Addiction Medicine Made Easy | Fighting back against addiction
Addiction is killing us. Over 100,000 Americans died of drug overdose in the last year, and over 100,000 Americans died from alcohol use in the last year. We need to include addiction medicine as a part of everyone's practice! We take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. We are trying to create an army of health care providers all over the world who want to fight back against addiction - and we hope you will join us.*This podcast was previously the Addiction in Emergency Medicine and Acute Care podcast*
Addiction Medicine Made Easy | Fighting back against addiction
How My Friend Paul Got Sober, Slipped Up, and Got Sober Again
Imagine battling substance addiction for decades, only to find your path to recovery through personal growth and self-awareness. In this heartfelt episode, I, Dr. Casey Grover, sit down with Paul Giovino, a Monterey resident who courageously shares his transformative journey from dependency to resilience. Paul's story is not just about overcoming addiction; it's about addressing the emotional roots of substance use and finding strength in building self-esteem. Together, we explore the significant hurdles he faced, from professional setbacks to health challenges, and the pivotal role of personal development activities in his recovery process.
As we navigate the complexities of opioid addiction treatment, we uncover the challenges posed by substances like fentanyl and the groundbreaking impact of treatments such as buprenorphine. Our conversation sheds light on the societal stigma surrounding treatments like methadone, which can often hinder recovery efforts. Through personal anecdotes, we discuss how individual differences in brain chemistry influence responses to opioids, and the ongoing struggle to overcome self-shame and societal misconceptions. It's a deep dive into the science and personal stories behind addiction, shedding light on how these factors play into the recovery journey.
Community support emerges as a key theme in our discussion, emphasizing how networks like Alcoholics Anonymous can be instrumental in maintaining sobriety. We highlight the importance of creating compassionate and stigma-free healthcare environments, and how education is crucial in transforming addiction treatment. By sharing Paul's inspirational story, we underscore the life-saving impact of early access to addiction care and the power of a supportive community in fostering resilience and self-awareness. Join us for an episode that reminds us of the profound truth: treating addiction saves lives.
To contact Dr. Grover: ammadeeasy@fastmail.com
Hello, my friends, welcome to the Addiction Medicine Made Easy podcast, where we take topics in addiction medicine and break them down into digestible nuggets and clinical pearls that you can use at the bedside. Dr Casey Grover here as your host once again. All right, everyone, I am so glad to have you back for another episode If this is your first episode. My name is Casey Grover and I am an addiction medicine doctor working on the Central Coast of California and, if you're one of my regulars, so glad to have you back. A little housekeeping before we start. Thank you to the Montage Health Foundation for their support of my quest to improve this podcast to produce fun and engaging education for healthcare providers on addiction, and if you're not a healthcare provider, I'm glad you joined us too. Thank you also to my new partner, the nonprofit Central Coast Overdose Prevention, for partnering with me on this podcast to help provide good education about addiction.
Speaker 1:Now I am really excited about today's episode. I was introduced to a gentleman in my community, paul, who has had a lifelong struggle with addiction and he has been successful in conquering his addiction, but, as you'll hear, he still does a lot of work every day to maintain his recovery. He recently retired from his work running a car dealership and now he's looking to give back and help people with addiction. So we met for coffee and we talked and we felt that there was a lot for all of us to learn from his story. So let's get started with my interview with Paul, all right. Well, I am so glad to have you join me today. Why don't you just start by telling us who you are and a little bit about your story?
Speaker 2:My name is Paul Giovino. I've been here in Monterey now for 20 years. I was the general manager of the BMW store in town and just retired after 40 years in the car business and 20 years at BMW. Congrats, thank you. Yeah, it feels good to be retired.
Speaker 1:So you were just telling me a little bit of how you got started with substances, particularly with alcohol. Right, tell me how substance you started.
Speaker 2:So it started with just going to parties and feeling really uncomfortable, low self-esteem.
Speaker 2:I just felt like everybody was better than me and as soon as I started having a couple of drinks, I was the life of the party and I called myself a party person for a long time, not recognizing that I was getting myself deeper and deeper into alcohol, and then cocaine, and then anything that was available, just to be at the party, to be part of the party and feel good, to be at the party, to be part of the party and feel good.
Speaker 2:And this went on for a long time until I started getting sick, losing jobs, and started to affect me in a very, very negative way and it was very difficult to seek help, to find the right type of help and examine the underlying issues as to why did I want to get so drunk that I could barely stand. So I tried doctors, I tried people who were supposedly experts in the field at that time, and this was back in the 80s and the 90s, so there was very little resources for it. But I believe that the underlying issue was the emotional issues that I was facing that were never addressed, and I still think that that I was facing that were never addressed and I still think that that's a problem with people with addiction.
Speaker 1:Do you feel like you've gotten to a good place emotionally now?
Speaker 2:Yeah, after 25 or 30 years of personal growth, I barely graduated high school. And after I got sober I had a choice I could go back to college and get a degree. And I decided college isn't going to give me what I need, it's not going to give me the self-esteem that I need. So I started doing personal growth groups weekends, classes, just learning the emotional side of things and it started to build my self-esteem and I realized I'm a pretty good guy, pretty smart guy. But it took years of work to get through that, to get to that place, and now I'm confident in my abilities and I feel good about myself. How old are you now? I'm 69.
