Addiction Medicine Made Easy | Fighting back against addiction

Lessons Learned From the Front Lines of Addiction Medicine

• Casey Grover, MD, FACEP, FASAM

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This episode provides a deep dive into the complexities of addiction medicine learned from seeing patients in my practice. Through real patient cases, I highlight the importance of tailored approaches to addiction that consider both the physiological and psychological aspects of recovery.

We discuss
• Insights into demographics of substance use in a rural setting 
• The effectiveness of dual medication therapies for alcohol use disorder 
• The link between trauma and substance use disorders 
• Emerging concerns surrounding kratom as a public health issue 
• The significance of managing co-occurring ADHD in addiction treatment

To contact Dr. Grover: ammadeeasy@fastmail.com

Speaker 1:

Welcome to the Addiction Medicine Made Easy podcast. Hey there, I'm Dr Casey Grover, an addiction medicine doctor based on California's Central Coast. For 14 years I worked in the emergency department seeing countless patients struggling with addiction. Now I'm on the other side of the fight, helping people rebuild their lives when drugs and alcohol take control. Thanks for tuning in. Let's get started.

Speaker 1:

Today's episode will be on my experience practicing addiction medicine in a rural area near me. My primary practice is in Monterey, which is on the central coast of California. The county to the east of us is San Benito, and I drive there two days a month to see patients. It's a fairly rural area and the county is much smaller than where I practice in Monterey. I was asked to present on what sort of cases I am seeing there, so I prepared a lecture that shared my overall experience and I highlighted three cases that I thought had great learning points around how to treat addiction. Let's dig in All right. Well, I'm happy to get started.

Speaker 1:

My name is Casey Grover, I am an addiction medicine doctor and I come two days a month to see patients in person, and then I do a lot of follow-ups via telemedicine as well. So I'm going to share what I've been seeing in the last seven, eight months. Hi everyone. So I started driving over there in May of 2024, and I come out almost every month the first Monday of the month and the second Friday of every month and I'm there for about four hours and I see whoever I can. Sometimes I see folks once or twice and they don't follow up. Sometimes I see them every month. I actually looked in our electronic health record and here's about what I'm seeing, our electronic health record and here's about what I'm seeing. So I basically just looked at who I am seeing, what their drug of choice is, and some folks can't really name a drug of choice, so I classified them as polysubstance use. So it's about 50-50 men and women, about 40% alcohol. Less opioids than I expected only 23%. Less stimulants than I expected only 13%. Maybe that's because there aren't a lot of medication options for stimulants 8% cannabis, a very small number of benzos and kratom and if you're not too familiar with kratom, I'm going to talk about it in just a little bit. And then about 13% said I really can't pick a substance I use more than one. And about 13% said I really can't pick a substance I use more than one. So I'm going to go through a couple of cases that really highlight the work that I do and I can share some of the things that I've learned from seeing patients. And I just want to clarify before I go any further.

Speaker 1:

I am board certified in addiction medicine, but I didn't do a fellowship, so my first life was as an ER doc. I spent 14 years working in emergency departments and I decided I wanted to practice addiction medicine. So I started learning about it on my own and getting some clinical opportunities, and the way it works right now is we have so few addiction medicine doctors that if you can show that you're competent and actively practicing addiction medicine for enough time, they'll grant you the ability to sit for the board exam, which is what I did. So my approach to addiction medicine may be a little different than what folks are used to if they come from more of a formal training setting. I've really learned everything from my patients, so here we're going to go through the first case here.

Speaker 1:

So this is one of my patients. He's about 50 and I see him for alcohol use disorder. I've been seeing him for probably about six months and my first visit with him he'd had alcohol the night before and he was mostly a binge drinker and he described as using alcohol to manage negative emotions. So at the time I didn't have a great sense of how to really be more thoughtful about medications for alcohol use disorder, so I went with my usual go-to, which was naltrexone. Naltrexone, again, is an opioid blocker. It works by reducing the pleasure of alcohol and therefore the pleasure of anticipating alcohol, so it works to reduce cravings alcohol. So it works to reduce cravings. He actually couldn't get it because there was a shortage at the time and he continued to drink. And when he came for his next visit and I was talking to him, I'd had some recent luck with combining naltrexone and topamax and he really wanted to get sober. So I put him on naltrexone and topamax. Topamax, the generic name is tapiramate. It's a medication for seizures and migraines that works for alcohol cravings, and I put them on 50 milligrams each a day and he has had a profound response to the combination of naltrexone and topamax, also known as tapiramate. He has not had a single craving since I put him on this and so he's actually been sober for July of 2024.

