a difficult patient.
It looks like they are, youknow, medication seeking or they
are being disregarding therules, things of that nature,
(23:27):
and so a lot of it was aroundtraining other providers how to
manage these patients in anequitable way where everybody
got the opportunities to beafforded the same level of care,
regardless of the contributingfactors to why they were there.
Speaker 1 (23:41):
How many patients in America with addiction do you
think actually get discriminatedagainst because of their
addiction when they seek medicalcare?
Speaker 2 (23:47):
At some point, 100% I would agree.
I mean, I don't think that youcould find somebody that said
that they have had anoverwhelmingly welcome response
every time they've sought carefor addiction or have had
addiction brought up in theircare.
Speaker 1 (24:03):
Yeah, we've had the same issue here is there's no
detox in our county, so none.
Send them to the ER and hope.
Speaker 2 (24:12):
Do they give them one dose and send them out?
Give them a banana bag?
Speaker 1 (24:15):
It depends.
It's a little bit of a.
If they're sick enough to havealcohol withdrawal, they'll get
admitted.
In my hospital we have onefamily practice doctor who is
board certified in addiction,who's been practicing addiction
medicine longer than I've beenalive, who occasionally admits.
But sometimes the hospital getsreally full and those
admissions get viewed as lessurgent, which I would disagree.
(24:37):
But and then we're told wecan't admit for those it's.
There's not a good system hereand the county to the east of us
has one tiny little hospital.
I am the first doctor ever topractice addiction medicine in
that county.
All of our residentialtreatment programs send people
to the ER just as like ascreening, just to make sure
their withdrawal is not too bad.
We struggle with access here,even though I've been practicing
(25:00):
medicine in this community forabout 11 years.
We just we don't have a lot ofresources for acute detox.
Speaker 2 (25:07):
When I was I don't know, I don't know how many
years, probably a decade ago Ihad a patient that came to our
unit and was detoxing on ourpsych unit.
We gave him 72 milligrams ofAtivan in.
I think it was maybe over 36hours or something.
So people got uncomfortable,sent him to the medical side.
They found out he had a pendingrape charge and they sent him
right back because they didn'tfeel comfortable with him on the
(25:29):
medical side and I said allright, you know what?
Who cares how many milligramsof Ativan this is.
We're still going to do it herebecause they're discounting his
need for medical treatmentbecause of the contributing
factors to something that mayhave actually honestly become a
product of intoxication.
He's out as a freestandingcitizen.
(25:51):
Some court has said that thisis fine for this man to be in
the community, so we're going totreat him.
But it spoke to the fact thatit didn't matter that the
medical necessity was there.
They didn't want to.
So we detoxed him on site andhe did fine.
Speaker 1 (26:01):
It's funny you mentioned that I mentioned my
lovely spouse and colleague, drClose.
Yesterday we were chatting.
She, as I mentioned, practicesmedicine in the jail and there
was a gentleman that she wasseeing and his attorney said do
you know what his charges are?
In this kind of menacing way,like he's such a bad guy and
she's like that's not mydepartment, that's yours, I do
the medical care, you do thelegal, and then ordered him some
(26:22):
buprenorphine.
Speaker 2 (26:27):
Oh, that's a whole other scenario.
Mat for opiate medication,assisted therapy for opiate use.
It sort of saves lives.
There's absolutely no reason torestrict it.
Zero, zero reason.
It's also cheap.
Speaker 1 (26:36):
Stigma.
Speaker 2 (26:37):
Yeah, but it's.
I mean, there really isn't.
I think that one of the thingsthat I have brought to this
hospital because Connecticut'sdefinitely different than New
York is the idea that Suboxoneshould be something that we
should consider.
For anyone that has everstruggled with kratom or opiate
use disorder, it is somethingthat saves lives.
It allows people to function.
(26:58):
I tell it to people.
I mean, I see you're wearingglasses, I wear contacts, I get
up and I put my contacts in myeyes every morning because I
want to see the world aparticular way.
Could in my eyes every morning,because I want to see the world
a particular way.
Could I function without them?
Sure, will it be hard,absolutely.
Is it safer for me to drive anddo other things with it?
Yes, the same thing forbuprenorphine.
If it's something that helpsyou function and it makes it
safer for you to be out andabout doing your things, do it.
(27:19):
There's really, honestly, thereshould not be stigma attached
to it, especially now that wehave injectable formulations
where you don't even have to betaking something.
Nobody has to know.
It's like getting an allergyshot once a month.
Speaker 1 (27:31):
So you had mentioned that many of our patients with
addiction have trauma.
I'm going to channel Dr GaborMate and say that everyone with
addiction has been traumatized.
So I came into addictionmedicine.
I went through the practicepathway.
I didn't do a fellowship and Iwas like, oh yeah, it's all
(27:51):
about penaltrexone and theacamprosate.
