June 9, 2025 • 54 mins
In this episode, we discuss the fundamentals of treating opioid and alcohol use disorders with medication-assisted approaches. We review how to understand addiction as self-regulation with substances and how healthcare providers can leverage familiar medications alongside specialized treatments to help patients recover.
We also discuss
• Addiction fundamentally involves helping patients shift from self-regulating with substances to self-regulating without them
• Distinguishing opioid dependence (physical brain chemistry changes) from opioid use disorder (psychological addiction)
• Buprenorphine as a partial agonist that blocks other opioids, reduces cravings, and decreases overdose risk by 70%
• Three FDA-approved medications for alcohol use disorder: disulfiram , naltrexone, and acamprosate
• Off-label medications like gabapentin and topiramate can enhance alcohol use disorder treatment
• Understanding the fentanyl crisis and emergence of counterfeit pills containing dangerous synthetic opioids
• Addressing stigma through person-first language and recognizing addiction as a disorder of executive functioning
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 on addictionin general, as well as on
(00:44):
buprenorphine and themedications that are used to
treat alcohol use disorder.
We are really working in myarea to educate all of our
doctors on the basics of how totreat addiction, so I gave a
lecture on this topic to some ofmy primary care doctor
colleagues and I recorded it toshare with all of you care
(01:05):
doctor colleagues, and Irecorded it to share with all of
you.
The focus was on how tounderstand addiction, use
buprenorphine and also how touse the three FDA-approved
medications for alcohol usedisorder acamprosate, naltrexone
and disulfiram.
I got good feedback from mycolleagues that attended the
lecture, so I hope you find ithelpful.
Here we go.
Hope you find it helpful.
(01:29):
Here we go.
Well, I think I will getstarted.
So I think I know everybody onthe call.
So my name is Casey Grover andI am currently in recovery from
emergency medicine.
I practiced emergency medicinefor 14 years and I actually had
to leave the specialty because Iwas diagnosed with
post-traumatic stress disorderfrom the emergency department
and I now do full-timeoutpatient addiction medicine.
(01:49):
And to my primary carecolleagues on the call, I
respect you immensely because Inow do things like return to
work and disability and have adifferent respect for the clinic
workflow than I used to when Iwas in the emergency department.
So very pleased to be able totalk about medications for
opioid use disorder and alcoholuse disorder.
So we're going to go throughthree things, which is
(02:13):
understanding how to diagnosealcohol use disorder and opioid
use disorder, and then usingbuprenorphine for opioid use
disorder and then medicationsfor alcohol use disorder.
So I'm going to stop herebefore we really get into the
slide deck and just talk alittle bit about what addiction
is and really what we need to do.
So I believe we have primarycare and one psychiatrist on the
(02:38):
call and many of themedications that you already use
are effective to treataddiction.
So let's think about someonewho's using alcohol.
They have a reason why theyconsume alcohol.
Right Alcohol, you have todrive to get it or pay for it to
be delivered.
You have to pay to consume it,and then there are the
consequences of using it, likegetting sick or having hangovers
(03:00):
.
In other words, there's a costthat the person incurs when they
go to consume alcohol.
For illegal drugs, that cost iseven higher.
Right, so you got to find adealer.
You have to risk exposure tolaw enforcement in getting the
drug.
You use the drug, you're atrisk of overdose.
You may be incarcerated.
Your dealer could rob you.
There's a lot of cost that mypatients incur when they buy
(03:23):
drugs.
So the question I always askthem is what does this substance
do for you?
In other words, they're clearlyspending their time and money
to get the substance for areason.
What is that reason?
Let's say they drink alcoholbecause they're anxious.
Well, gosh, primary care andpsychiatry treat anxiety all the
time.
Let's say someone uses cannabisbecause they can't sleep.
(03:46):
Same thing Common medicationswe know around sleep are in all
of our wheelhouses and a lot oftimes it's trauma, it's
post-traumatic stress disorder,and a lot of what I do,
particularly with victims ofsexual assault, is help them to
understand how their trauma,which they may or may not
recognize, affects their brainand leads them to seek
(04:09):
substances.
At the most fundamental level,what I do as an addiction doctor
is I take people whoself-regulate with substances
and I help them learn toself-regulate without substances
.
We might use medications andwith things like cognitive
behavioral therapy and mutualsupport group meetings and
(04:31):
developing emotional resilience,they may get to the point where
they don't need any prescribedmedication.
In fact, for many of mypatients that's the goal.
So we're going to talk aboutbuprenorphine for opioids and
the three FDA-approvedmedications for alcohol
addiction.
But I want you to realize thatyou already probably have more
skills around treating addictionthan you may realize.
(04:52):
So the simple question of whydo you use?
Is usually what I lead withonce I get to know the patient
and then I really focus onfiguring out what unmet need
they have.
In fact, my number oneprescribed medications are
usually probably clonidine, aselective serotonin reuptake
inhibitors, hydroxazine foranxiety and trazodone, which I
(05:17):
know are medications you all arefamiliar with.
So I just want to give thatcontext and that caveat that
we're going to talk aboutaddiction-specific meds.
But there's actually a lot moreprimary care and psychiatry in
what I do than addictionmedicine sometimes.
So with that, I hope thatcontext is helpful.
(05:37):
Let's talk about opioiddependence.
So opioid dependence is theidea that when we use opioids
regularly, our brain chemistrychanges Right.
It's usually about somethinglike a week to two of sustained
(05:57):
exposure to an opioid throughoutthe day, and this is from any
opioid right.
Let's say one of our patientshas a hip replacement and is on
oxycodone for three weeks.
They will develop opioiddependence.
Let's say one of our patientsis using fentanyl, buying it on
the street.
Regular opioid use leads toopioid dependence.
It really happens in everyhuman being with sustained
(06:20):
exposure to opioids and it'sreally frustrating because once
opioid dependence develops wereally only have two ways to
treat it.
We either give people back anopioid so they don't withdraw,
or they kick.
They go through withdrawal andmy patients find medications
like methadone and buprenorphinevery frustrating because they
(06:43):
do all the work to stop usingfentanyl or stop using heroin
and they're like I did it.
I got on Suboxone, but how do Iget off Suboxone?
And they oftentimes get reallymad at methadone and
buprenorphine, which is themedication in Suboxone, and
methadone and buprenorphine arenot the problem.
It's opioid dependence that isthe problem.
(07:04):
And I remember going back, youknow, 10 to 15 years ago in the
emergency department.
We did not recognize this asdoctors.
How many people came to theemergency department said I need
more Norco and I said no, theyjust would go withdraw.
So really, where medicationsfor addiction treatment in
opioids shine is that they allowpeople to function without
(07:25):
withdrawal, and that's reallywhat we're going to talk about
today around buprenorphine.
All right, next slide.
Okay, now on the other side ofthe opioid equation, from opioid
dependence is opioid usedisorder, and the older name for
this was opioid abuse or opioidaddiction.
(07:47):
But opioid use disorder is akind of the best way we have
right now to describe a personwho psychologically has a
problem with opioids.
And there's basically threecomponents to addiction or a use
disorder Compulsive use,cravings, or an intense desire
to use, and consequences.
(08:08):
So compulsive use would betrying to stop and you can't.
Cravings is a fixation on thesubstance and not being able to
think about anything else untilthey use, and then consequences
could be physical, interpersonalor legal, and so I think this
is the part of opioids thatpeople find to be much more
(08:29):
challenging to treat, and thatis because, in my opinion,
addiction is a disorder ofexecutive functioning.
So what is executive functioning?
Executive functioning is how tokeep a schedule, deciding to
save money instead of spendingit, being on time to pick your
kid up from school, knowing thatyou have a doctor's appointment
(08:52):
, and calling ahead because youcan't make it.
It's the organizational,decision-making part of life,
and so what I find with mycolleagues is, when they look at
someone with addiction, they gowell, why would you do that?
And I myself say that all thetime.
What made you think that was agood idea?
And that's addiction.
Addiction is a disorder ofexecutive functioning and that's
(09:14):
why they get compulsive use.
They want to stop, but theycan't.
Cravings they know they need togo pick up their kid from
school, but they can't stopthinking about the drug.
And then they get consequencesbecause they can't actually make
rational decisions.
So again, opioid use disorderis the best way to describe an
opioid addiction and again Ithink of it as a disorder of
(09:37):
executive functioning.
This is very common where peoplehave an opioid use disorder, so
they use the drug regularly andthey get dependence.
The vast minority of patientswith opioid use disorder will
binge.
It's really more consistent usebecause withdrawal is so common
and it's unfortunately a majorcontributor to drug overdoses in
(09:58):
America.
Next slide, please.
Now, as I was mentioning,there's opioid dependence and
there's opioid use disorder.
There's a spectrum where somepeople are pure addiction.
Others are, for example, onchronic pain meds and they're
not addiction.
But, as I mentioned, anyone onplanet earth who takes opioids
(10:20):
regularly will get dependence.
Not everyone develops anaddiction or a use disorder when
they're exposed to opioids, butsome will.
So an older term we used to usewas drug seeking.
Bad patients drug seeking, theywant oxycodone.
That's a very imprecise term,right?
That's like saying oh, thedefinitive diagnosis is nausea.
Well, why are they nauseated?
(10:42):
Drug seeking is the pursuit ofof a substance.
Is it withdrawal?
Is it a use disorder?
Is it untreated pain?
So I think it's reallyimportant when assessing people
to understand exactly what'sgoing on, and I usually find
that most of my patients havesome semblance of a use disorder
(11:03):
and also dependence, and I haveto make sure to address both of
them.
Next slide, please.
Okay, so this is something I'llgo through fairly quickly,
because I have to look this upevery time.
But how do we diagnose anopioid use disorder?
There are 11 criteria.
(11:23):
It's in the DSM-5.
I don't know how much all ofyou know and love the DSM-5, but
I'm sure, dr Blaine and I do.
But yes, it's basically 11criteria for addiction.
You ask the patient thequestions.
If they have two to threecriteria it's a mild use
disorder.
Four to five it's a moderateopioid use disorder and six or
more it's a severe opioid usedisorder.
(11:43):
In my line of work I don'tactually do this.
If they come to see AddictionMedicine, it's usually a bad
problem.
But if you want to get into thenuts and bolts you can actually
do this.
As an example, I had someonewho was identified as having a
problem with alcohol and theyneed me to sign off on forms
going back to work and in thatcase I got into this specific
criteria.
But usually if someone comes tome and said, hey, doc, I need
(12:04):
help, they definitely have a usedisorder.
Next slide, please.
All right, so let's go ahead.
This slide is out of order.
Okay, so here are the criteriafor opioid use disorder.
And again, it's compulsive use,cravings, consequences Opioids
(12:24):
are taken in larger amounts fora longer period of time.
People want to cut down but theycan't.
People are doing a lot ofactivities to get the drug or
recover from the drug.
They have cravings.
They're not fulfilling theirobligations at work, school or
home, they continue to use theopioid despite having problems.
Next slide, please.
And then they're giving upactivities because of the drug.
(12:47):
They're using it when it'shazardous, they know it's making
their health worse and theycontinue to use.
And then, because of persistentuse, they develop tolerance and
withdrawal.
So that's the basic criteriaand again, I would encourage you
, if you want to look them up,truly, just Google DSM-5 opioid
use disorder criteria and you'llbe able to look them up.
Truly, just Google DSM-5 opioiduse disorder criteria and
you'll be able to look them up.
All right, next slide, please.
(13:09):
So buprenorphine is one of themedications that we can
prescribe for opioid usedisorder and opioid use
dependence.
Okay, this medication used tobe restricted and now, if you
have a valid license in DEA, youcan prescribe it, which is
great.
It's a very interestingmolecule.
