May 5, 2025 • 48 mins
Dr. Casey Grover interviews fellow addiction medicine physician Dr. Jason Giles to explore how addiction specialists approach treatment using long-acting injectable medications as tools for recovery.
We discuss:
• Dr. Giles shares his personal journey from anesthesiology to addiction medicine after developing his own dependency on fentanyl
• Addiction as a disease of executive functioning that impairs decision-making ability
• Recovery requires building new neural pathways - learning to manage emotions without substances
• Long-acting injectable medications (Sublocade, Brixadi, Vivitrol) , and how these medications reduce cravings and provide protection while patients develop new coping skills
• The process of stopping buprenorphine
• Individualized tapering approaches help patients transition from daily medications to occasional use
• Creating a safe environment where patients can be honest is essential for successful 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.
(00:22):
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 fellow addiction medicine
(00:44):
physician, dr Jason Giles.
We connected to discuss how we,as addiction medicine doctors,
think about treating addiction,with a focus on using
long-acting injectablemedications.
A few clarifications before weget into the interview.
In the world of addictionmedicine, there are three
medications which can be givenas once-monthly injections.
(01:08):
The first is naltrexone and thebrand name is Vivitrol.
It is used to treat opioid usedisorder and alcohol use
disorder.
The second is buprenorphine.
There are two differentproducts.
One is called Sublocade and theother is called Brixati.
They're made by differentcompanies and have slightly
(01:28):
different characteristics and,just to clarify, I have no
financial ties to any drugcompanies.
Dr Giles and I focused ourdiscussion for this episode on
Sublocade and Brixati.
With that, let's dig in.
All right, why don't we startby having you tell us who you
are and what you do?
Speaker 2 (01:48):
Thanks, doc.
I'm Dr Jason Giles and I am anaddiction medicine doctor.
I've been doing that job forabout the last 20 years and my
specialty is taking care ofpatients in residential and
post-acute residential so theycall it PHP or aftercare step
down, add to drug and alcoholtreatment centers across the
country.
We also in our group we dopsychiatry as part of incidental
(02:12):
services, but we're also inmental health primary facilities
.
But that's my job Telemedicine,addiction medicine.
Speaker 1 (02:19):
How did you get interested in addiction medicine
?
Speaker 2 (02:23):
Well, my first inkling of it as a thing
probably goes back to when I wasa kid and my own father
struggled with alcohol, wentinto a recovery program himself,
ultimately got it.
And so I was aware from asingle digit early age that
(02:43):
people people had trouble withsubstances, that sometimes the
things that we sought, that weseek for relief, become problems
of their own.
So I, I knew, I knew about thatfrom before.
I didn't have interest inpursuing that in in school or in
in training until I was forcedto get some education in it when
(03:06):
I myself developed a problemwith substances on the tail end
of my residency inanesthesiology.
My particular substance wasn'talcohol.
It was well when I used to saythis.
I would have to repeat itbecause this is 25 years ago.
People would say what's that?
But they don't say that anymore.
(03:27):
But the substance that I gottangled up with is called
fentanyl, and now everyone knowswhat that is.
So it was a pioneer in thatsense, a trailblazer, but it's
what was around.
There are a lot of reasons why Iwent that way, perhaps genetic,
maybe there's a geneticcomponent because of the family
history, but for whatever thereasons were, I wound up as a
(03:47):
patient needing help, dealingwith my own dependence and then
getting into the deeper reasons.
What was behind that, why anice guy like me was in a place
like that.
And as I learned more aboutthis problem or malady, or some
call it a disease I don't likethat word, but whatever this
thing is that you and I dealwith all the time, it became
(04:10):
endlessly fascinating to me, notjust from a personal standpoint
of wanting to make sure thatthings didn't go back the way
they were, but also it's a, it'sa whole frontier in medicine.
That is the most exciting, mostinteresting, endlessly
fascinating field of medicine,because you're dealing with the
(04:32):
decisions that people make.
You're dealing with the choicesthat they make and how can we
favorably influence theirchoices, how can we keep them on
track.
So I, I, I'm like the fish whoflopped off of the dock and back
into the lake.
I felt like I was home.
So my training is inanesthesiology.
I did cardiac anesthesia.
I did a fellowship in painmedicine.
(04:55):
That's probably part of where Istarted to get interested in
the medical interventions andalso the management of emotional
pain, not just physical painno-transcript.
Speaker 1 (05:25):
One thing you said when you talked about the
decisions that people make theway I'm describing addiction to
family members is addiction is adisease of executive
functioning, and executivefunctioning is the ability to
keep a calendar, to know when tosave money versus spend it when
something's a good decision ora bad decision.
(05:45):
And it's really challenging forfamily members to understand
this that the actual ability tomake good decisions is very
impaired in addiction.
I'm just curious how thatresonates with you, given your
both lived experience andprofessional experience.
Speaker 2 (05:57):
I agree with you completely.
I think that's exactly on point.
You can make analogies.
It's like having your steeringwheel on your car obey you,
sometimes, ah, that's a good one, but not all the time I'm going
to steal that.
So you know, here we are, thethe arrow's green, it's time to
turn left.
And you, you start pulling handover hand as you, as you
(06:20):
accelerate, and the car says youknow, actually we're going to
go straight and maybe, and maybeinto another car, maybe into
the island, or maybe, you know.
So it's not that the decisionsare always bad.
That would be fine.
We would just become conserved.
We would say I can't makedecisions anymore.
And you know that that's a,that's a thought disorder, right
(06:43):
?
So you don't course connectedwith the real world of how
things work.
So we're not going to let youmake decisions about yourself
anymore.
To protect you, the trouble isit's faulty.
So sometimes it works andsometimes it doesn't.
People hold up their strengthsand say look I just, I had my
best quarter ever, my best year,or I won the, I'm the
(07:04):
valedictorian, or I you knowsomething, something great in
their life.
But but it's not consistent,right?
It's keep a calendar, it's,it's exercise self-discipline
through the difficult periods.
But yeah, it's, it's, it'simpaired decision-making is is
is the heart of it.
I agree with you completely.
Speaker 1 (07:22):
I think also, you pointed out something really
useful to pause and consider,which is that sometimes it works
and sometimes it doesn't.
To your point, someone withschizophrenia cannot understand
reality and may require to beliving in an institution where
they have someone to makedecisions for them.
But I like what you said aboutsometimes they can make
decisions and sometimes theycan't, which I know for my
(07:42):
families of my patients theyreally struggle with, because
that's where trust becomes.
Such an issue is that you didgreat today, but not tomorrow.
When can I trust you?
So I talk a lot about trying tobe consistent when things are
good and bad for my patientswhen they communicate with their
families.
Have I had a good day today andI had a bad day today, but I am
totally going to give youcredit for that.
My next visit I have with afamily member.
Speaker 2 (08:04):
There's a neuro anatomical explanation for why
that's true.
So another way of thinkingabout addiction is learning.
So it's like it's learning andwe all everyone learns.
We learned how to walk and welearned how to speak and we
learned.
Most people about 96% inAmerica learn how to ride a
(08:24):
bicycle and even if you don'tride a bicycle every day, most
people don't forget how to ridea bicycle Because of all the
repetition and because of thepracticed building of an
automatic routine to keep youbalanced on the bike, which is
what riding a bicycle isbalancing.
Keep you balanced on the bike,which is what riding a bicycle
(08:47):
is balancing.
That routine that you spent allthose hours learning, usually
as a kid, is still there and youcan access it later when you
get back on a bike.
It's the same with usingsubstances to change the way you
feel.
It's just another loop.
So I feel scared, I have adrink, or I feel I feel, you
know, ineffective and I havesome cocaine so that I feel
(09:08):
powerful, whatever, whatever thethe substance habit loop is, we
learn if I smoke weed, I'm notbothered by my parents, or I'm
not bothered by my wife, or I'mnot whatever, whatever the thing
is.
So we, we develop this shortcutloop of when I do this, I can
(09:29):
control my feelings.
Well, that is like learning toride a bike, and you don't
forget that.
So when the circumstances comeup later, and until you've built
another, stronger automaticloop which is when I feel scared
stronger automatic loop, whichis when I feel scared I talk to
(09:49):
my buddy Casey.
When I feel uncertain, I ask forhelp.
That is usually something we'renot very good at in the
beginning, and so, as people say, well, is this a situation
where I'm going to have a drinkor is this a situation where I'm
going to raise my hand and askfor help In the early stages?
Sometimes it's flip a coin forwhich one of those things is
going to win, because one'sbuilt more robust, more
(10:11):
automatic, feels morecomfortable.
It's scary to ask for help, andso it looks like I can't tell
how he's going to act.
Well, he can't either.
That's the anatomical basis forthe faulty decision-making is.
You've got these competingstructures.
And also why relapse sometimeshappens way down the road,
(10:32):
because if we don't maintain thenew system, it atrophies and
then the other one might pop upand it's confounding.
But it's just learning.
It's just learning.
Speaker 1 (10:43):
It's confounding, but it's just learning, it's just
learning.
So I want to pause there andunpack what you just said, and I
mean this as a compliment.
You truly understand addiction.
I came out of taking myaddiction medicine boards and
went it's about the naltrexone,it's about the acamprosate, it's
(11:05):
about the methadone.
It was about the medicine.
And the more I do addictionmedicine, so much of it is not
the medicine.
And here's the fundamental wayI think of what I do as an
addiction doctor.
People learn to self-regulatewith substances and I have to
teach them how to self-regulatewithout substances.
Bingo, I know how I came to it,which was just sitting there
and listening to my patientsover and over and over again.
How did you learn that?
Speaker 2 (11:28):
probably the same.
Probably there's now thousandsof patients that I've looked,
looked after in the last 20years and you and you pick up
their patterns, their, theirstories from what used to be the
most painful, most embarrassing, 25 years ago before, before I
was able to get help with for myproblem.
I certainly wouldn't lead withthat conversation.