I was really med-focused and Ihave to say the single most
enlightening thing that happenedto me was to get diagnosed with
PTSD myself.
I had no idea the profoundchanges that my brain would go
through and it really helps meto understand what my patients
go through.
And I've started to try to makeeverything trauma-informed.
(28:12):
Like I have a CrossFit coachthat works with me and my family
.
She has been through a lotherself and I send my young
female sexual assault victims toher.
I call it trauma-informedfitness.
So how do we make addictioncare trauma-informed?
Speaker 2 (28:27):
So that's it's funny because we at our hospital we're
really a trauma-informedfitness.
So how do we make addictioncare trauma-informed?
So that's it's funny because weat our hospital we're really a
trauma-informed hospital becausewe have a trauma-based
residential program which is, Ithink, the only one in the
country.
But so it was already happeninghere.
But I was happy to see thatbecause it was really consistent
with the way that I practiceaddiction.
You cannot practice addictionwithout being trauma-informed,
because even if you hadn'tidentified what the direct or
(28:48):
indirect trauma was coming intoyour addiction, once you're
already using an addictivesubstance, the chances that
you've been in another traumaticinstance after that are, like
you're saying, 100%.
So even if you can't figure outwhat some indirect trauma was
coming into it, it's going to becompounding trauma.
You're now a vulnerablepopulation.
(29:09):
So I think that there are twothings that we really try and be
explicit about is notvillainizing people.
You can't blame the victim,right?
Many people are very shamefulabout the situations they've
been in when they've been usingsubstances, and we have to kick
that out the window.
But the other thing is, as Ispoke about before, is
(29:30):
identifying what are the keythings that are so hard to sit
with, because if we could tryand address some of that in a
therapeutic manner then thealcohol or whatever use could
diminish.
We had one patient that came in, went to our substance use
program, went out drank.
Went to another one of ourpsychodynamic programs, went out
, drank.
It wasn't until this person didthe trauma program that the
(29:52):
drinking stopped.
Because that's what it was.
We were seeing the tip of theiceberg, but it was just the
symptom that was visible.
All the other things we neededto address first to have that
iceberg go back under thesurface first to have that
iceberg go back under thesurface.
Speaker 1 (30:09):
So just to level set around who my audience is some
of them are healthcare providers, some of them are not.
Can you explain what atrauma-informed approach is and
then give me an example of,let's say, a program or a
modality that is nottrauma-informed and how you make
it trauma-informed?
Speaker 2 (30:23):
So one of the things that is really important first,
like first blush looking at apatient is that you have to
understand that asking somebodydirect assessment questions of
whether or not they've been avictim, have you ever been
sexually assaulted those sort ofthings People are going to tell
you no or they're going to tellyou yes, but it's not a way to
inspire conversation about howwe can address it.
So it has to be aconversational assessment to
(30:46):
begin with, about just towingthe water of have you felt
unsafe before?
I'm not validating whether ornot your assessment of your
safety was real.
I just need to know if you feellike you've been at risk before
of being vulnerable, becausethat's where the conversation
starts.
As we get to know people, we cansuss out a little bit more of
(31:06):
what it looks like to build ahistory of if they have some of
the symptoms that would beconsistent with, for example, a
PTSD.
We can ask about hypervigilance, we can ask about nightmares.
We can get some of thosecriteria met, but at the end of
the day, I actually don't needto know so much about the
specific trauma.
I need to know about yourresponse to it.
I need to know how it'simpacting your functioning today
(31:27):
.
And that's where when we saytrauma-informed care is that we
need to get a little bit of abase, but then watch and observe
the patient and see how we'reseeing it play out, because
that's where we can start tomake measured changes and
customize our approach to how weindividualize trauma-informed
care.
Speaker 1 (31:45):
Give me an example of a program that is not
trauma-informed, and then howyou make it trauma-informed.
Let's say, a residentialtreatment program.
Speaker 2 (31:51):
So all of ours here are trauma-informed.
I would say that, honestly, anysubstance use program, any
rehab that is not consideringhow to process trauma whether it
be from before a substance usestarted or during is not going
to approach.
It's not trauma informed,because once you've been
intoxicated and do not have yourexecutive function intact, you
(32:14):
are potentially a victim.
You're vulnerable.
Things that happen during thattime A you might have not have
consolidated memory from whichis scary, or.
B you might have memories thatare kicking around in your mind
as bringing up negative emotions.
You don't like those emotions,you're scared of having them
again and you can't quit thesubstance.
(32:35):
So the potential that thosethings are going to happen again
is hanging over your headconstantly.
There is going to be ahyperarousal associated with
that.
So to just say no, no, no,let's talk about cues, let's
talk about triggers, let's talkabout relapse prevention that's
not going to work if you're notthinking about the things that
will amplify those cues.