(13:30):
The generic name isbuprenorphine.
It comes in severalpreparations.
There's sublingual, which issuboxone or subutex.
It comes as a patch calledbutrans.
There's some other formulations, like Zubzolve, that are
different proprietaryformulations, but the basic idea
is that it's buprenorphinethat's doing the heavy lifting.
(13:50):
Okay, buprenorphine bindstighter to the opiate receptor
than anything else we know of,so it has a very tight binding
affinity at the opioid receptor,but it's not a complete agonist
.
What does that mean?
It will out-compete otheropioids at the opiate receptor
to bind and it's less euphoricand doesn't cause respiratory
(14:11):
depression the way other opioidsdo.
So let's say, one of mypatients is on buprenorphine and
they use fentanyl Becausebuprenorphine binds so tightly
at the opiate receptor.
The fentanyl is largely inert.
So that's one of the reasons Ilove it as an addiction doctor
is, once my patients are on bup,I do this.
Oh, thank goodness.
Right, if they have a relapse,they're protected.
(14:35):
Now the activation of the opiatereceptor by buprenorphine it's
only a partial agonist.
It's enough to treat cravingsand withdrawal and help with
pain, but it doesn't really haveeuphoria.
Again, there's what's called aceiling effect where you really
can't overdose on it.
You can just keep going up onthe dose and people will not get
(14:56):
respiratory depression oroverdose the way we do with
other opioids.
Next slide, please.
So it is a schedule threemedication, so it is something
that requires a certain amountof oversight and monitoring.
And it is FDA approved for bothopioid use disorder and pain,
and let's just take a quickminute here and talk about pain.
(15:17):
So if you don't know the otherpart of my addiction medicine
practice is with some of thelocal pain physicians.
You guys probably know SularDeldar, so he's one of our local
pain docs.
We're in the same practice.
So I actually have adisproportionate number of pain
patients in my addictionpractice.
Full agonist opioids likehydrocodone or oxycodone or
(15:37):
morphine change the painsensitivity over time.
Here's how I think of it.
Pain is protective.
Right, If I go to put my handdown on my desk and my desk is
hot, I need to be able to pullmy hand away so I can protect
myself.
The brain does not actuallylike being on opioids because it
realizes it cannot protectitself if pain is present and
(15:58):
just to level set.
Pain is meant to be an acuteresponse.
Chronic pain is non, it'snon-functional pain.
It doesn't alert the body ofany tissue damage.
So our response to chronic painis somewhat maladaptive because
we keep thinking tissue damage,because we're used to acute
pain.
So chronic pain is a specialthing that is addressed
separately.
(16:18):
But basically the brain thinks,uh-oh, opioids are making me
not able to feel acute pain.
I better dial up the painsensitivity so I could protect
myself if I need to.
So these poor patients on fullagonist opioids end up with
worse pain over time.
It's called opioid-inducedhyperalgesia.
It's a fancy way to say.
Your pain goes up over time dueto increased pain sensitivity
(16:42):
with chronic opioid use.
There are two opioids that weknow do not do this to the same
extent as other opioids, andthey are methadone and
buprenorphine.
So in our pain practice wedon't start really anybody on
oxycodone or norco or morphine.
We really start everyone oneither methadone or
buprenorphine.
So it's actually more effectivethan other opioids for pain.
(17:05):
Next slide, please.
So we talked about some of theunique things about
buprenorphine.
We talked about how it protectsagainst opioid-induced
hyperalgesia Because it blocksthe effects of other opioids and
protects against respiratorydepression.
It absolutely saves lives inpeople with opioid use disorder.
(17:27):
People's risk of dying fromopioid use disorder through
overdose once they're onbuprenorphine is down by 70%
compared to if they're not on it.
Very effective, and then, as Imentioned, it does not cause
euphoria and we can talk aboutthe dosing.
Next slide, please.
As I mentioned, this used to besomething that was restricted
(17:51):
by the DEA and that is nowcompletely gone.
If you have a valid DEA, youcan prescribe it.
Patients tell me all the timeoh, the doctor said they
couldn't prescribe it.
Thank you, joe Biden.
All politics aside, under theBiden administration they got
rid of this requirement in early2023.
Next slide, please.
Okay, when should you usebuprenorphine?
(18:12):
Well, we've been talking aboutit.
It's very effective for opioiduse disorder the addiction side
of things.
It also is an opioid, so itwill keep people out of
withdrawal, so it manages opioiddependence, and it also can be
used for pain, both acute andchronic.
Next slide, please.
There are a couple ofcontraindications.
Like other opioids, if combinedwith multiple sedating
(18:36):
substances, it can result inoverdose.
Buprenorphine by itself isreally unlikely to cause an
overdose because of that ceilingeffect.
Again, it only opens the opiatereceptor partway, which is why
it doesn't cause respiratorydepression.
But if you mix it with alcoholor benzos, the downer effects of
the different classes can addup.
(18:56):
Buprenorphine is metabolizedhepatically.
There's some older literaturethat showed that it was causing
people's LFTs to go up.
We still don't fully know yetand that's probably overblown.
But if somebody has cirrhosisyou need to choose another
medicine and, as I mentioned,should be avoided with heavy
alcohol use.
But if you think about it,given that buprenorphine does
(19:17):
not cause respiratory depression, if you have a patient with
alcohol use disorder who is inpain.
Buprenorphine is going to besafer than, say, oxycodone.
Next slide, please.
All right, dosing.
So there's a ton of differentformulations of this stuff.
I'll keep it really easy.
90 to 95% of this medication isgiven in the sublingual form.
(19:40):
It comes as a tablet by itself.
Buprenorphine is called Subutex.
And then there's anotherproduct where naloxone is mixed
in the naloxone doesn't doanything.
It gets excreted in the stool.
But if somebody tried to snortit or smoke it or inject it they
would get withdrawal.
(20:01):
So I actually don't care.
They taste a little different,they dissolve differently in the
mouth.
I let the patient choose.
For someone who is opiatesophisticated meaning they have
a history of opioid dependence,they've been on opioids or
they've got opioid use disorderI usually start them on
somewhere between about 8 to 24milligrams a day.
For someone who's opioid naive,it's more, like you know, 2 to
(20:22):
6 milligrams a day.
For someone who's opioid naive,it's more, like you know, two
to six milligrams a day.
So let's say, for example, I,you know, have to have shoulder
surgery next week.
I would probably take somethinglike one to two milligrams of
bup three times a day.
But if 10 years down the roadI've developed a fentanyl
addiction, then I would probablybe on something more like 24 to
(20:44):
32 milligrams a day.
It also does come as a once amonth injection for those with
addiction, which we do all thetime in the office.
It's absolutely wonderful.
Next slide, please.
The only other thing I wouldpoint out on this is that if
people do swallow buprenorphineit really doesn't get absorbed.
It's only like 10 to 20% of thedose.
(21:04):
So if people are starting it,we have to instruct them to take
it sublingually.
And we talked about dosing.
All right, next slide, please.
It's important to realize thatit's a very potent opioid, which
is why the dosing is so low.
For opioid-naive patients.
(21:24):
One milligram of sublingualbupe is about 30 to 40 morphine
mill equivalents.
So that's pretty potent.
And in the era of fentanylpeople have such incredible
opioid tolerances that are justthrough the roof.
Buprenorphine is actually oneof the only opioids that is a
potent enough agonist to keepthem out of withdrawal.
Even methadone some of mypatients get put on these
(21:45):
ridiculously high doses ofmethadone and they're still in
withdrawal.
I think we covered everythingon this slide.
Next slide, please.
Okay, so let's say you'rethinking about putting a patient
on buprenorphine.
What would you want to dobefore you start?
Well, if they have obvioussigns of liver disease, as in
(22:06):
you can see it from across theroom on physical exam they are
not a candidate for bup and,sorry, we abbreviate
buprenorphine as bup.
So if somebody has significant,significant liver dysfunction,
choose another med.
It's recommended to check LFTsperiodically.
I have dozens and dozens ofpatients on this.
I don't check LFTs Lee Goldman,for context, maybe does it once
(22:27):
a year.
The risk of it causing liverdysfunction is overstated.
And then it's important to knoware they using other substances
?
Are they using meth?
Do we want to address that?
Are they using cannabis?
What other substances do weneed to address while we're
working on getting them on bupe?
Next slide, please.
(22:49):
Pregnant patients can get opioidaddiction as well, and the
treatment for opioid addictionin pregnancy is methadone or
buprenorphine.
We dose it almost identically.
In terms of buprenorphine, itused to be that we only used the
monoproduct, the buprenorphine,or Subutex, in pregnancy, but
(23:09):
it's now been found that bothsuboxone, which is the
buprenorphine naloxone, andbuprenorphine by itself are both
safe in pregnancy andessentially you dose them until
they don't feel cravings andthey don't feel withdrawal.
It is recommended that we donot taper people off of opioids
during pregnancy because thereis an association with preterm
labor and opioid withdrawal.
(23:31):
In terms of youth, we treatyouth with buprenorphine all the
time.
I think our youngest on bup is14.
In the practice the dosing isfairly similar because most kids
by about 14 are pretty close toadult size and it's important
to know that any child 16 andolder can consent to bup without
parental consent.
I know parents and addiction.
(23:52):
It's a difficult population.
The parents have obviously highexpectations for their children
.
The teenage brain is not superresponsive to insight, it's
still growing, so that can be adifficult population.
So kids can get bupe on theirown.
16 and older.
Next slide, please.
Common things in terms of sideeffects it's an opioid.
(24:13):
It's an opioid agonist.
It's a partial agonist.
So you're going to get the samestuff you get with opioids
constipation, nausea, drowsinesswhen we give the once a month
shot.
It's called Sublocade, that'sone brand and Brixadi is the
other.
It's essentially a shot wherethey don't take medicine every
day, they just get a once amonth shot.
So compliance is great.
They usually get an injectionsite reaction.
(24:35):
And then we are unfortunatelyseeing that there's increasing
literature that sublingualbuprenorphine in either the
subutex or the suboxone isassociated with dental carries.
So I've got a couple of folksthat have come to me and said I
got to get off this stuff, I'mlosing teeth.
I didn't know about that untilrecently.
Really disappointing because itworks so well.
(24:56):
If that is the case, if it's apain patient, you can transition
them to the transdermal, theButrans, which is FDA approved
for pain and it's for opioid usedisorder.
You can use the patch off label.
But we might need to transitionthat patient to the sublocate
or the brixati, the once a monthinjection.
(25:17):
So if you're having troublewith somebody on bup and they're
having dental caries issues,absolutely you can refer over to
Addiction Medicine and we'llsee what their options are.
Next slide, please.
Okay, how do you start thisstuff?
If buprenorphine had akryptonite it would be this For
an opioid-naive patient.
(25:38):
You can just start it right.
So let's say one of yourpatients has an upcoming surgery
and you want to start them onbuprenorphine in advance of
surgery.
Go ahead and write, for youknow two milligrams of Subutex
or Suboxone, you know a half toone three times a day for pain,
or four times a day for pain, noproblem.
Now for people that aredependent on opioids.
(26:02):
They have to be in a period ofwithdrawal before they start
buprenorphine, and it's a majorproblem and frustrating.
Here's how this works In mybrain.
This is how I understand it.
Let's imagine that we'redriving a car and that car is
fueled by opioids A full agonistopioid, meaning it activates
(26:22):
the opioid receptor.
All the way is going to take youto 100 miles an hour.
Morphine, oxycodone,hydrocodone, fentanyl they all
take you to 100 miles an hour.
Buprenorphine, because it'sonly a partial agonist, takes
you only to about 60, 65.
You're going fast enough thatyou're not in withdrawal or
(26:43):
craving, but it doesn't push youall the way up to some of that
level of euphoria.
