July 31, 2024 • 32 mins
This episode we're joined by Dr. Joshua Lee, a clinician, researcher, and professor specializing in medication-assisted treatment (MAT) for alcohol and opioid use disorders. Dr. Lee discusses his extensive research on medications such as naltrexone and buprenorphine, their significance in treating substance use disorders, and the transformative potential of telemedicine platforms like Oar Health. He highlights the underutilization of effective medications in primary care, the barriers to accessibility, and the enduring stigma associated with addiction. The conversation also touches on emerging trends and the future of addiction treatment.
Dr. Lee's Bio
Joshua specializes in medication-assisted treatment of alcohol and opioid use disorders. He conducts clinical trials and treats patients struggling with addiction as a primary care physician. As a Professor at NYU Grossman School of Medicine, he leads the Addiction Medicine Fellowship and conducts research focused on justice and community outcomes.
https://www.oarhealth.com/
https://med.nyu.edu/faculty/joshua-d-lee
https://x.com/drjoshuadlee
00:00 Introduction and Podcast Overview
00:38 Introducing Dr. Joshua Lee
01:20 Clinical Trials and Medication Insights
03:46 Challenges in Alcohol and Opioid Treatment
08:50 Telemedicine and Its Impact
11:59 Addressing Misconceptions and Barriers
19:35 Success Rates and Future Trends
30:14 Fun Personal Question
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Meg Sinclair (00:17):
Hi everyone.
And thank you for tuning in tofrom lab to launch podcast by
Qualio.
I'm Meg, your host, and I'mdelighted to be here with you
today.
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(00:38):
Today, we're excited to welcomeDr.
Joshua Lee.
He's a distinguished clinician,researcher, and professor
specializing in medicationassisted treatment for alcohol
and opioid use disorders.
Dr.
Lee's extensive experienceincludes conducting clinical
trials on naloxone, Now,Traxalone and Binafrone in
(00:59):
various settings from primarycare to criminal justice.
Dr.
Lee serves as the clinical chiefadvisor at Or Health, a
telemedicine platform that makesmedication assisted treatment
for alcohol use disorderconvenient and private.
Join us as we delve more intohis work and insights.
Welcome to the show, Josh.
Thanks for having me.
(01:20):
Great.
So, Josh, you've conductednumerous clinical trials on
naloxone and Binafrone.
Thank you.
Can you help me pronounce thatone?
Dr. Joshua Lee (01:27):
Yeah, it's naltrexone and buprenorphine.
Yeah.
Meg Sinclair (01:33):
And can you share some of those most significant
findings you found from yourresearch and their implications
for treatments of alcohol andopiate use disorders?
Dr. Joshua Lee (01:42):
Yeah, for sure.
These are pretty well knownmedications.
They're, they're decades longinto their approval for alcohol
use disorder in the case ofnaltrexone and for opiate use
disorder in the case of Bothnaltrexone and a pill and an
extended release form and thenbuprenorphine.
Buprenorphine is best known asSuboxone that came on the U.
(02:02):
S.
market in 2002, which was kindof when I was starting as a
prescriber and young faculty andtreatment provider in New York
City and at NYU and at BellevueHospital where I've worked ever
since.
And that really revolutionizedkind of primary care treatment
of opiate use disorder, whichPrior to 2002, it was really
(02:23):
restricted medically to, um,methadone clinics or opiate
treatment programs where thatremains the kind of exclusive
setting to get methadone.
So we couldn't prescribemethadone, which works great for
opiate use disorder, heroin andfentanyl addictions, but you
have to be working in an OTP ora methadone clinic to prescribe
(02:44):
it.
uh, We didn't have much to do inprimary care for, uh, about
opioid use disorder and that allchanged in 2002.
With buprenorphine products, uh,brand name at that time was
Suboxone, uh, and that, um, thatkind of brand name is lived on,
but now we have a variety ofbuprenorphine products we can
prescribe in general caresettings, emergency rooms, in
(03:05):
the hospital, in primary care,mental health clinics, and you
don't have to be in a licensedaddiction treatment, um, clinic
to, to provide those, and that'sreally gotten a lot more people
into treatment with effectivemedications for opiate use
disorder.
On the alcohol side, we have hadnaltrexone approved for any,
anyone to prescribe.
It's not a controlled substance.
(03:26):
It's not restricted to anyparticular setting.
Um, and it was originally kindof developed in the seventies
and eighties and initiallyapproved for alcohol, I think in
the early nineties.
And then by 2006, we had anextended release, which is like
a monthly depot version of that.
An injectable form of themedication approved.
(03:46):
Um, but we found along thedecades and throughout my career
with alcohol, and this is whatthe or kind of app and
intervention is meant to addressis that not enough people were
ever kind of told aboutmedication options for alcohol.
Um, not a lot of doctors wereaware or felt comfortable
prescribing these medications,even though they're fairly easy
(04:09):
to prescribe.
They're generic, they're cheap,they're, um, uh, safe and
effective.
Uh, and yet, um, there wasn't alot of uptake.
So there, there was a real gapin the alcohol Kind of treatment
landscape between everydaypatients, what they would hear
from a doctor, if ever, if theyever discussed alcohol with the
(04:30):
doctor, and then eventual kindof like net prescribing rates,
you know, in this country, uh,and probably in any other.
Developed economy.
There's just not a lot of use ofnaltrexone relative to the scale
of alcohol problems, which arequite vast, quite common and
quite, um, you know, deadly,costly and in large part because
(04:52):
we have good treatments.
We don't use enough of, um,arguably, you know, quite
preventable.
So, The goal of something likeor, um, and this was what I was
kind of working on in mypublications and our trials
before or existed was just kindof proving or documenting how
kind of safe, effective and easyit is to use some of these
(05:12):
medications and primary care andthen using that as an argument
for more primary care docs, moregeneral practitioners.
Uh, and that includes nursepractitioners, physician
assistants.
It's not all doctor driven.
Anyone that could prescribe itmight be talking to someone with
an alcohol problem could be alsoprescribing these medications.
And then the basic rationalebetween behind the medications
(05:36):
are that they really move theneedle on less drinking, less
opiate use.
fewer overdoses in the case ofopioid use disorder.
Um, and you know, they work.
Uh, you don't have to treat thatmany patients to get one patient
to do a lot better.
And so our, our rates of likesuccess are comparable to most
other medications we'veprescribed for chronic diseases
(05:58):
in primary care.
Like I'm going to treat you forhypertension.
I'm going to treat you fordiabetes.
That's, that's the stock andtrade of primary care.
We do it all day long.
Nobody questions that we're allquite familiar with it and
confident in doing it.
But we just haven't had that foralcohol.
And then it has taken a while todevelop anything like those
competencies across the wholeworkforce for opiate use
(06:20):
disorder and the strugglecontinues.
Like, we're still investing alot.
Um, I, my, my prime, uh, primaryappointment and full time job is
at NYU Grossman School ofMedicine.
I work with our students, ourresidents, our, uh, trainees and
fellows in addiction medicine.
And we're working on that.
We're doing it one by one,trying to get the next
(06:40):
generation of docs to beskilled, confident, and, um,
quick to prescribe thesemedications.