Speaker 1:And when do you feel?
Speaker 2:like you actually got emotionally to a place where you are now. So I got sober when I was 33. And I would say it took me till about mid-40s before I really felt like I had control of my life. It took quite a while of going to classes, going to seminars, just learning about why I was doing what I was doing to destroy my life and how I could turn it around. It took a long time.
Speaker 1:What was the experience being sober in that early emotional recovery? What was that like versus now?
Speaker 2:So the first year was difficult, very difficult, because I was in debt, I was overweight, I was unhealthy, and it was a series of tackling one thing at a time and after a couple of years when I had things under control, I felt really good about myself. But now I was sober and what's next of learning about myself and becoming confident in my abilities to go to the next stage was to get a good job. When I was drinking, I would go through 10 jobs in a year. I'd just continually get fired. That was my pattern, and it was very difficult for me to change people's opinion of who I was. I was a drug addict alcoholic. In the community that's what I was known as, and when I got sober it took many years for people to finally recognize that I was serious about not being an alcoholic drug addict and being sober, which. Once that happened, then the ability to go to the next level became easier. People trusted me where prior they hadn't.
Speaker 1:So let me ask the question a little bit differently. So we had coffee a few weeks ago and you talked about even today. It's still a very mindful, thoughtful, deliberate practice that you do to stay sober. Oh, absolutely, what were cravings like when you were in that early recovery period, as opposed to now?
Speaker 2:I couldn't go into a bar in the early recovery period. It was too much temptation. I had to leave all my so-called friends. They were all drug addicts and alcoholics. So I found myself alone because I couldn't go back with them or I would be drinking again. And now that I have surrounded myself with a group of people who are not interested in that kind of lifestyle, it's much easier, but I still.
Speaker 2:I think I told you this I get up every morning and I look at the edge of the bed and the devil's sitting there and I say, not today, and it's a daily thing for me, but the cravings are not there like they were in the beginning. Right, and I relapsed after 10 years because I got involved with. I bought a motorcycle and a boat, which you know. You drink on the boat and you ride the motorcycle from bar to bar. And I started drinking again and within a very short period of time I was almost right back to where I was within eight months. I was drinking every day and staying up late at night and I had to instantly slow that down because I could see where it was going.
Speaker 1:Let's talk about that a little bit. So your first drink in 10 years what did that feel like?
Speaker 2:Lit me up. I was at a wedding. I was feeling really uncomfortable. It was the owner of the dealership I was working at, I didn't know anybody, and the lady comes by with a tray Would you like a glass of wine? And I drank the wine and the room lit up and I thought, oh, I really miss this. And I started slowly a couple of drinks every other night. And then I bought a motorcycle and hang out with these guys that were drinkers and I stayed away from it for a while. And then I bought a boat and every weekend the only thing you do on a boat in a slip is drink. And I started drinking and it just got out of hand. Do you feel?
Speaker 1:like you actually could see that relapse getting out of hand with that first drink, or you felt like you'd been sober long enough that you had it under control.
Speaker 2:For a couple of months I thought I had it under control and then I started recognizing some of the old patterns Like after a bottle of wine, where's the cocaine? And the old patterns started to come back and that's when I got scared. It didn't take long.
Speaker 1:What was the process of realizing? Uh-oh, things are not good again. To getting sober again.
Speaker 2:I started contacting people that I had known gotten sober and started talking to them and then I actually went to my doctor and I said I'd like to get some antabuse. And I started taking antabuse so that if I did drink I'd get violently ill. And it was difficult, but it helped me through that period of two or three months till I finally got used to being sober again and living my life sober, because when you're drinking you're living a different life than when you're sober. It's a completely different life. So the transition I needed something to stop the alcohol so that I can transition back into a responsible lifestyle.
Speaker 1:Was the Antabuse helpful? Yes, so it's interesting. So I almost never prescribe Antabuse because the data would suggest it doesn't work for most people. How did it help you?
Speaker 2:I was afraid to drink because the story's about how sick you get.
Speaker 1:Oh, it can put you in the hospital if you binge drink on it, yeah.
Speaker 2:I was told that even if you have a sip, I mean I would panic if somebody would tell me they made a cake and it had rum in it. I wouldn't even eat that. So it was fear that drove me to stop. What made you keep taking it every day? Because I didn't want to drink again. I didn't want to go back to that life and I didn't feel like at that point in my life I didn't feel like I had the ability to just say no. I needed a little bit of time to get back into the rhythm of living a sober life.
Speaker 1:It's interesting, the person I think of when I think of the ideal candidate for Antabuse is someone who's very motivated and you definitely fit that bill. How long were you on Antabuse for Four months and what was the transition like, coming off of it Coming?
Speaker 2:off the Antabuse. I didn't notice any transition at all.
Speaker 1:How did you deal with not wanting to drink?
Speaker 2:I just refused, I just said no. I mean, that's really all that it's about. You just have to say no. Was it like the?