(11:49):
I wouldn't say, hey, you knowI'll be your doctor today and
just so you know, I used to havea problem with fentanyl.
That's not how I would start aconversation.
But with the substance usepatients having the common
experience of having beenthrough it, it actually puts us
on this even footing.
They know I'm not judging them,which is a big piece of their
(12:11):
defensiveness, of course, andalso I mean, if a knucklehead
like me can get through it, thenmaybe there's hope for them.
I see them processing that like, wait, there might be life
after this.
So some of it is just havinghope that there's a way out.
But your question about how didI come to this?
(12:34):
I don't want to go back to whatmy life was before.
Okay, I've got to learn allabout this so that I can control
it.
But the way the way to controlit is to not try to control it.
The way to guarantee or giveyourself the best shot of
staying in recovery is where itjust becomes your life.
Of course it's.
It's, it becomes second nature.
(12:55):
It has to be for a person to toget it and stay on the good
side, on the on thenon-substance use side, of
auto-regulation.
It has to be.
Before you realize it, you'vealready texted your buddy to
talk about what is actuallyhappening in your life.
You're not even you just sortof come to in the middle of
(13:17):
asking for help, in the middleof being engaged in honest
conversation with somebody whogets it and can help you, the
same way that people wake uphungover and forgot how they got
to the bar, that theautomaticity of managing their
feelings with substances has tobe replaced with the automatic.
(13:37):
I just raised my hand, I justmake a phone call, I just go to
a meeting, I just talk to mydoctor, and that's when you well
and truly changed.
We're not even thinking aboutit.
William James talks about secondnature, right?
Second nature.
So we have a nature.
Our nature is to avoid pain,seek pleasure, get through, get
(14:02):
by.
But second nature is our habits, and so keeping a calendar
becomes not something you haveto rigorously concentrate on and
it's difficult, it's just.
I'm a guy who keeps a calendar,I'm a guy who goes to the gym,
I'm a guy who gets to bed andgets as much sleep as I can, and
you start to see yourselfdifferently and then that new
(14:26):
habit takes over.
It takes time right, it takestime, takes over.
It takes time right, it takestime.
So the medications can behelpful in the early stages
until you've got the automaticdance steps of living a
different kind of life.
Speaker 1 (14:44):
I have to say our practices are very similar.
We employ peer supportspecialists in my practice to
help with that peer-to-peerrelationship, and it's almost
like you heard me speaking inclinic yesterday to my patients.
Medication is a great way tohelp the brain work better in
the early stage of recoverywhile people build their skills
Absolutely.
So you and I today we're goingto talk about long-acting
(15:06):
injectable medications mypractice.
There are two doctors in thepractice the very lovely and
very beautiful Dr Reb Close, whohappens to be my spouse, and
then me, and we've largelydeveloped our own way of doing
things, mentored by a localphysician around here who's been
doing addiction medicine longerthan I've been alive.
But we really like thelong-acting injectable
(15:28):
medications.
They're very effective and justto level set for everyone.
There are three long-actinginjectable medications.
They're very effective and justto level set for everyone.
There are three long-actinginjectable medications we use in
addiction medicine and nofinancial ties to anything here.
There is naltrexone, also knownas Vivitrol, and then there's
the two forms of buprenorphine.
One form is called Sublocade,the other is called Brixati and
(15:49):
there's a little bit of nuanceto each.
So the one that my patientshave the most interest in is
Sublocade.
Speaker 2 (15:58):
Talk to me about how you're using Sublocade in your
practice.
So yeah, these are super, supercool tools that can help be
that bridge.
So I like analogies we'retalking about the steering wheel
earlier.
I think of these medicationslike a cast for a broken ankle.
So if you break your ankle, ithurts, you can't put weight on
(16:19):
it.
You go see the doctor.
They said it, maybe it needssurgery, Maybe it doesn't, but
you get a cast.
And how long would you leave thecast on?
Cast on Rest of your life?
Probably not right.
You're going to get problemsfrom that.
You're going to get atrophy,you're going to get arthritis on
the other side.
You're not mobile.
Eventually you probably getskin breakdown and so forth.
(16:41):
So you wouldn't leave a cast onfor the rest of your life.
In the case of a broken bone,six weeks, eight weeks, four
weeks, depending on how high andhow complex the fracture is,
maybe longer.
In the case of a substance usedisorder that takes years to
develop and then in many waysfeels like it's taken on a life
(17:02):
of its own, probably six weeksis not enough.
Probably six weeks is notenough to develop a new
automatic habit system.
So even though the cast analogyis apt in terms of a temporary
support.
It's probably not in terms ofthe timeline it takes longer.
The other thing that I say andthis didn't used to be
(17:25):
controversial at all, butthere's a, you know, some people
think that you should be onopiates the rest of your life.
I don't think anyone is bornopiate deficient.
I don't think you come into theworld two quarts low of
endorphins.
I don't think that's how itworks.
So, and to that end, I'm not afan of lifelong opiates or even
(17:50):
opiate blockers.
I think they they're helpful,but I think their utility wears
off over time.
So I like what you said aboutusing them as offset.
We had a little chat before thethe pod about using them for
people who have been onmaintenance for some time, and
(18:10):
that has to do with pharmacology.
They wear off in the.
It's like the finest wear offyou can.
You can imagine.
So these medications for the,for the listeners who don't know
, they're injectable and they'rein formulations that cause them
to be absorbed very slowly.
So some shots when you get ashot, you want it to be absorbed
quickly.
If you get a shot ofantibiotics, you want it to be
(18:31):
absorbed quickly.
If you get a shot ofantibiotics, you want that to be
absorbed quickly.
But there's actually someantibiotics you want to be
absorbed very slowly becausethey've got to kill a certain
germ and they need to be aroundfor a long time.
Penicillin is one of them.
It's mixed in a certain depotform that takes a long time to
be absorbed to kill a certaininfection.
In the case of these long-actingopiates, they're mixed in
(18:54):
substances that when they stayin the body, the body can't get
access to all of the medicine atthe same time, and so the
body's macrophages, the littlecells that clear away foreign
material, they go to work onthese things and as they do, the
depot of medication is slowlyrevealed and it's slowly
(19:14):
dissolved.
And what's nice about that isthe tapering function, or the
tapering aspect is so gentlethat you never get dropped from
a high level of opiate supportto a low one, so you don't get
the withdrawal feelings.
So they're wonderful off-rampsto a maintenance or to a
(19:36):
long-term substance.
But, as you said, what I heardyou say is when I was doing my
boards it was all about themedications.
But if that were the case, thenwe would just put people on
Suboxone and they'd be fine,they wouldn't have a problem.
The thing is when people come infor treatment.
The upfront concern is thesubstance use disorder.
(19:59):
But the real issue is why theywere using these chemicals in
the first place.
There's a term, matmedication-assisted treatment.
It's not medication instead oftreatment.
It's not that the medicines doall the work.
So in our practice what we usethem for is people who are at
(20:23):
the tail end of a substantialperiod of time.
No-transcript is two reasons.
(21:14):
We'll set Vivitrol asidebecause it's sort of a special
class.
The reason we use thesemedications comes from
Niswander's work on methadone.
If you are driven by thecravings to go score and to go
get opiates, then your life isdysregulated.
You're caught up in themerry-go-round of getting drugs
(21:36):
and getting money to get thedrugs and the addict lifestyle.
If you're not compelled to goget drugs because there's enough
opioid around in your systemthat you don't have cravings
they figured this out in the 60sthat that helps people.
That's the so-called methadonemaintenance and that idea is
(21:57):
actually even older.
That goes back to the old dayswhen people got on heroin and
morphine was what they drank allthe time and they carried
around and they just stayed onit.
That's Halstead, if you knowthe famous surgeon Halstead.
He had an opiate problem and hejust stayed on opiates for his
entire career.
So that was his.
His maintenance strategy wasstaying on opiates.
(22:17):
Methadone is better because it'slonger acting.
Suboxone, which is the drugthat's in sublocade, is long
acting and it's a cool drugbecause it blocks the effect of
other opiates.
It even blocks the effect ofitself.
So you take a lot of sublocate.
It's like you took a certainamount.
It has a speed limit, if youwill.
It's got a block of itself andof other opiates.
(22:39):
So if you feel like you knowwhat I need to get some fentanyl
today and you have a shot ofsublocate on board, then the
fentanyl doesn't really work.
You can overcome it withmassive amounts of fentanyl, but
you're largely protected fromthe effects.
You're protected from theeffects of the fentanyl.
(22:59):
So these long-actingmedications do two things they
reduce cravings and then theyalso make it so if you use you
don't get the effect and itprotects you from something
really bad happening happeningfrom overdose.
But they are not a substitutefor getting to the heart of the
matter, which is this faultydecision making.
Speaker 1 (23:21):
Well said, yeah, I think the way I've learned to
describe it to my patients, andI love the speed limit analogy
because I use it myself.
Opiates and substances thatcause dependence are unique
because we have essentially twoissues right.
So a person uses a substanceregularly, you and I both know
their brain chemistry changesand then when they stop using,
(23:41):
they feel sick and sometimesthat withdrawal syndrome can be
life-threatening.
So it's almost like whensomeone comes to me as a new
patient, step one is we have toaddress their dependence and
withdrawal while we build thefoundation of understanding why
they use, what their triggersare, how bad is their PTSD, et
cetera.
And so I've been very active inlearning about Kratom and shout
(24:03):
out to my friends at the KratomSobriety Podcast for
interviewing me.
But when folks use Kratom, whichcan act like an opioid if they
use it enough, they go intoopiate withdrawal.
When they stop it acts like anopioid, and then they'll get on
suboxone, which is veryeffective at treating opioid
withdrawal.
And then they get frustratedthat now they're stuck on
suboxone.
(24:23):
And if you've read MatthewPerry's book before he passed,
matthew Perry talked about beingaddicted to regular opioids
like oxycodone and they wouldput him on suboxone and he was
saying suboxone was the hardestmedicine to get off of.
