March 17, 2025 • 19 mins
This episode provides a deep dive into the complexities of addiction medicine learned from seeing patients in my practice. Through real patient cases, I highlight the importance of tailored approaches to addiction that consider both the physiological and psychological aspects of recovery.
We discuss
• Insights into demographics of substance use in a rural setting
• The effectiveness of dual medication therapies for alcohol use disorder
• The link between trauma and substance use disorders
• Emerging concerns surrounding kratom as a public health issue
• The significance of managing co-occurring ADHD in addiction treatment
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.
(00:21):
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 will be on myexperience practicing addiction
(00:43):
medicine in a rural area near me.
My primary practice is inMonterey, which is on the
central coast of California.
The county to the east of us isSan Benito, and I drive there
two days a month to see patients.
It's a fairly rural area andthe county is much smaller than
where I practice in Monterey.
I was asked to present on whatsort of cases I am seeing there,
(01:05):
so I prepared a lecture thatshared my overall experience and
I highlighted three cases thatI thought had great learning
points around how to treataddiction.
Let's dig in All right.
Well, I'm happy to get started.
My name is Casey Grover, I am anaddiction medicine doctor and I
(01:31):
come two days a month to seepatients in person, and then I
do a lot of follow-ups viatelemedicine as well.
So I'm going to share what I'vebeen seeing in the last seven,
eight months.
Hi everyone.
So I started driving over therein May of 2024, and I come out
almost every month the firstMonday of the month and the
second Friday of every month andI'm there for about four hours
(01:51):
and I see whoever I can.
Sometimes I see folks once ortwice and they don't follow up.
Sometimes I see them everymonth.
I actually looked in ourelectronic health record and
here's about what I'm seeing,our electronic health record and
here's about what I'm seeing.
So I basically just looked atwho I am seeing, what their drug
of choice is, and some folkscan't really name a drug of
(02:11):
choice, so I classified them aspolysubstance use.
So it's about 50-50 men andwomen, about 40% alcohol.
Less opioids than I expectedonly 23%.
Less stimulants than I expectedonly 13%.
Maybe that's because therearen't a lot of medication
options for stimulants 8%cannabis, a very small number of
(02:34):
benzos and kratom and if you'renot too familiar with kratom,
I'm going to talk about it injust a little bit.
And then about 13% said Ireally can't pick a substance I
use more than one.
And about 13% said I reallycan't pick a substance I use
more than one.
So I'm going to go through acouple of cases that really
highlight the work that I do andI can share some of the things
that I've learned from seeingpatients.
(02:55):
And I just want to clarifybefore I go any further.
I am board certified inaddiction medicine, but I didn't
do a fellowship, so my firstlife was as an ER doc.
I spent 14 years working inemergency departments and I
decided I wanted to practiceaddiction medicine.
So I started learning about iton my own and getting some
clinical opportunities, and theway it works right now is we
(03:18):
have so few addiction medicinedoctors that if you can show
that you're competent andactively practicing addiction
medicine for enough time,they'll grant you the ability to
sit for the board exam, whichis what I did.
So my approach to addictionmedicine may be a little
different than what folks areused to if they come from more
of a formal training setting.
I've really learned everythingfrom my patients, so here we're
(03:41):
going to go through the firstcase here.
So this is one of my patients.
He's about 50 and I see him foralcohol use disorder.
I've been seeing him forprobably about six months and my
first visit with him he'd hadalcohol the night before and he
was mostly a binge drinker andhe described as using alcohol to
manage negative emotions.
So at the time I didn't have agreat sense of how to really be
(04:05):
more thoughtful aboutmedications for alcohol use
disorder, so I went with myusual go-to, which was
naltrexone.
Naltrexone, again, is an opioidblocker.
It works by reducing thepleasure of alcohol and
therefore the pleasure ofanticipating alcohol, so it
works to reduce cravings alcohol.
So it works to reduce cravings.
(04:26):
He actually couldn't get itbecause there was a shortage at
the time and he continued todrink.
And when he came for his nextvisit and I was talking to him,
I'd had some recent luck withcombining naltrexone and topamax
and he really wanted to getsober.
So I put him on naltrexone andtopamax.