Speaker 1:I guess let me ask the question differently. So in my mind I think of you're someone who's gotten sober. You've had a slip up. Was it relatively easy getting sober the?
Speaker 2:because I had gotten in with a group of people that I liked, but they also, their whole lives revolved around drinking and drugs. So again, I needed to separate myself from all the people that I had gotten to know very well. I had to sell the motorcycle and sell the boat and it was really difficult to go through that. Again, there were many times where I thought I can handle this, I can have just a few drinks. I really like riding the motorcycle but I'd have to ride the motorcycle by myself because everybody else it was bar to bar and it was pretty crazy what we would do.
Speaker 1:I was going to say motorcycles. As a former ER doctor, scare me, because you're so vulnerable in the case of accident and mixing alcohol.
Speaker 2:I mean Bloody Marys at eight o'clock in the morning and Jack Daniels shots before you leave the bar, and I watched some pretty nasty accidents from people that were drinking. That makes sense, so that scared me also.
Speaker 1:So you had your second round with alcohol, and then you got sober again. Yes, what was the new life that you built around?
Speaker 2:with alcohol and then you got sober again. Yes, what was the new life that you built? I concentrated on work, serious work in car dealerships, became really good at managing car dealerships, became general manager of dealerships and had a very successful career Up until I had the surgery for the sleep apnea and the doctor gave me a bottle of Roxycontin to drink and 200 or 120 Oxycontin pills and I drank the Roxycontin and took a couple of pills and I was off to the races again. It was like wow, and I was at the age where I've been active my whole life.
Speaker 2:I had aches and pains, I had back surgery, one pill and it's like you're brand new, nothing hurts, everything's good and I didn't see the harm in it with the pills. At that time in the late nineties, I really didn't see how bad it could get. But after a year I was taking 120, 130 milligrams of Oxycontin a day. I'd go to the doctor and get 250 to 300 pills at a time and go through 10 or 12 a day and I could function. That's the problem with those when you get the prescription, ones can function because it lights, lit me up did anyone ever talk to you about your alcohol history when they gave you the prescription?
Speaker 1:not a quote nothing.
Speaker 2:Yeah, it was like it is a painful operation.
Speaker 1:Let me know how many drugs you need did you have any self-awareness that this makes me feel the way alcohol does?
Speaker 2:Yeah, but I denied it at first. It was doctor prescribed, it was okay, interesting, yeah, and I denied that for quite a while until my wife started commenting that you know what's going on with you. What is this? I see you taking pills. Your moods are different. What's happening?
Speaker 1:How are you able to justify a medical diagnosis to stay on opioids that long? Did you just say your back hurt or what was it that you were getting treated for?
Speaker 2:There were doctors around here that all you had to do is walk in and say, ouch.
Speaker 1:Yeah, yeah, yeah, yeah, I can probably name some of them.
Speaker 2:I'm sure you can. Yeah, yeah, they're just sleazy, it's your profession. Just sleazy, it's your profession. I don't mean to downgrade your profession, but I could walk in and say, in fact, at one point this one doctor said you're taking 10 or 12 a day. Let me just get you on morphine. Let me just you know we can just give you morphine. It's more powerful. I mean, I could have with this particular doctor. I could have killed myself easily if I didn't regulate myself. But it's like Russian roulette with the OxyContin you don't know when you take too much. And you know. I started thinking when I got to five or six 10 milligram pills at one time. Maybe one of these times I'm not going to wake up. So it got scary because at first it's five hours of relief and then after that it's 20 minutes. It doesn't matter how many you take, you can't get that high again. So you're just chasing. Actually you're chasing the withdrawal. You're trying to stay, not withdrawn, rather than trying to get high.
Speaker 1:Did you get any withdrawal when you were coming off of alcohol?
Speaker 2:Not really. I was young enough where I had some uncomfortableness and it was a little difficulty sleeping, but I got right into running, I got right into exercising, I started eating right. I had gained 30 or 40 pounds and I had always been active before that. So I got into a very strict exercise program and that helped me through that. It was very difficult trying to come off the Oxycontin yes, like really, really difficult, and I think that might be one of the reasons why people are afraid to. They're afraid to stop because it's so painful and to find the buprenorphine is like a needle in a haystack and it's a miracle drug. It can prevent people from not wanting to stop. It's what saved me.
Speaker 1:What we struggle with and I was actually just seeing a patient before we're talking now the problem right now we have is that fentanyl has made it quite a bit harder to start buprenorphine, and here's what's interesting. So my addiction practice is affiliated with a pain medicine practice and the pain medicine patients talk much less about withdrawal than the opioid addiction patients and there's definitely a fear of withdrawal because it's very unpleasant and one of definitely a fear of withdrawal because it's very unpleasant and one of the early symptoms of withdrawal is anxiety or restlessness or irritability. And what's hard is right now, if somebody comes to me and they're on legitimate heroin or legitimate oxycodone, it's a relatively short period of time to transition from that to buprenorphine. It's like 12, 18 hours. You deal with it.
