Treating Substance Use Disorder Episode 1

This is episode 1 of the series: Treating Substance Use Disorder

Substance use disorder (SUD) is a complex and pervasive issue affecting millions of individuals and their families. Understanding and effectively treating SUD is crucial for healthcare professionals to improve patient outcomes, reduce the burden on healthcare systems, and support long-term recovery. This podcast series empowers healthcare providers with the knowledge and tools they need to address SUD comprehensively and compassionately, ultimately fostering a healthier society. 

Episode 1: Understanding Substance Use Disorder 
This episode educates healthcare professionals on the fundamentals of substance use disorder, covering its clinical definition, risk factors, and diagnostic criteria. Listeners will gain insights into the impact of SUD on physical and mental health, as well as its prevalence and the consequences of untreated conditions. By enhancing early identification and intervention strategies, the episode aims to empower professionals to recognize signs and symptoms of SUD, thus improving patient care and outcomes. 

Episode 2: Practical Strategies for Treating Substance Use Disorder 
In this episode, healthcare professionals receive practical and evidence-based strategies for managing substance use disorder. The discussion focuses on pharmacological and behavioral therapies, individualized treatment planning, and relapse prevention techniques. By the end of this episode, listeners will feel more equipped to implement effective treatment approaches and support long-term recovery for their patients with SUD. 

 
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Series:  Treating Substance Use Disorder

Transcript

Treating Substance Use Disorder

 The following transcript has been lightly edited for clarity. Elite Learning does not warrant the accuracy or totality of audio transcriptions provided by an independent contractor resulting from inaudible passages or transcription errors. An occasional transcription error may occur.

Guest: Brooke Schaefer MSN, MBA, FNP-C, CARN-AP, RN

BrookeSchaeferlives in central Indiana with her family and runs a small homestead with a menagerie of animals. She runs CHOICE: Recovery for Mothers through Community Health Network, and is the founder of Lily Pond, a patient comfort closet, and Legacy, a continuation of CHOICE programming. She is a family nurse practitioner, a certified addictions nurse practitioner, and has an MBA. 

 
Host: Candace PIERCE: DNP, MSN, RN, CNE 

Dr. Candace Pierce is a nurse leader committed to ensuring nurses are well prepared and offered abundant opportunities and resources to enhance their skills acquisition and confidence at the bedside. With 15 years in nursing, she has worked at the bedside, in management, and in nursing education. She has demonstrated expertise and scholarship in innovation and design thinking in healthcare and education, and collaborative efforts within and outside of healthcare. Scholarship endeavors include funded grants, publications, and presentations. As a leader, Dr. PIERCE: strives to empower others to create and deploy ideas and embrace their professional roles as leaders, change agents, and problem solvers. In her position as the Sr. Course Development Manager for Elite, she works as a project engineer with subject matter experts to develop evidence-based best practices in continuing education for nurses and other healthcare professionals.   

Episode 1: Treating Substance Use Disorder

Transcript

Candace Pierce: Welcome. Thank you for taking the time to join us for this podcast series on treating substance use disorder. I'm Dr. Candace Pierce with Elite Learning by Colibri Healthcare, and you are listening to our Elite Learning podcast, where we share the most up-to-date education for healthcare professionals. In this series, I have Brooke Schaefer joining me, and I'm really looking forward to this discussion with you, Brooke, not just because of the expertise that you bring to this topic, but because of that passion and energy that drives you for this particular issue.

Brooke Schaefer: Thank you so much. I'm so glad to be here.

PIERCE: Yes, thank you for joining me. I also want to say thank you for all that you do to work for and bring awareness to substance use disorder and to patients who are affected by substance use disorder. And before we really jump into what is substance use disorder, I wanted to talk about some of the latest statistics to really help us grasp the gravity of what it looks like for our country. I think it's really hard today to find someone who has not been affected by substance use.

SCHAEFER: Yeah, most definitely. It's definitely gone from being an "other people's problem" to everyone's problem. And there's different degrees of severity, right? But it really does impact, I mean, almost everyone.

PIERCE: And it does, not just from the addiction itself, but you also look at the disabilities that it causes, and even the death and grief that people have to live with. And I know we've been hearing about substance use disorder, unfortunately, for what feels like years now. And I think over time, a lot of our topics in healthcare really become more like white noise. After a while, you stop hearing about it—COVID became white noise. And I just kind of wonder if the difference here is that substance use is not really getting better. So I pulled some statistics. So I'm going to share some statistics. A lot of the 2024 sources were actually quoting still 2020 statistics. So I had to do a lot of digging, but I found some from 2023. All right, you ready? Feel free to interrupt me at all. Like I'm just going to kind of go through these if you want to add some information, because at the end, I'm going to ask you for your thoughts. Okay, around 48.5 million people battled a substance use disorder in the past year. That's 16.7% of the population. 10.2% had an alcohol use disorder. 7.5 million people struggled with alcohol and drug use disorder simultaneously. 20.4 million suffered from both a mental health disorder and a substance use disorder.

And there's one that really bothered me a lot because, I mean, these all bother me, but I'm a parent, and my kids have not yet graduated high school. So this one really bothered me because I felt more connected to this one. You know this one, you know where I'm going. 47% of young people use an illegal drug by the time they graduate high school. I mean, these are some staggering statistics. What are your thoughts?

SCHAEFER: Well, we also know that the younger people are when they start using substances, oftentimes the bigger impact it has. So, the brain is not done developing until we're in our mid-twenties, roughly 25, but that even varies a bit from person to person, right? We don't all, on our 25th birthday, automatically reach brain maturity. "Now I got it all figured out, I'm greater than 25, you know?" And so the younger people are when this impacts them, the more significant that impact can be. I will tell you that with the clients that I serve, I primarily serve women, pregnant and parenting women in the substance use disorder world. But I also serve other clients, and when I'm doing their intake appointments, many of them will talk about their first substance use exposure being at 12. 

PIERCE: Wow, I didn’t even I mean, my parents drank alcohol every once in a while. I remember as a child, my dad, he used to dip. They would use the Coke can, and you’d think it was Coke, and it was not Coke. Like I did that once, and I know, I still today do not drink out of a Coke can. But other than that, like I didn’t see a lot of the drugs growing up. And I grew up in a small town. I really didn’t see them until high school.