And in my humble opinion,suboxone's not the problem.
Opioid dependence is theproblem, and so the way I
(24:43):
describe it to my patients iswhen you use an opioid regularly
, your brain chemistry changesAfter about two weeks.
If you stop, you get sick, andthere is no one on planet Earth
that can fix that quickly oreasily.
And we have two strategies wegive you back an opioid like
methadone or suboxone so you'renot sick, or you kick, you go
through withdrawal.
(25:04):
There's no other option.
So the way I think of when I goto use a long-acting injectable
medication is somebody's onSuboxone, they're not in
withdrawal, they're not craving,they're going to meetings or
they have a sponsor, or they'regetting therapy and they're
processing their reason forusing.
But I don't want them to besick and I'll get them on
(25:24):
Suboxone and they stabilize.
Sometimes they forget.
Or I have one my patient, who'sabout 10 years sober, who's a
college professor, and sometimeshe's off in the field with his
students and his suboxone getsdamaged because they're kayaking
or backpacking.
And so I like to transition tothe injectable medications.
When somebody has a very activelifestyle, they're doing well
(25:48):
and taking a daily medicine isdifficult and their sublocate
and bruxati they're bothbuprenorphine or if someone's
not doing so well and I'mworried that they know that if
they stop taking the suboxoneand wait long enough, they can
start using fentanyl again andit's almost a little bit like
I'm going to push you intosobriety, where you really can't
(26:08):
use for about a month, and thatbuys me a month of time to
really intensely get you intoservices, get you a sponsor,
consider residential, and thetwo products are a little bit
different.
The Brixadi is very small volume.
My understanding is we don'tknow exactly how long it lasts.
The Sublocate is a biggervolume but we've had it for
longer and my understanding ispeople, after they get a
(26:30):
Sublocate shot, will testpositive for buprenorphine for
about four to six months andthat goes back to this very slow
tail as the medicine getsdissolved.
But that's how I'm using theinjectables.
But what I'd like to talk aboutis people have learned, based
on how you nicely describedthese shots, is they get
absorbed very slowly and sosomeone might absorb them over
(26:52):
several months and people foundthat they would get sublocate
month to month to month and thenstop and they raced for the
withdrawal and it didn't happen,and so I'm currently treating
patients with sublocate as a wayto deal with that opioid
dependence and get them offsuboxone over several months.
I'm curious as to what yourexperience is with that.
Speaker 2 (27:13):
Yeah, I think that's a good indication for it.
I think that's reasonable.
Now listen, it's a tool.
People come up with clever waysto use tools.
Yes, they do.
If you go to the emergency roomas a fentanyl overdose and you
survive, your chances ofoverdosing again in the next
week are 100%.
(27:34):
So people who overdose overdose, and they it's just because the
nature of their supplierperhaps, or their unregulated
use or whatever.
And so some emergencyphysicians are giving people
sublocade in the ER afterthey're Narcan'd and reversed
(27:54):
and so forth.
You've already gone through theopiate withdrawal anyway, gone
through the opiate withdrawalanyway, and they'll keep them on
Narcan, sometimes because thesublicate is not as available,
and there's a paper that cameout, I think in 22, about this
particular strategy.
So they're getting 300milligrams of sublicate in the
ER on presentation for an opiateoverdose.
(28:15):
So if they survive, they getsent out with essentially, an
airbag to protect them from thishappening again, and it has
enormous efficacy in the shortrun.
So that for me is thequintessence of harm reduction.
And the overdose has a wholecascade of depression and
(28:37):
sadness and disconnection and itmakes it really much more
difficult for people to connect.
So their cravings are mitigatedand they're protected from the
effects of the sublocate beingan opiate blocker.
So that's a clever strategy forusing a medication really in a
different way.
There's another paper that cameout in 23 about the duration of
(29:01):
action of sublocate.
So the traditional way that weuse it is we give initial
loading dose of 300 milligramsand it's a cool delivery system,
right, it's a liquid in thesyringe and when it goes in
underneath the skin itpolymerizes and turns into this
lump that you can feel.
And the appropriate disclaimeris just because you feel the
(29:23):
lump doesn't mean there's stillsublocate around in it.
So it's not correlated with howmuch is left.
So I still feel it, so I mustbe okay.
Is not necessarily true.
Also, I don't feel it so itmust be gone.
Is not true either, because itcould still be in there and you
can't feel it.
It's not perfectly correlatedAnyhow.
So the way the manufacturerteaches us to use it is you get
(29:45):
300 to start.
This is assuming somebody hasreached stable state on Suboxone
.
You give them the larger shotand then the maintenance
follow-up shots are 100milligrams every 30 days.
But what we know now is thatthat's a very optimistic rate of
clearance.
It's probably cleared faster.
(30:06):
And then the reason for beingon these medications in terms of
medication-assisted treatmentis to protect you from the
cravings driving you to use, andthere is a therapeutic blood
level at which point thathappens.
So with the 100 milligrammonthly maintenance, about a
third of people fall below thatsafety margin.
(30:31):
We're probably not using enoughor we're not going often.
Enough is really the way to fixthat from a pharmacokinetic
standpoint is you probablyshould come in every three weeks
rather than every four weeks.
It's an expensive medication.
It's expensive not just interms of the medication itself,
but has to be administered in anoffice by a medical person.
(30:51):
You have to rotate locations onthe abdomen so you don't want
to keep giving it in the samespot.
It's not just take a pill orOzempic shot at home.
It's more complicated.
So, yeah, there's some wrinkles.
There's some wrinkles to it.
I think the two groups that it'smost useful for is setting
aside the emergency room storyare people who have been on
(31:12):
maintenance, got their lives.
You know.
They're living like they wantto live, they're working where
they want to work, theirrelationships are tidied up,
they have this support system,recovery, whatever it is that
keeps them going.
That group who's ready to beoff Suboxone.
I think it's elegant and it's alovely way to finish.
The other group is people whohave compliance problems and are
(31:35):
not fully invested in recoveryand are looking to figure out
how to stop suboxone.
Use that as a managementstrategy.
There's a lot of divertedsuboxone in the black market.
Patients use this stuff to dealwith withdrawals.
They use it as a bridge tomethadone or as a bridge to the
(31:56):
next time they can get fentanylthat group of less than
dedicated daily suboxone users.
I think that the injectablesare helpful, very helpful.
Speaker 1 (32:08):
So I'm going to give another kudos to a podcast I
work with the Addiction MedicineJournal Club, dr Sonia
Deltredici and Dr John Keenan.
I've done a couple of episodeswith them and they covered a
paper on discontinuingbuprenorphine and the data on
people who get off ofbuprenorphine after a period of
sustained sobriety onbuprenorphine.
(32:29):
Again, buprenorphine is themedicine in Suboxone, subutex.
Sublocade Brixadi is thatwithin 18 months of stopping,
two-thirds will relapse, have anoverdose or go back on
buprenorphine.
So I know what I do in mypractice around getting people
off of a Suboxone orbuprenorphine product.
What are you currently doing?
Speaker 2 (32:47):
Well, let me ask you a question about that.
Speaker 1 (32:54):
How long were they on buprenorphine before getting
off of it?
I don't remember exactly, but Ibelieve it was something like
18 months to two years ofsobriety on a buprenorphine
product, and then they followedthem for 18 months after
successful weaning.
Speaker 2 (33:04):
So this gets a little bit into the gnarly part of
addiction medicine.
So there's a strong contingentfrom the traditional 12-step
based recovery world who feelthat use of any of these
medications is not sobriety.
Now we addiction doctors, webristle at that because we're
(33:25):
not trying to replace lifestylechange and habit change and the
rest of the stuff that you needto be a successful human being
with chemicals, with even theselong-acting injectables.
With that said, I think it'simportant to listen to what the
old-timers say about that.
There's something about dealingwith the world.
(33:48):
Just to be extra vague, there'ssomething about dealing with
the world without chemicals interms of managing your feelings
that may speed the process ofchange.
So we act as if givingbuprenorphine is a risk-free
(34:09):
choice, that it doesn't affectthe process of learning this new
habit system of self-regulationwithout chemicals, because
we're giving it and saying it'snot having an effect on your, on
your growth and emotionaldevelopment.
But of course it is.
It must have been, or you wouldhave grown during your fentanyl
(34:31):
phase.
You would have matured out ofthat or learned out of that.
So there are kaplan-meiercurves for probability of
relapse based on time.
So the longer a person is inrecovery, the less likely he is
to return to whatever it isdrinking or opiates.
There's a shoulder in the curvearound two years.
(34:52):
So if you can stay abstinentfor two years, your chances of
staying abstinent go up tosomething like 70 or 80% If you
can get to two years.
If you can get to five yearsthey go up to 90%.
So it's pretty flat from two tofive and then the data gets a
(35:12):
little murky.
But there's papers about peoplein AA for 10 years or more.
It's never fully gone becauseof the learning thing we talked
about, but successfullydefeating it, if you will, so
that they don't relapse.
So I'm just throwing a questionmark in there about that, which
is to say, 18 months to twoyears without buprenorphine.
(35:34):
We know some of the wings arestill wet, right?
The people don't have theirlives together in a way.
That's more automatic Withbuprenorphine.
I'm not surprised that thismaturation has delayed.
Some of it may even be because,well, I'm not really sober, I'm
still on this medicine, or themanagement of it, or the use of
(35:57):
it.
So, yeah, that's morecomplicated than it presents
itself.
The suboxone crowd would saythis is why you should stay on
this for the rest of your life,right.
The methadone clinics would saywell, this is why you need
opiates the rest of your life.
But I still don't feel that way.
Back to what I said, that noone is missing opiates, you get
into the conversation about risk.
(36:19):
So if the risk of relapse isreturning to taking one Vicodin
that's actually a Vicodin, thenI'm probably less worried about
that.
You get back on track.
It tells you it's feedback.