Speaker 1:We'll give you some clonidine, we'll make you more comfortable, but fentanyl it just builds up in the fatty tissue and people will test positive for more than a week after they've been on it and so it's almost like it creates like this giant depot of fentanyl in the body and they go to take the buprenorphine and it's like taking it too soon all the time and they're getting precipitated withdrawal. Wow. So it's frustrating. People will come to me on heroin and I, number one, don't believe it's heroin because it's gone. We usually do run a drug test. Most of them are positive for fentanyl. And then it's this difficult challenge of waiting three days to start the buprenorphine and then, once we get them on the buprenorphine, they're like to start the buprenorphine and then, once we get them on the buprenorphine, they're like okay, it was worth it.
Speaker 2:But yeah, buprenorphine is my number one agent in my practice. Go ahead, well, I'm surprised so the fentanyl, you have to wait.
Speaker 1:They go through withdrawal for three days prior. There's a lot of controversy in addiction medicine around this right now, so this three-day number is largely what we've come up with locally. The other addiction doctors around here Dr Lee Goldman, dr Reb Close, dr Christina Zaro these are my colleagues and we'll actually put our heads together on like a Zoom call and meet and talk about it. But essentially what we're recommending to people is, if you're going to stop using opioids on a Monday, you probably need to wait till about Thursday to start the buprenorphine, and then we do our best to keep them comfortable. So it's a non-addictive muscle relaxant for that tightness, muscle spasm, restlessness. It's a non-addictive anxiety med for the anxiety. It's a non-addictive sleep med for the insomnia. Getting on buprenorphine is much harder now than it was when people were using either heroin or prescription opioids.
Speaker 2:Yeah, because with the opioids, you stop the opioids and you take the buprenorphine and 12 hours later you're normal. Yeah, yeah, it's a very easy transition.
Speaker 1:In the era of fentanyl it's quite a bit more challenging, and we're seeing some people choose methadone instead. Wow, and methadone's a big lift. Right, you got to go every day. For some people it's great, they love it, they see the drug and alcohol counselor, but for others, they're so tied to it, they feel like they can't go anywhere or do anything, and getting to work is hard too.
Speaker 2:And you had talked about stigma. Methadone has a terrible stigma. It does you tell people you're on methadone and right away they think you're a practicing drug addict.
Speaker 1:Well, it's interesting, we were actually right next to the methadone clinic. This weekend. We were in Salinas doing an event and I took my daughter and her friend to get frozen yogurt, which is right next to the methadone clinic in Salinas and I asked my daughter, like if you were a new drug dealer in town, where would you go? We talk about drug policy all the time. She actually taught her classmates this morning how to use Narcan at her school. Oh wow, she's a good kid.
Speaker 1:But I said, if you were a new drug dealer in town, where would you go? And she looks around and she was like, do you think the methadone clinic would be a good target? And I was like ding, ding, ding. But yeah, so let's talk about stigma, because that's a great topic and you thank you so much came to help me educate my colleagues about stigma and know and my listeners can't hear right now, but Paul presents very well, well-dressed, well-spoken, you would never know and I did a lecture for some doctors on stigma and I had Paul in the audience as my secret plant and we were talking about stigma and everybody saw this nicely dressed gentleman and then Paul stood up and told some of his story. How did that experience talking about stigma feel for you?
Speaker 2:At first it was a little uncomfortable because I could feel a little bit of stigma. From when I mentioned that I was sober and I had been an alcoholic, there was a little bit of shift in the room but after I started speaking I felt a lot of empathy, I felt a connection from the people around there. There was a lot of heads nodding and there was a lot of people, you know, really looking and listening. So it felt really good for me to be able to put that out there, hoping that it makes a difference for the people that were in the room, because when you were speaking, some of it seemed like it was brand new to them, like they had no idea that this was going on, which really surprised me.
Speaker 1:It's a topic that we've worked on. But there's not a lot out there. If you go to the National Library of Medicine and search for stigma in medicine, there's plenty of articles on it. But we started trying to educate here at our hospital on stigma and we went to a national speaker bureau and said we need a topic. Excuse me, we need someone to speak on the topic of stigma. And they were like we don't have anyone. They were like Grover, you do it. I was like, okay, I mean, I learned a lot and, as I shared when I was speaking, you know I have some stigmatizing conditions myself. I used to engage in self-harm, I had depression, I'm in recovery from an eating disorder and that's really where we break down. Stigma is if we present in one way, people make up their minds about us and then we reveal later that we've had this condition. They think, oh, paul's such a nice guy, I never would have guessed. And then the next person it's hey, congrats on being in recovery.
Speaker 2:Yeah, yeah, and some of the statistics that you showed about what stigma does in the medical profession to patients was pretty eye-opening about the percentage of how people, how they end up after seeing medical professionals the good and the bad. I was really shocked at those high numbers.
Speaker 1:Yeah, what's it been like for you as a patient trying to seek medical care after you got sober and felt like you had gotten some of the stuff behind you? I mean so, if you have a new doctor's appointment next week, is that something you bring up or talk about?