But I'm from a generation thatdidn't get that training.
I graduated med school in 99,and we just didn't have a lot of
teaching.
We didn't have a lot of kind ofmodels of practice to learn
from, and so it was kind ofbrand new in the 2000s when I
(07:03):
kind of started my career, uh,to, uh, to be doing a lot of
this.
Now it's more commonplace, moreprimary care, family medicine,
FQHCs, especially, uh, kind ofpublic sector, um, primary care
sites are able to do this, butstill not enough.
And so one of the reasons whyoverdose rates remain stubbornly
high, um, despite really goodtreatments is that we just We
(07:26):
have trouble connecting day today the patient in need to to
the available treatment.
Um, so that's what that's kindof in my whole career.
Like, get get more of this stuffout to more people.
I didn't invent the medications.
I'm not doing a lot ofmedication development or kind
of novel.
Molecular interventions forthese problems.
(07:47):
I'm more like, okay, we have allthis stuff.
Why aren't we using it more?
You know, we got to use it inthe jails.
We got to use it in the prisons.
We got to use it in primarycare.
We got to get more of this topeople with housing and security
that are coming in and out ofthe emergency room every every
week, but don't necessarilyfollow up.
How do we get more of thesemedications started?
You know, at the at the time wehave a patient with us.
(08:09):
So that has been.
Mm hmm.
Kind of the theme of myresearch, some of my findings
in, in, uh, in my clinicaltrials that I've, um, developed
and run, uh, and a lot of that'sNIH funded.
And then, uh, or has been anopportunity to really be more
kind of consumer oriented, uh,be at a startup and then work on
(08:31):
a kind of new approach.
Obviously made very common andfamiliar since COVID of kind of
telemedicine and in a kind oflike prescription medication app
that is directed at onecondition and one medication in
this case with or oralnaltrexone for alcohol use
disorder.
Meg Sinclair (08:49):
Great.
And as the chief clinicaladvisor at OR, and speaking
about, you know, telemedicine,how do you see it transforming
the landscape of addictiontreatment, especially in terms
of privacy and convenience forour patients?
Dr. Joshua Lee (09:02):
I think quite transformative in that we didn't
have any of it and then we hadCOVID and then all of a sudden
we can do a lot of it.
Um, and then in the case ofnaltrexone, it's a, it's the
generic medication.
It's relatively inexpensive, uh,out of pocket or, you know, in
terms of insurance coverage.
And it is not a controlledsubstance, so there's very few
(09:23):
restrictions on its use intelemedicine.
We don't have any of the lightcontrolled substance prescribing
issues, which have, in fact,complicated a lot of, like, big
telehealth.
Headlines and addiction.
Part of that is centered around,um, and mental health.
Part of that centered aroundcontrolled substance
prescribing, which is kind of alandmine that or doesn't have to
(09:45):
deal with because thismedication doesn't have any of
those issues.
Um, so for us, it's been prettystraightforward.
Um, and then, uh, the challengeis reaching enough patients, you
know, reaching enough patientsfast enough so that the business
grows and is healthy, um, fromstart up to, you know, fuller
(10:05):
maturity.
Um, and I think in general, Doesdoes, um, we don't know the full
answer to this, but doesaddiction fit in with like care
loss, erectile dysfunction,stuff that other companies have
tackled 1st and are morefamiliar, like direct to
consumer telehealth models?
Um, we think, uh, uh, Alcoholsmoking cessation and then other
(10:30):
companies do do telehealth, um,opiate use disorder treatment.
So they're really good examples.
And I think kind of welldeveloped algorithms for that.
Um, you know, will it will itget to enough people?
Will it?
Um.
Can it coexist and not just kindof like animal eyes like real
treatment?
Like, um, it doesn't have to bean opposition to like, you can
(10:52):
get this from your doctor.
You can get this from atelehealth.
Like, we don't care how you getit.
Just like, get it because itwould be helpful to you and your
health long term.
So, you know, so far, so good.
Uh, I don't think all thechapters have been written on
where telehealth is going.
Um, but it certainly seems likeit's here to stay.
Like it made your medicalcenters like NYU make it
(11:13):
Telehealth, the routine offeringnow, just if I want to interact
with any of my providers, Imostly do my my own health care
at NYU.
Um, and it's not, it's not apredominant way that I talk to
my doctors.
I still do a lot of physicalvisits, but it's an option.
And then, of course, you havesomething like, or, which is
purely telehealth.
There's no brick and mortar.
(11:34):
We're not going to get you fromthe app to, you know, to a face
to face physical encounter.
Um, and that's okay too.
Uh, Because it seems to be, fromour experience, still an
effective way to reach peopleand then treat them.
Meg Sinclair (11:51):
Yeah, and the two can complement each other,
right?
Telemedicine and those physicalvisits are great complements to
getting that full spectrum ofcare.
What do you think the biggestmisconception about medication
assisted treatment for alcoholuse disorder and how can we
address that to improve patientoutcomes?
As a, as a person with lovedones who have suffered from
alcohol use disorder,
Dr. Joshua Lee (12:12):
Sure.
Meg Sinclair (12:13):
And thinking, like, I'm a pretty well informed
person when it comes to healthand what's out there.
Really, the only option thatI've ever felt for them was AA.
So, it's great to hear thatthere are other options, but I
think a lot of people just kindof go there first, right?
Dr. Joshua Lee (12:28):
Yeah, there's a handful of medications that are
approved for alcohol usedisorder.
Um, you could say that thenarrative is largely the same
with all of them, that peopledon't hear about them, know
about them, or talk to theirdoctor about them enough.
Yeah, it hasn't made it into themovies.
You know, AA is very familiar toeveryone, but starting a
(12:48):
medication to reduce cravings,reduce your kind of liking of
alcohol, and then if you dodrink, you don't drink as much
that occasion.
That's how naltrexone works.
Um, that just hasn't beenfamiliar or popular, you know,
in terms of, um, public healthmessaging or just how people
(13:09):
talk about alcohol and alcoholtreatment with friends and
family, uh, hasn't really madeit into the culture where, you
know, we're trying, uh, andthat's what like every paper
I've ever written.
Uh talks about but nobody readsmy papers like in the end, you
know, it's not reallypenetrating Media that people
consume on a daily basis or howthey think about You know
(13:31):
alcohol itself and that thatgets to a whole raft of like
historical and current issuesstigma It's it's shameful
embarrassing to have um, kind ofa compulsive disorder like heavy
drinking Um, it doesn't have tobe but it is and then people
They think about themselvesdifferently, and they think
about that as as not as a healthproblem, but often still, it's
(13:53):
kind of like a moral failing.
We would like to convince you.
Otherwise, like, we have a lotof kind of convincing
foundational neurobiologic.
You know, proof that it's, it'skind of like an acquired and you
can have genetic predisposition,but it's eventually like an
acquired, you know, kind ofbrain disease.
(14:13):
That's been the motto of theNational Institute on Drug
Abuse, for instance, likeaddiction is a brain disease.
Um, And in that sense, it couldbe like a seizure disorder, it
could be like depression, itcould be like ADHD.
It's not your fault, it'ssomething that's happened to
you, but now it's a medicalproblem and we can treat it.