You need to make some changes.
If the risk of relapse istaking a fake Vicodin or a fake
Percocet that's actuallyfentanyl and you overdose and
(36:40):
maybe lose your life, well, nowthe stakes are much, much higher
.
So I don't have a great answerfor you about that.
I will say this that patientswho come to a 30-day treatment
program to taper off suboxonewithout getting on the
long-acting stuff, that'susually a bad idea.
(37:02):
I agree, because your lifecan't be that together if you
have to check into a treatmentcenter to get off suboxone.
For those of you at home whowant to come off suboxone, you
drop by half whatever it is.
This is how we do it.
You drop whatever you're on.
You can cut it in half, andthat's because of the nature of
(37:22):
the Michaelis-Menten curve,which is a fancy way of saying
how the receptor binds the drugso you can cut it by half and
then see how you feel.
You have to give it four orfive days to equilibrate.
If you feel fine, cut it byhalf again.
At some point you'll feel icky,you'll feel withdrawal symptoms.
The move there is to not cut itanymore until you don't feel
(37:46):
the withdrawal symptoms.
That's sometimes a few days,that's sometimes a couple of
weeks.
Now low-grade symptoms, don'tput yourself into massive
withdrawal.
But you feel like, yeah, I'mnot feeling that great.
That's the time to lean on therest of your support system and
tell them hey, I've been on 16milligrams of Suboxone.
I went to eight.
I felt fine.
(38:06):
The next week I went to fourand I start to feel kind of
crummy.
So keep an eye on me, guys.
I'm going through it.
And then you wait until you'reno longer going through it, so
to speak, having physicalwithdrawal symptoms.
Then you go down to two, havingphysical withdrawal symptoms.
Then you go down to two.
Now, that process can take awhile, but who cares?
(38:27):
Time is your friend in thatsituation.
And you're transferring thedependence on the substance to
the dependence on your recoverysystem In a treatment center,
doing it in 30 days verydifficult.
It's not your usual supportnetwork.
It's this, you know, bolted onwell-meaning and professional
people, but they're not yourcrew.
And then the, the calendar isin charge and time is not your
(38:49):
friend.
So in general, I wouldn'trecommend that.
If they've changed the, the waythey regard themselves and how
they manage their feelings, thenI think sublocate or tapering
are great and in fact you should.
If you haven't, if there's someexternal pressure, if you're
(39:09):
hearing it from your familymembers hey, why are you still
on that stuff?
You need to get off.
Then those are fraughtsituations because you probably
aren't stable, you're probablynot in good shape and maybe the
medication is protecting youfrom something bad happening.
So the message I would say isto try for the clinicians, for
(39:30):
the docs, is to try and see ifyou can figure out what's going
on For the patients.
Help them be honest with what'sreally happening.
I don't really want to get offof this, but my wife is on me
about.
She thinks I'm different orwhatever the details are.
Does that make sense?
Speaker 1 (39:48):
Yeah, I guess I have a slightly different approach,
which is that and I'm going togive credit to my lovely bride
and fellow addiction doctor, drReb Close the way she describes
addiction is feel something,take something.
Dr Reb Close, the way shedescribes addiction is feel
something, take something.
And so what I'm doing in mypractice is, let's say, someone
says to me hey, doc, I've beenon Suboxone for three years, I'm
(40:09):
tired of this stuff, I'm readyto get off of it.
I'll say great, we put them onSublocade.
That's my preferred product,simply because I have more
experience with it and it seemsto last longer.
I give them, let's say, fourinjections, allow the sublocate
to reach steady state, and thenI tell them to stop.
If they get withdrawal, we givemore, we work it out.
The issue is, though, to yourpoint to riding a bike they are
(40:29):
used to, when they don't feelgood, using some sort of
substance to make them feelbetter, and I want them to take
my substances, not whateverhorrible substances are out
there, right?
So common dosing forbuprenorphine under the tongue
is anywhere from, you know, inthe fentanyl era, 16 to 32
milligrams, right, and what Iwill do is I say I'm going to
(40:51):
give you the two milligrams, thelittle baby ones, and I want
you to know that if you'rehaving a bad day, you can take
one.
Yeah, I like that.
And the idea would be is thatyou never say goodbye to
buprenorphine.
It's that you don't take itevery day and you're not
dependent, but while youcontinue to work on building
your skills and building yoursupport group and working on
(41:13):
your sobriety, if you have a badday, the Suboxone is like a
little tiny parachute yeah, thatif you take three doses a week
for six months while you'regetting off of it great, you
didn't use fentanyl.
And then I always tell them youhave to keep seeing me, even
after you stop until X date, oryou've got a primary doctor that
(41:33):
you're going to work on it with, et cetera.
But it's almost like Suboxoneis always there as a tool.
You may not need that tool, butit's always there for you,
particularly as the sublocateshots wear off and the
buprenorphine gets out of theirsystem.
People are often overlyconfident on buprenorphine
because it works so well foropiate use disorder and opiate
cravings and they're like wherethe heck do these cravings come
(41:55):
from?
Great, let's work on it.
Here's your four doses of twomilligrams of buprenorphine a
week and I'll see you next week.
That's my approach.
Speaker 2 (42:08):
Yeah, no, I've done that.
I've done that.
It's patient to patient.
I've done it with partialstrips also.
And listen, there's the placeboeffect as well for smokers on
an airplane.
You can't smoke on an airplane,right, but feeling the pack of
cigarettes in your coat pocketor in your in your blouse pocket
, ok, I've got these.
So when we land, I'm OK, andsometimes the idea of having it
just in case, paradoxicallymakes it so that they don't need
(42:32):
to take it.
Whatever works, so long as aperson doesn't go back to
fentanyl and we're movingforward and don't go backwards,
it's all good with me, and sothat's maybe one of the best
things about this specialty isyou're dealing oftentimes in
uncharted territory.
Well said Doesn't standardize,it's not.
We always do this this way withthis situation.
(42:55):
It's true in all the medicine,right?
So even the guy fixing theankles, all the ankles are
different and where they'rebroken is different.
So it's true in all themedicine, right?
So even the guy fixing theankles, all the ankles are
different and where they'rebroken is different.
So it's true in all themedicine.
Why would we think in addictionmedicine?
Oh, opiates.
Here's the rubber stamp on whatyou need to do.
It's not how it works.
So, yes, I think creating aspace where the patient can be
(43:16):
honest is essential.
The patients need to be able tosay hey, you know, dr Grover, I
feel scared, or I took someextra Suboxone, or I got some
fentanyl.
Speaker 1 (43:30):
Well, I have to say, you and I could probably geek
out about addiction for at leastanother 90 to 120 minutes For
sure.
Let's wrap up here.
What would you say are sometake-home points that our
listeners can take away fromwhat we've talked about in terms
of learning about how to treataddiction, including long-acting
injectable medications?
Speaker 2 (43:47):
Sure, I would say that long-acting injectable
medications are valuable anduseful tools.
They are not magical Swiss armyknives that solve all problems.
We've narrowed our discussionto, in the most part, to talk
about opiate use disorder.
We don't have long-actinginjectable medications for the
(44:08):
rest of the substance use andthe rest of the substances that
people get tangled up with andthe opiate use disorder.
Long-acting medications are notgoing to keep you from drinking
and they're not going to keepyou from using cocaine.
So to a certain extent they'relimited in scope and efficacy
and it's dangerous for people tosay well, I'm just an opiate
(44:31):
guy, I don't have a problem withwhatever because of the
phenomenon of cross addiction.
Right, so you can.
You can develop something else.
I would say that if you'recommitted to changing the way
you respond to your feelings andyou manage them with these
other strategies CBT, you know,insight oriented therapy,
(44:53):
exercise, all the stuff that wehave to help sobriety If you're
doing that and you have anopiate use disorder, these
long-acting medications can bevery helpful.
They can be very helpful.
When to get off of them dependson how far along you are and
how much of your life hasfundamentally changed.
(45:15):
People do grow out of theiropiate use disorder with time.
How long that takes, I'm notsure.
It's person to person, becausethe consequences can be so grave
, and by that I mean literallythe grave.
Yes, I would rather if it weresomeone I loved or a patient of
mine that I cared about.
(45:36):
I'd rather that they got anextra month or two of sublocade
passed when they actually neededit than stopping too soon
before they're fully cooked, asthe kids would say right, let
them cook.
And that has to do with thephilosophy.
So if you believe that you'vegot a faulty decision-making
(45:56):
system and you trust that it'sfaulty, then you won't trust
your decision-making.
You'll say how does this sound,casey, I am going to Las Vegas
and all of my friends are goingto be doing cocaine and speed
balls, but I'm just going tohang out with them and I'm going
to be the designated driver.
Now, when you hear that plan,you're laughing, right, I'm
(46:20):
watching you laugh.
And so when you hear that plan,that's insane, right, that's an
insane.
You might think that's a reallygood idea because you're not
going to use, but you're puttingyourself in a dangerous
environment with camaraderie andso on and so forth, and and so
running your plan by anotherhuman being.
It's like those bumps in theroad when you start to get out
of the lane, the tire runningover them will let you know.
(46:48):
So get some bumps in your lanesso that you can see when you're
starting to drift off track.
Otherwise you'll be the last toknow.
Speaker 1 (46:54):
I have to say, so many nuggets of knowledge that
you have given me today will beused in clinic next week.
I have to say this has beenabsolutely fantastic.
I can't wait to get thispodcast out there.
So great to get to talk to youtoday.
Speaker 2 (47:05):
I enjoyed it.
I learned a lot.
For me, it's a delight to talkto a wise colleague and I made
this choice to abandon a verytraditional specialty and to
pioneer and be one of the guysin the trenches out here, and
it's inspirational to me to seethat there's a whole other crop
that's going to take over andpush the frontiers farther out.
(47:27):
It's an endlessly fascinatingspecialty and I'm grateful to be
here.
I'm grateful for the time youspent and thanks.