So if you take buprenorphinewhen you have a full agonist
opioid in your system,buprenorphine binds more tightly
to the opiate receptor thananything else we know.
So buprenorphine will actuallykick those other opiates off the
opiate receptor.
(27:03):
So it's literally like goingfrom 100 miles an hour and
slamming on the brakes and goingdown to 65.
And that's called precipitatedwithdrawal.
So people will go intowithdrawal when they start
buprenorphine, unless they'realready in withdrawal.
So the idea would be is ifthey're driving 100 miles an
hour on opioids as the opioidswear off they'll slow down.
(27:26):
We have to get them like downto 30 miles an hour in bad
withdrawal and then bring themup with buprenorphine.
It's a little frustrating andcertainly you know you can refer
to addiction medicine if you'rehaving trouble getting someone
started on this.
For people who are on regularopioids, like an oxycodone or
even heroin, it's only about a12-hour wait.
(27:48):
You can have them take theirlast dose of opioid or use
heroin at 10 pm and then theycan start buprenorphine the next
morning.
For fentanyl it's a much biggerproblem.
Fentanyl is lipophilic so itbuilds up in the body for days.
Usually those folks have towait even up to three days to
get enough fentanyl out of theirsystem that they're ready to
(28:09):
start buprenorphine.
It's a really frustratingproblem.
Next slide, please, and thenonce patients get on it, their
withdrawal is better.
If they're a pain patient,their pain is better and then
their cravings are better andessentially you titrate to the
dose where if they have painthey're feeling better and if
they have opioid addictionthey're, you know, not craving
(28:32):
and if they're dependent theydon't have withdrawal and I let
them self-titrate.
I'll just say you know here's,you know up to where you could
take about 24 milligrams a day.
Tell me what dose feels rightand people will self-titrate.
Some people will take one inthe morning and they're good for
the day.
Some people will take two inthe morning, one in the evening.
Almost all of my patients havea different regimen and I let
(28:52):
them choose whatever works forthem.
Again, because of itsincredible safety profile.
If somebody starts escalatingthe dose on their own, I don't
have to worry about them havingan overdose.
Next slide, please.
It is a controlled substance, soyou're going to want to see
your patients pretty regularly,initially until they stabilize
and then, once they're stable,it's I mean, I do this once a
(29:15):
month with some of my patients.
I've got some folks that are,you know, 10 years sober on bupe
and I just see them once amonth, give them a high five.
We chat about, you know, sportsteams and we send them on their
way.
It's exceptionally effectivefor folks to stay in long, long,
long-term recovery.
Again, if you're, if you wantto monitor liver function tests
six months to once a year wouldbe totally fine, all right.
Next slide, please.
And then the last thing wouldbe just realizing that if folks
(29:40):
do have underlying opioidaddiction, relapse can happen.
So making sure they havenaloxone and getting them into
some sort of supportivecommunity around their sobriety
is very important.
Next slide, please.
So once again, take-home points.
Buprenorphine saves lives.
You can use it for patientswith opioid use disorder.
It also treats pain.
It treats opioid dependence andwithdrawal.
(30:00):
Anyone with a valid DEA canprescribe it and it has unique
pharmacology which means that itis protective in relapse
because it blocks the effects ofother opioids.
But it is a little bit hard tostart, as you have to be in a
period of withdrawal before youstart as an opioid dependent
patient.
Again, for opioid naivepatients, you can just start it
straight off.
Next slide, please.
(30:22):
Okay, so we are now going to goon to alcohol and I just briefly
want to rant about alcohol.
I feel like I'm in a ranty moodtoday.
So it's interesting.
We call it alcohol and drugslike.
Alcohol's not a drug, andrecently we had the Pebble Beach
Food and Wine Festival.
For some reason we have decidedthat alcohol is okay and it's
(30:43):
our one societally acceptabledrug.
If I asked any of you like, hey, should we go wine tasting this
weekend?
You might say, gosh, thatsounds great.
If I told you, let's gomethamphetamine tasting this
weekend you'd look at me like Ihad three heads.
So in terms of what I do,alcohol is like any other
substance and it's actuallyharder for my alcohol patients
because alcohol is freakingeverywhere.
(31:06):
There are liquor stores.
I think there's like threeliquor stores on the way home
from my office to my home.
7-eleven sells alcohol, gasstations sell alcohol, wineries,
distilleries, local breweriesit's just everywhere.
Number one addiction in Americais alcohol.
So alcohol dependence is thephenomenon where people, again
(31:34):
their brain chemistry, changesbecause of regular use.
It's a little harder to predictwho gets alcohol dependence
than opioid dependence and mostoften we see it in people who
drink heavily, in terms of thequantity, and people who drink
throughout the day.
For people who are nighttimedrinkers, they tend to not have
as much dependence becausethey'll have like a 20-hour
period during the day.
For people who are nighttimedrinkers, they tend to not have
as much dependence becausethey'll have like a 20-hour
(31:55):
period during the day where theydon't have alcohol in their
system.
It's really morning, noon,afternoon, evening, nighttime
drinkers that we tend to see themost dependence Dependence can
develop in again about the sametime frame as opioids, usually
about somewhere between a weekor two of heavy use leads to
alcohol dependence.
Next slide, please.
(32:15):
And then again, just likeopioids, we have opioid
dependence and opioid usedisorder.
We also have alcohol dependenceand alcohol use disorder With
alcohol because it's notprescribed medically, it's very,
very unusual to have anyone whois dependent but doesn't have a
use disorder.
(32:35):
I'm trying to think of ascenario where some would be
dependent on alcohol withouthaving a problem.
I don't know if I can come upwith one, but the idea is again
is that we have to treat twoissues they are dependent on
alcohol and then they also havean alcohol use disorder.
The treatment of alcoholdependence I'm not going to
cover in this, because sometimesit requires inpatient
hospitalization or ICU care.
(32:56):
But the basic idea we're goingto talk about today is, once
people are through theirdependence, we have to work on
helping them not go back todrinking.
So same thing, it's those threeC's with alcohol use disorder,
just like opiate use disorder,cravings, compulsive use and
consequences.
Next slide, please.
(33:17):
Just one point on alcoholwithdrawal, just because it is
pretty important.
Alcohol withdrawal is fairlyunpredictable.
We have some people that weadmit you know with Dr Goldman
who we are sure are going tohave bad withdrawal not so bad.
One of my patients, literallytoday is getting discharged.
She was so afraid of badwithdrawal, was drinking 16
(33:38):
beers a day, minimal.
I had one 19-year-old who I wassure was going to be just fine
and ended up hospitalized withalcoholic hallucinosis.
The single biggest predictor ofbad withdrawal is previous
withdrawal.
So if you're talking to someonein the clinic and they're
talking about stopping and youthink like, yeah, I can probably
give them a couple days ofValium, get them off alcohol, a
(34:00):
really important question to askis have they had bad alcohol
withdrawal before?
In which case most likely we'dwant to have them assessed at
the hospital, and in my careerin the ER, sometimes what we do
is we just put them in a roomand let them metabolize and if
they don't develop badwithdrawal, we know they're safe
to go home.
All right, next slide, please.
(34:22):
So the diagnostic criteria foralcohol addiction or alcohol use
disorder are very similar tothe ones from opioid use
disorder and it's actually inthe same reference, the
Diagnostic and StatisticalManual 5th edition.
There are 11 criteria and it'sthe same threshold 2 to 3 is
mild, 4 to 5 is moderate, 6 plusis severe.
Next slide, please, and you'llrecognize these criteria for
(34:46):
alcohol use disorder becausethey are exactly the same as
opioid use disorder.
The only difference is they sayalcohol instead of opioid, so
trying to cut down giving upother activities to use the
substance craving is not able tomanage their obligations.
Consequences Next slide, please.
And then the same thing usingit when it's hazardous,
(35:08):
particularly around driving, andthen tolerance and withdrawal.
So very similar in terms of howwe diagnose alcohol use
disorder and opioid use disorder.
Next slide, please.
Okay, so we have threeFDA-approved medications for
alcohol use disorder and I justwant to remind you all these do
not treat dependence orwithdrawal.
They are for the alcohol usedisorder, craving, compulsive
(35:31):
use side of things.
So let's go through them.
Next slide, please.
All right, so the first one iscalled disulfiram and most
people know it by its brand name, antabuse, and this is the one,
for some reason, that everybodythinks of.
The mechanism of action is itblocks alcohol metabolism,
leading to a toxic buildup ofone of the metabolites of
(35:53):
alcohol, and it basically makespeople sick.
So somebody drinks alcohol onday sulfuram, the toxic
metabolites of alcohol build upand people will get nausea,
vomiting, flushing, upsetstomach, a general sense of
malaise when they drink.
I was always taught that it'sfairly minor.
It actually can belife-threatening.
(36:15):
If somebody binge drinks withdisulfiram in their system it
can be fatal.
The toxic metabolite of alcoholthat builds up is cardiotoxic,
so you can get hypotension,bradycardia and cardiovascular
collapse.
I have seen it once.
There was a gentleman that cameinto the emergency department
as a lights and sirens codethree near death ambulance run
(36:40):
and he looked like garbage.
Oh my gosh.
His pulse was like 40, hisblood pressure, I think it was
like 60 on 40.
We tanked him up with fluidsand I couldn't figure out why he
was hypotensive.
And then I looked at my drugreference and it cautioned
against binge drinking while ondisulfiram.
So definitely not an option foranyone who's binge drinking.
(37:01):
And that's actually why thereare contraindications of
cardiovascular disease, becauseif somebody drinks on disulfiram
it can exacerbate theirunderlying cardiovascular
disease.
It is hepatically metabolized,so somebody with cirrhosis is
not a candidate.
And I put the dosing on there250 to 500 milligrams a day.
How well does disulfiram work?
(37:21):
The answer is it doesn't.
Maybe maybe in some unusualclinical circumstances where
somebody's really motivated andvery afraid of health
consequences and they've got aloved one that's going to make
them take it every morning.
Be in some unusual clinicalcircumstances where somebody's
really motivated and very afraidof health consequences and
they've got a loved one that'sgoing to make them take it every
morning.
For the most part, people willjust stop taking it and drink.
So I usually don't prescribe it.
I have one patient on it rightnow and he's about to be kicked
(37:43):
out by his parents.
So the agreement is we watchyou take your disulfiram in the
morning or you leave the house.
So he's very motivated, has alot of support and it's again
that regimented way of using it.
One other thing people need tobe off alcohol for three days
around this medication,otherwise the residual alcohol
still in their system can causethose unpleasant side effects
(38:05):
when the alcohol metabolite isbuilt up in the system.
All right, next slide, please.
So the next one is one of theones I use the most and this is
naltrexone.
So naltrexone is an opioidblocker.
Think of it like Narcan for 24hours.
The way it works is when somepeople who are genetically
(38:27):
predisposed to alcohol addictiondrink, their brain releases
more dopamine than the averageperson, dopamine being again the
reward chemical of the brainthat makes us feel good, and
that excessive dopamine releasecauses endorphin relief.
So they get a double high fromalcohol.
They get the pleasure releaseof the dopamine and they get the
(38:49):
calming opioid effect of theendorphins.
So what naltrexone does is itblocks the endorphins, so it
actually makes alcohol lesspleasurable.
And interesting.
What we know about craving andthe anticipation of use is when
somebody who has an addiction toalcohol pulls into the parking
lot to buy alcohol, the brainstarts to release dopamine and
(39:11):
those endorphins in anticipationof the drug.
So naltrexone makes the drugless pleasurable and thinking
about the drug less pleasurable,which is how it blocks cravings
.