Topamax, the generic name istapiramate.
It's a medication for seizuresand migraines that works for
(04:47):
alcohol cravings, and I put themon 50 milligrams each a day and
he has had a profound responseto the combination of naltrexone
and topamax, also known astapiramate.
He has not had a single cravingsince I put him on this and so
he's actually been sober forJuly of 2024.
(05:08):
And this might seem like afairly simple case, but I wanted
to bring up some wisdom aboutmedications for alcohol use
disorder, which is that theydon't work very well.
If we had really goodmedications for alcohol use
disorder, which is that theydon't work very well, if we had
really good medications foralcohol use disorder, the way we
do for opioids, we couldprobably help a lot of people
(05:29):
get sober faster.
But here's what I learned.
So naltrexone works, but itdoesn't work that well in
everyone.
Some people on naltrexone haveno desire to drink and as long
as they stay on it they do great.
But let's say, for example, onnaltrexone have no desire to
drink and as long as they stayon it they do great.
But let's say, for example,that naltrexone does work, but
it only drops the alcoholcravings by maybe 20%.
Topiramate or Topamax can alsobe very effective for some
(05:51):
people.
In a couple of my patients it'scompletely gotten rid of the
desire to drink.
But again, in most people itdoesn't.
So let's say that thetapiramate reduces the alcohol
cravings by 30%.
With either drug alone it's asmall difference.
But when you add anti-cravingmeds for alcohol in from
different drug classes, I findthat they have an additive
(06:11):
effect.
So this is an example for thispatient where and I actually
didn't try him on monotherapy,but with dual therapy he has a
significant reduction in hiscravings and he's now able to be
alcohol-free.
So my go-to is now to reallystart all my patients with
alcohol use disorder on twomedications to reduce cravings,
because each individuallydoesn't have a huge effect, but
(06:35):
together they have a much biggeradditive effect.
So if you've referred me any ofyour clients and they come back
to you on two medications foralcohol use disorder, that's why
the second case that I found tobe very, very educational we're
going to go through now.
A patient in her early 30sreferred to me for alcohol use
disorder had been drinkingrelatively recently.
(06:56):
Before our first visit she wasalso a binge drinker.
I didn't actually ask too muchabout why she was drinking, but
she described as binging.
And then on her first year indrug tests she was also positive
for cocaine and it turned outthat she would use mostly
alcohol and then occasionallywent under the influence.
She would use cocaine.
And she was doing a lot ofrecovery work.
(07:17):
She was going to groups, shewas going to meetings and wanted
to make some progress.
So same thing I put her on dualtherapy.
I put her on gabapentin, whichcan be used to reduce alcohol
cravings, and naltrexone, andshe was able to stay sober for
about two months.
Unfortunately she missed afollow-up.
I heard back from her aboutthree months later.
(07:38):
A friend had passed, she hadsome very strong emotions, went
back to drinking and was readyto get some help again.
And so, probably learning frommy first case, I put her on the
combination the second time ofnaltrexone and topiramate, again
also known as Topamax, to seehow she would respond.
Same pattern she was able tostay sober about two months.
(08:04):
She mentioned she was havingsome strong emotions.
We talked about antidepressants.
She had had some experiencewith Zoloft, so I restarted that
.
And then unexpectedly she had apositive pregnancy test and she
was worried about medicationscausing harm in pregnancy.
For context, topamax orTopiramate cannot be taken in
pregnancy.
Zoloft or Sertraline is thesafest of that class of
(08:28):
antidepressants in pregnancy andthere's not a lot of data on
naltrexone in pregnancy.
But she was worried so shewanted to stop and unfortunately
without her meds.
But she was worried, so shewanted to stop and unfortunately
(08:59):
without her meds she relapsed.
We all know that alcohol causestons of damage to the pregnancy
.
So she immediately got back andgot an appointment with me and
she really wanted to stay soberand continue the pregnancy.
Unfortunately she had amiscarriage and she had a period
of drinking after themiscarriage and then came back
to see me again and at the nextvisit I'd spent quite a bit of
time before her visit learningabout post-traumatic stress
disorder and I always try to ask, like, why do you drink?