You know, that's what we're,that's the model we're trying to
(14:35):
promote, um, but it's not, ofcourse, been the, the kind of
popular conception of some ofthese problems.
Meg Sinclair (14:43):
Yeah, there's some multifaceted problems there, but
I love that you're spreadingother options for people
suffering from alcohol usedisorder.
Um, and you're very passionateabout making evidence based
treatment accessible.
What are the key barriers toaccessibility and what steps can
be taken to overcome them?
Dr. Joshua Lee (14:58):
Well, like along with like, okay, you have an
alcohol problem, go to AA,that's just not appealing to a
lot of people.
And it's a really scary firststep.
Um, uh, similar to that wouldbe, well, you have to detox, you
know, you're drinking a lotevery day.
You have to go to some center,you have to do an inpatient
(15:18):
episode, and then the AA starts,you know, two weeks later after
you've kind of dried out.
That, that's in the movies.
Um, but that's not the, that'snot really kind of the practical
case for most people.
Most people that have an alcoholuse disorder, Globally and in
the United States can in factsafely stop drinking.
The disorder is they don't dothat on their own often enough
(15:40):
and that's like one of thedefinitions of uh, a alcohol use
disorder, but you don't have tocheck yourself into a hospital
or a County psych center, uh,uh, or the, the kind of, uh, one
drug and alcohol treatmentcenter that everybody kind of
knows about, but doesn't likereally go to or talk about, um,
(16:00):
you, you can do it at home.
You can do it in private.
That's, of course, an appeal toan app like, uh, or, uh, You
don't have to engage with yourhealth care team, and a lot of
people don't have a health careteam.
Anyway, um, people are inbetween positions.
Never had a regular clinic tofollow up with.
They've moved.
They're busy.
(16:21):
They just haven't, like, kind ofbeen doing annual doctor visits,
like, um, uh, you know, in in inthe movies again, but, um, that
none of that is really requiredto access and start treatment.
That's probably the revolutionof telehealth, too, is that you
can get to it.
When you're ready at home byyourself and private, um, you
(16:42):
can disclose that to family ornot.
It can be extremely, you know,kind of private and
confidential, or it can besomething you're sharing with
the limited support network, butit doesn't necessarily involve
getting in your car and drivingto a doctor's office.
Um, Of course, you can do thatand we highly encourage that.
Um, but people have also hadnegative experiences in regards
(17:06):
to an addiction problem and thehealth care system.
You know, they've been scoffedat by a provider in the
emergency room when they werethere for something related to
alcohol use disorder.
Um, they, Have seen it loom as alegal threat and therefore
something that has to be hiddenand not kind of openly broached
and discussed and brought up.
(17:28):
Um, so, you know, brick andmortar health care should do a
better job at screening,discussing, diagnosing, treating
alcohol use disorder.
But it's no surprise that peopleare reluctant to or don't know
to.
You know, ever kind of like flagit themselves as a self reported
health problem.
And as a consequence, it justdoesn't ever get kind of picked
(17:50):
up by or treated in your medicalrecord.
And then you're living with thisproblem day in and day out.
Um, so telehealth there, youknow, if you get our, if you get
our ad on your phone, um, you'remore likely to, you know,
through a series of clicks, bean or customer.
And then at a pretty reasonablecost, you're essentially like
(18:11):
subscribing to a confidentialtreatment that is going to be
done by mail and purely througha computer or your phone.
And you never have to doanything else.
And you can make.
You know, quite a bit ofprogress with the treatment of
your alcohol use disorder.
The fun thing is thesemedications do most of the work.
Like, you can do morecounseling.
(18:32):
You can still go to AA.
You can eventually talk to yourdoctor.
But in the case of, like, opioiduse disorder or alcohol with
naltrexone, just getting on themedication and giving it a trial
is a huge part of, like, whatwe're trying to do anyway in any
kind of practice setting.
And then staying on it long termis, like, Tasks number two, and
(18:54):
you can do that probably assuccessfully, you know, from
home and through a mail orderpharmacy is or uses as you can,
you know, following up two hoursaway with your doctor or however
it works for you in real life.
So that that's certainly some ofthe advantages.
Telehealth some of the likeopportunities.
For a company like or, um, andthen part of the, part of the
(19:14):
overall kind of like problem isthat people just are not going
to get this ever, uh, unless westart to kind of like rethink,
you know, delivery.
Meg Sinclair (19:24):
Yeah.
Change the conversation and letpeople know they have more
options or reports that 65percent of their members are
meeting their goal to drink lessor quit.
What do you believe are the keyfactors contributing to that
high success rate?
Dr. Joshua Lee (19:40):
It's kind of the magic of the molecule.
Now, Trexone is not going towork in everyone.
So if you and I both use it toreduce our drinking, you know,
chances are like we will nothave the same exact experience,
kind of medication effect.
We don't drink for the samereasons.
Now, Trexone doesn't quiteinteract with our brain and our
(20:00):
receptors in the same way.
Uh, and then we can havevariable, kind of, You know,
careers as an outrex ownpatient.
So it's not a silver bullet.
It doesn't.
Those rates could be higher.
Uh, those are pretty good rates.
We think for for kind of what wehave done initially and how
we've developed the product.
(20:21):
And I think they reflect aboutthe.
The usual expected treatmenteffect of Naltrexone, which is
for some people it's reallytransformative, uh, to get into
the weeds.
Naltrexone is itself an opiateblocker.
It goes into parts of our brainthat have, it goes kind of
throughout the bloodstream, ofcourse, and then it gets in the
brain.
And then parts of our brain thathave the most opiate receptors,
(20:42):
in particular, the mu opiatereceptor, that's also where
alcohol can have someopiate-like effects that can
kind of stimulate that receptorsystem.
And drinking makes us kind offeel warm and fuzzy.
It reduces anxiety.
Eventually, we get kind ofsedated, inebriated, um, and
that is a lot like, uh, opiatesthat they're kind of a warm
(21:05):
blanket, um, can reduce pain,anxiety, make us feel, uh, much
better.
In the short term, and then asas longer term and higher doses,
they're sedating.
And of course, you can getthings like overdose.
So for some of us, not all ofus, alcohol is a is a kind of
opiate like drug.
And one of the reasons we likedrinking are for kind of opiate
(21:27):
like effects.
It's not alcohol is not anopiate, but it does have some
again, kind of activity in theopiate system.
And that drives, um, A reward,so we experiencing a lot of that
is like, pleasurable and then wekeep repeating it and learn how
to do it.
And that becomes kind of a.
A loop that it's hard to break,and it's successful loop and
(21:49):
that the loop is developed tokind of.
In a sense, like, tricky to keepusing that substance, opiates or
alcohol in this case, but that'sthe whole point of treatment is
to kind of disrupt that networkand get you back to before you
were exposed or like thesubstance so much.
So with now, Trexone andalcohol, if we plug up and kind
of block.
Opiate receptors and this thisis also how naltrexone works for
(22:11):
opiate use disorders Um, you getless activity less of a signal
from that receptor system whenyou do use alcohol And so you
don't find that next beer onceyou're on naltrexone as tasty
Uh, and then a month later whenyou haven't been drinking you
don't look forward to that afterwork drink as much Um, and then
(22:33):
net net, you're just drinking alot less over time, either
increasing days where you don'tdrink at all, uh, so called
abstinence days, um, or when youdo drink, you don't drink as
much.