SCHAEFER: Right. But seeing them is one of the big indicators of what happens later in life. And so, there are so many factors that go into what leads to substance use disorder, but part of that is seeing it as normal within the culture that you live in. So if you're seeing your parents use substances, your big sister use substances, your cousins, your grandma... like, it's way more likely that becomes more normalized to you. And then those risk factors increase even more.

PIERCE: Right? And your peers, you see your peers start going home and taking stuff out of their parents' cabinets and bringing it to school. And, you know, I’d heard those stories, but I never saw it. My brother was five years older than me, so a lot of those things, you know, like they closed campus. Like, no, I’m just now getting to high school and you closed the campus. I can’t go get lunch, you know? But that was part of the reason why they closed campus, is because, you know, kids were going home and bringing stuff back that they should not have brought back. Okay, so what is substance use disorder and how is it defined clinically?

SCHAEFER: Yes, this is really tricky because there are two key factors that you really have to think about here. The difference between addiction and dependency is really important because they’re not the same thing. So, you could very much be addicted to something like your phone. If the first thing you do is wake up in the morning and check your phone, like, before you get out of your bed, before your feet touch the ground, if you check your phone, you need to check in with where your phone sits in your heart from an addiction standpoint. Are you?

PIERCE: Well, you watch people with their phone, and like, they’ll set it down. And what is it, five seconds later? They’re like, and they don’t even look at anything. And then they pick it back up.

SCHAEFER: Well, it’s designed to please us, right? It hits those dopamine receptors. Look at my likes on Facebook, you know? And then it really hits those dopamine receptors, and you like it. Even subconsciously, you like it. And so, those moments are really important when thinking about this concept of addiction. Really, we define addiction as the use of substances regardless of harm and consequences. It could also be things beyond substances. People can be addicted to sex. People can be addicted to the internet, gambling. There are all sorts of things, but addiction itself requires you to have that concept of use beyond the ramifications, regardless of harm and consequences. But then also there’s the concept of dependency, and dependency is a physical need. There’s tolerance potential, there’s withdrawal potential, and you could have both. Definitely, if you are struggling with fentanyl use disorder, you are physically dependent on that fentanyl and you are also addicted to that fentanyl. You could be being prescribed pain pills from your doctor that you’re taking exactly as prescribed. That would mean that you’re not addicted to them, but you are dependent upon them. And so it’s really important to understand this addiction versus dependency. You can be both things at the same time. You can be one thing at the same time. If you're only dependent, you do not have a substance use disorder. So, I'll get clients sent to me where they say, okay, she has a chronic pain disorder. She's been on opiates for three years, but she takes them exactly as prescribed from her doctor. She doesn't have a substance use disorder. So, that's really important we understand that because substance use disorders, the definition of them clinically, is really careful between... you’ll see overlap where people try to make dependency addiction, but it’s not the same thing. They're separate from each other.

PIERCE: So, I’m going to go back to your story where you were just saying she is prescribed opioids because she has a pain disorder. She takes them correctly. So, she has a dependency on them. Can that then turn into an addiction?

SCHAEFER: Absolutely. And, you know, that’s the one... as a mother of... my kids range from 26 to 12, so I've been through a couple of these wheelhouses. I have four kids that range significantly in age, but you'll see a lot of the clients I serve, when they first start coming to me, I’ll say, “What was your first experience with opiates?” And many of them say it was when they had their wisdom teeth taken out. They were prescribed an opiate and they said, “I loved it. The first time I took it, I never felt anything better in my life.” And that was the starting point for this. And that’s where we have to be really careful. So, I myself am a nurse practitioner, and I have to be very careful about prescribing narcotics in a way that explains to people, hey, you had this major surgery, this is appropriate use of this medicine, but if you take it and you really, really like it, we need to reevaluate that. And these are clients who don’t have substance use disorders. It’s important conversations. If you took an opiate pill and you feel the best you’ve ever felt in your life, that’s very tricky and a very big indicator of long-term use problems.

PIERCE: So there’s something I’ve always heard. It was mainly around alcohol. And it was, “If you could take one drink and become addicted because of the way that it makes you feel.” So like what you were saying, I took an opioid and I just loved the way it made me feel. Are there some people that just are more likely to become addicted to something because... I don’t know how to ask the question I’m trying to ask, but...

SCHAEFER: Yeah, I think what you're getting at is what are the factors that make someone more susceptible to substance use disorders? Okay, so definitely a history of trauma is one of the biggest indicators. So I don't know if you've heard of ACE scores, but I'll summarize them real quickly for listeners. An ACE score is Adverse Childhood Experiences. And it has to do with things that happened to you prior to being 18 years old that were completely beyond your control. If you get online, you can look up quizzes where you go in and enter your own information, okay? Were your parents divorced? Okay, that’s one point. Did you grow up in a house where someone was incarcerated? That’s another point. Did you see your mother physically abused? Another point. Or was there violence in the house? And were you neglected, abused, sexually? There are so many... there are 10 different points possible. The higher your score, the more statistically likely it is that you will have a substance use disorder. And it’s linked very closely to things that happened to people as children that were not... that had nothing to do with them. You don’t pick what family raises you. You don’t pick where you were born. And a lot of how you’re... if you experience extreme childhood trauma, your risk factors for many things go through the roof. And that’s a really important part of us making sure that when we’re treating substance use disorder, we’re also ensuring that kids are not experiencing extreme trauma because they link to each other.

PIERCE: Right, and genetics, genetics play in there.

SCHAEFER: Definitely, there's definitely a genetic link. So, it's somewhere between 40 to 60%. This is according to the National Institute on Drug Abuse, which talks about how there's about a 40 to 60% chance of your risk if you have a parent who struggled with substance use disorder—your risk goes up about 40 to 60%. And so, that's an important conversation too. You got to say to your kids, “Hey, grandpa was an alcoholic. We got to be careful with this. You may not be the kind of person who can recreationally drink alcohol.” And you got to be realistic about that. It just may not be something you can do. And that’s really clear conversations about that. But then, you know, there’s also the mental health disorders that are so strongly linked to substance use disorder, these co-occurring issues that really have a big link to how predisposed you are for substance use disorder.

PIERCE: Right. When we're talking... yeah, it really is. It's hard to really look at the risk, to determine the risk. There are so many pieces that play into this puzzle to determine if this is the track that we're going to end up on.