Like what does alcohol do foryou?
How does it help you?
Or whether it's alcohol orcocaine or whatever, I try to
(09:22):
understand the why.
You know and I'm going toexaggerate to make a point Our
patients don't have problemswith drugs and alcohol.
They have problems with howthey feel and they get tricked,
their brain gets tricked intothinking that the drugs and
alcohol help.
So I always try to go back andsay why are you doing this?
And I hadn't really gotten agood answer from her, so I took
a shot in the dark and I said doyou have any trauma history?
And she initially said no, notreally.
And as I probed a little bit,it turns out that her stepfather
(09:45):
beat her as a child and wasverbally abusive and she had a
near fatal accident at about age20 that put her in the hospital
for three weeks and the legalproceedings after the accident
lasted for about two years.
So I went through the DSM-5criteria for PTSD with her and
she met every criteria.
And so I said and this is nother name I said, you know, sarah
(10:08):
, I wonder if alcohol isactually your problem.
Maybe we should start treatingyour PTSD that we didn't know
you had.
So I changed her medicationsaround.
I increased her Sertraline orZoloft, I stopped her Naltrexone
and I put her on Prazacin,which can help with nightmares,
and Propranolol to help her whenshe was triggered, and she felt
(10:31):
really empowered by knowingthat she had PTSD.
She was seeing a therapist atthe time.
She totally changed her mindsetand I just saw her on Friday.
She is so grateful that wefigured out some of why she
drinks and I just saw her.
I said on Friday I'm actually alittle bit off here.
(10:52):
She's about three months sober,feeling great, no cravings,
really wants to focus on thetrauma.
I actually apologize to her, asI have for many of my patients,
for not asking about traumasooner when I'm seeing them.
Now I'm a little more in tunewith that and I do much more of
a trauma screen with my patientswhen I first get to meet them
(11:12):
All right.
Case number three Some of youmay know this client because
she's a little unique, but thisis a young woman who came in to
ask for help with kratom, andthe reason I bring up kratom is
kratom is a kind of a brewingdisaster in the world of
addiction medicine and, just tolevel set, just to make sure
we're all on the same page,kratom is a leaf from a plant
(11:35):
that's grown in Southeast Asiathat has a number of effects on
the body At low doses it's astimulant, and at a higher dose
it acts like an opioid.
Most medical providers that youtalk to this about have no clue,
and so this particular patientmentioned to the staff at County
Behavioral Health that shereally hadn't found a doctor
(11:56):
that knew much about Kratom, andI outed myself as a Kratom geek
.
I've been on the KratomSobriety Podcast.
I've interviewed some folks inthe Kratom industry.
I've been on the KratomSobriety Podcast.
I've interviewed some folks inthe Kratom industry.
I even went to a local smokeshop and bought Kratom.
This is a big issue.
It's estimated that as many as20-something million Americans
use Kratom, and yet it's anunregulated supplement.
(12:16):
There's a huge division in theKratom community of users as to
what the right treatment is.
So she was very grateful that Ihad some experience with Kratom.
So when I talked to her, shewas predominantly using Kratom
for its stimulant-like effect.
She was doing it to be moreproductive.
She felt like she needed to getthings done and I actually
(12:36):
talked to her, as many of mypatients who use stimulants have
.
She had some ADHD tendencies.
She had some trouble in school,she really struggled with math,
she had trouble stayingproductive and that's where it
seemed like Kratom really helpedher.
So she was dependent on Kratomand it acts like an opioid.
So I put her on some Suboxone,which she did fairly well on,
(13:00):
and I actually put her on someStratera the generic name for
that is adamoxetine because Ithought she might have some
underlying ADHD, the way she wasusing Kratom to get its
stimulant effects and sheactually felt a lot better.
She was able to get more doneat work.
She didn't have any cravings touse Kratom.
And then we transitioned herfrom suboxone Again, that's
(13:20):
buprenorphine and naloxone thesublingual form over to the
long-acting injectablebuprenorphine and the form I
used for her was sublocaine.
Interestingly, she just came into see me last week and had had
a relapse on kratom, despitebeing on sublocaine.
So she was not in opiatewithdrawal but was having some
(13:42):
breakthrough cravings.