And that reduces so called heavydrinking days.
Both of those are extremelybeneficial.
We think in terms ofcontrolling, um, Alcohol use
disorders over time, uh, gettingpeople back to higher function
(22:55):
and then just helping your bodybe more healthy and avoid a lot
of the long term negativeconsequences from alcohol.
So we just want you to get themolecule into your brain like we
could have developed, um.
You know, like a queue redcoffee machine that spits out in
our truck zone.
We could have done vendingmachines outside of every liquor
store.
Like, you know, there's avariety of ways you could think
(23:17):
of, like, distributing more nowtruck zone to whoever needs it
or is the is the kind of directconsumer, you know, pharma app,
if you will, um, of which thereare many other examples now, but
that that seems like a prettystraightforward and now more
familiar way to do it.
Um, and that's, um, that's whereyou get back to those success
(23:37):
rates.
Meg Sinclair (23:40):
What is the success rates for you been like
in different treatment settingslike primary care and criminal
justice and communityenvironments?
Dr. Joshua Lee (23:47):
Yeah, about the same.
We haven't done a study withalcohol, naltrexone and criminal
justice populations.
I'd like to do that and I'vethought about it for many years.
We've done a lot of opiatedirected trials in the criminal
justice space.
In naltrexone for alcohol, mystudies have been more in
primary care.
Um, they've been using both.
The oral and the extendedrelease form and now Trexone.
(24:10):
Um, and they're, um, you know,that they're positive in that
they confirm what otherinvestigators and other trials
have shown, uh, is that nowTrexone is pretty easy for user
friendly.
Um, it has some side effects,but they're generally tolerable
and not, uh, they don't lead toa lot of treatment disruption
or, or discontinuation.
Um, and, and then or has kind ofmimic that.
(24:33):
So we haven't like discoveredanything new with or so much as
we've kind of found a new way tobring the science and an older,
familiar, well establishedtreatment to more people.
So I would say there's, there'svery little disconnect between
what I get when I prescribed atBellevue hospital in a brick and
mortar setting to a patient withalcohol.
And then what I expect whensomeone signs up for or now, I,
(24:57):
of course, I'm a.
Incredible physician and mypatients love me and yada, yada.
Like there probably is somethingto, you know, the human
connection for that patient thatI'm connecting to, but not
enough people ever kind of getto that point with the provider.
And many of us just don't havethat kind of long term access
and kind of follow through withthe primary care physician.
(25:19):
So it may be that, like, inprimary care, that's the optimal
place to kind of work with notrack zone, but it certainly is
a pretty good.
Other alternative to, to getmore people, you know, more
access through, um, through awebsite or an app like or, and
there are providers at or, um,you do communicate with real
(25:41):
people who are treatmentprofessionals, but we do it in,
you know, kind of the moststripped down way possible.
So it's largely asynchronous.
Um, it's not video chats.
It's largely kind of text andemails back and forth.
Um, but just if you'rewondering, it's not like, it's
not completely robot driven interms of how we prescribe, but
we do have to do it legally andwith care and in a way that we
(26:02):
think develops good successrates.
So we're not like ignorant tothe fact that, like, the human
touch can help here, uh, youknow, in primary care, it's all
about the therapeutic allianceand getting people to kind of
negotiate with the help of theirdoctor, what's best for them and
what they're motivated to do.
Um, and, or can do some of that,probably not exactly replicating
(26:23):
face to face, um, and long termrelationships, but, um, that may
be okay for a lot of people, andit may be really good for a lot
of people that wouldn'totherwise have access, you know,
to that same kind of traditionaldoctor patient relationship.
Meg Sinclair (26:39):
Great.
What emerging trends in theindustry do you find most
promising for the future ofaddiction treatment and
recovery?
Dr. Joshua Lee (26:46):
Uh, great question.
Uh, there's still a lot, youknow, there's a billion
molecules that are candidatesfor the next brain drug that
could help with smoking,shrinking, methamphetamine,
alcohol.
Um, it's, it's a long,laborious, expensive process to
like test them in humans andthen get one of them to market.
Um, so we're, we're not likewaiting for a new blockbuster
(27:08):
every year in this space.
Um, you know, we hadbuprenorphine in 2002.
We had extended lesion altraxonein 2006.
We had, by 2017, a extendedrelease buprenorphine
formulation, so just a newpackage to an old drug.
Uh, we haven't had, um, we hadacamprosate, another alcohol
(27:29):
drug, in the 2000s.
Um, so, you know, every decade,there's like one new label
emerging for addiction.
Uh, you know, across all drugsand alcohol.
So that's not, like, a reallyUh, you know, uh, pace that we
can't keep up with.
If anything, we'd like to seethat speed up.
And, you know, the federalgovernment to their credit
(27:49):
invests in this and is lookingfor that.
Um, I would call all too big andsmall pharma and entrepreneurs
out there to keep looking.
And, um, you know, I think thereis eventually a market for this
stuff, although these conditionshave traditionally been so
stigmatized and kind of, um,other that, um, That it hasn't
attracted some of the same typeof investment that, you know,
(28:11):
cancer, cardiovascular disease,uh, have, and yet smoking,
alcohol, opiates, when youconsider overdose, like they
contribute to about as muchcardiovascular and cancer death
as, as any other risk factor,um, that you could think of
beyond age.
Um, so.
I think there's something therein terms of opportunity and room
(28:31):
for improvement in all themedications we have.
One thing you'll hear about atany addiction conference or
psychiatry meeting now ispsychedelics.
Or doesn't do this.
I don't do this.
I know about it through friendsand colleagues.
And my spouse is a psychiatristkind of working in this space.
So, Um, do, uh, does psilocybin,does, uh, LSD, does MDMA, uh,
(28:54):
other forms of kind oftraditional and atypical, uh,
psychedelics, are they going tohelp with smoking, with
drinking, with opiates?
Um, there's some realpossibility there, uh, but then
it's also hard to imaginescaling psychedelics To help a
lot of people as soon aspossible because the protocols
have been pretty intensive onthe therapy side and not just
(29:16):
the drug and people do seemreluctant as we saw the FDA just
kind of pause or or thumbs downto MDMA for PTSD, um, just
recently, and many people in thefield expected that to kind of
fly through and get approval.
But the caution was like, Thesestudies are still limited.
We haven't done it in that manypatients.
(29:38):
Um, there's some limitations tothe resource that gave the FDA
pause.
And then there's some realsafety diversion and and
addiction kind of liability.
You know, people can develop,um, Misuse of some of the same
compounds that we're seeing astherapeutic agents.
So watch the psychedelic space.
It's not my kind of item.
(29:59):
Um, I'm not working on itdirectly, but I think that one
is getting a lot of press a lotof attention in terms of
addiction.
Meg Sinclair (30:07):
Yeah, we've had a few of those founders and CEOs
on on there for conversation onhere for conversations before.
Dr. Joshua Lee (30:13):
Yeah,
Meg Sinclair (30:14):
well, Josh, our last question is more of a fun
one to ask each of our guests.