Speaker 1 (32:55):
Let's weave our conversation together here.
How do you address stigmaagainst PTSD when people don't
understand what it is?
Speaker 2 (33:02):
Well, that's the thing is you have to identify it
first.
They don't even know what'shappening.
I've had patients say I just Ican't calm down and I was like,
oh, we have a name for that,it's called hyperarousal.
But they really don't evenunderstand that.
Not everybody's living likethat and there are papers
written about this.
But if there was a traumaticupbringing, these adverse
childhood experiences, if theywere like on edge all the time,
(33:24):
then they may have justfunctionally started to be quite
numb.
So as they felt very, very numband then got into this
adolescent age, they might seeksubstances that stimulate them,
that bring them to life, becausethey've spent a whole time
retreating back, that they don'treally feel like they're alive
until they bring something up.
So our stimulants, ourhallucinogens, things like that,
our stimulants, ourhallucinogens, things like that.
(33:48):
The other side is the peoplethat are constantly, constantly
so scared and that hyperarousalhas started early that they
cannot tolerate it.
They just want to break, theywant to come in from the cold.
So they seek the numbingsubstances.
They're looking at thesedatives, the opiates, alcohol,
things like that.
But when we remove those, theother state remains, and so that
can be traumatic in and ofitself.
Now you're being reminded ofthis mood state when something
(34:10):
bad was happening.
So now something bad happened.
You became numb.
You started using stimulantsand we tell you, it gets over.
You get sober, you're back tonumb, and now that's cuing you
of that time period where youneeded to be numb.
So we have to deal with it.
Speaker 1 (34:28):
It's how it all interconnects.
How about, in terms of stigma,when loved ones of a person
getting treatment don'tunderstand PTSD?
Speaker 2 (34:33):
So PTSD is something that you know because we've all
lived through some of the warsand things like that.
People really associate it withveterans.
By no means is itwholeheartedly associated with
veterans.
That is our poster child,because almost 100%, I would say
, of people that have servedhave some traumatic experience.
But that does not discount thatanybody walking around on the
(34:54):
street can have traumaticexperiences and it does not mean
that you're again a defectiveperson.
It means that the emotionsconnected with the event created
some disruption in your brainwhere it is no longer firing in
the way that it was before.
Whatever experience, it's not afault of yours.
It's literally a brain wiringthing where your brain is now
(35:16):
signaling be worried, be aware,let's not let this happen again.
Let me remind you about this itis not a choice to make this
thing impactful.
It is something that happenedin your brain when that thing or
situation or string ofsituations happened.
That now you cannot correctwithout a measured response to
it Therapy, sometimes somemedications, or just really
(35:39):
being mindful of how you areresponding to the intrusive
thoughts that are present withPTSD.
Speaker 1 (35:45):
I have to say, when I was diagnosed with PTSD I was
embarrassed.
I was afraid to share with mycolleagues.
It took me about four to fivemonths to finally get up the
nerve to tell my colleagues.
And then I realized I had toown it and if I was going to
break down some of the stigmaaround mental illness at my
institution I had to share it.
So I finally got up the nerveand I was chief of staff at the
(36:08):
time.
So I wrote my chief of staffletter to the board of trustees
in my hospital about my PTSDdiagnosis and I was really
pleased.
The board had a very favorableresponse.
They thanked me for sharing andthen I shared that same letter
with my emergency departmentgroup and I got a lot of
positive support.
But I still feel like a coupleof my colleagues are like yeah,
grover's a sissy.
So I don't know.
(36:30):
Personally I feel like now I'min a place where I can own my
diagnosis and I can talk freelyabout it.
But I was really scared when Ifirst got that diagnosis.
Speaker 2 (36:38):
Tough men don't get PTSD yeah.
Speaker 1 (36:40):
Yeah.
Speaker 2 (37:00):
I see you smiling to it.
It is not something again, likeyou said, nobody's going to
grow up and say I want thistraumatic event to impact me in
this way.
It is not a choice we made towallow in our sorrows of
something that has happened tous.
It is something that we cannotmanage the impact of, for
(37:23):
whatever reason.
The chemistry of our brain didnot allow us to manage it.
I think about a lot.
I don't know I forget if it wasa podcast or a documentary I
watched but about how you couldhave a bunch of people, for
example, in a bus crash, right,and everybody's experience or
impact of it is different.
And how do you predict whose iswhat?
Honestly, you can't.
You cannot predict who getswhat from that same event.
(37:46):
They all brought differentthings to it, they took
different things away from it.
But looking at it, that spaceand time you cannot point around
and say this person's going tohave a PTSD diagnosis in six
months from this.
It's just not predictable inthat way, because it doesn't
happen to people that haveidentified shared
characteristics.