And what had happened is herpsychiatrist had stopped her
Stratera for various reasons.
So she was feeling unfocusedagain and then she really didn't
have anything as needed forcravings.
So I just put her on a littlebaby dose of sublingual
buprenorphine, I gave her theSubutex formulation and then
she's going to see herpsychiatrist about managing her
(14:04):
ADHD.
So she might still be a goodcandidate for the adamoxetine,
but given the fact that she'salso having some depressive
symptoms, we may want to put heron some bupropion, also known
as Welbutrin.
So that's really an overview ofwhat I'm seeing.
Again, this is the breakdown ofthe various percentages of the
substances I'm treating peoplefor and, as you heard, a lot of
(14:29):
what I do is understandingmental health and trying to
support people with their mentalhealth, in addition to the
traditional MAT medications foraddiction.
So I'm going to leave you withfive take-home points and then,
if we have time for questions,I'm certainly happy to discuss.
(14:50):
The first is that medicationsfor alcohol use disorder really
don't work that well.
We have three of themdisulfiram or antibuse.
A camprosate or camperol andnaltrexone.
Most people really don't usethe brand names.
Each of them has maybe a littlebit of an effect, but when you
add them together they can bevery helpful.
I also use a lot of off-labelmedications for alcohol use
disorder and there are lots.
(15:11):
My go-to are really gabapentin,tapiramate or topamax and then
baclofen, and these are allmedications that can be used in
an additive fashion.
Usually I start with two againto have that additive
anti-craving effect.
The next issue is we mustunderstand how trauma affects
our patients and I know you allknow that I'm still fairly new
(15:34):
to this.
I'm getting very interested inthe work of Dr Gabor Mate.
In his words, everyone withaddiction is traumatized,
whether that's small traumaslike bullying as a child, or the
more severe traumas likepersonal violence, assault,
sexual assault.
We really have to co-managePTSD because many of our
(15:55):
patients are just trying to numbthemselves and I know that's an
oversimplification, butliterally yesterday my first
patient of the day years andyears of sexual assault in the
foster care system and she saidexactly, and I quote I drink
alcohol to numb my feelings.
So we have to address PTSD.
Number three as I mentioned,kratom is a developing public
(16:18):
health issue.
The industry is changing andmaking more and more potent
products.
Kratom is actually a leaf butyou can dry it and then put it
in a capsule so you can consumemore.
You can also chemically treatthe leaf and extract the
chemicals so you can get evenmore.
And they're actually evenstarting to really modify the
(16:40):
leaf and make some synthetic andsemi-synthetic versions of the
chemicals in kratom, almost likecoca leaf got turned into crack
cocaine.
We're seeing the same thing inthe kratom industry.
So we are going to see more andmore kratom, as it's
unregulated and these extractsand synthetics are extremely
potent.
(17:00):
The next is ADHD.
I was always taught in the ERthat ADHD is kind of a minor
issue.
Defer it to outpatientpsychiatry.
But really co-managing ADHD isimportant in treating addiction.
If you can imagine you can'tfocus on your schoolwork Because
you have ADHD.
It's very hard to focus on therecovery work.
So I am now very aggressive intreating unmanaged ADHD in
(17:24):
patients.
I use a lot of thenon-addictive ADHD medications.
And then the last thing isbuprenorphine.
A lot of our patients don'tlike to be dependent on anything
.
I get countless people askingme when am I done with
buprenorphine?
The data would suggest thatwhen people come off of
buprenorphine when they'restable for opioid use disorder.
(17:45):
Within about 18 monthstwo-thirds will relapse, get
back on buprenorphine or have anoverdose.
So, as we heard in the thirdcase, being fairly liberal with
small amounts of as-needed forbreakthrough cravings can be
very helpful.
And if someone does want tocome off their buprenorphine,
it's a lot of regular contact tomake sure that they know what
(18:07):
to do if they're craving.
And then again, for a lot of mypatients, I just give them like
maybe a few doses ofbuprenorphine a week that they
can take when they are craving.
So for this patient, we'regoing to keep her on sublocade
for several months and then useit to wean her off of
buprenorphine, and then I'llstill keep her on just a few
doses of buprenorphine a week,as needed.