Okay.
If we ran into you at abookstore or at your local
library at NYU, in which sectionwould we find you?
Dr. Joshua Lee (30:25):
I would say I'm a broad reader, but I
consistently go back to kind ofhistory and nonfiction.
Um, I love just kind of learningtrivia about past events,
biographies, etc.
So probably non fiction, youknow, world's history.
Meg Sinclair (30:42):
Well, maybe I will bump into you there.
It was a pleasure speaking withyou today, Josh.
Thank you so much.
Dr. Joshua Lee (30:47):
Thanks so much, Meg.
Hi everyone.
And thank you for tuning in tofrom lab to launch podcast by
Qualio.
I'm Meg, your host, and I'mdelighted to be here with you
today.
Before we dive into today'sepisode, we'd love it if you
could take a moment to rate andshare the podcast with your
circle of enthusiasts.
And if you're interested inbeing a guest on the show,
please check out the applicationin the show notes.
(00:38):
Today, we're excited to welcomeDr.
Joshua Lee.
He's a distinguished clinician,researcher, and professor
specializing in medicationassisted treatment for alcohol
and opioid use disorders.
Dr.
Lee's extensive experienceincludes conducting clinical
trials on naloxone, Now,Traxalone and Binafrone in
(00:59):
various settings from primarycare to criminal justice.
Dr.
Lee serves as the clinical chiefadvisor at Or Health, a
telemedicine platform that makesmedication assisted treatment
for alcohol use disorderconvenient and private.
Join us as we delve more intohis work and insights.
Welcome to the show, Josh.
Thanks for having me.
(01:20):
Great.
So, Josh, you've conductednumerous clinical trials on
naloxone and Binafrone.
Thank you.
Can you help me pronounce thatone?
Dr. Joshua Lee (01:27):
Yeah, it's naltrexone and buprenorphine.
Yeah.
Meg Sinclair (01:33):
And can you share some of those most significant
findings you found from yourresearch and their implications
for treatments of alcohol andopiate use disorders?
Dr. Joshua Lee (01:42):
Yeah, for sure.
These are pretty well knownmedications.
They're, they're decades longinto their approval for alcohol
use disorder in the case ofnaltrexone and for opiate use
disorder in the case of Bothnaltrexone and a pill and an
extended release form and thenbuprenorphine.
Buprenorphine is best known asSuboxone that came on the U.
(02:02):
S.
market in 2002, which was kindof when I was starting as a
prescriber and young faculty andtreatment provider in New York
City and at NYU and at BellevueHospital where I've worked ever
since.
And that really revolutionizedkind of primary care treatment
of opiate use disorder, whichPrior to 2002, it was really
(02:23):
restricted medically to, um,methadone clinics or opiate
treatment programs where thatremains the kind of exclusive
setting to get methadone.
So we couldn't prescribemethadone, which works great for
opiate use disorder, heroin andfentanyl addictions, but you
have to be working in an OTP ora methadone clinic to prescribe
(02:44):
it.
uh, We didn't have much to do inprimary care for, uh, about
opioid use disorder and that allchanged in 2002.
With buprenorphine products, uh,brand name at that time was
Suboxone, uh, and that, um, thatkind of brand name is lived on,
but now we have a variety ofbuprenorphine products we can
prescribe in general caresettings, emergency rooms, in
(03:05):
the hospital, in primary care,mental health clinics, and you
don't have to be in a licensedaddiction treatment, um, clinic
to, to provide those, and that'sreally gotten a lot more people
into treatment with effectivemedications for opiate use
disorder.
On the alcohol side, we have hadnaltrexone approved for any,
anyone to prescribe.
It's not a controlled substance.
(03:26):
It's not restricted to anyparticular setting.
Um, and it was originally kindof developed in the seventies
and eighties and initiallyapproved for alcohol, I think in
the early nineties.
And then by 2006, we had anextended release, which is like
a monthly depot version of that.
An injectable form of themedication approved.
(03:46):
Um, but we found along thedecades and throughout my career
with alcohol, and this is whatthe or kind of app and
intervention is meant to addressis that not enough people were
ever kind of told aboutmedication options for alcohol.
Um, not a lot of doctors wereaware or felt comfortable
prescribing these medications,even though they're fairly easy
(04:09):
to prescribe.
They're generic, they're cheap,they're, um, uh, safe and
effective.
Uh, and yet, um, there wasn't alot of uptake.
So there, there was a real gapin the alcohol Kind of treatment
landscape between everydaypatients, what they would hear
from a doctor, if ever, if theyever discussed alcohol with the
(04:30):
doctor, and then eventual kindof like net prescribing rates,
you know, in this country, uh,and probably in any other.
Developed economy.
There's just not a lot of use ofnaltrexone relative to the scale
of alcohol problems, which arequite vast, quite common and
quite, um, you know, deadly,costly and in large part because
(04:52):
we have good treatments.
We don't use enough of, um,arguably, you know, quite
preventable.
So, The goal of something likeor, um, and this was what I was
kind of working on in mypublications and our trials
before or existed was just kindof proving or documenting how
kind of safe, effective and easyit is to use some of these
(05:12):
medications and primary care andthen using that as an argument
for more primary care docs, moregeneral practitioners.
Uh, and that includes nursepractitioners, physician
assistants.
It's not all doctor driven.
Anyone that could prescribe itmight be talking to someone with
an alcohol problem could be alsoprescribing these medications.
And then the basic rationalebetween behind the medications
(05:36):
are that they really move theneedle on less drinking, less
opiate use.
fewer overdoses in the case ofopioid use disorder.
Um, and you know, they work.
Uh, you don't have to treat thatmany patients to get one patient
to do a lot better.
And so our, our rates of likesuccess are comparable to most
other medications we'veprescribed for chronic diseases
(05:58):
in primary care.
Like I'm going to treat you forhypertension.
I'm going to treat you fordiabetes.
That's, that's the stock andtrade of primary care.
We do it all day long.
Nobody questions that we're allquite familiar with it and
confident in doing it.
But we just haven't had that foralcohol.
And then it has taken a while todevelop anything like those
competencies across the wholeworkforce for opiate use
(06:20):
disorder and the strugglecontinues.
Like, we're still investing alot.
Um, I, my, my prime, uh, primaryappointment and full time job is
at NYU Grossman School ofMedicine.
I work with our students, ourresidents, our, uh, trainees and
fellows in addiction medicine.
And we're working on that.
We're doing it one by one,trying to get the next
(06:40):
generation of docs to beskilled, confident, and, um,
quick to prescribe thesemedications.
But I'm from a generation thatdidn't get that training.
I graduated med school in 99,and we just didn't have a lot of
teaching.
We didn't have a lot of kind ofmodels of practice to learn
from, and so it was kind ofbrand new in the 2000s when I
(07:03):
kind of started my career, uh,to, uh, to be doing a lot of
this.
Now it's more commonplace, moreprimary care, family medicine,
FQHCs, especially, uh, kind ofpublic sector, um, primary care
sites are able to do this, butstill not enough.
And so one of the reasons whyoverdose rates remain stubbornly
high, um, despite really goodtreatments is that we just We
(07:26):
have trouble connecting day today the patient in need to to
the available treatment.