Now, unfortunately, not everyoneconsumes alcohol for the same
reason.
If you consume alcohol becauseyou're anxious, this one doesn't
really work.
They're not seeking thepleasure, they're seeking the
(39:31):
downer effect.
If you consume alcohol becauseyou're anxious, this one doesn't
really work.
They're not seeking thepleasure, they're seeking the
downer effect.
If you drink alcohol becauseyou can't sleep, this one
doesn't really work.
You're not trying to get theeuphoria, you're trying to get
the downer effect.
So it only works in apercentage of patients.
The two big side effects and Isee this all the time is
somnolence and nausea, andusually that's something that
(39:54):
goes away with time.
So I usually start people on ahalf dose of the oral medicine
for a few days to let them getused to it before they go to a
full dose, and then it willcause horrible opioid withdrawal
if they're on opioids regularly.
So anyone who's on opioids isnot a candidate for naltrexone,
and then anyone with cirrhosisshould not get it as well.
It is given as an oralmedication and it can be taken
(40:18):
daily to block cravings, like Iget up in the morning and I take
it so I don't drink.
It also can be used as needed,like I'm about to go to a
wedding and I don't want todrink, I'll take my naltrexone
right before.
And you can do both.
So daily dosing as an anchorand then as needed on top of
that.
And then it also comes as aonce a month shot which is
called Vivitrol.
I give I don't know a couple ofthose a week.
(40:39):
It's given as a once a monthinjection so people can't again
stop the naltrexone and go backto drinking.
Next slide, please.
How well does it work?
It's okay.
So the number needed to treatto reduce drinking with
(40:59):
naltrexone is somewhere between12 and 20.
So what that means is is I haveto treat somewhere between 10
and 20 people to see it beeffective and that's pretty
consistent with my my clinicalpractice most people, for most
people it's just not a oh wow,doctor.
Thank you, it works a littlebit in most people.
I have a handful of patientsthat have horrible alcohol
(41:21):
addictions and they takenaltrexone and the desire to
drink goes completely away.
It is absolutely a miracle drugfor some people, but for the
vast majority of people it helpsa little.
So often what I do withnaltrexone is I combine it with
another medicine and then theanti-craving effect of
naltrexone is combined withanother, say gabapentin, and
(41:41):
then the two anti-cravingeffects are additive.
So that's usually what I do.
The IM once a month shot doeswork better.
The number needed to treat toreduce alcohol is six, and
that's likely because thecompliance is better.
Next slide, please, oops, otherdirection.
There we go.
Okay, acamprosate this is onethat I had never heard of until
(42:02):
I sat for my addiction boardsand I didn't use.
And it works great, way betterthan naltrexone.
So what acamprosate does is itactually mimics alcohol's
effects in the brain to a veryminor extent.
So alcohol makes GABA, which isa downer brain chemical.
(42:22):
Alcohol makes GABA work better,which is where the downer
effects of alcohol come from.
And then we have glutamate,which is the brain's natural
upper chemical.
Alcohol makes glutamate workless well, so let's think about
that.
Alcohol makes GABA work better,so that's a downer effect, and
alcohol makes glutamate workless well, so that's another
(42:44):
downer effect.
So essentially, alcohol is adouble downer.
And so what acamprosate does isit does that same thing, but on
a very tiny amount, and the bestway I can describe it to people
it's like you've had a half ofa beer.
It just takes the edge off.
It's actually fairly effectivefor people with anxiety.
That's where I've had the mostsuccess with it.
Unfortunately it is renallycleared, so it cannot be used if
(43:09):
somebody has renalinsufficiency.
But in people who have liverdisease or are on opiates this
is a great choice.
I've actually not had anyonehave side effects on it, but the
manufacturer notes thatdiarrhea is the most common side
effect.
Now I don't know if anyone issuperstitious, but the dosing is
weird.
It's 666 milligrams three timesa day, so it's six pills a day.
(43:33):
Most people can't remember that.
So you can dose it BID and thenthe compliance is a little bit
better For my older patients whowere already on a bunch of meds
.
Then I just put them on threetimes a day and they put it in
the pillbox.
How well does it work?
Well, the number needed totreat to reduce drinking is
between 9 and 12.
So let's compare that tonaltrexone, which was between 12
(43:55):
and 20.
So it's more effective thannaltrexone and it works better
the longer people are sober.
So if somebody gets admitted,gets detoxed and then they come
out, that's a great time tostart a campersate.
Next slide, please.
Now.
If you dig into the literature,there's been all sorts of stuff
that's been studied for alcoholuse disorder in terms of
(44:16):
cravings, been studied foralcohol use disorder in terms of
cravings Topiramate, baclofen,gabapentin, frazacin.
There's all sorts of stuff.
We just went over the FDAapproved medications.
There's only three of them, butI use off-label meds for
alcohol use disorder all thetime.
The one that we're all probablythe most familiar with is
(44:37):
gabapentin, and so I usually doput people on gabapentin for
alcohol use disorder.
It does help with mildwithdrawal and it does help with
cravings.
I usually dose it somewherebetween 300 and 600 TID and you
can take an extra dose ofbedtime to sleep.
If you are interested, you cancertainly look up to pyrimate
and baclofen on how to use itfor alcohol use disorder.
But yeah, I usually starteither ac, campersate or
(45:04):
naltrexone plus something elsewhen I'm treating my patients
with alcohol use disorder.
Next slide, please.
Okay, take-home points here.
Naltrexone makes alcohol lesspleasurable, so if somebody
drinks it doesn't feel as goodand it makes the thought of
consuming alcohol lesspleasurable.
A campersate works on thatchemistry in the brain around
alcohol and makes people lesslikely to want alcohol because
(45:26):
it mimics alcohol to a very,very tiny extent.
And the disulfiram is theso-called enforced sobriety of
people will get sick if theydrink and it largely is not very
effective.
Next slide, please.
And it largely is not veryeffective.
Next slide, please.
Okay, couple of things just toshare.
You know, just in general isfor our patients using opioids.
(45:52):
The drug market is drasticallydifferent than it was about five
to six years ago.
So brief history.
Where did America's problemwith opioids start?
It started with prescriptionmedication.
So when I was in college myfriends loved Vicodin.
I don't know why Vicodin, but alot of my friends use Vicodin.
I had no interest in it.
Vicodin is now off the market.
It is hydrocodone andacetaminophen.
(46:13):
It used to be that if you got apill from the non-legal market.
It was a prescription that hadbeen diverted, so it would be
oxycodone.
That was a legitimate oxycodone.
Starting in about 2019, here inMonterey County, everything
changed.
Fall of 2019, specificallyOctober, is exactly when
(46:37):
fentanyl arrived in our drugsupply.
Initially we were seeing itreally just as counterfeit pills
.
So people were buying anoxycodone and it looked like an
oxycodone.
Maybe it was a little morelikely to crumble than a regular
pill, but people had stampsthey were able to press fake
pills.
All of it contained fentanyl.
(46:58):
Now, unfortunately, we'reseeing that fentanyl is not the
worst.
We are now detecting acetylfentanyl, acryl fentanyl,
paraflora fentanyl, even someweird novel benzos like atizolam
and bromazolam.
The illicit market changes veryregularly with all these
research, chemicals beingpressed into counterfeit pills.
(47:20):
The majority of my patients usefentanyl in the form of
counterfeit oxycodone.
So be liberal in co-prescribingnaloxone, you know, refer people
for treatment and then alsorealizing that a lot of patients
, particularly older patients,were put on multiple scheduled
sedating medications at the sametime and trying to come up with
(47:43):
safer regimens can be a win.
Let's say someone comes to youon fairly high-dose oxycodone
and high-dose clonazepam.
If you're able to wean the dosedown to the clonazepam and
transition them from oxycodoneto buprenorphine.
That is a safer regimen.
So sometimes we're stuck withthese older regimens, but that
is a safer regimen.
So sometimes we're stuck withthese older regimens, but at
least we can make them safer.
Next slide, please.
(48:03):
Oh, stigma, good heavens.
Stigma's really hard.
Stigma is the judgment of onegroup by another based on a
particular attribute that theyhave.
And in medicine, stigma is whatpatients feel when their
healthcare providers judge them.
Next slide, please.
And it comes up in all sorts ofways.
(48:27):
We might make one patient waitlonger because they're a quote
difficult patient In academicmedical centers.
Sometimes they'll make themedical student see the patient
with the undesirable diagnosis.
We often attribute blame orintent in non-compliance to
patients based on theirdiagnosis.
Oh, you know?
Oh, that patient wasschizophrenia.
(48:47):
He doesn't want to be on hismeds.
It's important to be veryobjective with our patients.
We really need to check ourbiases and realize that we can
have implicit bias aboutparticular conditions.
There is stigma in healthcareabout all sorts of stuff
Psoriasis, epilepsy, urinaryincontinence, dementia,
(49:13):
addiction, depression, ptsd.
Medical providers may makepatients feel judged for all
sorts of stuff.
What can we do?
There's two simple things wecan do.
The first is really avoid termsof the judgment.
Please don't call it a dirtyurine drug test, right?
Think about that.
We're calling the patient dirty.
It is an abnormal urine drugtest, right?
They didn't come in herebecause they're using cocaine to
(49:36):
be called dirty.
They came in to be treated fortheir cocaine use disorder.
Let's call it an abnormal urinedrug test, or?
Hey, their urine drug test waspositive for cocaine.
The other thing is let's callpatients what they are, which is
people.
I have asthma.
I am not defined by my asthma.
(49:56):
I would prefer the term apatient with asthma rather than
an asthmatic.
Simple things avoidingstigmatizing language and using
person-first language, where wesay a 35-year-old male with
alcohol use disorder instead ofa 35-year-old alcoholic, can
make a big difference.
Next slide, please.
The other thing we have torealize is addiction is fairly
(50:20):
common.
One in seven americans willdevelop an addiction at some
point in their lives.
Our organization employs maybelike 4 000 people.
That's somewhere between 500and 600 people in our
institution that could havelived with or be living with
addiction.
So if you make a remark thatalcoholic, what's the doctor in
(50:44):
the next office hearing?
Could their best friend be inrecovery?
Could their wife be still inactive addiction.
We had a Schwartz Rounds talkingabout stigma and one of our
social workers reported being inrecovery and how hard it was
every day to hear her colleaguesjudge people with alcohol
addiction because she had livedwith it herself.
(51:06):
Also, just even recognizingthat stigma happens, and
sometimes it's so built in thatterm dirty urine we are taught
that throughout our careers.
It's so easy to not realizewhat we are doing is
stigmatizing.
Next slide, please.
So, yes, our words matter.
(51:27):
I think this quote is up.
Next, if we want to killsomething, we call it a weed.
If we want it to grow, we callit a flower.
The words we use around ourpatients confer judgment and
convey our intent, even if it'snot explicit.
Just saying you know tosomebody and calling them
something like a junkie, oh, assuch a judgmental term lets them
(51:50):
know that they're already in anuphill battle with their
healthcare provider.
Next slide, please.
Here are some examples of whatwe talked about person-first
language A person with anorexiarather than an anorexic.
This is my biggest pet peevewhen psychiatrists call people
crazy.
There is no DSM-5 diagnosis forcrazy.
(52:10):
Call it what it is Psychosis,anxiety, dependent personality
disorder.
The word crazy just confersjudgment.
We really need to continue towork on person-first language
and avoiding judgment.
Next slide, please.
I knew this quote was coming upOnce again if you want to care
(52:31):
something, you call it a flower.
If you want to kill it, you callit a weed.
The words, and the choice ofour words makes a big difference
.
Next slide, please.
So yeah, addiction is killingAmericans.
About 750,000 Americans willdie every year from drugs,
alcohol and cigarettes.