(18:27):
Before we wrap up, a huge thankyou 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
(18:50):
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
(19:13):
saves lives.
I'll see you next time.
Welcome to the Addiction Medicine Made Easy
podcast.
Hey there, I'm Dr Casey Grover,an addiction medicine doctor
based on California's CentralCoast.
(00:21):
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 will be on myexperience practicing addiction
(00:43):
medicine in a rural area near me.
My primary practice is inMonterey, which is on the
central coast of California.
The county to the east of us isSan Benito, and I drive there
two days a month to see patients.
It's a fairly rural area andthe county is much smaller than
where I practice in Monterey.
I was asked to present on whatsort of cases I am seeing there,
(01:05):
so I prepared a lecture thatshared my overall experience and
I highlighted three cases thatI thought had great learning
points around how to treataddiction.
Let's dig in All right.
Well, I'm happy to get started.
My name is Casey Grover, I am anaddiction medicine doctor and I
(01:31):
come two days a month to seepatients in person, and then I
do a lot of follow-ups viatelemedicine as well.
So I'm going to share what I'vebeen seeing in the last seven,
eight months.
Hi everyone.
So I started driving over therein May of 2024, and I come out
almost every month the firstMonday of the month and the
second Friday of every month andI'm there for about four hours
(01:51):
and I see whoever I can.
Sometimes I see folks once ortwice and they don't follow up.
Sometimes I see them everymonth.
I actually looked in ourelectronic health record and
here's about what I'm seeing,our electronic health record and
here's about what I'm seeing.
So I basically just looked atwho I am seeing, what their drug
of choice is, and some folkscan't really name a drug of
(02:11):
choice, so I classified them aspolysubstance use.
So it's about 50-50 men andwomen, about 40% alcohol.
Less opioids than I expectedonly 23%.
Less stimulants than I expectedonly 13%.
Maybe that's because therearen't a lot of medication
options for stimulants 8%cannabis, a very small number of
(02:34):
benzos and kratom and if you'renot too familiar with kratom,
I'm going to talk about it injust a little bit.
And then about 13% said Ireally can't pick a substance I
use more than one.
And about 13% said I reallycan't pick a substance I use
more than one.
So I'm going to go through acouple of cases that really
highlight the work that I do andI can share some of the things
that I've learned from seeingpatients.
(02:55):
And I just want to clarifybefore I go any further.
I am board certified inaddiction medicine, but I didn't
do a fellowship, so my firstlife was as an ER doc.
I spent 14 years working inemergency departments and I
decided I wanted to practiceaddiction medicine.
So I started learning about iton my own and getting some
clinical opportunities, and theway it works right now is we
(03:18):
have so few addiction medicinedoctors that if you can show
that you're competent andactively practicing addiction
medicine for enough time,they'll grant you the ability to
sit for the board exam, whichis what I did.
So my approach to addictionmedicine may be a little
different than what folks areused to if they come from more
of a formal training setting.
I've really learned everythingfrom my patients, so here we're
(03:41):
going to go through the firstcase here.
So this is one of my patients.
He's about 50 and I see him foralcohol use disorder.
I've been seeing him forprobably about six months and my
first visit with him he'd hadalcohol the night before and he
was mostly a binge drinker andhe described as using alcohol to
manage negative emotions.
So at the time I didn't have agreat sense of how to really be
(04:05):
more thoughtful aboutmedications for alcohol use
disorder, so I went with myusual go-to, which was
naltrexone.
Naltrexone, again, is an opioidblocker.
It works by reducing thepleasure of alcohol and
therefore the pleasure ofanticipating alcohol, so it
works to reduce cravings alcohol.
So it works to reduce cravings.
(04:26):
He actually couldn't get itbecause there was a shortage at
the time and he continued todrink.
And when he came for his nextvisit and I was talking to him,
I'd had some recent luck withcombining naltrexone and topamax
and he really wanted to getsober.
So I put him on naltrexone andtopamax.
Topamax, the generic name istapiramate.
It's a medication for seizuresand migraines that works for
(04:47):
alcohol cravings, and I put themon 50 milligrams each a day and
he has had a profound responseto the combination of naltrexone
and topamax, also known astapiramate.