Um, so that's what that's kindof in my whole career.
Like, get get more of this stuffout to more people.
I didn't invent the medications.
I'm not doing a lot ofmedication development or kind
of novel.
Molecular interventions forthese problems.
(07:47):
I'm more like, okay, we have allthis stuff.
Why aren't we using it more?
You know, we got to use it inthe jails.
We got to use it in the prisons.
We got to use it in primarycare.
We got to get more of this topeople with housing and security
that are coming in and out ofthe emergency room every every
week, but don't necessarilyfollow up.
How do we get more of thesemedications started?
You know, at the at the time wehave a patient with us.
(08:09):
So that has been.
Mm hmm.
Kind of the theme of myresearch, some of my findings
in, in, uh, in my clinicaltrials that I've, um, developed
and run, uh, and a lot of that'sNIH funded.
And then, uh, or has been anopportunity to really be more
kind of consumer oriented, uh,be at a startup and then work on
(08:31):
a kind of new approach.
Obviously made very common andfamiliar since COVID of kind of
telemedicine and in a kind oflike prescription medication app
that is directed at onecondition and one medication in
this case with or oralnaltrexone for alcohol use
disorder.
Meg Sinclair (08:49):
Great.
And as the chief clinicaladvisor at OR, and speaking
about, you know, telemedicine,how do you see it transforming
the landscape of addictiontreatment, especially in terms
of privacy and convenience forour patients?
Dr. Joshua Lee (09:02):
I think quite transformative in that we didn't
have any of it and then we hadCOVID and then all of a sudden
we can do a lot of it.
Um, and then in the case ofnaltrexone, it's a, it's the
generic medication.
It's relatively inexpensive, uh,out of pocket or, you know, in
terms of insurance coverage.
And it is not a controlledsubstance, so there's very few
(09:23):
restrictions on its use intelemedicine.
We don't have any of the lightcontrolled substance prescribing
issues, which have, in fact,complicated a lot of, like, big
telehealth.
Headlines and addiction.
Part of that is centered around,um, and mental health.
Part of that centered aroundcontrolled substance
prescribing, which is kind of alandmine that or doesn't have to
(09:45):
deal with because thismedication doesn't have any of
those issues.
Um, so for us, it's been prettystraightforward.
Um, and then, uh, the challengeis reaching enough patients, you
know, reaching enough patientsfast enough so that the business
grows and is healthy, um, fromstart up to, you know, fuller
(10:05):
maturity.
Um, and I think in general, Doesdoes, um, we don't know the full
answer to this, but doesaddiction fit in with like care
loss, erectile dysfunction,stuff that other companies have
tackled 1st and are morefamiliar, like direct to
consumer telehealth models?
Um, we think, uh, uh, Alcoholsmoking cessation and then other
(10:30):
companies do do telehealth, um,opiate use disorder treatment.
So they're really good examples.
And I think kind of welldeveloped algorithms for that.
Um, you know, will it will itget to enough people?
Will it?
Um.
Can it coexist and not just kindof like animal eyes like real
treatment?
Like, um, it doesn't have to bean opposition to like, you can
(10:52):
get this from your doctor.
You can get this from atelehealth.
Like, we don't care how you getit.
Just like, get it because itwould be helpful to you and your
health long term.
So, you know, so far, so good.
Uh, I don't think all thechapters have been written on
where telehealth is going.
Um, but it certainly seems likeit's here to stay.
Like it made your medicalcenters like NYU make it
(11:13):
Telehealth, the routine offeringnow, just if I want to interact
with any of my providers, Imostly do my my own health care
at NYU.
Um, and it's not, it's not apredominant way that I talk to
my doctors.
I still do a lot of physicalvisits, but it's an option.
And then, of course, you havesomething like, or, which is
purely telehealth.
There's no brick and mortar.
(11:34):
We're not going to get you fromthe app to, you know, to a face
to face physical encounter.
Um, and that's okay too.
Uh, Because it seems to be, fromour experience, still an
effective way to reach peopleand then treat them.
Meg Sinclair (11:51):
Yeah, and the two can complement each other,
right?
Telemedicine and those physicalvisits are great complements to
getting that full spectrum ofcare.
What do you think the biggestmisconception about medication
assisted treatment for alcoholuse disorder and how can we
address that to improve patientoutcomes?
As a, as a person with lovedones who have suffered from
alcohol use disorder,
Dr. Joshua Lee (12:12):
Sure.
Meg Sinclair (12:13):
And thinking, like, I'm a pretty well informed
person when it comes to healthand what's out there.
Really, the only option thatI've ever felt for them was AA.
So, it's great to hear thatthere are other options, but I
think a lot of people just kindof go there first, right?
Dr. Joshua Lee (12:28):
Yeah, there's a handful of medications that are
approved for alcohol usedisorder.
Um, you could say that thenarrative is largely the same
with all of them, that peopledon't hear about them, know
about them, or talk to theirdoctor about them enough.
Yeah, it hasn't made it into themovies.
You know, AA is very familiar toeveryone, but starting a
(12:48):
medication to reduce cravings,reduce your kind of liking of
alcohol, and then if you dodrink, you don't drink as much
that occasion.
That's how naltrexone works.
Um, that just hasn't beenfamiliar or popular, you know,
in terms of, um, public healthmessaging or just how people
(13:09):
talk about alcohol and alcoholtreatment with friends and
family, uh, hasn't really madeit into the culture where, you
know, we're trying, uh, andthat's what like every paper
I've ever written.
Uh talks about but nobody readsmy papers like in the end, you
know, it's not reallypenetrating Media that people
consume on a daily basis or howthey think about You know
(13:31):
alcohol itself and that thatgets to a whole raft of like
historical and current issuesstigma It's it's shameful
embarrassing to have um, kind ofa compulsive disorder like heavy
drinking Um, it doesn't have tobe but it is and then people
They think about themselvesdifferently, and they think
about that as as not as a healthproblem, but often still, it's
(13:53):
kind of like a moral failing.
We would like to convince you.
Otherwise, like, we have a lotof kind of convincing
foundational neurobiologic.
You know, proof that it's, it'skind of like an acquired and you
can have genetic predisposition,but it's eventually like an
acquired, you know, kind ofbrain disease.
(14:13):
That's been the motto of theNational Institute on Drug
Abuse, for instance, likeaddiction is a brain disease.
Um, And in that sense, it couldbe like a seizure disorder, it
could be like depression, itcould be like ADHD.
It's not your fault, it'ssomething that's happened to
you, but now it's a medicalproblem and we can treat it.
You know, that's what we're,that's the model we're trying to
(14:35):
promote, um, but it's not, ofcourse, been the, the kind of
popular conception of some ofthese problems.
Meg Sinclair (14:43):
Yeah, there's some multifaceted problems there, but
I love that you're spreadingother options for people
suffering from alcohol usedisorder.
Um, and you're very passionateabout making evidence based
treatment accessible.
What are the key barriers toaccessibility and what steps can
be taken to overcome them?
Dr. Joshua Lee (14:58):
Well, like along with like, okay, you have an
alcohol problem, go to AA,that's just not appealing to a
lot of people.