Really fun time, doc.
Speaker 1 (47:35):
Yeah, I was going to say I mean, I think for me, the
two things I love about what Ido is the gratitude and the
people are so nice when they'rein their addiction.
Sometimes they struggle, butaddiction can happen to anyone.
Some of the nicest people Iknow are my patients and I'm
just grateful to be able to takecare of them.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
(47:58):
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
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
(48:20):
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
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 fellow addiction medicine
(00:44):
physician, dr Jason Giles.
We connected to discuss how we,as addiction medicine doctors,
think about treating addiction,with a focus on using
long-acting injectablemedications.
A few clarifications before weget into the interview.
In the world of addictionmedicine, there are three
medications which can be givenas once-monthly injections.
(01:08):
The first is naltrexone and thebrand name is Vivitrol.
It is used to treat opioid usedisorder and alcohol use
disorder.
The second is buprenorphine.
There are two differentproducts.
One is called Sublocade and theother is called Brixati.
They're made by differentcompanies and have slightly
(01:28):
different characteristics and,just to clarify, I have no
financial ties to any drugcompanies.
Dr Giles and I focused ourdiscussion for this episode on
Sublocade and Brixati.
With that, let's dig in.
All right, why don't we startby having you tell us who you
are and what you do?
Speaker 2 (01:48):
Thanks, doc.
I'm Dr Jason Giles and I am anaddiction medicine doctor.
I've been doing that job forabout the last 20 years and my
specialty is taking care ofpatients in residential and
post-acute residential so theycall it PHP or aftercare step
down, add to drug and alcoholtreatment centers across the
country.
We also in our group we dopsychiatry as part of incidental
(02:12):
services, but we're also inmental health primary facilities
.
But that's my job Telemedicine,addiction medicine.
Speaker 1 (02:19):
How did you get interested in addiction medicine
?
Speaker 2 (02:23):
Well, my first inkling of it as a thing
probably goes back to when I wasa kid and my own father
struggled with alcohol, wentinto a recovery program himself,
ultimately got it.
And so I was aware from asingle digit early age that
(02:43):
people people had trouble withsubstances, that sometimes the
things that we sought, that weseek for relief, become problems
of their own.
So I, I knew, I knew about thatfrom before.
I didn't have interest inpursuing that in in school or in
in training until I was forcedto get some education in it when
(03:06):
I myself developed a problemwith substances on the tail end
of my residency inanesthesiology.
My particular substance wasn'talcohol.
It was well when I used to saythis.
I would have to repeat itbecause this is 25 years ago.
People would say what's that?
But they don't say that anymore.
(03:27):
But the substance that I gottangled up with is called
fentanyl, and now everyone knowswhat that is.
So it was a pioneer in thatsense, a trailblazer, but it's
what was around.
There are a lot of reasons why Iwent that way, perhaps genetic,
maybe there's a geneticcomponent because of the family
history, but for whatever thereasons were, I wound up as a
(03:47):
patient needing help, dealingwith my own dependence and then
getting into the deeper reasons.
What was behind that, why anice guy like me was in a place
like that.
And as I learned more aboutthis problem or malady, or some
call it a disease I don't likethat word, but whatever this
thing is that you and I dealwith all the time, it became
(04:10):
endlessly fascinating to me, notjust from a personal standpoint
of wanting to make sure thatthings didn't go back the way
they were, but also it's a, it'sa whole frontier in medicine.
That is the most exciting, mostinteresting, endlessly
fascinating field of medicine,because you're dealing with the
(04:32):
decisions that people make.
You're dealing with the choicesthat they make and how can we
favorably influence theirchoices, how can we keep them on
track.
So I, I, I'm like the fish whoflopped off of the dock and back
into the lake.
I felt like I was home.
So my training is inanesthesiology.
I did cardiac anesthesia.
I did a fellowship in painmedicine.
(04:55):
That's probably part of where Istarted to get interested in
the medical interventions andalso the management of emotional
pain, not just physical painno-transcript.
Speaker 1 (05:25):
One thing you said when you talked about the
decisions that people make theway I'm describing addiction to
family members is addiction is adisease of executive
functioning, and executivefunctioning is the ability to
keep a calendar, to know when tosave money versus spend it when
something's a good decision ora bad decision.
(05:45):
And it's really challenging forfamily members to understand
this that the actual ability tomake good decisions is very
impaired in addiction.
I'm just curious how thatresonates with you, given your
both lived experience andprofessional experience.
Speaker 2 (05:57):
I agree with you completely.
I think that's exactly on point.
You can make analogies.
It's like having your steeringwheel on your car obey you,
sometimes, ah, that's a good one, but not all the time I'm going
to steal that.
So you know, here we are, thethe arrow's green, it's time to
turn left.
And you, you start pulling handover hand as you, as you
(06:20):
accelerate, and the car says youknow, actually we're going to
go straight and maybe, and maybeinto another car, maybe into
the island, or maybe, you know.
So it's not that the decisionsare always bad.
That would be fine.
We would just become conserved.
We would say I can't makedecisions anymore.
And you know that that's a,that's a thought disorder, right
(06:43):
?
So you don't course connectedwith the real world of how
things work.
So we're not going to let youmake decisions about yourself
anymore.
To protect you, the trouble isit's faulty.
So sometimes it works andsometimes it doesn't.
People hold up their strengthsand say look I just, I had my
best quarter ever, my best year,or I won the, I'm the
(07:04):
valedictorian, or I you knowsomething, something great in
their life.
But but it's not consistent,right?
It's keep a calendar, it's,it's exercise self-discipline
through the difficult periods.
But yeah, it's, it's, it'simpaired decision-making is is
is the heart of it.
I agree with you completely.
Speaker 1 (07:22):
I think also, you pointed out something really
useful to pause and consider,which is that sometimes it works
and sometimes it doesn't.
To your point, someone withschizophrenia cannot understand
reality and may require to beliving in an institution where
they have someone to makedecisions for them.
But I like what you said aboutsometimes they can make
decisions and sometimes theycan't, which I know for my
(07:42):
families of my patients theyreally struggle with, because
that's where trust becomes.
Such an issue is that you didgreat today, but not tomorrow.
When can I trust you?
So I talk a lot about trying tobe consistent when things are
good and bad for my patientswhen they communicate with their
families.
Have I had a good day today andI had a bad day today, but I am
totally going to give youcredit for that.
My next visit I have with afamily member.
Speaker 2 (08:04):
There's a neuro anatomical explanation for why
that's true.
So another way of thinkingabout addiction is learning.
So it's like it's learning andwe all everyone learns.
We learned how to walk and welearned how to speak and we
learned.
Most people about 96% inAmerica learn how to ride a
(08:24):
bicycle and even if you don'tride a bicycle every day, most
people don't forget how to ridea bicycle Because of all the
repetition and because of thepracticed building of an
automatic routine to keep youbalanced on the bike, which is
what riding a bicycle isbalancing.
Keep you balanced on the bike,which is what riding a bicycle
(08:47):
is balancing.
That routine that you spent allthose hours learning, usually
as a kid, is still there and youcan access it later when you
get back on a bike.
It's the same with usingsubstances to change the way you
feel.
It's just another loop.
So I feel scared, I have adrink, or I feel I feel, you
know, ineffective and I havesome cocaine so that I feel
(09:08):
powerful, whatever, whatever thethe substance habit loop is, we
learn if I smoke weed, I'm notbothered by my parents, or I'm
not bothered by my wife, or I'mnot whatever, whatever the thing
is.
So we, we develop this shortcutloop of when I do this, I can
(09:29):
control my feelings.
Well, that is like learning toride a bike, and you don't
forget that.
So when the circumstances comeup later, and until you've built
another, stronger automaticloop which is when I feel scared
stronger automatic loop, whichis when I feel scared I talk to
(09:49):
my buddy Casey.
When I feel uncertain, I ask forhelp.
That is usually something we'renot very good at in the
beginning, and so, as people say, well, is this a situation
where I'm going to have a drinkor is this a situation where I'm
going to raise my hand and askfor help In the early stages?
Sometimes it's flip a coin forwhich one of those things is
going to win, because one'sbuilt more robust, more
(10:11):
automatic, feels morecomfortable.
It's scary to ask for help, andso it looks like I can't tell
how he's going to act.
Well, he can't either.
That's the anatomical basis forthe faulty decision-making is.
You've got these competingstructures.
And also why relapse sometimeshappens way down the road,
(10:32):
because if we don't maintain thenew system, it atrophies and
then the other one might pop upand it's confounding.
But it's just learning.
It's just learning.
Speaker 1 (10:43):
It's confounding, but it's just learning, it's just
learning.
So I want to pause there andunpack what you just said, and I
mean this as a compliment.
You truly understand addiction.
I came out of taking myaddiction medicine boards and
went it's about the naltrexone,it's about the acamprosate, it's
(11:05):
about the methadone.
It was about the medicine.
And the more I do addictionmedicine, so much of it is not
the medicine.
And here's the fundamental wayI think of what I do as an
addiction doctor.
People learn to self-regulatewith substances and I have to
teach them how to self-regulatewithout substances.
Bingo, I know how I came to it,which was just sitting there
and listening to my patientsover and over and over again.
How did you learn that?
Speaker 2 (11:28):
probably the same.
Probably there's now thousandsof patients that I've looked,
looked after in the last 20years and you and you pick up
their patterns, their, theirstories from what used to be the
most painful, most embarrassing, 25 years ago before, before I
was able to get help with for myproblem.
I certainly wouldn't lead withthat conversation.
(11:49):
I wouldn't say, hey, you knowI'll be your doctor today and
just so you know, I used to havea problem with fentanyl.
That's not how I would start aconversation.
But with the substance usepatients having the common
experience of having beenthrough it, it actually puts us
on this even footing.
They know I'm not judging them,which is a big piece of their
(12:11):
defensiveness, of course, andalso I mean, if a knucklehead
like me can get through it, thenmaybe there's hope for them.