SCHAEFER: Yes, and we're humans. We're complicated, right? I mean, no one is as simple as just, "This is how this works for me, so it works for everyone like this." That’s one of the really big things we have to be careful with in treating people with substance use disorders. This "one size fits all" concept is a terrible idea and does not help clients. It is not the way that we serve our patients because it makes it, “You do it my way or you get out,” but your way might not work for them. So we got to have a lot of different ways. There are lots of paths to recovery.

PIERCE: Yes, just like there are lots of paths to raise your children. There are lots of paths to recovery. Now, when we hear the term substance use disorder, you also hear the term alcohol use disorder. You used another term earlier in our conversation where you said fentanyl. Can all of these be used interchangeably? Is substance use disorder like that umbrella term? Is there an official definition of substance? And what about nicotine vaping? Does it fall there?

SCHAEFER: Yes. So, absolutely. No, nicotine use disorder, 100%. I diagnose people with that all the time, almost every day. So, you know, and there may very possibly—like I’ve had clients where I’m diagnosing them with a nicotine use disorder, alcohol use disorder, opiate use disorder, benzo use disorder. Like, you know, they’ve got this whole list of things that they are struggling with. So, you can say they have a substance use disorder. That is an umbrella term that covers all the types of substance use disorders. So, it’s not wrong to say substance use disorder. It would be wrong to say alcohol use disorder if they have an opiate use disorder. So, that’s where substance use disorder covers everything. If you know specifically what substances you’re dealing with, then you can use the substance name as part of the disorder diagnosis.

PIERCE: Okay, yes. How often do you see kids coming in with nicotine use disorder? Just out of curiosity.

SCHAEFER: I primarily treat clients who have severe substance use disorder. So, if you came in with only nicotine to see me, I would be delighted. Like, cause I’m dealing with people who are... I’m like, nicotine? Okay. Like, we can figure that out. And, you know, we joke about that, but really the nicotine disorders are significant long-term impacts and have huge effects on our healthcare system and how people... you know, especially the vaping is so new. We don’t even really totally know, but we know it’s not good. And so, you know, we’re getting data about that now, but it’s tough because the vapes are so unregulated that I’m always like warning my teenagers, like, “You guys, the vapes are bad stuff. You don’t know what’s in them. You don’t know how much concentration is in them. Like, this is bad stuff. Don’t play with this.” And, you know, it’s really... the vapes are not the safe version of smoking that we thought they were when they first got marketed, when they first came out.

PIERCE: Right, and we’re seeing more and more youth using vapes, and I just... yeah.

SCHAEFER: Absolutely. They’re marketed towards kids. I mean, when you go in a gas station, they put them on a level where the kids can see them. They’re bright, colorful, like cereal boxes. Yeah.

PIERCE: How to hide them, how to hide them, you know, you buy this one, nobody will ever know, it looks like a pen or... but I think that we are going to see, and are going to continue to see, a rise in nicotine use disorder because of the unregulation and the push for vapes.

SCHAEFER: Well, the products are smarter and faster than the regulations. So, when they cut one down, they just stop making it and start making a new one and then it’s out. So, yes, they’re bad news. They’re definitely bad news. Now, they’re not killing people immediately like opiate use disorder is. And so, the concept of "one pill kills" is a program they’ve been working on about... you know that, right? Right now, with fentanyl, fentanyl is primarily the opiate that’s on the streets right now. And fentanyl, it’s not fentanyl like, you know, the fentanyl patch that your grandma may have had when she was in hospice. Like, it’s a different kind of fentanyl. It’s much stronger, it’s much higher concentrated. It’s not hospital-grade, pharmacological-grade fentanyl. It’s very different and it’s way stronger. And this fentanyl is being made synthetically and brought into the United States and sold, and it is being—because of 3D printers, people can create pill presses to make these pressed pills that are made out of fentanyl powder that look like Adderall, that look like Roxicodone, that look like a pill that you would sell to somebody and say, “Hey, this is not fentanyl, this is a pill, you know exactly what you're getting, this is a safer use option.” And people buy them and they're pressed pills. And so, you'll get kids, younger people, teenagers, college kids, who will be buying what they think is an Adderall and it’s a fentanyl pill and it’ll kill them. I mean, the dose is so high that a single pill, with no tolerance, is absolutely a deadly exposure. And so that’s something we’ve got to be really careful with kids. And that’s part of why you should always carry Narcan. I mean, opiate overdose is reversible. And so if you get a dose of Narcan, if you overdose on an opiate and your heart stops beating and you stop breathing, you get a dose of Narcan, you will start breathing again. Your heart will start beating again, especially if done quickly. And so, in my household, for example, we’re talking about our kids, if you’re 12 years old or older, you carry Narcan because you never know when you’re going to be at a gas station and the person at the pump next to you is going to overdose. I mean, it’s all over the place and we need to be ready to Narcan people because that’s how we save lives. And then people find recovery. And I’m a big believer that if you have to be Narcan’d 13 times in your life, and that’s how many it took for you to find recovery, then that’s how many it took. I mean, we need to treat people as often as it takes for them to find recovery. The only time you can’t find recovery is if you’re dead. And so we need to keep treating people, because you’ll see stories all the time of people who were at the lowest of the low for a very long time, but then something finally happened where they were ready. Something clicks and they met the right providers at the right point in their life, and they got better. Yeah.

PIERCE: Right? So earlier you did mention, you know, mental health disorders usually accompany substance use disorders. Which usually comes first? Do we really even know which comes first?

SCHAEFER: Yeah, and that's really hard to pull all those apart, right? Because oftentimes you'll see that people who have anxiety, depression, post-traumatic stress disorder (PTSD), ADHD, you'll see these people have much higher rates of substance use disorder. People who have bipolar disorders or personality disorders also have much higher risks of substance use disorders. But did it happen first, or did it happen after? And that's tricky to say. I'll have clients report to me, “I started using these substances because it made me feel significantly braver, or less afraid, or calmer, or able to focus,” or any of these self-medicating-type behaviors. But certainly, when we see these co-morbidities of different substance use disorders plus a mental health disorder, I mean, that's extremely common. You'll see about 41% of individuals with post-traumatic stress disorder end up with a substance use disorder at some point. And we see a lot of alcoholism, especially for people who have a history of PTSD. And it’s serious stuff, and it majorly affects the people around them, obviously.