Speaker 2:Not unless I have to. But when I first got here to this area, they would pull up my chart and see all of the OxyContin, because it was all there and there was an instant disconnection with the doctor and it was a very suspicious, uncomfortable experience. For whatever I had gone there for, I just felt like I lost this person. I'm not really able to connect with this doctor. For whatever I was there for, whether it was for sore throat or whatever, I think they would think that I'm just there. They were waiting for me to say I'm in pain, Just waiting for the word.
Speaker 1:Yeah, gosh. I mean, did you feel like you were able to repair some of those relationships?
Speaker 2:I have. I've developed some really good relationships, but it took some time. Rarely did I walk into a doctor's office and feel comfortable. Most of the doctors that I see now are doctors that I've met outside of the medical field, at CrossFit and other places and then I start seeing them because they know me as who I am today. There's no stigma involved. But to go to a new doctor in fact there's a doctor that you know that Kathy, a friend of mine, referred me to and she hadn't known me and it just was very uncomfortable when somehow she looked at the chart and saw some old stuff on there and I got a notice about two months after that that I was being shifted to another doctor and you know might have been a legitimate reason she was cutting back on her practice, but it just felt weird.
Speaker 1:Do you have to be careful in how you speak in your medical appointments? I'm assuming yes, but I guess the answer is how do you approach that?
Speaker 2:Well, I don't ask for, I don't volunteer that I'm in pain and need something for it. I stay away from that because as soon as I open that door then there's a chance that the stigma comes up. But it's been so long I've been sober long enough where I really don't think about it anymore. I don't feel like I have to be careful and I know most of the doctors that I see my cardiologist and certain doctors that I go see for my heart condition that I know them well enough that they don't know me as the other person.
Speaker 1:Interesting, yeah, it's funny. So the art that is the icon, the little picture that when you look at my podcast, the little picture that comes up is a painting by a guy who talked about living with addiction and I'll show it to you here on my phone while we're talking. And it was interesting because when I met him for the first time he was in the ER and I was his doctor and he literally said and one of the coincidences, my name is Paul no opioids. And that was his opening and at the time I didn't know anything about addiction and I said hey, if I buy you coffee, will you tell me some of your life story. So my lovely bride is the other addiction doctor in the practice.
Speaker 1:We both went to med school at UCLA. She did residency at UCLA, I did residency at Stanford, great institutions I think I may have told you this during the stigma lecture Between us 15 years of medical education, one hour of education on addiction, and I learned from Paul and this is his painting, I showed it to my daughter's school today when I was educating about addiction that addiction is a horrible disease that can happen to really nice people. And it was funny because that's how he introduced himself to me. I walked in. I'm like, hey, I'm Dr Grove. And he's like I'm Paul, no opioids. I was like, okay, we're going to be friends.
Speaker 1:I'm curious how that resonates with you.
Speaker 2:That's a great opening because it gets it right out there. And when I had my knees done, it came around to that when the doctor asked I'm going to prescribe this, this and this? And I said, well, I prefer that you don't prescribe opioids. And he said, well, it's going to be painful. I said, well, I'll work through it and that's as far as the conversation went. I'll work through it and that's as far as the conversation went. But I like that because you could eliminate all of the crap that might be hanging in the room and just get it out. It's great.
Speaker 1:Yeah, and we became friends. Unfortunately we lost him to an overdose, but I learned so much about addiction and life from him. I think back to another patient who's a young man, who's in recovery and he'd gotten off of opioids and we know what a beast that is and he got appendicitis and the surgeon just gave him morphine and I never followed up, unfortunately, but I remember him almost like biting his nails of just like what am I going to do? And we've really tried here to come up with alternatives for pain management. You know, iv lidocaine, iv anti-inflammatories, iv acetaminophen, topical meds, physical therapy there's a lot of great options. So if you need surgery in the future, there are some options. And then when people are on buprenorphine, there's a particular way we approach pain management as well. I've got a couple of folks that need surgery and I told them like when you need surgery, I need to be involved.
Speaker 2:Well, casey, I think you're one of the few doctors that knows that, because I live in fear of having to have surgery or, god forbid, I get in an accident and I need painkillers. Because most the doctors that I've dealt with, through the knee surgery and the back surgery, had no clue when I told them how does buprenorphine affect if I take the OxyContin? How does it? Well, we don't know much about that. Go talk to the doctor that prescribed it. You talk to the doctor that prescribed it. They don't know. That's when I had to call a colleague of yours and say, hey, help me here, I'm about to have a knee surgery. They're telling me it's extremely painful, but no one knows what's going to happen if I take OxyContin with the buprenorphine. You guys are the experts. I don't know what's going to happen.
Speaker 1:So if you had asked me this question five years ago, I would have given you the I don't know face. So I wrote the hospital's policy for surgery. When someone's on buprenorphine and yeah, it's a great topic I actually think we probably should use buprenorphine more as a first-line agent for pain for people, not on opioids, because it can be effective and it doesn't have that same level of euphoria it doesn't have any euphoria, basically euphoria.