Speaker 1 (38:02):
So we've talked about your work as a deputy chief
medical officer overseeingsubstance use treatment.
You try to make addiction caremore friendly, such as by
accommodating difficulties withscheduling when people are in
active addiction because ofdiminished executive function.
You talked about trying toreduce stigma.
You talked about beingtrauma-informed.
What else do you do to makeaddiction care better where you
(38:25):
work?
Speaker 2 (38:25):
informed.
What else do you do to makeaddiction care better where you
work?
We have to involve families.
We have to.
You can't do it without.
It's like fixing a car andsending it back to somebody that
doesn't know how to drive.
If the family around, orwhoever it doesn't have to be
family, the support systemdoesn't understand addiction.
It's very hard for the personwith the addictive disorder to
go back out and fend forthemselves.
It has to be a team effort.
(38:46):
When I meet with patients, Iactually I meet with patients
and I spend a ton of time withthe families because they have
questions.
I mean, I just did an opiatedetox for a gentleman and
probably spent I don't knowmaybe an hour and a half on the
phone with his wife because shehad so many questions.
He'd come by the prescription,honestly, but the way that it
affected his brain, he ended upwith an opiate use disorder and
(39:08):
so she really wanted to go fromthe beginning.
How did this happen?
How did this start?
When did you know?
Just, it was like having accessto somebody to ask the
questions was huge for her, andit made me realize how little
access some of the generalpopulation has to these
questions and they just don'thave the knowledge, and without
the knowledge it's hard todiscount the stigma that's
(39:29):
attached to it.
Speaker 1 (39:30):
It really is.
As we get to the end of ourtime here recording this episode
, what's next on your to-do listto improving addiction care at
your institution?
Speaker 2 (39:41):
Well, one of the big things and we're doing it this
year when I'm speaking at one ofthe high schools locally here
is we got to get it out to theyouth.
If we don't start this earlierand earlier, then it's harder
for me to treat it later andlater we're already in the
addiction field.
I don't know if you're seeingit too, dealing with the kind of
the baby boomers that they werethe 60s 70s.
Pot was not that dangerous thenas it is now.
They really have a differentrelationship with drugs and
alcohol than this populationhere.
(40:02):
But if we don't, youth does too.
They've stigmatized alcohol ina way that's a little bit newer.
But they're doing all kinds ofother what they think are clean
things that aren't.
Speaker 1 (40:10):
Like whippets.
Speaker 2 (40:17):
Exactly Like.
They think there's no lastingimpact of it.
So this is fine, but there islasting impact.
So one of the things that we'rereally and I'm really trying to
do is provide psychoeducationfor the dangers of cannabis use
in adolescents and whatconversations parents should be
having with their loved ones.
It's about being able to be theone to say no.
It's really hard in a group ofteenagers to say no and to be
comfortable saying no.
So doing that kind ofsupportive interventions in the
(40:39):
community studies show that ifyou target the most at-risk
youth, it has a herd effect andyou can disseminate it to other
people.
So being able to make an effort, knowing that, even if you
don't see it right now, that itwill be impactful later on.
Speaker 1 (40:53):
Well, if you need any slide decks, let me know.
I've been going to schools andtalking to students and parents
for about a decade.
Speaker 2 (40:59):
Amazing.
Well maybe I will hit you upfor that.
Speaker 1 (41:02):
It's actually one of the things I would encourage you
to do is walk into a smoke shop.
If you haven't done it already.
I've done a couple of episodeson Kratom and just seeing how
Kratom is sold and then takingsome photos of just how vapes
are sold and really targetedtowards kids, colors, flavors I
got plenty of slide decks, sowhen you're ready, reach out.
It's something we've beenworking on for quite a while
here in Monterey County.
(41:23):
As a deputy chief medicalofficer, what's the rest of your
day look like?
Speaker 2 (41:26):
I only got two more hours of the day, so I'm going
to go check on the detoxes weadmitted today to make sure
everybody is tucked in for theweekend, particularly the one
that was using Kratom, because,listen, you got to understand
what we're doing with theSuboxone that she doesn't think
she needs, but she definitelyneeds.
Speaker 1 (41:42):
I would agree.
So that's my day.
Okay, well, I have to say I, Iwould agree.
So that's my day.
Okay, well, I have to say I amso glad someone like yourself is
leading the ship at yourinstitution, because I can tell,
in speaking to you, yourpassion for your patients and
for what you do.
Thank you so much for joiningme.
I have learned a ton andappreciate the work that you do.
Speaker 2 (41:57):
Of course, it was lovely to meet you.
Speaker 1 (42:01):
Before we wrap up, a huge thank you to the Montage
Health Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
addiction and prevent overdosesTo those healthcare providers
(42:24):
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
treated.
Together we can make it happen.
Thanks for listening andremember treating addiction
(42:47):
saves lives.
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