PIERCE: You see it a lot too with veterans, unfortunately. You see a lot of alcohol use with veterans. So, we've talked a lot about some of the common substances that we see, you know, fentanyl, alcohol, but also, do the ADHD drugs fit into substance use disorders?

SCHAEFER: Huge impacts, right? Right. Yeah, most definitely. If you're misusing them. So if your doctor’s prescribing this medication and you're taking it as prescribed, then no, it does not count as a substance use disorder.

PIERCE: But we see a lot of college students who are like, “I’m going to go buy some, not at the pharmacy.”

SCHAEFER: Right, which is not legal. And if they're using it regardless of harm and consequences, that counts as addiction. And so, that can get a little squirrely sometimes when you get somebody who's like, “I bought one Adderall from my friend who has a script, and I know it's a real script. I used it once because, for whatever reason, whatever recreational reason, and it’s just a once-in-a-lifetime thing, I’m done.”

PIERCE: For finals week.

SCHAEFER: That’s the one I hear a lot. You know, that’s not addiction necessarily. Now, if you know that you're snorting it and you're taking five pills a day and you're buying it from illicit sources, you've got a problem at that point. Then you’re using it regardless of harm and consequences. And that’s when things start to escalate. Oftentimes, people get started with a legal or at least a pharmacological-grade substance like Adderall and then transition to methamphetamine. So, not everybody that ever recreationally uses Adderall will try methamphetamine. But oftentimes, people who are using methamphetamine started with something else first. They didn’t just start right with methamphetamine.

PIERCE: That’s a big jump right there, for sure. So go ahead.

SCHAEFER: Yeah, it is. And I was just going to say one of the things we don’t talk about a lot is the misuse of caffeine.

PIERCE: I actually wanted to ask you about that, but I thought you might think that I am silly for asking you about caffeine because, you know, it’s caffeine. But you see all of these drinks out there, and they just seem very unregulated. Even restaurants, you know, restaurant chains having... people are young, people are being affected hard. So yes, I am so curious about caffeine.

SCHAEFER: Yeah, definitely the most widely abused stimulant is caffeine. And especially in our culture, it's almost considered kind of funny. Like, “My gosh, they drink so much caffeine. She could float a battleship with the amount of coffee she drinks,” kind of thing. “I drank two whole pots,” and people are like laughing, right? And I'm like, I mean, I do like to make a coffee run every now and then. I am not caffeine-free. But if you cannot function in your life without caffeine.

PIERCE: She had 10 cups of coffee this morning.

SCHAEFER: That’s the use of caffeine regardless of harm and consequences, and that’s where you got to think about, “Crap, I’m addicted to this stuff.” You know, you can... you're definitely going to withdraw from it as well.

PIERCE: Yes, so there’s that dependency versus addiction. Because my husband, for some reason, stopped drinking coffee. He drinks coffee every morning. He just stopped drinking it. I don’t know why he stopped drinking it. He just decided to stop drinking it. And after a couple of days, he was having some severe headaches. And it took him a while to be like, “You know what? I think this is caffeine. I haven’t been drinking my coffee.”

SCHAEFER: Yep. Yep. Yep. And I mean, people don’t die from caffeine withdrawal, from caffeine withdrawal. And they don’t die, and they usually don’t have to be...

PIERCE: They can, I will.

SCHAEFER: You know, put into any kind of special placement, you know, recovery unit or program for caffeine recovery. But you certainly can overdose on caffeine. I mean, people... there are definitely cases. They’re not as big as what we see with, like... you know, there's not as many people, but we do have to be careful with these things. I mean, alcohol is a legal substance. You can buy that legally. It absolutely can kill you. That doesn’t mean it’s safe, you know? And the caffeine is the same. It definitely can harm you in high doses. And so anything that is a recreational substance use must be done in moderation or it’s an issue. So, I had a friend who was a recovering alcoholic, and she said to me... I said, “I just want a cocktail at this place.” And she said something like, “Do you have to have a cocktail to have fun?” I thought, well, now that’s an interesting concept, right? Like, no, I don’t have to have one to have fun, right? And that’s just something that you got to think about. But the real high levels of death that we’re seeing right now in the United States are related to the opiate use disorders and primarily fentanyl. Yeah.

PIERCE: Still, yeah, still today, started with the pills and now we're up to the fentanyl. So if I am looking at a patient, how can I really identify signs and symptoms of substance use disorder?

SCHAEFER: It’s tricky because you certainly cannot look at people and say, “You look like you have a substance use disorder,” and always be right. Right, right? And so, the real question... there's a great screening tool that I really love called a CAGE, and it stands for Cut down, Annoyed, Guilty, and Eye opener. So it's the four questions about, “Have you tried to cut down before and you can’t?”

PIERCE: You’ve been drinking a lot of alcohol.

SCHAEFER: Is anyone in your life annoyed with you about your substance use disorder? Do you feel guilty about how much alcohol you drink or how much, you know, methamphetamine you use? Do you feel guilty about it? And do you have to have an eye-opener? So, when you wake up in the morning, do you have to have like a small drink of alcohol to just get going in the day, or whatever substance? And that CAGE screener, it’s free. It’s very accurate. It’s a great way to just open up a conversation. As we cannot just look at people and tell... I know people who have been in recovery for long periods of time who were functional opiate use disorder for 10 years. They kept their job. Their family didn’t know. They had their ups and downs, but they hid it. And it’s very... you’ve got to ask the questions.

PIERCE: I really like that because it comes across as not judgmental, per se.

SCHAEFER: Yeah, yeah, if you ask everybody, you're being universal. Yeah.

PIERCE: Right. You’re just, you’re asking them real questions, non-judgmental. So that’s a good way for us to kind of assess where we are when they come in. But what about diagnostic criteria for substance use disorder?

SCHAEFER: Yeah, diagnostic criteria gets much trickier, and it’s certainly nothing that, like, a family practice can’t handle. I mean, it’s not... that's addiction medicine. You can figure this out, but it’s nice to have a “phone-a-friend” in those scenarios. You know, somebody who specializes in substance use disorder is a great buddy to have. So you can call them and say, “Hey, how do we do this?” Because we use DSM-5 criteria to diagnose, and it’s a whole list of criteria that has to do with, like, risky use, social impairment, let me see, impaired control, and pharmacological criteria. Okay? And then there’s all a bunch of different factors, and if you have at least two of those, then you have a mild disorder. And then you go up to moderate or severe use disorder based on how many of those criteria. It’s very straightforward. I’m not going to read it because it’s easy to look up online.