And it's a really scary firststep.
Um, uh, similar to that wouldbe, well, you have to detox, you
know, you're drinking a lotevery day.
You have to go to some center,you have to do an inpatient
(15:18):
episode, and then the AA starts,you know, two weeks later after
you've kind of dried out.
That, that's in the movies.
Um, but that's not the, that'snot really kind of the practical
case for most people.
Most people that have an alcoholuse disorder, Globally and in
the United States can in factsafely stop drinking.
The disorder is they don't dothat on their own often enough
(15:40):
and that's like one of thedefinitions of uh, a alcohol use
disorder, but you don't have tocheck yourself into a hospital
or a County psych center, uh,uh, or the, the kind of, uh, one
drug and alcohol treatmentcenter that everybody kind of
knows about, but doesn't likereally go to or talk about, um,
(16:00):
you, you can do it at home.
You can do it in private.
That's, of course, an appeal toan app like, uh, or, uh, You
don't have to engage with yourhealth care team, and a lot of
people don't have a health careteam.
Anyway, um, people are inbetween positions.
Never had a regular clinic tofollow up with.
They've moved.
They're busy.
(16:21):
They just haven't, like, kind ofbeen doing annual doctor visits,
like, um, uh, you know, in in inthe movies again, but, um, that
none of that is really requiredto access and start treatment.
That's probably the revolutionof telehealth, too, is that you
can get to it.
When you're ready at home byyourself and private, um, you
(16:42):
can disclose that to family ornot.
It can be extremely, you know,kind of private and
confidential, or it can besomething you're sharing with
the limited support network, butit doesn't necessarily involve
getting in your car and drivingto a doctor's office.
Um, Of course, you can do thatand we highly encourage that.
Um, but people have also hadnegative experiences in regards
(17:06):
to an addiction problem and thehealth care system.
You know, they've been scoffedat by a provider in the
emergency room when they werethere for something related to
alcohol use disorder.
Um, they, Have seen it loom as alegal threat and therefore
something that has to be hiddenand not kind of openly broached
and discussed and brought up.
(17:28):
Um, so, you know, brick andmortar health care should do a
better job at screening,discussing, diagnosing, treating
alcohol use disorder.
But it's no surprise that peopleare reluctant to or don't know
to.
You know, ever kind of like flagit themselves as a self reported
health problem.
And as a consequence, it justdoesn't ever get kind of picked
(17:50):
up by or treated in your medicalrecord.
And then you're living with thisproblem day in and day out.
Um, so telehealth there, youknow, if you get our, if you get
our ad on your phone, um, you'remore likely to, you know,
through a series of clicks, bean or customer.
And then at a pretty reasonablecost, you're essentially like
(18:11):
subscribing to a confidentialtreatment that is going to be
done by mail and purely througha computer or your phone.
And you never have to doanything else.
And you can make.
You know, quite a bit ofprogress with the treatment of
your alcohol use disorder.
The fun thing is thesemedications do most of the work.
Like, you can do morecounseling.
(18:32):
You can still go to AA.
You can eventually talk to yourdoctor.
But in the case of, like, opioiduse disorder or alcohol with
naltrexone, just getting on themedication and giving it a trial
is a huge part of, like, whatwe're trying to do anyway in any
kind of practice setting.
And then staying on it long termis, like, Tasks number two, and
(18:54):
you can do that probably assuccessfully, you know, from
home and through a mail orderpharmacy is or uses as you can,
you know, following up two hoursaway with your doctor or however
it works for you in real life.
So that that's certainly some ofthe advantages.
Telehealth some of the likeopportunities.
For a company like or, um, andthen part of the, part of the
(19:14):
overall kind of like problem isthat people just are not going
to get this ever, uh, unless westart to kind of like rethink,
you know, delivery.
Meg Sinclair (19:24):
Yeah.
Change the conversation and letpeople know they have more
options or reports that 65percent of their members are
meeting their goal to drink lessor quit.
What do you believe are the keyfactors contributing to that
high success rate?
Dr. Joshua Lee (19:40):
It's kind of the magic of the molecule.
Now, Trexone is not going towork in everyone.
So if you and I both use it toreduce our drinking, you know,
chances are like we will nothave the same exact experience,
kind of medication effect.
We don't drink for the samereasons.
Now, Trexone doesn't quiteinteract with our brain and our
(20:00):
receptors in the same way.
Uh, and then we can havevariable, kind of, You know,
careers as an outrex ownpatient.
So it's not a silver bullet.
It doesn't.
Those rates could be higher.
Uh, those are pretty good rates.
We think for for kind of what wehave done initially and how
we've developed the product.
(20:21):
And I think they reflect aboutthe.
The usual expected treatmenteffect of Naltrexone, which is
for some people it's reallytransformative, uh, to get into
the weeds.
Naltrexone is itself an opiateblocker.
It goes into parts of our brainthat have, it goes kind of
throughout the bloodstream, ofcourse, and then it gets in the
brain.
And then parts of our brain thathave the most opiate receptors,
(20:42):
in particular, the mu opiatereceptor, that's also where
alcohol can have someopiate-like effects that can
kind of stimulate that receptorsystem.
And drinking makes us kind offeel warm and fuzzy.
It reduces anxiety.
Eventually, we get kind ofsedated, inebriated, um, and
that is a lot like, uh, opiatesthat they're kind of a warm
(21:05):
blanket, um, can reduce pain,anxiety, make us feel, uh, much
better.
In the short term, and then asas longer term and higher doses,
they're sedating.
And of course, you can getthings like overdose.
So for some of us, not all ofus, alcohol is a is a kind of
opiate like drug.
And one of the reasons we likedrinking are for kind of opiate
(21:27):
like effects.
It's not alcohol is not anopiate, but it does have some
again, kind of activity in theopiate system.
And that drives, um, A reward,so we experiencing a lot of that
is like, pleasurable and then wekeep repeating it and learn how
to do it.
And that becomes kind of a.
A loop that it's hard to break,and it's successful loop and
(21:49):
that the loop is developed tokind of.
In a sense, like, tricky to keepusing that substance, opiates or
alcohol in this case, but that'sthe whole point of treatment is
to kind of disrupt that networkand get you back to before you
were exposed or like thesubstance so much.
So with now, Trexone andalcohol, if we plug up and kind
of block.
Opiate receptors and this thisis also how naltrexone works for
(22:11):
opiate use disorders Um, you getless activity less of a signal
from that receptor system whenyou do use alcohol And so you
don't find that next beer onceyou're on naltrexone as tasty
Uh, and then a month later whenyou haven't been drinking you
don't look forward to that afterwork drink as much Um, and then
(22:33):
net net, you're just drinking alot less over time, either
increasing days where you don'tdrink at all, uh, so called
abstinence days, um, or when youdo drink, you don't drink as
much.
And that reduces so called heavydrinking days.
Both of those are extremelybeneficial.
We think in terms ofcontrolling, um, Alcohol use
disorders over time, uh, gettingpeople back to higher function
(22:55):
and then just helping your bodybe more healthy and avoid a lot
of the long term negativeconsequences from alcohol.
So we just want you to get themolecule into your brain like we
could have developed, um.