I see them processing that like, wait, there might be life
after this.
So some of it is just havinghope that there's a way out.
But your question about how didI come to this?
(12:34):
I don't want to go back to whatmy life was before.
Okay, I've got to learn allabout this so that I can control
it.
But the way the way to controlit is to not try to control it.
The way to guarantee or giveyourself the best shot of
staying in recovery is where itjust becomes your life.
Of course it's.
It's, it becomes second nature.
(12:55):
It has to be for a person to toget it and stay on the good
side, on the on thenon-substance use side, of
auto-regulation.
It has to be.
Before you realize it, you'vealready texted your buddy to
talk about what is actuallyhappening in your life.
You're not even you just sortof come to in the middle of
(13:17):
asking for help, in the middleof being engaged in honest
conversation with somebody whogets it and can help you, the
same way that people wake uphungover and forgot how they got
to the bar, that theautomaticity of managing their
feelings with substances has tobe replaced with the automatic.
(13:37):
I just raised my hand, I justmake a phone call, I just go to
a meeting, I just talk to mydoctor, and that's when you well
and truly changed.
We're not even thinking aboutit.
William James talks about secondnature, right?
Second nature.
So we have a nature.
Our nature is to avoid pain,seek pleasure, get through, get
(14:02):
by.
But second nature is our habits, and so keeping a calendar
becomes not something you haveto rigorously concentrate on and
it's difficult, it's just.
I'm a guy who keeps a calendar,I'm a guy who goes to the gym,
I'm a guy who gets to bed andgets as much sleep as I can, and
you start to see yourselfdifferently and then that new
(14:26):
habit takes over.
It takes time right, it takestime, takes over.
It takes time right, it takestime.
So the medications can behelpful in the early stages
until you've got the automaticdance steps of living a
different kind of life.
Speaker 1 (14:44):
I have to say our practices are very similar.
We employ peer supportspecialists in my practice to
help with that peer-to-peerrelationship, and it's almost
like you heard me speaking inclinic yesterday to my patients.
Medication is a great way tohelp the brain work better in
the early stage of recoverywhile people build their skills
Absolutely.
So you and I today we're goingto talk about long-acting
(15:06):
injectable medications mypractice.
There are two doctors in thepractice the very lovely and
very beautiful Dr Reb Close, whohappens to be my spouse, and
then me, and we've largelydeveloped our own way of doing
things, mentored by a localphysician around here who's been
doing addiction medicine longerthan I've been alive.
But we really like thelong-acting injectable
(15:28):
medications.
They're very effective and justto level set for everyone.
There are three long-actinginjectable medications.
They're very effective and justto level set for everyone.
There are three long-actinginjectable medications we use in
addiction medicine and nofinancial ties to anything here.
There is naltrexone, also knownas Vivitrol, and then there's
the two forms of buprenorphine.
One form is called Sublocade,the other is called Brixati and
(15:49):
there's a little bit of nuanceto each.
So the one that my patientshave the most interest in is
Sublocade.
Speaker 2 (15:58):
Talk to me about how you're using Sublocade in your
practice.
So yeah, these are super, supercool tools that can help be
that bridge.
So I like analogies we'retalking about the steering wheel
earlier.
I think of these medicationslike a cast for a broken ankle.
So if you break your ankle, ithurts, you can't put weight on
(16:19):
it.
You go see the doctor.
They said it, maybe it needssurgery, Maybe it doesn't, but
you get a cast.
And how long would you leave thecast on?
Cast on Rest of your life?
Probably not right.
You're going to get problemsfrom that.
You're going to get atrophy,you're going to get arthritis on
the other side.
You're not mobile.
Eventually you probably getskin breakdown and so forth.
(16:41):
So you wouldn't leave a cast onfor the rest of your life.
In the case of a broken bone,six weeks, eight weeks, four
weeks, depending on how high andhow complex the fracture is,
maybe longer.
In the case of a substance usedisorder that takes years to
develop and then in many waysfeels like it's taken on a life
(17:02):
of its own, probably six weeksis not enough.
Probably six weeks is notenough to develop a new
automatic habit system.
So even though the cast analogyis apt in terms of a temporary
support.
It's probably not in terms ofthe timeline it takes longer.
The other thing that I say andthis didn't used to be
(17:25):
controversial at all, butthere's a, you know, some people
think that you should be onopiates the rest of your life.
I don't think anyone is bornopiate deficient.
I don't think you come into theworld two quarts low of
endorphins.
I don't think that's how itworks.
So, and to that end, I'm not afan of lifelong opiates or even
(17:50):
opiate blockers.
I think they they're helpful,but I think their utility wears
off over time.
So I like what you said aboutusing them as offset.
We had a little chat before thethe pod about using them for
people who have been onmaintenance for some time, and
(18:10):
that has to do with pharmacology.
They wear off in the.
It's like the finest wear offyou can.
You can imagine.
So these medications for the,for the listeners who don't know
, they're injectable and they'rein formulations that cause them
to be absorbed very slowly.
So some shots when you get ashot, you want it to be absorbed
quickly.
If you get a shot ofantibiotics, you want it to be
(18:31):
absorbed quickly.
If you get a shot ofantibiotics, you want that to be
absorbed quickly.
But there's actually someantibiotics you want to be
absorbed very slowly becausethey've got to kill a certain
germ and they need to be aroundfor a long time.
Penicillin is one of them.
It's mixed in a certain depotform that takes a long time to
be absorbed to kill a certaininfection.
In the case of these long-actingopiates, they're mixed in
(18:54):
substances that when they stayin the body, the body can't get
access to all of the medicine atthe same time, and so the
body's macrophages, the littlecells that clear away foreign
material, they go to work onthese things and as they do, the
depot of medication is slowlyrevealed and it's slowly
(19:14):
dissolved.
And what's nice about that isthe tapering function, or the
tapering aspect is so gentlethat you never get dropped from
a high level of opiate supportto a low one, so you don't get
the withdrawal feelings.
So they're wonderful off-rampsto a maintenance or to a
(19:36):
long-term substance.
But, as you said, what I heardyou say is when I was doing my
boards it was all about themedications.
But if that were the case, thenwe would just put people on
Suboxone and they'd be fine,they wouldn't have a problem.
The thing is when people come infor treatment.
The upfront concern is thesubstance use disorder.
(19:59):
But the real issue is why theywere using these chemicals in
the first place.
There's a term, matmedication-assisted treatment.
It's not medication instead oftreatment.
It's not that the medicines doall the work.
So in our practice what we usethem for is people who are at
(20:23):
the tail end of a substantialperiod of time.
No-transcript is two reasons.
(21:14):
We'll set Vivitrol asidebecause it's sort of a special
class.
The reason we use thesemedications comes from
Niswander's work on methadone.
If you are driven by thecravings to go score and to go
get opiates, then your life isdysregulated.
You're caught up in themerry-go-round of getting drugs
(21:36):
and getting money to get thedrugs and the addict lifestyle.
If you're not compelled to goget drugs because there's enough
opioid around in your systemthat you don't have cravings
they figured this out in the 60sthat that helps people.
That's the so-called methadonemaintenance and that idea is
(21:57):
actually even older.
That goes back to the old dayswhen people got on heroin and
morphine was what they drank allthe time and they carried
around and they just stayed onit.
That's Halstead, if you knowthe famous surgeon Halstead.
He had an opiate problem and hejust stayed on opiates for his
entire career.
So that was his.
His maintenance strategy wasstaying on opiates.
(22:17):
Methadone is better because it'slonger acting.
Suboxone, which is the drugthat's in sublocade, is long
acting and it's a cool drugbecause it blocks the effect of
other opiates.
It even blocks the effect ofitself.
So you take a lot of sublocate.
It's like you took a certainamount.
It has a speed limit, if youwill.
It's got a block of itself andof other opiates.
(22:39):
So if you feel like you knowwhat I need to get some fentanyl
today and you have a shot ofsublocate on board, then the
fentanyl doesn't really work.
You can overcome it withmassive amounts of fentanyl, but
you're largely protected fromthe effects.
You're protected from theeffects of the fentanyl.
(22:59):
So these long-actingmedications do two things they
reduce cravings and then theyalso make it so if you use you
don't get the effect and itprotects you from something
really bad happening happeningfrom overdose.
But they are not a substitutefor getting to the heart of the
matter, which is this faultydecision making.
Speaker 1 (23:21):
Well said, yeah, I think the way I've learned to
describe it to my patients, andI love the speed limit analogy
because I use it myself.
Opiates and substances thatcause dependence are unique
because we have essentially twoissues right.
So a person uses a substanceregularly, you and I both know
their brain chemistry changesand then when they stop using,
(23:41):
they feel sick and sometimesthat withdrawal syndrome can be
life-threatening.
So it's almost like whensomeone comes to me as a new
patient, step one is we have toaddress their dependence and
withdrawal while we build thefoundation of understanding why
they use, what their triggersare, how bad is their PTSD, et
cetera.
And so I've been very active inlearning about Kratom and shout
(24:03):
out to my friends at the KratomSobriety Podcast for
interviewing me.
But when folks use Kratom, whichcan act like an opioid if they
use it enough, they go intoopiate withdrawal.
When they stop it acts like anopioid, and then they'll get on
suboxone, which is veryeffective at treating opioid
withdrawal.
And then they get frustratedthat now they're stuck on
suboxone.
(24:23):
And if you've read MatthewPerry's book before he passed,
matthew Perry talked about beingaddicted to regular opioids
like oxycodone and they wouldput him on suboxone and he was
saying suboxone was the hardestmedicine to get off of.
And in my humble opinion,suboxone's not the problem.
Opioid dependence is theproblem, and so the way I
(24:43):
describe it to my patients iswhen you use an opioid regularly
, your brain chemistry changesAfter about two weeks.
If you stop, you get sick, andthere is no one on planet Earth
that can fix that quickly oreasily.