But it definitely gives you a great idea, and it’s interesting sometimes to people when you go through that and they’re like, “No, I’m okay. I’m not an alcoholic. I mean, I drink, but it’s like, you know, I just... I’m just chill after work.” And then when you go through that list and they’re like, “Okay, so you have a moderate alcohol use disorder.” “Wait a minute, this is starting to get away from me.” And so that really is a way to narrow down when you identify there’s an issue on the CAGE screening, then doing that DSM-5 criteria is a really nice way to narrow down, "What are we really talking about?"

PIERCE: Right. It seems like it could be really eye-opening for the patient as well to be like, "Whoa, I didn’t realize that that is where I had gotten to today." So we know.

SCHAEFER: Yes, yes. Because before it gets out of control, you think it's under control. You know?

PIERCE: Yes, very true. You don’t realize it sometimes until it’s in your face and you see it. And hopefully, you see it before you have to deal with the consequences, you know, the mental, the physical, the emotional.

SCHAEFER: I mean, it can be a complete destruction of a person’s life and literally death. It’s a big impact. Early is definitely easier than coming in when things have really escalated.

PIERCE: Absolutely. Well, that wraps us up for this episode to help us really understand substance use disorder. To our listeners, we are so glad you have joined us for this series. Brooke will be back for episode two to give us more insight into the most current evidence-based treatment approaches and best practices for really managing substance use disorders.

SCHAEFER: Thank you.

Episode 2: Treating Substance Use Disorder

Transcript

Candace Pierce: Welcome back to Treating Substance Use Disorder. In this second episode, we're going to focus on evidence-based treatment approaches and best practices for managing substance use disorder. Hopefully, at the end of this series, you will feel more equipped with some practical strategies and interventions to effectively treat SUD and support patient recovery, and I'm excited to share that Brooke is back with her passion and her expertise. And I know this is a really hard topic for a lot of us to talk through, especially emotionally. And it's a hard area to practice, probably emotionally as well, huh?

SCHAEFER: Definitely. But I think that you have to be realistic about that in this work and really ensure that you're taking care of yourself because if you have nothing to give, you can't help. Yeah.

PIERCE: Absolutely. And I just, again, I just want to commend you for taking the time to share your passion and share your expertise. Because I also know this is an area where we need more practitioners who have that same passion and compassion and encouragement and expertise that I see in you every time that you take time to just share and to teach. And I just want to commend you for what you do.

SCHAEFER: Thank you. I have to tell you that in all honesty, it is extremely rewarding work. There, you know, people think there are two schools when I tell them what I do usually, and one is, "My gosh, that must be so hard to not get burnt out." But then there's also always a group that says, "That would be amazing. Like, you're always just seeing people fighting hard to get better." And that's very motivating. And I specifically work mostly with parenting women and pregnant or parenting women. And it is really... they fight so hard. I mean, they want to care for their children. They want to be mothers, the ones I'm caring for. And they really fight hard to do their best and to break that cycle.

PIERCE: And there's also, I'm sure you see this a lot too, just that negative stigma around this area as well and how disheartening it can be and how that affects your patients.

SCHAEFER: Absolutely. Definitely. And I think that stigma is one of the worst aspects of their care that they run into. I mean, I frequently get told by clients, you know, “If that person's going to treat me like I'm actively using, then why not just do it? You know, and like, if they're going to be that cruel to me and I have to deal with that, why be sober? What's the point of this?” And that's very disheartening. And you see it a lot in the medical community. And so, it's lovely when you meet... I work with a cardiologist who is the kindest, most compassionate woman and treats these patients with so much dignity. And, she doesn't say things like, "Well, we don’t want to give you a heart valve for your endocarditis because you're just going to relapse and we'll have to do it again." She would never talk like that. And she doesn’t think like that. And that's really critical in the care of these clients. Because I meet other providers. I mean, I had a physician tell me once, “We shouldn't treat hep C in these clients because they’re just going to re-infect themselves anyway.” And that's a horrifying mindset. You know, we've got to change that. And so we're working towards it and we're getting better, but, you know, we’ve got to keep working and being actively aware of those things. One of the things I think about a lot is the first time I learned... when we're talking about, like, a drug screen for a client with a substance use disorder, we should not call the drug screen "clean" or "dirty." We should refer to it as "positive" or "negative" for substances. And because calling someone's urine "clean" or "dirty" is immediately labeling them and themselves and their body. And so when you say the drug screen was positive for substances, it's very different than saying it was "dirty." And so we know better, we can do better. That's one simple stigma-free language change that is very obtainable.

PIERCE: And communication, we've really been emphasizing how we communicate patient-first language because it doesn't just affect care for those who are struggling with substance use disorder. It really affects care across the spectrum, even gender, even race. So we see this in so many areas of healthcare today, and we really have to do better with how we talk to our patients.

SCHAEFER: It's amazing when we learn that us being kind has an impact on our clients. We feel that instinctively a lot, but there's a book called Compassionomics that really goes into a great deal of detail about how us being kind to our clients improves their health outcomes. It’s important. Yeah. Yeah.

PIERCE: Yeah, it does. It makes them feel safe. It builds that patient-provider relationship trust, really builds up the trust in that relationship. And that's so important because you want them to keep coming back. You want them to do better. You want them to make better choices. You want them to learn. And if we're not paying attention, I think that's kind of one of the first strategies that you should have as a provider in healthcare: how we treat our patients is going to affect their success, a lot of it.

SCHAEFER: It is, and if you can't find compassion, then maybe it's time for you to take a break. I mean, if you have gotten to the point where you don't feel compassionate towards your patients, you need to reevaluate that. Because is that how you'd want your mom, your sister, your loved one to be treated by a provider who doesn't care about them? I mean, it makes a huge impact. And so we have to take that very seriously. It's really important. It's not a negative, and it's good for us. We build up more. We feel more compassionate when we give compassion. We think we have to hang on to it as this finite resource that if I give away all my compassion, I won't have any left for me. And that's not how this works. If you give compassion, you feel better about it. And so it's sometimes just in the wrong situation, but it's really important that we give compassion to the people we care for.