Bupe is amazing.
It is life-changing for mypatients and we underutilize
medications to treat alcohol usedisorder.
(52:52):
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
(53:14):
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(53:35):
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 on addictionin general, as well as on
(00:44):
buprenorphine and themedications that are used to
treat alcohol use disorder.
We are really working in myarea to educate all of our
doctors on the basics of how totreat addiction, so I gave a
lecture on this topic to some ofmy primary care doctor
colleagues and I recorded it toshare with all of you care
(01:05):
doctor colleagues, and Irecorded it to share with all of
you.
The focus was on how tounderstand addiction, use
buprenorphine and also how touse the three FDA-approved
medications for alcohol usedisorder acamprosate, naltrexone
and disulfiram.
I got good feedback from mycolleagues that attended the
lecture, so I hope you find ithelpful.
Here we go.
Hope you find it helpful.
(01:29):
Here we go.
Well, I think I will getstarted.
So I think I know everybody onthe call.
So my name is Casey Grover andI am currently in recovery from
emergency medicine.
I practiced emergency medicinefor 14 years and I actually had
to leave the specialty because Iwas diagnosed with
post-traumatic stress disorderfrom the emergency department
and I now do full-timeoutpatient addiction medicine.
(01:49):
And to my primary carecolleagues on the call, I
respect you immensely because Inow do things like return to
work and disability and have adifferent respect for the clinic
workflow than I used to when Iwas in the emergency department.
So very pleased to be able totalk about medications for
opioid use disorder and alcoholuse disorder.
So we're going to go throughthree things, which is
(02:13):
understanding how to diagnosealcohol use disorder and opioid
use disorder, and then usingbuprenorphine for opioid use
disorder and then medicationsfor alcohol use disorder.
So I'm going to stop herebefore we really get into the
slide deck and just talk alittle bit about what addiction
is and really what we need to do.
So I believe we have primarycare and one psychiatrist on the
(02:38):
call and many of themedications that you already use
are effective to treataddiction.
So let's think about someonewho's using alcohol.
They have a reason why theyconsume alcohol.
Right Alcohol, you have todrive to get it or pay for it to
be delivered.
You have to pay to consume it,and then there are the
consequences of using it, likegetting sick or having hangovers
(03:00):
.
In other words, there's a costthat the person incurs when they
go to consume alcohol.
For illegal drugs, that cost iseven higher.
Right, so you got to find adealer.
You have to risk exposure tolaw enforcement in getting the
drug.
You use the drug, you're atrisk of overdose.
You may be incarcerated.
Your dealer could rob you.
There's a lot of cost that mypatients incur when they buy
(03:23):
drugs.
So the question I always askthem is what does this substance
do for you?
In other words, they're clearlyspending their time and money
to get the substance for areason.
What is that reason?
Let's say they drink alcoholbecause they're anxious.
Well, gosh, primary care andpsychiatry treat anxiety all the
time.
Let's say someone uses cannabisbecause they can't sleep.
(03:46):
Same thing Common medicationswe know around sleep are in all
of our wheelhouses and a lot oftimes it's trauma, it's
post-traumatic stress disorder,and a lot of what I do,
particularly with victims ofsexual assault, is help them to
understand how their trauma,which they may or may not
recognize, affects their brainand leads them to seek
(04:09):
substances.
At the most fundamental level,what I do as an addiction doctor
is I take people whoself-regulate with substances
and I help them learn toself-regulate without substances
.
We might use medications andwith things like cognitive
behavioral therapy and mutualsupport group meetings and
(04:31):
developing emotional resilience,they may get to the point where
they don't need any prescribedmedication.
In fact, for many of mypatients that's the goal.
So we're going to talk aboutbuprenorphine for opioids and
the three FDA-approvedmedications for alcohol
addiction.
But I want you to realize thatyou already probably have more
skills around treating addictionthan you may realize.
(04:52):
So the simple question of whydo you use?
Is usually what I lead withonce I get to know the patient
and then I really focus onfiguring out what unmet need
they have.
In fact, my number oneprescribed medications are
usually probably clonidine, aselective serotonin reuptake
inhibitors, hydroxazine foranxiety and trazodone, which I
(05:17):
know are medications you all arefamiliar with.
So I just want to give thatcontext and that caveat that
we're going to talk aboutaddiction-specific meds.
But there's actually a lot moreprimary care and psychiatry in
what I do than addictionmedicine sometimes.
So with that, I hope thatcontext is helpful.
(05:37):
Let's talk about opioiddependence.
So opioid dependence is theidea that when we use opioids
regularly, our brain chemistrychanges Right.
It's usually about somethinglike a week to two of sustained
(05:57):
exposure to an opioid throughoutthe day, and this is from any
opioid right.
Let's say one of our patientshas a hip replacement and is on
oxycodone for three weeks.
They will develop opioiddependence.
Let's say one of our patientsis using fentanyl, buying it on
the street.
Regular opioid use leads toopioid dependence.
It really happens in everyhuman being with sustained
(06:20):
exposure to opioids and it'sreally frustrating because once
opioid dependence develops wereally only have two ways to
treat it.
We either give people back anopioid so they don't withdraw,
or they kick.
They go through withdrawal andmy patients find medications
like methadone and buprenorphinevery frustrating because they
(06:43):
do all the work to stop usingfentanyl or stop using heroin
and they're like I did it.
I got on Suboxone, but how do Iget off Suboxone?
And they oftentimes get reallymad at methadone and
buprenorphine, which is themedication in Suboxone, and
methadone and buprenorphine arenot the problem.
It's opioid dependence that isthe problem.
(07:04):
And I remember going back, youknow, 10 to 15 years ago in the
emergency department.
We did not recognize this asdoctors.
How many people came to theemergency department said I need
more Norco and I said no, theyjust would go withdraw.
So really, where medicationsfor addiction treatment in
opioids shine is that they allowpeople to function without
(07:25):
withdrawal, and that's reallywhat we're going to talk about
today around buprenorphine.
All right, next slide.
Okay, now on the other side ofthe opioid equation, from opioid
dependence is opioid usedisorder, and the older name for
this was opioid abuse or opioidaddiction.
(07:47):
But opioid use disorder is akind of the best way we have
right now to describe a personwho psychologically has a
problem with opioids.
And there's basically threecomponents to addiction or a use
disorder Compulsive use,cravings, or an intense desire
to use, and consequences.
(08:08):
So compulsive use would betrying to stop and you can't.
Cravings is a fixation on thesubstance and not being able to
think about anything else untilthey use, and then consequences
could be physical, interpersonalor legal, and so I think this
is the part of opioids thatpeople find to be much more
(08:29):
challenging to treat, and thatis because, in my opinion,
addiction is a disorder ofexecutive functioning.
So what is executive functioning?
Executive functioning is how tokeep a schedule, deciding to
save money instead of spendingit, being on time to pick your
kid up from school, knowing thatyou have a doctor's appointment
(08:52):
, and calling ahead because youcan't make it.
It's the organizational,decision-making part of life,
and so what I find with mycolleagues is, when they look at
someone with addiction, they gowell, why would you do that?
And I myself say that all thetime.
What made you think that was agood idea?
And that's addiction.
Addiction is a disorder ofexecutive functioning and that's
(09:14):
why they get compulsive use.
They want to stop, but theycan't.
Cravings they know they need togo pick up their kid from
school, but they can't stopthinking about the drug.
And then they get consequencesbecause they can't actually make
rational decisions.
So again, opioid use disorderis the best way to describe an
opioid addiction and again Ithink of it as a disorder of
(09:37):
executive functioning.
This is very common where peoplehave an opioid use disorder, so
they use the drug regularly andthey get dependence.
The vast minority of patientswith opioid use disorder will
binge.
It's really more consistent usebecause withdrawal is so common
and it's unfortunately a majorcontributor to drug overdoses in
(09:58):
America.
Next slide, please.
Now, as I was mentioning,there's opioid dependence and
there's opioid use disorder.
There's a spectrum where somepeople are pure addiction.
Others are, for example, onchronic pain meds and they're
not addiction.
But, as I mentioned, anyone onplanet earth who takes opioids
(10:20):
regularly will get dependence.
Not everyone develops anaddiction or a use disorder when
they're exposed to opioids, butsome will.
So an older term we used to usewas drug seeking.
Bad patients drug seeking, theywant oxycodone.
That's a very imprecise term,right?
That's like saying oh, thedefinitive diagnosis is nausea.
Well, why are they nauseated?
(10:42):
Drug seeking is the pursuit ofof a substance.
Is it withdrawal?
Is it a use disorder?
Is it untreated pain?
So I think it's reallyimportant when assessing people
to understand exactly what'sgoing on, and I usually find
that most of my patients havesome semblance of a use disorder
(11:03):
and also dependence, and I haveto make sure to address both of
them.
Next slide, please.
Okay, so this is something I'llgo through fairly quickly,
because I have to look this upevery time.
But how do we diagnose anopioid use disorder?
There are 11 criteria.
(11:23):
It's in the DSM-5.
I don't know how much all ofyou know and love the DSM-5, but
I'm sure, dr Blaine and I do.
But yes, it's basically 11criteria for addiction.
You ask the patient thequestions.
If they have two to threecriteria it's a mild use
disorder.
Four to five it's a moderateopioid use disorder and six or
more it's a severe opioid usedisorder.
(11:43):
In my line of work I don'tactually do this.
If they come to see AddictionMedicine, it's usually a bad
problem.
But if you want to get into thenuts and bolts you can actually
do this.
As an example, I had someonewho was identified as having a
problem with alcohol and theyneed me to sign off on forms
going back to work and in thatcase I got into this specific
criteria.
But usually if someone comes tome and said, hey, doc, I need
(12:04):
help, they definitely have a usedisorder.
Next slide, please.
All right, so let's go ahead.
This slide is out of order.
Okay, so here are the criteriafor opioid use disorder.
And again, it's compulsive use,cravings, consequences Opioids
(12:24):
are taken in larger amounts fora longer period of time.
People want to cut down but theycan't.
People are doing a lot ofactivities to get the drug or
recover from the drug.
They have cravings.
They're not fulfilling theirobligations at work, school or
home, they continue to use theopioid despite having problems.
Next slide, please.
And then they're giving upactivities because of the drug.
(12:47):
They're using it when it'shazardous, they know it's making
their health worse and theycontinue to use.
And then, because of persistentuse, they develop tolerance and
withdrawal.
So that's the basic criteriaand again, I would encourage you
, if you want to look them up,truly, just Google DSM-5 opioid
use disorder criteria and you'llbe able to look them up.
Truly, just Google DSM-5 opioiduse disorder criteria and
you'll be able to look them up.
All right, next slide, please.
(13:09):
So buprenorphine is one of themedications that we can
prescribe for opioid usedisorder and opioid use
dependence.
Okay, this medication used tobe restricted and now, if you
have a valid license in DEA, youcan prescribe it, which is
great.
It's a very interestingmolecule.
(13:30):
The generic name isbuprenorphine.
It comes in severalpreparations.
There's sublingual, which issuboxone or subutex.
It comes as a patch calledbutrans.
There's some other formulations, like Zubzolve, that are
different proprietaryformulations, but the basic idea
is that it's buprenorphinethat's doing the heavy lifting.
(13:50):
Okay, buprenorphine bindstighter to the opiate receptor
than anything else we know of,so it has a very tight binding
affinity at the opioid receptor,but it's not a complete agonist
.
What does that mean?
It will out-compete otheropioids at the opiate receptor
to bind and it's less euphoricand doesn't cause respiratory
(14:11):
depression the way other opioidsdo.
So let's say, one of mypatients is on buprenorphine and
they use fentanyl Becausebuprenorphine binds so tightly
at the opiate receptor.