Speaker 1:It doesn't have any euphoria basically. So yeah, essentially the answer is that we divide the surgeries into mild, moderate and severe in terms of the anticipated pain. Mild you're going to continue taking your buprenorphine and then maximize other agents that act differently, so acetaminophen, ibuprofen, gabapentin, topical lidocaine patches, whatever it's going to be. If it's a more moderate surgery, there's kind of two approaches. One is we increase the dose of buprenorphine and give it more frequently. So when we use it to keep people out of withdrawal or treat opiate addiction, we dose it one, two or three times a day. For pain we want to dose it four or even more times a day. It's a short-acting duration for pain relief. And so let's say somebody is on one suboxone strip a day at eight milligrams. I might put them up to eight milligrams four times a day around pain and then they just self-titrate and they might end up on 16 milligrams a day after surgery. And that's okay, they're still sober.
Speaker 1:The other thing that's interesting is once buprenorphine binds to the opiate receptors in your brain, nothing will take it out. It has the tightest binding connection to the opiate receptors in the brain. So if you take a lot of buprenorphine and you take, let's say OxyContin. The OxyContin just sits there in your bloodstream and has nowhere to bind. So, depending on your dose of buprenorphine, you can actually take oxycodone on top of it. In other words, the buprenorphine is your foundation. Let's say it occupies 90% of the opiate binding sites in your brain but there's still 10% left. The oxycodone can be effective there, just like a little bit of breakthrough pain relief. And then the last is something where we think it's going to be really, really painful. We might just wean somebody off of the buprenorphine, put them on a regular opioid for a few days and then plan to transition after surgery and really hope it's not too triggering.
Speaker 2:Well, I wish I had been given those options.
Speaker 1:Well, if you need surgery, let me know, I'll talk you through it.
Speaker 2:No, I mean, like I said, I live in fear that it might come a point in my life where I might need to take pain medication and I wouldn't know where to start other than the explanation you just gave me, which makes total sense.
Speaker 1:Yeah, so it's interesting. You know, there was an original thought around pain and addiction that if you were a pain patient you couldn't get addicted because you're treating the pain and we obviously and I see the look on your face that was the original hypothesis back in the day when OxyContin was getting monitored, when they were trying to sell it.
Speaker 1:Well, I was being nice. I guess I shouldn't be nice as the Sackler family. Shame on them. But yes, that was the original wisdom, was that? Well, if you're in pain, the opioids aren't going to be addictive. I'll share an interesting anecdote to see what you think about this.
Speaker 1:So when I was 18 years old opioids that was a time when the people were prescribing them heavily. I turned 18 in 2001. And so I got a really bad case of sore throat. So they gave me a shot of penicillin and sent me home with Vicodin, which is an opioid hydrocodone For a sore throat, for a strep throat. So I did nothing but drink water, sleep and take Vicodin for three days, and I don't think I've ever shared this on the podcast. But on the fourth day I was feeling much better and I took a Vicodin and I just thought this is the coolest, funnest thing I have ever done. I can never touch this stuff again.
Speaker 1:I don't know how I had that wisdom at 18, but I had shoulder surgery four years ago and I was completely miserable. My surgeon gave me 60 Norco that's hydrocodone and I asked the pharmacist like no, no, no, no, please, only give me 10. I only took maybe eight and I have to tell you, when I was completely miserable, it was not euphoric at all, given your lived experience. How does that resonate with you when I'm in pain? Is it euphoric at all, given your lived experience? How?
Speaker 2:does that resonate with you when I'm in pain? Is it euphoric?
Speaker 1:Yeah, yeah, it is, yeah, so you feel the pain relief and the euphoria, yeah.
Speaker 2:For me I do, and that's how it started. I was in pain when I had the apnea surgery. They break your nose. I mean, that's a painful surgery and that was my first time ever taking the pills and I just noticed I felt fine through the whole thing. I'd lay on the couch and my nose was bleeding and I'd be you know, I'd have a broken nose, my tongue would be swollen and it was like life is great.
Speaker 1:Oh, that's so interesting. I think what this really speaks to is that each of us has a different relationship with the substance based on how our brain chemistry works, has a different relationship with the substance based on how our brain chemistry works. I mean, I've been doing a lot of education, trying to help people with addiction realize that some of what their life experience is wasn't their fault. And I'll give you an example. One of my dear friends just had surgery and I get a text message about a week after surgery oxycodone is the dumbest drug ever. I'm tired, I'm stupid and I can't poop. That particular person's response to oxycodone is the dumbest drug ever. I'm tired.
Speaker 2:I'm stupid and I can't poop. That particular person's response to oxycodone is fundamentally different than yours. My brother's is the same way. Interesting In the family In the family Hates them, Can't take them Constipated. He had his knee done a week after I did and he called me and he said everything about this is fine except for these damn pills.
Speaker 1:I can't take them, I hate them, and yet when I take them, it lights me up, yeah, I think. A reason I bring that up, though, is that obviously we talked about stigma. There's so much self-stigma and self-shame around opioids, and for someone like yourself to realize that your brain is wired a particular way, you might like Mercedes and I might like, or I say sorry, you like BMW, you like BMW, I like Ford. I mean, that's just our inherent preferences. Your brain responds in that way to opioids. It's almost like there is a component of some of the things that happen to you being under your control, but how your brain responds to opioids is likely not.