PIERCE: We all have bad days. We all make negative choices. Some just have more consequences than others, and we're all human, and we just need to be there to help each other. So, going back to substance use disorder and other practical strategies besides communication, what are some of the current evidence-based treatment options for substance use disorder? And if you want to get into some of those specifics, you can because there are so many that are potential options, but we also know that alcohol is a big one, fentanyl is a big one, methamphetamine is a big one.

Absolutely. Yes, and those outcomes are so significant. And so, you know, one of the things I always bring up when we talk about care is that every care model we talk about should be individualized to the clients we serve. As medical providers, we are here to be of service to our clients. They are not here to be obedient to us. They are not here to do everything we tell them to do because we told them to. They are here because we are here to serve them, and they can decline any recommendation we make to them because they know themselves better than we know them. I promise.

So when I tell a client something and I can see by their eyes that they’re not buying in with what I said, I say, "You don’t have to do anything I tell you to. You’re the boss of you. These are my recommendations. These are what I’ve seen work in the past. Do any of those sound right for you?" And we have to listen to them saying, "No, that’s not right for me." Okay. I’ve been in situations where they tell me no to every single thing I recommended, and I’ll say, "Okay, those are the ones I have to offer. Is there something else that you want to do? What do you think?"

You know, I’ll hear a lot of clients right now bring up psychedelic therapy. There’s a lot of research coming out about that. There are some great outcomes coming from that. It’s not legal in the state I live in, so it’s not an option, right? They’ll say, "Well, if I could just have psychedelic therapy," and I’m like, "Yeah, but you can’t in this state." So that one’s not an option right now, maybe someday, but right now, no.

We really talk a lot about that integrated model of care, that co-occurring moment of care. Ideally, patients are dealing with what I call a "one-stop shop," where they come in for treatment and they are going to one location where they have a therapist, a medical provider, a case manager, and a peer recovery coach. And those people are used to working together and communicating with each other. The client gets those full wraparound services all at the same time. They’re not going to four different places for those services. And sometimes they have to, and that’s okay. But in an ideal world, you have a one-stop shop for these clients—one place.

And we’ll hear a lot of people talk about, "What about telehealth?" Telehealth is great if you have a working cell phone, a private place to do your phone call, and you can keep an appointment. Like, going in at a certain time is going to make sense for you. That’s not the reality of where some of these clients are. And so, you know, sometimes coming in person is a much better option for them. But then we need to be realistic about, "Okay, if they’re coming in person and they have no transportation, how can we teach them to utilize transportation in order to be able to get here?" So we’ve got to be realistic about those barriers.

Super important that we are focusing on trauma-informed care. Many people who struggle with substance use disorders, especially severe substance use, have a strong history of trauma in their past. We need to be really cautious with that. For people who have trauma histories, it’s very stressful to have to go to new doctors, new offices, new locations. It’s very stressful for them to have to retell their story to a new therapist or to try to change these programs. "You graduated this program, now you’re going to this program." That can be extremely stressful for them because they don’t want to retell what they’ve told so far. They don’t want to restart.

And so that’s where we think like, "You’re graduating programs." And in reality, we’re actually setting them up to not succeed in this because of the trauma aspect of it. Same thing with our offices. They need to be very carefully trauma-focused. You know, everything I... every single thing that happens with a client, I ask them or talk to them about it before it happens. "Is it okay if I check your thyroid? It’s going to mean I have to touch your throat, and I’m going to kind of move and push around a little. Is it all right for me to do that? You can tell me no."

That’s the other thing too. Every client I care for, I give them permission at every appointment to say no to me. "Hey, you can tell me no. You don’t even have to tell me why. You can just say no. I’m not going to be mad. I’m going to do whatever you want me to do." Because I need them to know they control their own care, and that’s a very trauma-focused approach.

We also have to be open-minded to the holistic therapies that exist. I mean, some people have exceptional outcomes with art therapy, mindfulness, yoga, all these things, aromatherapy. Man, if it helps you, I don’t care, we’ll do it. Like, bring in your lavender oils, and we can do that all day because if it helps you, then I’m here for it. And it hurts no one else, great, right? We’ll do it. And so those are where we need to be open-minded as providers that the client, if they really want to try acupuncture, great. Acupuncture can work great for people. And so we need to be open-minded that our ways, again, are not the only way.

PIERCE: I really liked when you were talking about your clinic having the entire team, like the whole team that someone’s going to need when they’re struggling with substance use disorder. But what about insurance? I’m just curious about insurance with that. Yeah.

SCHAEFER: Money, yeah, money’s tricky, right? And so the thing is, in my professional experiences, I do not have data on this, okay? So, just my own personal professional experiences, you can get insurances to pay, and I’m primarily working with state-funded Medicaid-type insurance, okay? You can get those insurances to pay for therapy, you can get them to pay for medical appointments, but they will not pay or pay very low numbers for peer recovery coaches. And often the case management part is very difficult to get covered.

But those parts are so important that you have to set up a model that understands that we’re going to lose money on the case managers, and we might break even on the therapists. But we’ve got to consider the pros and cons here, and really focus on, you know, is the goal to make as much money as possible or is the goal to break even? We’ve got to pay everybody, we’ve got to keep the lights on, right? But break even with the understanding that we’re not going to be able to bill for some of these services that are necessary.

Insurance keeps getting better and better at understanding that you’ve got to do more than just give somebody a pill. We know that the medications are important, but what I haven’t spoken to are the behavioral therapies, which are so important. Cognitive behavioral therapy, contingency management—those are all very important therapy methods. They make a huge impact.

I pulled some data from the Beck Institute, 2021, that shows cognitive behavioral therapy really reduces relapse rates. This data speaks to how cognitive behavioral therapy improves retention in care and helps people get better. But, you know, we also have 12-step programs that can have huge impacts for people. They’re not right for everybody. I get really nervous about programs that mandate that you do 12-step. What if you hate 12-step? What if you’ve done it three times and it’s not right for you? Well, then there might be something else that works for you.

So, if you only say you have to do 12-step, that works for you, but it might not work for them. I get really nervous about that. I get nervous about teams that are made up of only one kind of professional. For example, I’ll see a team that’s all peer recovery coaches. And I’m like, but where are the doctors? Where are the nurse practitioners? Where are the therapists? We need to all work together.

Because peers are unbelievable. A peer recovery coach, for those who don’t know, is an individual who has lived experience with substance use disorder, who is then trained to help people who are seeking recovery on their journey. They’re wonderful. They’re absolutely fantastic. I’ve worked with some of the most skilled peers in the industry, and they are a huge part of the team. But we need to be a team.