The fentanyl is largely inert.
So that's one of the reasons Ilove it as an addiction doctor
is, once my patients are on bup,I do this.
Oh, thank goodness.
Right, if they have a relapse,they're protected.
(14:35):
Now the activation of the opiatereceptor by buprenorphine it's
only a partial agonist.
It's enough to treat cravingsand withdrawal and help with
pain, but it doesn't really haveeuphoria.
Again, there's what's called aceiling effect where you really
can't overdose on it.
You can just keep going up onthe dose and people will not get
(14:56):
respiratory depression oroverdose the way we do with
other opioids.
Next slide, please.
So it is a schedule threemedication, so it is something
that requires a certain amountof oversight and monitoring.
And it is FDA approved for bothopioid use disorder and pain,
and let's just take a quickminute here and talk about pain.
(15:17):
So if you don't know the otherpart of my addiction medicine
practice is with some of thelocal pain physicians.
You guys probably know SularDeldar, so he's one of our local
pain docs.
We're in the same practice.
So I actually have adisproportionate number of pain
patients in my addictionpractice.
Full agonist opioids likehydrocodone or oxycodone or
(15:37):
morphine change the painsensitivity over time.
Here's how I think of it.
Pain is protective.
Right, If I go to put my handdown on my desk and my desk is
hot, I need to be able to pullmy hand away so I can protect
myself.
The brain does not actuallylike being on opioids because it
realizes it cannot protectitself if pain is present and
(15:58):
just to level set.
Pain is meant to be an acuteresponse.
Chronic pain is non, it'snon-functional pain.
It doesn't alert the body ofany tissue damage.
So our response to chronic painis somewhat maladaptive because
we keep thinking tissue damage,because we're used to acute
pain.
So chronic pain is a specialthing that is addressed
separately.
(16:18):
But basically the brain thinks,uh-oh, opioids are making me
not able to feel acute pain.
I better dial up the painsensitivity so I could protect
myself if I need to.
So these poor patients on fullagonist opioids end up with
worse pain over time.
It's called opioid-inducedhyperalgesia.
It's a fancy way to say.
Your pain goes up over time dueto increased pain sensitivity
(16:42):
with chronic opioid use.
There are two opioids that weknow do not do this to the same
extent as other opioids, andthey are methadone and
buprenorphine.
So in our pain practice wedon't start really anybody on
oxycodone or norco or morphine.
We really start everyone oneither methadone or
buprenorphine.
So it's actually more effectivethan other opioids for pain.
(17:05):
Next slide, please.
So we talked about some of theunique things about
buprenorphine.
We talked about how it protectsagainst opioid-induced
hyperalgesia Because it blocksthe effects of other opioids and
protects against respiratorydepression.
It absolutely saves lives inpeople with opioid use disorder.
(17:27):
People's risk of dying fromopioid use disorder through
overdose once they're onbuprenorphine is down by 70%
compared to if they're not on it.
Very effective, and then, as Imentioned, it does not cause
euphoria and we can talk aboutthe dosing.
Next slide, please.
As I mentioned, this used to besomething that was restricted
(17:51):
by the DEA and that is nowcompletely gone.
If you have a valid DEA, youcan prescribe it.
Patients tell me all the timeoh, the doctor said they
couldn't prescribe it.
Thank you, joe Biden.
All politics aside, under theBiden administration they got
rid of this requirement in early2023.
Next slide, please.
Okay, when should you usebuprenorphine?
(18:12):
Well, we've been talking aboutit.
It's very effective for opioiduse disorder the addiction side
of things.
It also is an opioid, so itwill keep people out of
withdrawal, so it manages opioiddependence, and it also can be
used for pain, both acute andchronic.
Next slide, please.
There are a couple ofcontraindications.
Like other opioids, if combinedwith multiple sedating
(18:36):
substances, it can result inoverdose.
Buprenorphine by itself isreally unlikely to cause an
overdose because of that ceilingeffect.
Again, it only opens the opiatereceptor partway, which is why
it doesn't cause respiratorydepression.
But if you mix it with alcoholor benzos, the downer effects of
the different classes can addup.
(18:56):
Buprenorphine is metabolizedhepatically.
There's some older literaturethat showed that it was causing
people's LFTs to go up.
We still don't fully know yetand that's probably overblown.
But if somebody has cirrhosisyou need to choose another
medicine and, as I mentioned,should be avoided with heavy
alcohol use.
But if you think about it,given that buprenorphine does
(19:17):
not cause respiratory depression, if you have a patient with
alcohol use disorder who is inpain.
Buprenorphine is going to besafer than, say, oxycodone.
Next slide, please.
All right, dosing.
So there's a ton of differentformulations of this stuff.
I'll keep it really easy.
90 to 95% of this medication isgiven in the sublingual form.
(19:40):
It comes as a tablet by itself.
Buprenorphine is called Subutex.
And then there's anotherproduct where naloxone is mixed
in the naloxone doesn't doanything.
It gets excreted in the stool.
But if somebody tried to snortit or smoke it or inject it they
would get withdrawal.
(20:01):
So I actually don't care.
They taste a little different,they dissolve differently in the
mouth.
I let the patient choose.
For someone who is opiatesophisticated meaning they have
a history of opioid dependence,they've been on opioids or
they've got opioid use disorderI usually start them on
somewhere between about 8 to 24milligrams a day.
For someone who's opioid naive,it's more, like you know, 2 to
(20:22):
6 milligrams a day.
For someone who's opioid naive,it's more, like you know, two
to six milligrams a day.
So let's say, for example, I,you know, have to have shoulder
surgery next week.
I would probably take somethinglike one to two milligrams of
bup three times a day.
But if 10 years down the roadI've developed a fentanyl
addiction, then I would probablybe on something more like 24 to
(20:44):
32 milligrams a day.
It also does come as a once amonth injection for those with
addiction, which we do all thetime in the office.
It's absolutely wonderful.
Next slide, please.
The only other thing I wouldpoint out on this is that if
people do swallow buprenorphineit really doesn't get absorbed.
It's only like 10 to 20% of thedose.
(21:04):
So if people are starting it,we have to instruct them to take
it sublingually.
And we talked about dosing.
All right, next slide, please.
It's important to realize thatit's a very potent opioid, which
is why the dosing is so low.
For opioid-naive patients.
(21:24):
One milligram of sublingualbupe is about 30 to 40 morphine
mill equivalents.
So that's pretty potent.
And in the era of fentanylpeople have such incredible
opioid tolerances that are justthrough the roof.
Buprenorphine is actually oneof the only opioids that is a
potent enough agonist to keepthem out of withdrawal.
Even methadone some of mypatients get put on these
(21:45):
ridiculously high doses ofmethadone and they're still in
withdrawal.
I think we covered everythingon this slide.
Next slide, please.
Okay, so let's say you'rethinking about putting a patient
on buprenorphine.
What would you want to dobefore you start?
Well, if they have obvioussigns of liver disease, as in
(22:06):
you can see it from across theroom on physical exam they are
not a candidate for bup and,sorry, we abbreviate
buprenorphine as bup.
So if somebody has significant,significant liver dysfunction,
choose another med.
It's recommended to check LFTsperiodically.
I have dozens and dozens ofpatients on this.
I don't check LFTs Lee Goldman,for context, maybe does it once
(22:27):
a year.
The risk of it causing liverdysfunction is overstated.
And then it's important to knoware they using other substances
?
Are they using meth?
Do we want to address that?
Are they using cannabis?
What other substances do weneed to address while we're
working on getting them on bupe?
Next slide, please.
(22:49):
Pregnant patients can get opioidaddiction as well, and the
treatment for opioid addictionin pregnancy is methadone or
buprenorphine.
We dose it almost identically.
In terms of buprenorphine, itused to be that we only used the
monoproduct, the buprenorphine,or Subutex, in pregnancy, but
(23:09):
it's now been found that bothsuboxone, which is the
buprenorphine naloxone, andbuprenorphine by itself are both
safe in pregnancy andessentially you dose them until
they don't feel cravings andthey don't feel withdrawal.
It is recommended that we donot taper people off of opioids
during pregnancy because thereis an association with preterm
labor and opioid withdrawal.
(23:31):
In terms of youth, we treatyouth with buprenorphine all the
time.
I think our youngest on bup is14.
In the practice the dosing isfairly similar because most kids
by about 14 are pretty close toadult size and it's important
to know that any child 16 andolder can consent to bup without
parental consent.
I know parents and addiction.
(23:52):
It's a difficult population.
The parents have obviously highexpectations for their children
.
The teenage brain is not superresponsive to insight, it's
still growing, so that can be adifficult population.
So kids can get bupe on theirown.
16 and older.
Next slide, please.
Common things in terms of sideeffects it's an opioid.
(24:13):
It's an opioid agonist.
It's a partial agonist.
So you're going to get the samestuff you get with opioids
constipation, nausea, drowsinesswhen we give the once a month
shot.
It's called Sublocade, that'sone brand and Brixadi is the
other.
It's essentially a shot wherethey don't take medicine every
day, they just get a once amonth shot.
So compliance is great.
They usually get an injectionsite reaction.
(24:35):
And then we are unfortunatelyseeing that there's increasing
literature that sublingualbuprenorphine in either the
subutex or the suboxone isassociated with dental carries.
So I've got a couple of folksthat have come to me and said I
got to get off this stuff, I'mlosing teeth.
I didn't know about that untilrecently.
Really disappointing because itworks so well.
(24:56):
If that is the case, if it's apain patient, you can transition
them to the transdermal, theButrans, which is FDA approved
for pain and it's for opioid usedisorder.
You can use the patch off label.
But we might need to transitionthat patient to the sublocate
or the brixati, the once a monthinjection.
(25:17):
So if you're having troublewith somebody on bup and they're
having dental caries issues,absolutely you can refer over to
Addiction Medicine and we'llsee what their options are.
Next slide, please.
Okay, how do you start thisstuff?
If buprenorphine had akryptonite it would be this For
an opioid-naive patient.
(25:38):
You can just start it right.
So let's say one of yourpatients has an upcoming surgery
and you want to start them onbuprenorphine in advance of
surgery.
Go ahead and write, for youknow two milligrams of Subutex
or Suboxone, you know a half toone three times a day for pain,
or four times a day for pain, noproblem.
Now for people that aredependent on opioids.
(26:02):
They have to be in a period ofwithdrawal before they start
buprenorphine, and it's a majorproblem and frustrating.
Here's how this works In mybrain.
This is how I understand it.
Let's imagine that we'redriving a car and that car is
fueled by opioids A full agonistopioid, meaning it activates
(26:22):
the opioid receptor.
All the way is going to take youto 100 miles an hour.
Morphine, oxycodone,hydrocodone, fentanyl they all
take you to 100 miles an hour.
Buprenorphine, because it'sonly a partial agonist, takes
you only to about 60, 65.
You're going fast enough thatyou're not in withdrawal or
(26:43):
craving, but it doesn't push youall the way up to some of that
level of euphoria.
So if you take buprenorphinewhen you have a full agonist
opioid in your system,buprenorphine binds more tightly
to the opiate receptor thananything else we know.
So buprenorphine will actuallykick those other opiates off the
opiate receptor.
(27:03):
So it's literally like goingfrom 100 miles an hour and
slamming on the brakes and goingdown to 65.
And that's called precipitatedwithdrawal.
So people will go intowithdrawal when they start
buprenorphine, unless they'realready in withdrawal.
So the idea would be is ifthey're driving 100 miles an
hour on opioids as the opioidswear off they'll slow down.
(27:26):
We have to get them like downto 30 miles an hour in bad
withdrawal and then bring themup with buprenorphine.