He has not had a single cravingsince I put him on this and so
he's actually been sober forJuly of 2024.
(05:08):
And this might seem like afairly simple case, but I wanted
to bring up some wisdom aboutmedications for alcohol use
disorder, which is that theydon't work very well.
If we had really goodmedications for alcohol use
disorder, which is that theydon't work very well, if we had
really good medications foralcohol use disorder, the way we
do for opioids, we couldprobably help a lot of people
(05:29):
get sober faster.
But here's what I learned.
So naltrexone works, but itdoesn't work that well in
everyone.
Some people on naltrexone haveno desire to drink and as long
as they stay on it they do great.
But let's say, for example, onnaltrexone have no desire to
drink and as long as they stayon it they do great.
But let's say, for example,that naltrexone does work, but
it only drops the alcoholcravings by maybe 20%.
Topiramate or Topamax can alsobe very effective for some
(05:51):
people.
In a couple of my patients it'scompletely gotten rid of the
desire to drink.
But again, in most people itdoesn't.
So let's say that thetapiramate reduces the alcohol
cravings by 30%.
With either drug alone it's asmall difference.
But when you add anti-cravingmeds for alcohol in from
different drug classes, I findthat they have an additive
(06:11):
effect.
So this is an example for thispatient where and I actually
didn't try him on monotherapy,but with dual therapy he has a
significant reduction in hiscravings and he's now able to be
alcohol-free.
So my go-to is now to reallystart all my patients with
alcohol use disorder on twomedications to reduce cravings,
because each individuallydoesn't have a huge effect, but
(06:35):
together they have a much biggeradditive effect.
So if you've referred me any ofyour clients and they come back
to you on two medications foralcohol use disorder, that's why
the second case that I found tobe very, very educational we're
going to go through now.
A patient in her early 30sreferred to me for alcohol use
disorder had been drinkingrelatively recently.
(06:56):
Before our first visit she wasalso a binge drinker.
I didn't actually ask too muchabout why she was drinking, but
she described as binging.
And then on her first year indrug tests she was also positive
for cocaine and it turned outthat she would use mostly
alcohol and then occasionallywent under the influence.
She would use cocaine.
And she was doing a lot ofrecovery work.
(07:17):
She was going to groups, shewas going to meetings and wanted
to make some progress.
So same thing I put her on dualtherapy.
I put her on gabapentin, whichcan be used to reduce alcohol
cravings, and naltrexone, andshe was able to stay sober for
about two months.
Unfortunately she missed afollow-up.
I heard back from her aboutthree months later.
(07:38):
A friend had passed, she hadsome very strong emotions, went
back to drinking and was readyto get some help again.
And so, probably learning frommy first case, I put her on the
combination the second time ofnaltrexone and topiramate, again
also known as Topamax, to seehow she would respond.
Same pattern she was able tostay sober about two months.
(08:04):
She mentioned she was havingsome strong emotions.
We talked about antidepressants.
She had had some experiencewith Zoloft, so I restarted that
.
And then unexpectedly she had apositive pregnancy test and she
was worried about medicationscausing harm in pregnancy.
For context, topamax orTopiramate cannot be taken in
pregnancy.
Zoloft or Sertraline is thesafest of that class of
(08:28):
antidepressants in pregnancy andthere's not a lot of data on
naltrexone in pregnancy.
But she was worried so shewanted to stop and unfortunately
without her meds.
But she was worried, so shewanted to stop and unfortunately
(08:59):
without her meds she relapsed.
We all know that alcohol causestons of damage to the pregnancy
.
So she immediately got back andgot an appointment with me and
she really wanted to stay soberand continue the pregnancy.
Unfortunately she had amiscarriage and she had a period
of drinking after themiscarriage and then came back
to see me again and at the nextvisit I'd spent quite a bit of
time before her visit learningabout post-traumatic stress
disorder and I always try to ask, like, why do you drink?
Like what does alcohol do foryou?
How does it help you?
Or whether it's alcohol orcocaine or whatever, I try to
(09:22):
understand the why.
You know and I'm going toexaggerate to make a point Our
patients don't have problemswith drugs and alcohol.