Speaker 2:Isn't it similar to alcohol? Absolutely Same thing.
Speaker 1:Yeah, some people drink alcohol and they don't really have much of a pleasure response they're like meh.
Speaker 2:My wife drinks a glass of wine just about every night, and that's it one glass. And I still, to this day after 20 years, can't imagine how she does it. I go through three bottles in a night.
Speaker 1:So funny you mentioned that. So my vice was food. So I used to binge eat, so I would consume 15 donuts in a single sitting. I still, to this day, can't eat them. Wow, and my roommate at the time, one of the most positive influences in my life, just a wonderful human. He was my college roommate third and fourth year. He's the only person on the planet I've ever met that can open a Reese's peanut butter cup package and only eat one. And I would see in our fridge I have all these half-eaten Reese's peanut butter cup packages and I was like, how do you do it? I can never have just one. One turns into like 10. Same thing.
Speaker 2:I have a desire for chocolate and I don't know if that's related to the alcohol, to the sugar, but if my wife will buy a chocolate bar and put it in the drawer, she'll have one little chunk. I'll eat the whole thing. Oh, you're like me, yeah, or I'm like you, yeah, so I don't know if that. I've heard that people who have had alcohol issues crave sugar. I don't know how true that is, so I've heard this people who have had alcohol issues crave sugar.
Speaker 1:I don't know how true that is, so I've heard this in the recovery world, but I haven't found this in the scientific literature. They call it enhanced dopamine receptors. Dopamine is the pleasure chemical that makes all this stuff feel good. Dopamine is what makes alcohol pleasurable, cheeseburgers pleasurable sex. Methamphetamine, cocaine it's all about the dopamine. Pleasurable cheeseburgers, pleasurable sex, methamphetamine, cocaine it's all about the dopamine.
Speaker 1:And there's an idea that some people get more dopamine from life than the average person, and I've looked it up on the National Library of Medicine. I've never really found anything on it, but conceptually it makes sense. Right, when you enjoy something pleasurable, your brain starts firing out that pleasure chemical, dopamine, and you're like this sounds great, I'll take two. So there's probably some signal there. Interestingly, we found that with both humans and rats there's a link between alcohol addiction and enjoying fitness. Oh wow, when they train mice to like alcohol, they find that they run more compared to non-alcohol liking mice. And in humans there's a link between enjoying alcohol and fitness as well. I haven't really dug into it all the way yet, but again, fitness gives us dopamine, alcohol gives us dopamine. There's probably a connection there.
Speaker 2:Yeah, yeah, interesting, interesting stuff.
Speaker 1:So, as you transition into your next phase of life in retirement, what's on your to-do list?
Speaker 2:As I've mentioned to you, I'd like to help people who have and have gone through the same issues that I've gone through, to help especially teenagers, young people that have their whole lives ahead of them and you can see that they're starting down the wrong path. I don't know much about the current drug situation with fentanyl and I'd like to learn more about it, because most of my when I was drinking and doing drugs, it was cocaine and you knew what you were getting. Even though you were getting it off the street, it wasn't as dangerous as it is today. So I would like to be a part of some kind of group or organization or volunteer group or even, at some point, council. That's the direction that I'm going.
Speaker 1:Did you ever mentor anyone when you were sober that was not doing well?
Speaker 2:Yes, I went to AA fairly consistently for a couple of years and I mentored some people and I've also mentored some. When I was in a Wednesday group, we had a group of eight of us that would meet every Wednesday and when a new person came in I would mentor them and spend time with them and meet them for coffee and try and keep them on track and I get a lot of satisfaction out of that, seeing people go to the next level, and there were certainly some that dropped off, but it's a great feeling to help someone through that, Because I know how bad it can get and it gets bad.
Speaker 1:So the good news is that's dopamine that feeling good human connection, that same chemical that took you down a bad path, can help you be on a good path. And if you think about dopamine, it can help you be on a good path. And if you think about dopamine, it's basically it's a survival hormone. It's to make the things that fundamentally help us survive feel good Human connection, sex and food. And so what I think about in recovery is building the team right. The individual has to build their skills, understanding cravings, understanding triggers.
Speaker 1:But if you've got a good team and there's people like we talked about, you've got folks that drink, that they're your friends you're more likely to go back to drinking. You find a strong, sober community. You're more likely to stay sober. And the best way I can describe how we do things in our clinic is you come see the doctor, we talk about the medical stuff and then you talk to someone in recovery recovery and we want to make it enjoyable, pleasurable, warm, welcoming respect. I mean I joke that one of my best treatments as a doctor for addiction is to give someone a hug. Yeah, right, that positive human connection, sure. So I think that really fits in with what you're thinking about yes, absolutely, as an athlete. Do you feel like there's anything you can do around helping young people with sports or in terms of working on sobriety?
Speaker 1:I hadn't considered that but I'm sure there is. I mean, you think about the structure of the team. So we started this and you and I, or you, came to the gym to check out what we're doing. Yeah, I mean, exercise is such an important part of recovery and just finding something that you can get rid of negative energy and feel good, and exercises releases dopamine.