You know, like a queue redcoffee machine that spits out in
our truck zone.
We could have done vendingmachines outside of every liquor
store.
Like, you know, there's avariety of ways you could think
(23:17):
of, like, distributing more nowtruck zone to whoever needs it
or is the is the kind of directconsumer, you know, pharma app,
if you will, um, of which thereare many other examples now, but
that that seems like a prettystraightforward and now more
familiar way to do it.
Um, and that's, um, that's whereyou get back to those success
(23:37):
rates.
Meg Sinclair (23:40):
What is the success rates for you been like
in different treatment settingslike primary care and criminal
justice and communityenvironments?
Dr. Joshua Lee (23:47):
Yeah, about the same.
We haven't done a study withalcohol, naltrexone and criminal
justice populations.
I'd like to do that and I'vethought about it for many years.
We've done a lot of opiatedirected trials in the criminal
justice space.
In naltrexone for alcohol, mystudies have been more in
primary care.
Um, they've been using both.
The oral and the extendedrelease form and now Trexone.
(24:10):
Um, and they're, um, you know,that they're positive in that
they confirm what otherinvestigators and other trials
have shown, uh, is that nowTrexone is pretty easy for user
friendly.
Um, it has some side effects,but they're generally tolerable
and not, uh, they don't lead toa lot of treatment disruption
or, or discontinuation.
Um, and, and then or has kind ofmimic that.
(24:33):
So we haven't like discoveredanything new with or so much as
we've kind of found a new way tobring the science and an older,
familiar, well establishedtreatment to more people.
So I would say there's, there'svery little disconnect between
what I get when I prescribed atBellevue hospital in a brick and
mortar setting to a patient withalcohol.
And then what I expect whensomeone signs up for or now, I,
(24:57):
of course, I'm a.
Incredible physician and mypatients love me and yada, yada.
Like there probably is somethingto, you know, the human
connection for that patient thatI'm connecting to, but not
enough people ever kind of getto that point with the provider.
And many of us just don't havethat kind of long term access
and kind of follow through withthe primary care physician.
(25:19):
So it may be that, like, inprimary care, that's the optimal
place to kind of work with notrack zone, but it certainly is
a pretty good.
Other alternative to, to getmore people, you know, more
access through, um, through awebsite or an app like or, and
there are providers at or, um,you do communicate with real
(25:41):
people who are treatmentprofessionals, but we do it in,
you know, kind of the moststripped down way possible.
So it's largely asynchronous.
Um, it's not video chats.
It's largely kind of text andemails back and forth.
Um, but just if you'rewondering, it's not like, it's
not completely robot driven interms of how we prescribe, but
we do have to do it legally andwith care and in a way that we
(26:02):
think develops good successrates.
So we're not like ignorant tothe fact that, like, the human
touch can help here, uh, youknow, in primary care, it's all
about the therapeutic allianceand getting people to kind of
negotiate with the help of theirdoctor, what's best for them and
what they're motivated to do.
Um, and, or can do some of that,probably not exactly replicating
(26:23):
face to face, um, and long termrelationships, but, um, that may
be okay for a lot of people, andit may be really good for a lot
of people that wouldn'totherwise have access, you know,
to that same kind of traditionaldoctor patient relationship.
Meg Sinclair (26:39):
Great.
What emerging trends in theindustry do you find most
promising for the future ofaddiction treatment and
recovery?
Dr. Joshua Lee (26:46):
Uh, great question.
Uh, there's still a lot, youknow, there's a billion
molecules that are candidatesfor the next brain drug that
could help with smoking,shrinking, methamphetamine,
alcohol.
Um, it's, it's a long,laborious, expensive process to
like test them in humans andthen get one of them to market.
Um, so we're, we're not likewaiting for a new blockbuster
(27:08):
every year in this space.
Um, you know, we hadbuprenorphine in 2002.
We had extended lesion altraxonein 2006.
We had, by 2017, a extendedrelease buprenorphine
formulation, so just a newpackage to an old drug.
Uh, we haven't had, um, we hadacamprosate, another alcohol
(27:29):
drug, in the 2000s.
Um, so, you know, every decade,there's like one new label
emerging for addiction.
Uh, you know, across all drugsand alcohol.
So that's not, like, a reallyUh, you know, uh, pace that we
can't keep up with.
If anything, we'd like to seethat speed up.
And, you know, the federalgovernment to their credit
(27:49):
invests in this and is lookingfor that.
Um, I would call all too big andsmall pharma and entrepreneurs
out there to keep looking.
And, um, you know, I think thereis eventually a market for this
stuff, although these conditionshave traditionally been so
stigmatized and kind of, um,other that, um, That it hasn't
attracted some of the same typeof investment that, you know,
(28:11):
cancer, cardiovascular disease,uh, have, and yet smoking,
alcohol, opiates, when youconsider overdose, like they
contribute to about as muchcardiovascular and cancer death
as, as any other risk factor,um, that you could think of
beyond age.
Um, so.
I think there's something therein terms of opportunity and room
(28:31):
for improvement in all themedications we have.
One thing you'll hear about atany addiction conference or
psychiatry meeting now ispsychedelics.
Or doesn't do this.
I don't do this.
I know about it through friendsand colleagues.
And my spouse is a psychiatristkind of working in this space.
So, Um, do, uh, does psilocybin,does, uh, LSD, does MDMA, uh,
(28:54):
other forms of kind oftraditional and atypical, uh,
psychedelics, are they going tohelp with smoking, with
drinking, with opiates?
Um, there's some realpossibility there, uh, but then
it's also hard to imaginescaling psychedelics To help a
lot of people as soon aspossible because the protocols
have been pretty intensive onthe therapy side and not just
(29:16):
the drug and people do seemreluctant as we saw the FDA just
kind of pause or or thumbs downto MDMA for PTSD, um, just
recently, and many people in thefield expected that to kind of
fly through and get approval.
But the caution was like, Thesestudies are still limited.
We haven't done it in that manypatients.
(29:38):
Um, there's some limitations tothe resource that gave the FDA
pause.
And then there's some realsafety diversion and and
addiction kind of liability.
You know, people can develop,um, Misuse of some of the same
compounds that we're seeing astherapeutic agents.
So watch the psychedelic space.
It's not my kind of item.
(29:59):
Um, I'm not working on itdirectly, but I think that one
is getting a lot of press a lotof attention in terms of
addiction.
Meg Sinclair (30:07):
Yeah, we've had a few of those founders and CEOs
on on there for conversation onhere for conversations before.
Dr. Joshua Lee (30:13):
Yeah,
Meg Sinclair (30:14):
well, Josh, our last question is more of a fun
one to ask each of our guests.
Okay.
If we ran into you at abookstore or at your local
library at NYU, in which sectionwould we find you?
Dr. Joshua Lee (30:25):
I would say I'm a broad reader, but I
consistently go back to kind ofhistory and nonfiction.
Um, I love just kind of learningtrivia about past events,
biographies, etc.
So probably non fiction, youknow, world's history.
Meg Sinclair (30:42):
Well, maybe I will bump into you there.
It was a pleasure speaking withyou today, Josh.
Thank you so much.
Dr. Joshua Lee (30:47):
Thanks so much, Meg.
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