They have problems with howthey feel and they get tricked,
their brain gets tricked intothinking that the drugs and
alcohol help.
So I always try to go back andsay why are you doing this?
And I hadn't really gotten agood answer from her, so I took
a shot in the dark and I said doyou have any trauma history?
And she initially said no, notreally.
And as I probed a little bit,it turns out that her stepfather
(09:45):
beat her as a child and wasverbally abusive and she had a
near fatal accident at about age20 that put her in the hospital
for three weeks and the legalproceedings after the accident
lasted for about two years.
So I went through the DSM-5criteria for PTSD with her and
she met every criteria.
And so I said and this is nother name I said, you know, sarah
(10:08):
, I wonder if alcohol isactually your problem.
Maybe we should start treatingyour PTSD that we didn't know
you had.
So I changed her medicationsaround.
I increased her Sertraline orZoloft, I stopped her Naltrexone
and I put her on Prazacin,which can help with nightmares,
and Propranolol to help her whenshe was triggered, and she felt
(10:31):
really empowered by knowingthat she had PTSD.
She was seeing a therapist atthe time.
She totally changed her mindsetand I just saw her on Friday.
She is so grateful that wefigured out some of why she
drinks and I just saw her.
I said on Friday I'm actually alittle bit off here.
(10:52):
She's about three months sober,feeling great, no cravings,
really wants to focus on thetrauma.
I actually apologize to her, asI have for many of my patients,
for not asking about traumasooner when I'm seeing them.
Now I'm a little more in tunewith that and I do much more of
a trauma screen with my patientswhen I first get to meet them
(11:12):
All right.
Case number three Some of youmay know this client because
she's a little unique, but thisis a young woman who came in to
ask for help with kratom, andthe reason I bring up kratom is
kratom is a kind of a brewingdisaster in the world of
addiction medicine and, just tolevel set, just to make sure
we're all on the same page,kratom is a leaf from a plant
(11:35):
that's grown in Southeast Asiathat has a number of effects on
the body At low doses it's astimulant, and at a higher dose
it acts like an opioid.
Most medical providers that youtalk to this about have no clue,
and so this particular patientmentioned to the staff at County
Behavioral Health that shereally hadn't found a doctor
(11:56):
that knew much about Kratom, andI outed myself as a Kratom geek
.
I've been on the KratomSobriety Podcast.
I've interviewed some folks inthe Kratom industry.
I've been on the KratomSobriety Podcast.
I've interviewed some folks inthe Kratom industry.
I even went to a local smokeshop and bought Kratom.
This is a big issue.
It's estimated that as many as20-something million Americans
use Kratom, and yet it's anunregulated supplement.
(12:16):
There's a huge division in theKratom community of users as to
what the right treatment is.
So she was very grateful that Ihad some experience with Kratom.
So when I talked to her, shewas predominantly using Kratom
for its stimulant-like effect.
She was doing it to be moreproductive.
She felt like she needed to getthings done and I actually
(12:36):
talked to her, as many of mypatients who use stimulants have
.
She had some ADHD tendencies.
She had some trouble in school,she really struggled with math,
she had trouble stayingproductive and that's where it
seemed like Kratom really helpedher.
So she was dependent on Kratomand it acts like an opioid.
So I put her on some Suboxone,which she did fairly well on,
(13:00):
and I actually put her on someStratera the generic name for
that is adamoxetine because Ithought she might have some
underlying ADHD, the way she wasusing Kratom to get its
stimulant effects and sheactually felt a lot better.
She was able to get more doneat work.
She didn't have any cravings touse Kratom.
And then we transitioned herfrom suboxone Again, that's
(13:20):
buprenorphine and naloxone thesublingual form over to the
long-acting injectablebuprenorphine and the form I
used for her was sublocaine.
Interestingly, she just came into see me last week and had had
a relapse on kratom, despitebeing on sublocaine.
So she was not in opiatewithdrawal but was having some
(13:42):
breakthrough cravings.
And what had happened is herpsychiatrist had stopped her
Stratera for various reasons.
So she was feeling unfocusedagain and then she really didn't
have anything as needed forcravings.