Speaker 2:I've often thought of if I had the ability to start a group that meets weekly, that has 15 or 20 minutes of exercise and then 15 or 20 minutes of just chatting and having somebody facilitate it with people who are trying to get through, because the exercise, as you said, is really good for people and the group, the camaraderie in the group is huge, especially with people who are going through the same thing and then to be able to talk about it. I think it's important for people who are struggling with it to talk about what they're struggling with, because people in in the, in your world, really don't ask those questions like what are you struggling with?
Speaker 1:you know they they just write another prescription for something half the time from what we talked about today and I know you've taken some notes how much of what you thought through preparing for this and what we've talked about today.
Speaker 2:How much of that was the first time you've processed it in your life it's the first time I thought about it to this degree to really start from March of 1989 and take it all the way through. I've done a lot of working on this, so I've talked a lot about it, but in segments I've never actually, this is the first time in my life I've actually wrote down the whole sequence and it's been cleansing, so to speak. Yeah, it's like step four, right, yeah, and it also I mean to speak, yeah it's like step four right, fearless moral inventory yeah and it also I mean, I look at what I've been through and I think, god, I'm a pretty strong person through this.
Speaker 1:So I'm curious as to how this resonates with you. So we talked about stigma, we talked about judgment and I try to avoid judgmental terms like it's a person with alcohol addiction, or a person with addiction rather than alcoholic or addict. But I was at a Narcan training about two years ago and a woman took the microphone and this is not her name but she said you know, I'm Jill and I'm an addict and I'm so proud of that Because what I went through and the person I am today I am stronger than I ever could have been and I was really impressed by that. And if Jill wants to call herself an addict and that is the right meaning, then great. I'm curious as to how that resonates with you and what you think about it.
Speaker 2:I wouldn't have been able to live, I wouldn't be living the great life I'm living today without going through that. It's hard to describe, but there's a feeling that I've been through, I've been to hell and back, so to speak, and here I am and I'm successful, I feel good, I'm healthy and I've dealt with some really horrible things and have an awareness about them that hopefully I can help other people. So it definitely builds character. Yeah, no question.
Speaker 1:How do you refer to yourself in terms of your history? Do you think of it as a part of you or do you use any of those identities like alcoholic or addict?
Speaker 2:I consider myself an alcoholic addict. Okay.
Speaker 1:Are those terms helpful for you?
Speaker 2:Yeah, I don't think much about it anymore. Okay, I just yeah, I really don't think that much about it. I just I live my life and I just watch. I'm careful for triggers and there are very few triggers left because I've been through so many of them. The only one big trigger that always comes up is when we go to a really nice restaurant for dinner and they open up that beautiful bottle of wine and put a little bit in the glass and you could just smell it. That's when I'm like, oh man, I miss this.
Speaker 1:Wow, yeah, Gosh. All those years later, still it's amazing how strong those brain pathways are. So we're about towards the end of our time we've set aside together. I would ask if you could tell any of the healthcare providers that listen one thing that you'd like them to know about addiction. I think that'd be helpful in terms of how we can end this interview.
Speaker 2:Well, I think addiction has underlying reasons for it, emotional reasons, and I think that there needs to be a relationship established, there needs to be trust and there needs to be a pathway. The addict needs to see that there's a way out. And the only way for the addict to see a way out is for someone to explain to them what's going on with them, why it's happening, and it takes some work on the provider's part to get to that. It's not just a 20-minute, you know, visit to the doctor, so it takes a little bit of time. It takes a little bit of work.
Speaker 1:In your experience, how educated were the doctors that took care of you about addiction? They weren't.
Speaker 2:Nothing against them. They just weren't educated in that field. They were. It was. There was a look like a deer in the headlights.
Speaker 1:It's part of the reason why I do this podcast, yeah, yeah, I mean my goal is really to help healthcare providers have an enjoyable, simple way to learn about addiction, whether it's going into the National Library of Medicine, reviewing scientific studies or hearing people's lived stories. Both have their place in education for us. Because I just have to say, as we wrap up, I think about your story and I think about the struggles and I wonder if you'd had better access to addiction care earlier on, if your life arc might have been a little bit different. And I encourage people out there listening to continue to educate themselves about addiction and I mean I always tell my patients when they come in the office. I was like I'm so glad to see you, I'm so glad you're here and I think we're hopefully making some positive changes around addiction.
Speaker 2:And that's huge to say. Let them know that you are really happy to see them, as opposed to what you sometimes get, which is the opposite, yeah.
Speaker 1:Well, I appreciate your time. This has been very, very informative. Thank you. It's great to be here. Absolutely, and that is the end of this episode. I had one big takeaway from this episode. Addiction is a horrible disease that can happen to anyone, and many of my patients, just like Paul, are some of the nicest people. I've really enjoyed getting to know Paul. He's a great person and you obviously heard how much he has struggled. Hopefully, paul is going to be joining our team to help us with some peer support, given his lived experience. I am really grateful to him for being willing to share his story, as he reminded us, as healthcare providers, that we need to create warm, welcoming and stigma-free environments for our patients. And with that, thank you for listening and thank you for what you do, and don't forget treating addiction saves lives.