You shouldn’t be in a clinic that’s just doctors and nurse practitioners. You shouldn’t be with just peers. We need to be all working together. Or if we can’t be in the same clinic, we need to be overlapping.

Then, from a medical perspective, we get into all the different kinds of medications, and, you know, I can go into detail about those. Sometimes people start to kind of fuzz out on all the details of the medicines. It can get very boring for some people. But there are definitely lots of different medications to treat different substance use disorders as well that can have a big impact.

PIERCE: But those are used with other modalities of treatment.

SCHAEFER: They should be. Now, sometimes there are places that will treat... you'll get places that only use the medications for treatment and do nothing else. They give these medications, and that's a start. I always think of that as it's better than not getting any care at all. Patients who are getting, like for example, Suboxone, Buprenorphine, they're more likely to survive their substance use disorder if they have that medication.

But I always say if they want to thrive, not just survive, then we need other modalities to be part of this, not just the medications.

PIERCE: What I tend to see is you're seeing more and more of these methadone clinics that are kind of popping up just in random neighborhoods. And so they come every day, but without these other treatment modalities, are they looking at now, I'm no longer on my choice of drug or substance, but now I have a life spent going to the methadone clinic every day?

SCHAEFER: Yeah. And I hear that, but the thing with methadone is you know what dose you're getting. You know that you're going to predictably be getting it from someone who's not going to try to kill you. You know, you're not going to a drug dealer. You're not... insurance covers methadone. So you're not... where I live, at least. And that may be different from region to region, but where I live, they do. And I live in a pretty conservative state. So I think if they do here, they probably do just about everywhere. And you're not having to engage in dangerous activities. You're not using a substance regardless of harm and consequences at that point. So yes, you're physically dependent on the methadone. You will withdraw from it if you stop taking it. You will feel terrible, but you're not committing crimes to get it. You're not endangering your life to get it, hopefully. And most methadone clinics require some kind of therapy as part of their treatment modality. And so I see a lot of progress with methadone clinics and how they're being... I see people who find great sustainable recovery with methadone. It's, for some people, it's exactly the right medication for them. And we have to, as providers, treat that with a lot of respect because methadone takes a lot of commitment. You have to go every day. You can't miss a day. You have to do this for months before you're allowed to take home small amounts of take-home doses. And then, you're on that for... that can be done for a very long time. There are people who take advantage of the methadone system, absolutely. And you can become intoxicated on methadone if you take enough of it. It is a full agonist. You can definitely get intoxicated. But it can also be the treatment method that is perfect for people. And so when I hear the concept of replacing one drug with another, you know, she was taking heroin and now she's taking Suboxone, and she’s just replacing one drug with another, abstinence only is not the only way to find recovery. For some people, that’s the way. And I have a friend who... their grandma woke up one day, and she said, “Jesus told me to quit smoking cigarettes. I’m never smoking cigarettes again.” And she had smoked for 50 years. She quit that day. She never had another cigarette the rest of her life. That was it, right? Yeah.

PIERCE: Yeah, I have a patient that did that too. He had open heart surgery back when you could smoke in hospitals, and then the surgeon was like, “You need to quit smoking or you’re going to die,” and he set them down and never picked them up. Yeah, yeah.

SCHAEFER: Yeah, it was done. The end. And you know what? Great. That’s awesome. That’s not how that usually goes. Right? And so statistically, it’s pretty unlikely that abstinence only is going to match every person’s recovery. We are so complex. And abstinence only is not usually the safest way. Because if you have two or three weeks with no substances at all, and you relapse on opiates, you’ve lowered your tolerance so much that your overdose risk is through the roof. And that is why when people get out of incarceration, maybe they’ve been in jail for six months, they get out, they have not used any substances while incarcerated, they go right back to using a substance, that’s their highest risk of overdose is that first use moment.

PIERCE: Now, what are the key components, you think, of a successful substance use disorder treatment program? You listed a lot of... there’s a lot of options, but if we were to write together the key components, what would you say?

SCHAEFER: A passionate team who, even if they say the wrong thing, they say it with love. Because people get really nervous. Like, “I don’t want to say anything because I’m going to say the wrong thing.” It would be better to say it wrong and say to the client, “I don’t know if I said that right. Let me try to reword it.”

PIERCE: That’s not what I meant. Because they’re probably just as nervous as you are.

SCHAEFER: They are even more nervous because they’re terrified you’re calling the cops, you’re taking their kids, you’re putting them in jail, you’re going to frame them, you’re mean. I mean, being treated meanly, being treated as inhuman is some of the worst fears in seeking care. And so if you can at least be nice to people, that’s one of the key critical factors. Every person that client encounters should be nice to them. The front desk, the nurse that puts them in the room, the doctor that sees them, the therapy staff, everybody should be nice to them first. The concept of unconditional positive regard is so important. And that is simply, we believe that all people are doing the best they can. And that is just that optimistic outlook that changes people’s outcomes in the long term. Believing that they’re doing... you know what? She relapsed, but I’m not mad at her. I’m not going to punish her for it. The worst thing I could do is kick her out of my program. How’s she going to get better if I’ve kicked her out? Her chance of death just went through the roof if I get rid of her. And so we don’t just get rid of people for being imperfect. You say, “Okay, you messed up, but you came in here. That’s a good step. That shows that you are seeking help. Let’s figure this out.” And so that support, that protection, that... You need someone to help you learn how to build your resilience when you’re seeking recovery.

PIERCE: I was thinking coping skills. Like when you’re talking about the behavioral therapies especially, so cognitive behavioral therapy, and then you also bring in the trauma piece. It seems like we need to help them learn how to cope and to be stress-resistant. And a lot of people don’t think about that, but like the world is stressful, but family is stressful. Kids are stressful. Work is stressful. There is stress everywhere, positive stress and negative stress. And so we also need to teach them how to be resilient to stress.