Speaker 1:

And this might seem like a fairly simple case, but I wanted to bring up some wisdom about medications for alcohol use disorder, which is that they don't work very well. If we had really good medications for alcohol use disorder, which is that they don't work very well, if we had really good medications for alcohol use disorder, the way we do for opioids, we could probably help a lot of people get sober faster. But here's what I learned. So naltrexone works, but it doesn't work that well in everyone. Some people on naltrexone have no desire to drink and as long as they stay on it they do great. But let's say, for example, on naltrexone have no desire to drink and as long as they stay on it they do great. But let's say, for example, that naltrexone does work, but it only drops the alcohol cravings by maybe 20%. Topiramate or Topamax can also be very effective for some people. In a couple of my patients it's completely gotten rid of the desire to drink. But again, in most people it doesn't. So let's say that the tapiramate reduces the alcohol cravings by 30%. With either drug alone it's a small difference. But when you add anti-craving meds for alcohol in from different drug classes, I find that they have an additive effect. So this is an example for this patient where and I actually didn't try him on monotherapy, but with dual therapy he has a significant reduction in his cravings and he's now able to be alcohol-free. So my go-to is now to really start all my patients with alcohol use disorder on two medications to reduce cravings, because each individually doesn't have a huge effect, but together they have a much bigger additive effect. So if you've referred me any of your clients and they come back to you on two medications for alcohol use disorder, that's why the second case that I found to be very, very educational we're going to go through now.

Speaker 1:

A patient in her early 30s referred to me for alcohol use disorder had been drinking relatively recently. Before our first visit she was also a binge drinker. I didn't actually ask too much about why she was drinking, but she described as binging. And then on her first year in drug tests she was also positive for cocaine and it turned out that she would use mostly alcohol and then occasionally went under the influence. She would use cocaine. And she was doing a lot of recovery work. She was going to groups, she was going to meetings and wanted to make some progress. So same thing I put her on dual therapy.

Speaker 1:

I put her on gabapentin, which can be used to reduce alcohol cravings, and naltrexone, and she was able to stay sober for about two months. Unfortunately she missed a follow-up. I heard back from her about three months later. A friend had passed, she had some very strong emotions, went back to drinking and was ready to get some help again. And so, probably learning from my first case, I put her on the combination the second time of naltrexone and topiramate, again also known as Topamax, to see how she would respond. Same pattern she was able to stay sober about two months. She mentioned she was having some strong emotions.

Speaker 1:

We talked about antidepressants. She had had some experience with Zoloft, so I restarted that. And then unexpectedly she had a positive pregnancy test and she was worried about medications causing harm in pregnancy. For context, topamax or Topiramate cannot be taken in pregnancy. Zoloft or Sertraline is the safest of that class of antidepressants in pregnancy and there's not a lot of data on naltrexone in pregnancy. But she was worried so she wanted to stop and unfortunately without her meds. But she was worried, so she wanted to stop and unfortunately without her meds she relapsed. We all know that alcohol causes tons of damage to the pregnancy. So she immediately got back and got an appointment with me and she really wanted to stay sober and continue the pregnancy. Unfortunately she had a miscarriage and she had a period of drinking after the miscarriage and then came back to see me again and at the next visit I'd spent quite a bit of time before her visit learning about post-traumatic stress disorder and I always try to ask, like, why do you drink?