And we have two strategies wegive you back an opioid like
methadone or suboxone so you'renot sick, or you kick, you go
through withdrawal.
(25:04):
There's no other option.
So the way I think of when I goto use a long-acting injectable
medication is somebody's onSuboxone, they're not in
withdrawal, they're not craving,they're going to meetings or
they have a sponsor, or they'regetting therapy and they're
processing their reason forusing.
But I don't want them to besick and I'll get them on
(25:24):
Suboxone and they stabilize.
Sometimes they forget.
Or I have one my patient, who'sabout 10 years sober, who's a
college professor, and sometimeshe's off in the field with his
students and his suboxone getsdamaged because they're kayaking
or backpacking.
And so I like to transition tothe injectable medications.
When somebody has a very activelifestyle, they're doing well
(25:48):
and taking a daily medicine isdifficult and their sublocate
and bruxati they're bothbuprenorphine or if someone's
not doing so well and I'mworried that they know that if
they stop taking the suboxoneand wait long enough, they can
start using fentanyl again andit's almost a little bit like
I'm going to push you intosobriety, where you really can't
(26:08):
use for about a month, and thatbuys me a month of time to
really intensely get you intoservices, get you a sponsor,
consider residential, and thetwo products are a little bit
different.
The Brixadi is very small volume.
My understanding is we don'tknow exactly how long it lasts.
The Sublocate is a biggervolume but we've had it for
longer and my understanding ispeople, after they get a
(26:30):
Sublocate shot, will testpositive for buprenorphine for
about four to six months andthat goes back to this very slow
tail as the medicine getsdissolved.
But that's how I'm using theinjectables.
But what I'd like to talk aboutis people have learned, based
on how you nicely describedthese shots, is they get
absorbed very slowly and sosomeone might absorb them over
(26:52):
several months and people foundthat they would get sublocate
month to month to month and thenstop and they raced for the
withdrawal and it didn't happen,and so I'm currently treating
patients with sublocate as a wayto deal with that opioid
dependence and get them offsuboxone over several months.
I'm curious as to what yourexperience is with that.
Speaker 2 (27:13):
Yeah, I think that's a good indication for it.
I think that's reasonable.
Now listen, it's a tool.
People come up with clever waysto use tools.
Yes, they do.
If you go to the emergency roomas a fentanyl overdose and you
survive, your chances ofoverdosing again in the next
week are 100%.
(27:34):
So people who overdose overdose, and they it's just because the
nature of their supplierperhaps, or their unregulated
use or whatever.
And so some emergencyphysicians are giving people
sublocade in the ER afterthey're Narcan'd and reversed
(27:54):
and so forth.
You've already gone through theopiate withdrawal anyway, gone
through the opiate withdrawalanyway, and they'll keep them on
Narcan, sometimes because thesublicate is not as available,
and there's a paper that cameout, I think in 22, about this
particular strategy.
So they're getting 300milligrams of sublicate in the
ER on presentation for an opiateoverdose.
(28:15):
So if they survive, they getsent out with essentially, an
airbag to protect them from thishappening again, and it has
enormous efficacy in the shortrun.
So that for me is thequintessence of harm reduction.
And the overdose has a wholecascade of depression and
(28:37):
sadness and disconnection and itmakes it really much more
difficult for people to connect.
So their cravings are mitigatedand they're protected from the
effects of the sublocate beingan opiate blocker.
So that's a clever strategy forusing a medication really in a
different way.
There's another paper that cameout in 23 about the duration of
(29:01):
action of sublocate.
So the traditional way that weuse it is we give initial
loading dose of 300 milligramsand it's a cool delivery system,
right, it's a liquid in thesyringe and when it goes in
underneath the skin itpolymerizes and turns into this
lump that you can feel.
And the appropriate disclaimeris just because you feel the
(29:23):
lump doesn't mean there's stillsublocate around in it.
So it's not correlated with howmuch is left.
So I still feel it, so I mustbe okay.
Is not necessarily true.
Also, I don't feel it so itmust be gone.
Is not true either, because itcould still be in there and you
can't feel it.
It's not perfectly correlatedAnyhow.
So the way the manufacturerteaches us to use it is you get
(29:45):
300 to start.
This is assuming somebody hasreached stable state on Suboxone
.
You give them the larger shotand then the maintenance
follow-up shots are 100milligrams every 30 days.
But what we know now is thatthat's a very optimistic rate of
clearance.
It's probably cleared faster.
(30:06):
And then the reason for beingon these medications in terms of
medication-assisted treatmentis to protect you from the
cravings driving you to use, andthere is a therapeutic blood
level at which point thathappens.
So with the 100 milligrammonthly maintenance, about a
third of people fall below thatsafety margin.
(30:31):
We're probably not using enoughor we're not going often.
Enough is really the way to fixthat from a pharmacokinetic
standpoint is you probablyshould come in every three weeks
rather than every four weeks.
It's an expensive medication.
It's expensive not just interms of the medication itself,
but has to be administered in anoffice by a medical person.
(30:51):
You have to rotate locations onthe abdomen so you don't want
to keep giving it in the samespot.
It's not just take a pill orOzempic shot at home.
It's more complicated.
So, yeah, there's some wrinkles.
There's some wrinkles to it.
I think the two groups that it'smost useful for is setting
aside the emergency room storyare people who have been on
(31:12):
maintenance, got their lives.
You know.
They're living like they wantto live, they're working where
they want to work, theirrelationships are tidied up,
they have this support system,recovery, whatever it is that
keeps them going.
That group who's ready to beoff Suboxone.
I think it's elegant and it's alovely way to finish.
The other group is people whohave compliance problems and are
(31:35):
not fully invested in recoveryand are looking to figure out
how to stop suboxone.
Use that as a managementstrategy.
There's a lot of divertedsuboxone in the black market.
Patients use this stuff to dealwith withdrawals.
They use it as a bridge tomethadone or as a bridge to the
(31:56):
next time they can get fentanylthat group of less than
dedicated daily suboxone users.
I think that the injectablesare helpful, very helpful.
Speaker 1 (32:08):
So I'm going to give another kudos to a podcast I
work with the Addiction MedicineJournal Club, dr Sonia
Deltredici and Dr John Keenan.
I've done a couple of episodeswith them and they covered a
paper on discontinuingbuprenorphine and the data on
people who get off ofbuprenorphine after a period of
sustained sobriety onbuprenorphine.
(32:29):
Again, buprenorphine is themedicine in Suboxone, subutex.
Sublocade Brixadi is thatwithin 18 months of stopping,
two-thirds will relapse, have anoverdose or go back on
buprenorphine.
So I know what I do in mypractice around getting people
off of a Suboxone orbuprenorphine product.
What are you currently doing?
Speaker 2 (32:47):
Well, let me ask you a question about that.
Speaker 1 (32:54):
How long were they on buprenorphine before getting
off of it?
I don't remember exactly, but Ibelieve it was something like
18 months to two years ofsobriety on a buprenorphine
product, and then they followedthem for 18 months after
successful weaning.
Speaker 2 (33:04):
So this gets a little bit into the gnarly part of
addiction medicine.
So there's a strong contingentfrom the traditional 12-step
based recovery world who feelthat use of any of these
medications is not sobriety.
Now we addiction doctors, webristle at that because we're
(33:25):
not trying to replace lifestylechange and habit change and the
rest of the stuff that you needto be a successful human being
with chemicals, with even theselong-acting injectables.
With that said, I think it'simportant to listen to what the
old-timers say about that.
There's something about dealingwith the world.
(33:48):
Just to be extra vague, there'ssomething about dealing with
the world without chemicals interms of managing your feelings
that may speed the process ofchange.
So we act as if givingbuprenorphine is a risk-free
(34:09):
choice, that it doesn't affectthe process of learning this new
habit system of self-regulationwithout chemicals, because
we're giving it and saying it'snot having an effect on your, on
your growth and emotionaldevelopment.
But of course it is.
It must have been, or you wouldhave grown during your fentanyl
(34:31):
phase.
You would have matured out ofthat or learned out of that.
So there are kaplan-meiercurves for probability of
relapse based on time.
So the longer a person is inrecovery, the less likely he is
to return to whatever it isdrinking or opiates.
There's a shoulder in the curvearound two years.
(34:52):
So if you can stay abstinentfor two years, your chances of
staying abstinent go up tosomething like 70 or 80% If you
can get to two years.
If you can get to five yearsthey go up to 90%.
So it's pretty flat from two tofive and then the data gets a
(35:12):
little murky.
But there's papers about peoplein AA for 10 years or more.
It's never fully gone becauseof the learning thing we talked
about, but successfullydefeating it, if you will, so
that they don't relapse.
So I'm just throwing a questionmark in there about that, which
is to say, 18 months to twoyears without buprenorphine.
(35:34):
We know some of the wings arestill wet, right?
The people don't have theirlives together in a way.
That's more automatic Withbuprenorphine.
I'm not surprised that thismaturation has delayed.
Some of it may even be because,well, I'm not really sober, I'm
still on this medicine, or themanagement of it, or the use of
(35:57):
it.
So, yeah, that's morecomplicated than it presents
itself.
The suboxone crowd would saythis is why you should stay on
this for the rest of your life,right.
The methadone clinics would saywell, this is why you need
opiates the rest of your life.
But I still don't feel that way.
Back to what I said, that noone is missing opiates, you get
into the conversation about risk.
(36:19):
So if the risk of relapse isreturning to taking one Vicodin
that's actually a Vicodin, thenI'm probably less worried about
that.
You get back on track.
It tells you it's feedback.
You need to make some changes.
If the risk of relapse istaking a fake Vicodin or a fake
Percocet that's actuallyfentanyl and you overdose and
(36:40):
maybe lose your life, well, nowthe stakes are much, much higher
.
So I don't have a great answerfor you about that.
I will say this that patientswho come to a 30-day treatment
program to taper off suboxonewithout getting on the
long-acting stuff, that'susually a bad idea.