SCHAEFER: And that resiliency is one of the big factors we talk about, is that your resiliency has to build and it takes time. Like, we talk about it being a fortress and you, like, started with just like a log cabin, and we’re standing around you with an army protecting you, right? And then you built a wall around your log cabin, so we only needed a couple soldiers to protect you. And then you just keep getting better until you’ve built a castle of resilience, so that on the day that you cannot believe that you just got a note from the teacher saying your kid needs a cloud costume by tomorrow, your boss changed your work hours, your car has a flat tire, and your significant other’s driving you crazy, and there’s no food in the fridge because somebody ate everything that was supposed to be for dinner. Like those moments, and you’re just like, “I am exhausted, I just worked 12 hours,” and you’re just having a bad day, you don’t let substance use disorder say to you, “Hey, you’ve been sober for five years. You can have just one little vacation from your life right now. Use a little bit of heroin. It’s no big deal. You can handle it now.” And it starts slowly in your mind telling you, “It’s okay. You can handle it now.” And you have to keep really diligently saying, “I’m not listening to that voice. I’m not doing what it said.” And that takes time to build those walls of resilience and more than just pills, more than just medication. I’m a big believer in the medications, sorry. I’m a big believer in the medications to treat substance use disorders. They work. The data supports that they work for most people, not everyone, but for most people, but not for everyone. And you still have to work on the root causes. You still have... you don’t always have to turn and face your trauma full head-on, but you have to work on the why. What is with my repetitive... my repetitive behaviors? What is my self-awareness? What are my triggers? I know that every time I go back to my hometown, I’m so triggered to use. So I’m not going back to my hometown anymore, or at least not for a long time. And you really have to examine those and develop positive thinking patterns.

PIERCE: Right, there's a lot of options for treatment plans. What are some of the things you look at to help you really develop an individualized treatment plan?

SCHAEFER: I have a rule that when I sit down with people, that first half hour, however long they want to talk, I mean, I let them go. That first appointment, they have me as a medical provider, so I'm a nurse practitioner. They have a full hour of my time where they can talk to me forever. And I'll let them talk about... I'll just guide the conversation. If we want to talk about what got you here, we'll talk about that. If all you want to talk about is where you want to be, then we'll talk about that. Like I let them really guide that.

I get to know them and talk to them about, "Hey, these are my recommendations, but you don't have to listen to me. You're allowed to tell me no. You're allowed to decline anything I recommend, but here's the thought process." And sometimes I'll say, "Hey, we've tried this your way three times, it didn't work. What if you tried one of mine? What if you just tried it? What would happen?" And they're like, by that point, we've had three or four appointments together and they're like, "Fine." It’s building that rapport and being that good listener to these clients, understanding that I’ve got to check my ego at the door. It’s not about me. It’s about them and what happens next for them and how I can support them.

PIERCE: Now, when you're working on this individualized treatment plan with the patient and you're having success with them, they're having success on their journey, how do you help them with maintaining that long-term recovery and really helping them prevent relapse? I know we're talking about coping skills and building resilience, but how do we do that?

SCHAEFER: Yeah, we see them as often and as long as they want to stay in our program. So we don’t make things like, "Okay, you’ve been with us for a year, we’re done with you. Like you did great, you graduated, and go on with your life." They can stay with us as long as they feel they’re benefiting from the services we offer. And, specifically, I’m in a new role now where we’re really working with clients in long-term housing situations with behavioral health services there to help them and residential situations, and the long-term outcomes... you know, 30 days in a residential program is not going to fix everything in your life. And so we're developing new programming with them where we're able to be part of their programming as long as they want to, as long as they can benefit from our services. But them knowing that they can always reach out to us and say, "I’m about to mess up or I did mess up. Help me." And we’re not going to say, "But also nurturing," like they know they're safe to come to us and say, "This happened." And we say, "That’s a bummer. Okay, let’s work forward. Let’s keep going. We got this."

PIERCE: Yeah. Non-judgmental nurturing and accountability. That’s what I hear in what you’re saying as far as helping them with maintaining their long-term recovery and preventing relapse. So, you know, somebody cares about them. Somebody’s waiting, you know, they’re at the door waiting for them if they need help, if they need assistance, or if they’re trying not to fall, you know, open that door again. Keep the door closed.

SCHAEFER: And one other trick we’ve developed... yeah, we developed this concept of our work cell phones. So we have work cell phones and personal cell phones. We give our clients our work cell phone numbers because sometimes just having to go through a phone tree is so complicated and unloving and just hard to deal with that the fact that they can text us makes a huge difference. And we almost never have clients take advantage of that, almost never. I mean, they really respect it and they handle it appropriately.

PIERCE: They want to get better. They want to stay better. Yeah. Yes. Now, what resources and support services are really available for patients and their families who are going through substance use disorder?

SCHAEFER: They do. Desperately. Yes. I have found that really the best place to find resources is to ask around. I mean, this touches so many aspects. And so I’ll often get a friend call me and say, "Hey, my daughter is struggling with this. What do I do?" And we’re just talking as friends, you know? And that reaching out to people you know that work within substance use disorder fields or care for those with substance use disorders makes big impacts. You can get on Google and Google all the support groups you want and you might find great support in that, but a lot of word-of-mouth conversation, you know, really makes a difference in the impacts for these clients and these patients.

PIERCE: Yes. So we’re coming to the end of our discussion, but what do you really want listeners to walk away with to really remember from this discussion?

SCHAEFER: Above all else, just be nice. Just be kind. You can always look at people and say, "I’m so glad you’re here. I don’t know exactly what I’m going to... the solution is right this second, but I’m going to figure it out for you." And that makes such a difference to people. You don’t have to have all the answers. You just have to be nice.

PIERCE: Absolutely, because we do not have all the answers and a lot of times we’re learning right along with them. Everybody is different. Everybody has different needs, but just knowing that you’re there and you’re right along with them in this journey is so helpful. Thank you so much, Brooke, for being willing to sit down for this discussion today.

SCHAEFER: Excellent. Thank you so much for having me. I appreciate it.

PIERCE: Absolutely. And thank you to our listeners for tuning in to this episode and our series on treating substance use disorder. We hope you now have a better understanding of substance use disorder, evidence-based treatment approaches, and some best practices for supporting those who are affected by this disorder. Unfortunately, there are so many who are not able to participate in treatment.

And it could be due to stigmas around substance use disorders, or even not enough facilities and providers to be able to provide the care that they so desperately need and usually want. We know that with effective treatment and support, it can significantly improve patient outcomes and quality of life. And you may be the lifeline someone needs to pursue treatment as they navigate substance use disorder. For more information on substance use disorders and many other topics, I also encourage you to explore many of the courses that we have available on EliteLearning.com to help you continue to grow in your careers and earn CEs.