So I just put her on a littlebaby dose of sublingual
buprenorphine, I gave her theSubutex formulation and then
she's going to see herpsychiatrist about managing her
(14:04):
ADHD.
So she might still be a goodcandidate for the adamoxetine,
but given the fact that she'salso having some depressive
symptoms, we may want to put heron some bupropion, also known
as Welbutrin.
So that's really an overview ofwhat I'm seeing.
Again, this is the breakdown ofthe various percentages of the
substances I'm treating peoplefor and, as you heard, a lot of
(14:29):
what I do is understandingmental health and trying to
support people with their mentalhealth, in addition to the
traditional MAT medications foraddiction.
So I'm going to leave you withfive take-home points and then,
if we have time for questions,I'm certainly happy to discuss.
(14:50):
The first is that medicationsfor alcohol use disorder really
don't work that well.
We have three of themdisulfiram or antibuse.
A camprosate or camperol andnaltrexone.
Most people really don't usethe brand names.
Each of them has maybe a littlebit of an effect, but when you
add them together they can bevery helpful.
I also use a lot of off-labelmedications for alcohol use
disorder and there are lots.
(15:11):
My go-to are really gabapentin,tapiramate or topamax and then
baclofen, and these are allmedications that can be used in
an additive fashion.
Usually I start with two againto have that additive
anti-craving effect.
The next issue is we mustunderstand how trauma affects
our patients and I know you allknow that I'm still fairly new
(15:34):
to this.
I'm getting very interested inthe work of Dr Gabor Mate.
In his words, everyone withaddiction is traumatized,
whether that's small traumaslike bullying as a child, or the
more severe traumas likepersonal violence, assault,
sexual assault.
We really have to co-managePTSD because many of our
(15:55):
patients are just trying to numbthemselves and I know that's an
oversimplification, butliterally yesterday my first
patient of the day years andyears of sexual assault in the
foster care system and she saidexactly, and I quote I drink
alcohol to numb my feelings.
So we have to address PTSD.
Number three as I mentioned,kratom is a developing public
(16:18):
health issue.
The industry is changing andmaking more and more potent
products.
Kratom is actually a leaf butyou can dry it and then put it
in a capsule so you can consumemore.
You can also chemically treatthe leaf and extract the
chemicals so you can get evenmore.
And they're actually evenstarting to really modify the
(16:40):
leaf and make some synthetic andsemi-synthetic versions of the
chemicals in kratom, almost likecoca leaf got turned into crack
cocaine.
We're seeing the same thing inthe kratom industry.
So we are going to see more andmore kratom, as it's
unregulated and these extractsand synthetics are extremely
potent.
(17:00):
The next is ADHD.
I was always taught in the ERthat ADHD is kind of a minor
issue.
Defer it to outpatientpsychiatry.
But really co-managing ADHD isimportant in treating addiction.
If you can imagine you can'tfocus on your schoolwork Because
you have ADHD.
It's very hard to focus on therecovery work.
So I am now very aggressive intreating unmanaged ADHD in
(17:24):
patients.
I use a lot of thenon-addictive ADHD medications.
And then the last thing isbuprenorphine.
A lot of our patients don'tlike to be dependent on anything
.
I get countless people askingme when am I done with
buprenorphine?
The data would suggest thatwhen people come off of
buprenorphine when they'restable for opioid use disorder.
(17:45):
Within about 18 monthstwo-thirds will relapse, get
back on buprenorphine or have anoverdose.
So, as we heard in the thirdcase, being fairly liberal with
small amounts of as-needed forbreakthrough cravings can be
very helpful.
And if someone does want tocome off their buprenorphine,
it's a lot of regular contact tomake sure that they know what
(18:07):
to do if they're craving.
And then again, for a lot of mypatients, I just give them like
maybe a few doses ofbuprenorphine a week that they
can take when they are craving.
So for this patient, we'regoing to keep her on sublocade
for several months and then useit to wean her off of
buprenorphine, and then I'llstill keep her on just a few
doses of buprenorphine a week,as needed.
(18:27):
Before we wrap up, a huge thankyou 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
(18:50):
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
(19:13):
saves lives.
I'll see you next time.
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