(37:02):
I agree, because your lifecan't be that together if you
have to check into a treatmentcenter to get off suboxone.
For those of you at home whowant to come off suboxone, you
drop by half whatever it is.
This is how we do it.
You drop whatever you're on.
You can cut it in half, andthat's because of the nature of
(37:22):
the Michaelis-Menten curve,which is a fancy way of saying
how the receptor binds the drugso you can cut it by half and
then see how you feel.
You have to give it four orfive days to equilibrate.
If you feel fine, cut it byhalf again.
At some point you'll feel icky,you'll feel withdrawal symptoms.
The move there is to not cut itanymore until you don't feel
(37:46):
the withdrawal symptoms.
That's sometimes a few days,that's sometimes a couple of
weeks.
Now low-grade symptoms, don'tput yourself into massive
withdrawal.
But you feel like, yeah, I'mnot feeling that great.
That's the time to lean on therest of your support system and
tell them hey, I've been on 16milligrams of Suboxone.
I went to eight.
I felt fine.
(38:06):
The next week I went to fourand I start to feel kind of
crummy.
So keep an eye on me, guys.
I'm going through it.
And then you wait until you'reno longer going through it, so
to speak, having physicalwithdrawal symptoms.
Then you go down to two, havingphysical withdrawal symptoms.
Then you go down to two.
Now, that process can take awhile, but who cares?
(38:27):
Time is your friend in thatsituation.
And you're transferring thedependence on the substance to
the dependence on your recoverysystem In a treatment center,
doing it in 30 days verydifficult.
It's not your usual supportnetwork.
It's this, you know, bolted onwell-meaning and professional
people, but they're not yourcrew.
And then the, the calendar isin charge and time is not your
(38:49):
friend.
So in general, I wouldn'trecommend that.
If they've changed the, the waythey regard themselves and how
they manage their feelings, thenI think sublocate or tapering
are great and in fact you should.
If you haven't, if there's someexternal pressure, if you're
(39:09):
hearing it from your familymembers hey, why are you still
on that stuff?
You need to get off.
Then those are fraughtsituations because you probably
aren't stable, you're probablynot in good shape and maybe the
medication is protecting youfrom something bad happening.
So the message I would say isto try for the clinicians, for
(39:30):
the docs, is to try and see ifyou can figure out what's going
on For the patients.
Help them be honest with what'sreally happening.
I don't really want to get offof this, but my wife is on me
about.
She thinks I'm different orwhatever the details are.
Does that make sense?
Speaker 1 (39:48):
Yeah, I guess I have a slightly different approach,
which is that and I'm going togive credit to my lovely bride
and fellow addiction doctor, drReb Close the way she describes
addiction is feel something,take something.
Dr Reb Close, the way shedescribes addiction is feel
something, take something.
And so what I'm doing in mypractice is, let's say, someone
says to me hey, doc, I've beenon Suboxone for three years, I'm
(40:09):
tired of this stuff, I'm readyto get off of it.
I'll say great, we put them onSublocade.
That's my preferred product,simply because I have more
experience with it and it seemsto last longer.
I give them, let's say, fourinjections, allow the sublocate
to reach steady state, and thenI tell them to stop.
If they get withdrawal, we givemore, we work it out.
The issue is, though, to yourpoint to riding a bike they are
(40:29):
used to, when they don't feelgood, using some sort of
substance to make them feelbetter, and I want them to take
my substances, not whateverhorrible substances are out
there, right?
So common dosing forbuprenorphine under the tongue
is anywhere from, you know, inthe fentanyl era, 16 to 32
milligrams, right, and what Iwill do is I say I'm going to
(40:51):
give you the two milligrams, thelittle baby ones, and I want
you to know that if you'rehaving a bad day, you can take
one.
Yeah, I like that.
And the idea would be is thatyou never say goodbye to
buprenorphine.
It's that you don't take itevery day and you're not
dependent, but while youcontinue to work on building
your skills and building yoursupport group and working on
(41:13):
your sobriety, if you have a badday, the Suboxone is like a
little tiny parachute yeah, thatif you take three doses a week
for six months while you'regetting off of it great, you
didn't use fentanyl.
And then I always tell them youhave to keep seeing me, even
after you stop until X date, oryou've got a primary doctor that
(41:33):
you're going to work on it with, et cetera.
But it's almost like Suboxoneis always there as a tool.
You may not need that tool, butit's always there for you,
particularly as the sublocateshots wear off and the
buprenorphine gets out of theirsystem.
People are often overlyconfident on buprenorphine
because it works so well foropiate use disorder and opiate
cravings and they're like wherethe heck do these cravings come
(41:55):
from?
Great, let's work on it.
Here's your four doses of twomilligrams of buprenorphine a
week and I'll see you next week.
That's my approach.
Speaker 2 (42:08):
Yeah, no, I've done that.
I've done that.
It's patient to patient.
I've done it with partialstrips also.
And listen, there's the placeboeffect as well for smokers on
an airplane.
You can't smoke on an airplane,right, but feeling the pack of
cigarettes in your coat pocketor in your in your blouse pocket
, ok, I've got these.
So when we land, I'm OK, andsometimes the idea of having it
just in case, paradoxicallymakes it so that they don't need
(42:32):
to take it.
Whatever works, so long as aperson doesn't go back to
fentanyl and we're movingforward and don't go backwards,
it's all good with me, and sothat's maybe one of the best
things about this specialty isyou're dealing oftentimes in
uncharted territory.
Well said Doesn't standardize,it's not.
We always do this this way withthis situation.
(42:55):
It's true in all the medicine,right?
So even the guy fixing theankles, all the ankles are
different and where they'rebroken is different.
So it's true in all themedicine, right?
So even the guy fixing theankles, all the ankles are
different and where they'rebroken is different.
So it's true in all themedicine.
Why would we think in addictionmedicine?
Oh, opiates.
Here's the rubber stamp on whatyou need to do.
It's not how it works.
So, yes, I think creating aspace where the patient can be
(43:16):
honest is essential.
The patients need to be able tosay hey, you know, dr Grover, I
feel scared, or I took someextra Suboxone, or I got some
fentanyl.
Speaker 1 (43:30):
Well, I have to say, you and I could probably geek
out about addiction for at leastanother 90 to 120 minutes For
sure.
Let's wrap up here.
What would you say are sometake-home points that our
listeners can take away fromwhat we've talked about in terms
of learning about how to treataddiction, including long-acting
injectable medications?
Speaker 2 (43:47):
Sure, I would say that long-acting injectable
medications are valuable anduseful tools.
They are not magical Swiss armyknives that solve all problems.
We've narrowed our discussionto, in the most part, to talk
about opiate use disorder.
We don't have long-actinginjectable medications for the
(44:08):
rest of the substance use andthe rest of the substances that
people get tangled up with andthe opiate use disorder.
Long-acting medications are notgoing to keep you from drinking
and they're not going to keepyou from using cocaine.
So to a certain extent they'relimited in scope and efficacy
and it's dangerous for people tosay well, I'm just an opiate
(44:31):
guy, I don't have a problem withwhatever because of the
phenomenon of cross addiction.
Right, so you can.
You can develop something else.
I would say that if you'recommitted to changing the way
you respond to your feelings andyou manage them with these
other strategies CBT, you know,insight oriented therapy,
(44:53):
exercise, all the stuff that wehave to help sobriety If you're
doing that and you have anopiate use disorder, these
long-acting medications can bevery helpful.
They can be very helpful.
When to get off of them dependson how far along you are and
how much of your life hasfundamentally changed.
(45:15):
People do grow out of theiropiate use disorder with time.
How long that takes, I'm notsure.
It's person to person, becausethe consequences can be so grave
, and by that I mean literallythe grave.
Yes, I would rather if it weresomeone I loved or a patient of
mine that I cared about.
(45:36):
I'd rather that they got anextra month or two of sublocade
passed when they actually neededit than stopping too soon
before they're fully cooked, asthe kids would say right, let
them cook.
And that has to do with thephilosophy.
So if you believe that you'vegot a faulty decision-making
(45:56):
system and you trust that it'sfaulty, then you won't trust
your decision-making.
You'll say how does this sound,casey, I am going to Las Vegas
and all of my friends are goingto be doing cocaine and speed
balls, but I'm just going tohang out with them and I'm going
to be the designated driver.
Now, when you hear that plan,you're laughing, right, I'm
(46:20):
watching you laugh.
And so when you hear that plan,that's insane, right, that's an
insane.
You might think that's a reallygood idea because you're not
going to use, but you're puttingyourself in a dangerous
environment with camaraderie andso on and so forth, and and so
running your plan by anotherhuman being.
It's like those bumps in theroad when you start to get out
of the lane, the tire runningover them will let you know.
(46:48):
So get some bumps in your lanesso that you can see when you're
starting to drift off track.
Otherwise you'll be the last toknow.
Speaker 1 (46:54):
I have to say, so many nuggets of knowledge that
you have given me today will beused in clinic next week.
I have to say this has beenabsolutely fantastic.
I can't wait to get thispodcast out there.
So great to get to talk to youtoday.
Speaker 2 (47:05):
I enjoyed it.
I learned a lot.
For me, it's a delight to talkto a wise colleague and I made
this choice to abandon a verytraditional specialty and to
pioneer and be one of the guysin the trenches out here, and
it's inspirational to me to seethat there's a whole other crop
that's going to take over andpush the frontiers farther out.
(47:27):
It's an endlessly fascinatingspecialty and I'm grateful to be
here.
I'm grateful for the time youspent and thanks.
Really fun time, doc.
Speaker 1 (47:35):
Yeah, I was going to say I mean, I think for me, the
two things I love about what Ido is the gratitude and the
people are so nice when they'rein their addiction.
Sometimes they struggle, butaddiction can happen to anyone.
Some of the nicest people Iknow are my patients and I'm
just grateful to be able to takecare of them.
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
(47:58):
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
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
(48:20):
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
saves lives.
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