It's a little frustrating andcertainly you know you can refer
to addiction medicine if you'rehaving trouble getting someone
started on this.
For people who are on regularopioids, like an oxycodone or
even heroin, it's only about a12-hour wait.
(27:48):
You can have them take theirlast dose of opioid or use
heroin at 10 pm and then theycan start buprenorphine the next
morning.
For fentanyl it's a much biggerproblem.
Fentanyl is lipophilic so itbuilds up in the body for days.
Usually those folks have towait even up to three days to
get enough fentanyl out of theirsystem that they're ready to
(28:09):
start buprenorphine.
It's a really frustratingproblem.
Next slide, please, and thenonce patients get on it, their
withdrawal is better.
If they're a pain patient,their pain is better and then
their cravings are better andessentially you titrate to the
dose where if they have painthey're feeling better and if
they have opioid addictionthey're, you know, not craving
(28:32):
and if they're dependent theydon't have withdrawal and I let
them self-titrate.
I'll just say you know here's,you know up to where you could
take about 24 milligrams a day.
Tell me what dose feels rightand people will self-titrate.
Some people will take one inthe morning and they're good for
the day.
Some people will take two inthe morning, one in the evening.
Almost all of my patients havea different regimen and I let
(28:52):
them choose whatever works forthem.
Again, because of itsincredible safety profile.
If somebody starts escalatingthe dose on their own, I don't
have to worry about them havingan overdose.
Next slide, please.
It is a controlled substance, soyou're going to want to see
your patients pretty regularly,initially until they stabilize
and then, once they're stable,it's I mean, I do this once a
(29:15):
month with some of my patients.
I've got some folks that are,you know, 10 years sober on bupe
and I just see them once amonth, give them a high five.
We chat about, you know, sportsteams and we send them on their
way.
It's exceptionally effectivefor folks to stay in long, long,
long-term recovery.
Again, if you're, if you wantto monitor liver function tests
six months to once a year wouldbe totally fine, all right.
Next slide, please.
And then the last thing wouldbe just realizing that if folks
(29:40):
do have underlying opioidaddiction, relapse can happen.
So making sure they havenaloxone and getting them into
some sort of supportivecommunity around their sobriety
is very important.
Next slide, please.
So once again, take-home points.
Buprenorphine saves lives.
You can use it for patientswith opioid use disorder.
It also treats pain.
It treats opioid dependence andwithdrawal.
(30:00):
Anyone with a valid DEA canprescribe it and it has unique
pharmacology which means that itis protective in relapse
because it blocks the effects ofother opioids.
But it is a little bit hard tostart, as you have to be in a
period of withdrawal before youstart as an opioid dependent
patient.
Again, for opioid naivepatients, you can just start it
straight off.
Next slide, please.
(30:22):
Okay, so we are now going to goon to alcohol and I just briefly
want to rant about alcohol.
I feel like I'm in a ranty moodtoday.
So it's interesting.
We call it alcohol and drugslike.
Alcohol's not a drug, andrecently we had the Pebble Beach
Food and Wine Festival.
For some reason we have decidedthat alcohol is okay and it's
(30:43):
our one societally acceptabledrug.
If I asked any of you like, hey, should we go wine tasting this
weekend?
You might say, gosh, thatsounds great.
If I told you, let's gomethamphetamine tasting this
weekend you'd look at me like Ihad three heads.
So in terms of what I do,alcohol is like any other
substance and it's actuallyharder for my alcohol patients
because alcohol is freakingeverywhere.
(31:06):
There are liquor stores.
I think there's like threeliquor stores on the way home
from my office to my home.
7-eleven sells alcohol, gasstations sell alcohol, wineries,
distilleries, local breweriesit's just everywhere.
Number one addiction in Americais alcohol.
So alcohol dependence is thephenomenon where people, again
(31:34):
their brain chemistry, changesbecause of regular use.
It's a little harder to predictwho gets alcohol dependence
than opioid dependence and mostoften we see it in people who
drink heavily, in terms of thequantity, and people who drink
throughout the day.
For people who are nighttimedrinkers, they tend to not have
as much dependence becausethey'll have like a 20-hour
period during the day.
For people who are nighttimedrinkers, they tend to not have
as much dependence becausethey'll have like a 20-hour
(31:55):
period during the day where theydon't have alcohol in their
system.
It's really morning, noon,afternoon, evening, nighttime
drinkers that we tend to see themost dependence Dependence can
develop in again about the sametime frame as opioids, usually
about somewhere between a weekor two of heavy use leads to
alcohol dependence.
Next slide, please.
(32:15):
And then again, just likeopioids, we have opioid
dependence and opioid usedisorder.
We also have alcohol dependenceand alcohol use disorder With
alcohol because it's notprescribed medically, it's very,
very unusual to have anyone whois dependent but doesn't have a
use disorder.
(32:35):
I'm trying to think of ascenario where some would be
dependent on alcohol withouthaving a problem.
I don't know if I can come upwith one, but the idea is again
is that we have to treat twoissues they are dependent on
alcohol and then they also havean alcohol use disorder.
The treatment of alcoholdependence I'm not going to
cover in this, because sometimesit requires inpatient
hospitalization or ICU care.
(32:56):
But the basic idea we're goingto talk about today is, once
people are through theirdependence, we have to work on
helping them not go back todrinking.
So same thing, it's those threeC's with alcohol use disorder,
just like opiate use disorder,cravings, compulsive use and
consequences.
Next slide, please.
(33:17):
Just one point on alcoholwithdrawal, just because it is
pretty important.
Alcohol withdrawal is fairlyunpredictable.
We have some people that weadmit you know with Dr Goldman
who we are sure are going tohave bad withdrawal not so bad.
One of my patients, literallytoday is getting discharged.
She was so afraid of badwithdrawal, was drinking 16
(33:38):
beers a day, minimal.
I had one 19-year-old who I wassure was going to be just fine
and ended up hospitalized withalcoholic hallucinosis.
The single biggest predictor ofbad withdrawal is previous
withdrawal.
So if you're talking to someonein the clinic and they're
talking about stopping and youthink like, yeah, I can probably
give them a couple days ofValium, get them off alcohol, a
(34:00):
really important question to askis have they had bad alcohol
withdrawal before?
In which case most likely we'dwant to have them assessed at
the hospital, and in my careerin the ER, sometimes what we do
is we just put them in a roomand let them metabolize and if
they don't develop badwithdrawal, we know they're safe
to go home.
All right, next slide, please.
(34:22):
So the diagnostic criteria foralcohol addiction or alcohol use
disorder are very similar tothe ones from opioid use
disorder and it's actually inthe same reference, the
Diagnostic and StatisticalManual 5th edition.
There are 11 criteria and it'sthe same threshold 2 to 3 is
mild, 4 to 5 is moderate, 6 plusis severe.
Next slide, please, and you'llrecognize these criteria for
(34:46):
alcohol use disorder becausethey are exactly the same as
opioid use disorder.
The only difference is they sayalcohol instead of opioid, so
trying to cut down giving upother activities to use the
substance craving is not able tomanage their obligations.
Consequences Next slide, please.
And then the same thing usingit when it's hazardous,
(35:08):
particularly around driving, andthen tolerance and withdrawal.
So very similar in terms of howwe diagnose alcohol use
disorder and opioid use disorder.
Next slide, please.
Okay, so we have threeFDA-approved medications for
alcohol use disorder and I justwant to remind you all these do
not treat dependence orwithdrawal.
They are for the alcohol usedisorder, craving, compulsive
(35:31):
use side of things.
So let's go through them.
Next slide, please.
All right, so the first one iscalled disulfiram and most
people know it by its brand name, antabuse, and this is the one,
for some reason, that everybodythinks of.
The mechanism of action is itblocks alcohol metabolism,
leading to a toxic buildup ofone of the metabolites of
(35:53):
alcohol, and it basically makespeople sick.
So somebody drinks alcohol onday sulfuram, the toxic
metabolites of alcohol build upand people will get nausea,
vomiting, flushing, upsetstomach, a general sense of
malaise when they drink.
I was always taught that it'sfairly minor.
It actually can belife-threatening.
(36:15):
If somebody binge drinks withdisulfiram in their system it
can be fatal.
The toxic metabolite of alcoholthat builds up is cardiotoxic,
so you can get hypotension,bradycardia and cardiovascular
collapse.
I have seen it once.
There was a gentleman that cameinto the emergency department
as a lights and sirens codethree near death ambulance run
(36:40):
and he looked like garbage.
Oh my gosh.
His pulse was like 40, hisblood pressure, I think it was
like 60 on 40.
We tanked him up with fluidsand I couldn't figure out why he
was hypotensive.
And then I looked at my drugreference and it cautioned
against binge drinking while ondisulfiram.
So definitely not an option foranyone who's binge drinking.
(37:01):
And that's actually why thereare contraindications of
cardiovascular disease, becauseif somebody drinks on disulfiram
it can exacerbate theirunderlying cardiovascular
disease.
It is hepatically metabolized,so somebody with cirrhosis is
not a candidate.
And I put the dosing on there250 to 500 milligrams a day.
How well does disulfiram work?
(37:21):
The answer is it doesn't.
Maybe maybe in some unusualclinical circumstances where
somebody's really motivated andvery afraid of health
consequences and they've got aloved one that's going to make
them take it every morning.
Be in some unusual clinicalcircumstances where somebody's
really motivated and very afraidof health consequences and
they've got a loved one that'sgoing to make them take it every
morning.
For the most part, people willjust stop taking it and drink.
So I usually don't prescribe it.
I have one patient on it rightnow and he's about to be kicked
(37:43):
out by his parents.
So the agreement is we watchyou take your disulfiram in the
morning or you leave the house.
So he's very motivated, has alot of support and it's again
that regimented way of using it.
One other thing people need tobe off alcohol for three days
around this medication,otherwise the residual alcohol
still in their system can causethose unpleasant side effects
(38:05):
when the alcohol metabolite isbuilt up in the system.
All right, next slide, please.
So the next one is one of theones I use the most and this is
naltrexone.
So naltrexone is an opioidblocker.
Think of it like Narcan for 24hours.
The way it works is when somepeople who are genetically
(38:27):
predisposed to alcohol addictiondrink, their brain releases
more dopamine than the averageperson, dopamine being again the
reward chemical of the brainthat makes us feel good, and
that excessive dopamine releasecauses endorphin relief.
So they get a double high fromalcohol.
They get the pleasure releaseof the dopamine and they get the
(38:49):
calming opioid effect of theendorphins.
So what naltrexone does is itblocks the endorphins, so it
actually makes alcohol lesspleasurable.
And interesting.
What we know about craving andthe anticipation of use is when
somebody who has an addiction toalcohol pulls into the parking
lot to buy alcohol, the brainstarts to release dopamine and
(39:11):
those endorphins in anticipationof the drug.
So naltrexone makes the drugless pleasurable and thinking
about the drug less pleasurable,which is how it blocks cravings
.
Now, unfortunately, not everyoneconsumes alcohol for the same
reason.
If you consume alcohol becauseyou're anxious, this one doesn't
really work.
They're not seeking thepleasure, they're seeking the
(39:31):
downer effect.
If you consume alcohol becauseyou're anxious, this one doesn't
really work.
They're not seeking thepleasure, they're seeking the
downer effect.
If you drink alcohol becauseyou can't sleep, this one
doesn't really work.
You're not trying to get theeuphoria, you're trying to get
the downer effect.
So it only works in apercentage of patients.
The two big side effects and Isee this all the time is
somnolence and nausea, andusually that's something that
(39:54):
goes away with time.
So I usually start people on ahalf dose of the oral medicine
for a few days to let them getused to it before they go to a
full dose, and then it willcause horrible opioid withdrawal
if they're on opioids regularly.
So anyone who's on opioids isnot a candidate for naltrexone,
and then anyone with cirrhosisshould not get it as well.
It is given as an oralmedication and it can be taken
(40:18):
daily to block cravings, like Iget up in the morning and I take
it so I don't drink.
It also can be used as needed,like I'm about to go to a
wedding and I don't want todrink, I'll take my naltrexone
right before.
And you can do both.
So daily dosing as an anchorand then as needed on top of
that.
And then it also comes as aonce a month shot which is
called Vivitrol.
I give I don't know a couple ofthose a week.
(40:39):
It's given as a once a monthinjection so people can't again
stop the naltrexone and go backto drinking.
Next slide, please.
How well does it work?
It's okay.
So the number needed to treatto reduce drinking with
(40:59):
naltrexone is somewhere between12 and 20.
So what that means is is I haveto treat somewhere between 10
and 20 people to see it beeffective and that's pretty
consistent with my my clinicalpractice most people, for most
people it's just not a oh wow,doctor.
Thank you, it works a littlebit in most people.
I have a handful of patientsthat have horrible alcohol
(41:21):
addictions and they takenaltrexone and the desire to
drink goes completely away.
It is absolutely a miracle drugfor some people, but for the
vast majority of people it helpsa little.
So often what I do withnaltrexone is I combine it with
another medicine and then theanti-craving effect of
naltrexone is combined withanother, say gabapentin, and
(41:41):
then the two anti-cravingeffects are additive.
So that's usually what I do.
The IM once a month shot doeswork better.
The number needed to treat toreduce alcohol is six, and
that's likely because thecompliance is better.
Next slide, please, oops, otherdirection.
There we go.
Okay, acamprosate this is onethat I had never heard of until
(42:02):
I sat for my addiction boardsand I didn't use.
And it works great, way betterthan naltrexone.
So what acamprosate does is itactually mimics alcohol's
effects in the brain to a veryminor extent.
So alcohol makes GABA, which isa downer brain chemical.
(42:22):
Alcohol makes GABA work better,which is where the downer
effects of alcohol come from.
And then we have glutamate,which is the brain's natural
upper chemical.
Alcohol makes glutamate workless well, so let's think about
that.
Alcohol makes GABA work better,so that's a downer effect, and
alcohol makes glutamate workless well, so that's another
(42:44):
downer effect.
So essentially, alcohol is adouble downer.
And so what acamprosate does isit does that same thing, but on
a very tiny amount, and the bestway I can describe it to people
it's like you've had a half ofa beer.
It just takes the edge off.
It's actually fairly effectivefor people with anxiety.
That's where I've had the mostsuccess with it.
Unfortunately it is renallycleared, so it cannot be used if
(43:09):
somebody has renalinsufficiency.
But in people who have liverdisease or are on opiates this
is a great choice.
I've actually not had anyonehave side effects on it, but the
manufacturer notes thatdiarrhea is the most common side
effect.
Now I don't know if anyone issuperstitious, but the dosing is
weird.
It's 666 milligrams three timesa day, so it's six pills a day.
(43:33):
Most people can't remember that.
So you can dose it BID and thenthe compliance is a little bit
better For my older patients whowere already on a bunch of meds
.
Then I just put them on threetimes a day and they put it in
the pillbox.
How well does it work?
Well, the number needed totreat to reduce drinking is
between 9 and 12.
So let's compare that tonaltrexone, which was between 12
(43:55):
and 20.
So it's more effective thannaltrexone and it works better
the longer people are sober.
So if somebody gets admitted,gets detoxed and then they come
out, that's a great time tostart a campersate.
Next slide, please.
Now.
If you dig into the literature,there's been all sorts of stuff
that's been studied for alcoholuse disorder in terms of
(44:16):
cravings, been studied foralcohol use disorder in terms of
cravings Topiramate, baclofen,gabapentin, frazacin.
There's all sorts of stuff.
We just went over the FDAapproved medications.
There's only three of them, butI use off-label meds for
alcohol use disorder all thetime.
The one that we're all probablythe most familiar with is
(44:37):
gabapentin, and so I usually doput people on gabapentin for
alcohol use disorder.
It does help with mildwithdrawal and it does help with
cravings.
I usually dose it somewherebetween 300 and 600 TID and you
can take an extra dose ofbedtime to sleep.
If you are interested, you cancertainly look up to pyrimate
and baclofen on how to use itfor alcohol use disorder.
But yeah, I usually starteither ac, campersate or
(45:04):
naltrexone plus something elsewhen I'm treating my patients
with alcohol use disorder.
Next slide, please.
Okay, take-home points here.
Naltrexone makes alcohol lesspleasurable, so if somebody
drinks it doesn't feel as goodand it makes the thought of
consuming alcohol lesspleasurable.
A campersate works on thatchemistry in the brain around
alcohol and makes people lesslikely to want alcohol because
(45:26):
it mimics alcohol to a very,very tiny extent.
And the disulfiram is theso-called enforced sobriety of
people will get sick if theydrink and it largely is not very
effective.
Next slide, please.
And it largely is not veryeffective.
Next slide, please.
Okay, couple of things just toshare.
You know, just in general isfor our patients using opioids.
(45:52):
The drug market is drasticallydifferent than it was about five
to six years ago.
So brief history.
Where did America's problemwith opioids start?
It started with prescriptionmedication.
So when I was in college myfriends loved Vicodin.
I don't know why Vicodin, but alot of my friends use Vicodin.
I had no interest in it.
Vicodin is now off the market.
It is hydrocodone andacetaminophen.
(46:13):
It used to be that if you got apill from the non-legal market.
It was a prescription that hadbeen diverted, so it would be
oxycodone.
That was a legitimate oxycodone.
Starting in about 2019, here inMonterey County, everything
changed.
Fall of 2019, specificallyOctober, is exactly when
(46:37):
fentanyl arrived in our drugsupply.
Initially we were seeing itreally just as counterfeit pills
.
So people were buying anoxycodone and it looked like an
oxycodone.
Maybe it was a little morelikely to crumble than a regular
pill, but people had stampsthey were able to press fake
pills.
All of it contained fentanyl.
(46:58):
Now, unfortunately, we'reseeing that fentanyl is not the
worst.
We are now detecting acetylfentanyl, acryl fentanyl,
paraflora fentanyl, even someweird novel benzos like atizolam
and bromazolam.
The illicit market changes veryregularly with all these
research, chemicals beingpressed into counterfeit pills.
(47:20):
The majority of my patients usefentanyl in the form of
counterfeit oxycodone.
So be liberal in co-prescribingnaloxone, you know, refer people
for treatment and then alsorealizing that a lot of patients
, particularly older patients,were put on multiple scheduled
sedating medications at the sametime and trying to come up with
(47:43):
safer regimens can be a win.
Let's say someone comes to youon fairly high-dose oxycodone
and high-dose clonazepam.
If you're able to wean the dosedown to the clonazepam and
transition them from oxycodoneto buprenorphine.
That is a safer regimen.
So sometimes we're stuck withthese older regimens, but that
is a safer regimen.
So sometimes we're stuck withthese older regimens, but at
least we can make them safer.
Next slide, please.
(48:03):
Oh, stigma, good heavens.
Stigma's really hard.
Stigma is the judgment of onegroup by another based on a
particular attribute that theyhave.
And in medicine, stigma is whatpatients feel when their
healthcare providers judge them.
Next slide, please.
And it comes up in all sorts ofways.
(48:27):
We might make one patient waitlonger because they're a quote
difficult patient In academicmedical centers.
Sometimes they'll make themedical student see the patient
with the undesirable diagnosis.
We often attribute blame orintent in non-compliance to
patients based on theirdiagnosis.
Oh, you know?
Oh, that patient wasschizophrenia.
(48:47):
He doesn't want to be on hismeds.
It's important to be veryobjective with our patients.
We really need to check ourbiases and realize that we can
have implicit bias aboutparticular conditions.
There is stigma in healthcareabout all sorts of stuff
Psoriasis, epilepsy, urinaryincontinence, dementia,
(49:13):
addiction, depression, ptsd.
Medical providers may makepatients feel judged for all
sorts of stuff.
What can we do?
There's two simple things wecan do.
The first is really avoid termsof the judgment.
Please don't call it a dirtyurine drug test, right?
Think about that.
We're calling the patient dirty.
It is an abnormal urine drugtest, right?
They didn't come in herebecause they're using cocaine to
(49:36):
be called dirty.
They came in to be treated fortheir cocaine use disorder.
Let's call it an abnormal urinedrug test, or?
Hey, their urine drug test waspositive for cocaine.
The other thing is let's callpatients what they are, which is
people.
I have asthma.
I am not defined by my asthma.
(49:56):
I would prefer the term apatient with asthma rather than
an asthmatic.
Simple things avoidingstigmatizing language and using
person-first language, where wesay a 35-year-old male with
alcohol use disorder instead ofa 35-year-old alcoholic, can
make a big difference.
Next slide, please.
The other thing we have torealize is addiction is fairly
(50:20):
common.
One in seven americans willdevelop an addiction at some
point in their lives.
Our organization employs maybelike 4 000 people.
That's somewhere between 500and 600 people in our
institution that could havelived with or be living with
addiction.
So if you make a remark thatalcoholic, what's the doctor in
(50:44):
the next office hearing?
Could their best friend be inrecovery?
Could their wife be still inactive addiction.
We had a Schwartz Rounds talkingabout stigma and one of our
social workers reported being inrecovery and how hard it was
every day to hear her colleaguesjudge people with alcohol
addiction because she had livedwith it herself.
(51:06):
Also, just even recognizingthat stigma happens, and
sometimes it's so built in thatterm dirty urine we are taught
that throughout our careers.
It's so easy to not realizewhat we are doing is
stigmatizing.
Next slide, please.
So, yes, our words matter.
(51:27):
I think this quote is up.
Next, if we want to killsomething, we call it a weed.
If we want it to grow, we callit a flower.
The words we use around ourpatients confer judgment and
convey our intent, even if it'snot explicit.
Just saying you know tosomebody and calling them
something like a junkie, oh, assuch a judgmental term lets them
(51:50):
know that they're already in anuphill battle with their
healthcare provider.
Next slide, please.
Here are some examples of whatwe talked about person-first
language A person with anorexiarather than an anorexic.
This is my biggest pet peevewhen psychiatrists call people
crazy.
There is no DSM-5 diagnosis forcrazy.
(52:10):
Call it what it is Psychosis,anxiety, dependent personality
disorder.
The word crazy just confersjudgment.
We really need to continue towork on person-first language
and avoiding judgment.
Next slide, please.
I knew this quote was coming upOnce again if you want to care
(52:31):
something, you call it a flower.
If you want to kill it, you callit a weed.
The words, and the choice ofour words makes a big difference
.
Next slide, please.
So yeah, addiction is killingAmericans.
About 750,000 Americans willdie every year from drugs,
alcohol and cigarettes.
Bupe is amazing.
It is life-changing for mypatients and we underutilize
medications to treat alcohol usedisorder.
(52:52):
Before we wrap up, a huge thankyou to the Montage Health
Foundation for backing mymission to create fun, engaging
education on addiction, and ashout out to the nonprofit
Central Coast OverdosePrevention for teaming up with
me on this podcast.
Our partnership helps me getthe word out about how to treat
(53:14):
addiction and prevent overdosesTo those healthcare providers
out there treating patients withaddiction.
You're doing life-saving workand thank you for what you do
For everyone else tuning in.
Thank you for taking the timeto learn about addiction.
It's a fight we cannot winwithout awareness and action.
There's still so much we can doto improve how addiction is
(53:35):
treated.
Together, we can make it happen.
Thanks for listening andremember treating addiction
saves lives.
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