Speaker 1:

Like what does alcohol do for you? How does it help you? Or whether it's alcohol or cocaine or whatever, I try to understand the why. You know and I'm going to exaggerate to make a point Our patients don't have problems with drugs and alcohol. They have problems with how they feel and they get tricked, their brain gets tricked into thinking that the drugs and alcohol help. So I always try to go back and say why are you doing this?

Speaker 1:

And I hadn't really gotten a good answer from her, so I took a shot in the dark and I said do you have any trauma history? And she initially said no, not really. And as I probed a little bit, it turns out that her stepfather beat her as a child and was verbally abusive and she had a near fatal accident at about age 20 that put her in the hospital for three weeks and the legal proceedings after the accident lasted for about two years. So I went through the DSM-5 criteria for PTSD with her and she met every criteria. And so I said and this is not her name I said, you know, sarah, I wonder if alcohol is actually your problem. Maybe we should start treating your PTSD that we didn't know you had.

Speaker 1:

So I changed her medications around. I increased her Sertraline or Zoloft, I stopped her Naltrexone and I put her on Prazacin, which can help with nightmares, and Propranolol to help her when she was triggered, and she felt really empowered by knowing that she had PTSD. She was seeing a therapist at the time. She totally changed her mindset and I just saw her on Friday. She is so grateful that we figured out some of why she drinks and I just saw her. I said on Friday I'm actually a little bit off here. She's about three months sober, feeling great, no cravings, really wants to focus on the trauma. I actually apologize to her, as I have for many of my patients, for not asking about trauma sooner when I'm seeing them. Now I'm a little more in tune with that and I do much more of a trauma screen with my patients when I first get to meet them All right. Case number three Some of you may know this client because she's a little unique, but this is a young woman who came in to ask for help with kratom, and the reason I bring up kratom is kratom is a kind of a brewing disaster in the world of addiction medicine and, just to level set, just to make sure we're all on the same page, kratom is a leaf from a plant that's grown in Southeast Asia that has a number of effects on the body At low doses it's a stimulant, and at a higher dose it acts like an opioid.

Speaker 1:

Most medical providers that you talk to this about have no clue, and so this particular patient mentioned to the staff at County Behavioral Health that she really hadn't found a doctor that knew much about Kratom, and I outed myself as a Kratom geek. I've been on the Kratom Sobriety Podcast. I've interviewed some folks in the Kratom industry. I've been on the Kratom Sobriety Podcast. I've interviewed some folks in the Kratom industry. I even went to a local smoke shop and bought Kratom. This is a big issue. It's estimated that as many as 20-something million Americans use Kratom, and yet it's an unregulated supplement. There's a huge division in the Kratom community of users as to what the right treatment is.

Speaker 1:

So she was very grateful that I had some experience with Kratom. So when I talked to her, she was predominantly using Kratom for its stimulant-like effect. She was doing it to be more productive. She felt like she needed to get things done and I actually talked to her, as many of my patients who use stimulants have. She had some ADHD tendencies. She had some trouble in school, she really struggled with math, she had trouble staying productive and that's where it seemed like Kratom really helped her. So she was dependent on Kratom and it acts like an opioid.

Speaker 1:

So I put her on some Suboxone, which she did fairly well on, and I actually put her on some Stratera the generic name for that is adamoxetine because I thought she might have some underlying ADHD, the way she was using Kratom to get its stimulant effects and she actually felt a lot better. She was able to get more done at work. She didn't have any cravings to use Kratom. And then we transitioned her from suboxone Again, that's buprenorphine and naloxone the sublingual form over to the long-acting injectable buprenorphine and the form I used for her was sublocaine. Interestingly, she just came in to see me last week and had had a relapse on kratom, despite being on sublocaine. So she was not in opiate withdrawal but was having some breakthrough cravings. And what had happened is her psychiatrist had stopped her Stratera for various reasons. So she was feeling unfocused again and then she really didn't have anything as needed for cravings. So I just put her on a little baby dose of sublingual buprenorphine, I gave her the Subutex formulation and then she's going to see her psychiatrist about managing her ADHD. So she might still be a good candidate for the adamoxetine, but given the fact that she's also having some depressive symptoms, we may want to put her on some bupropion, also known as Welbutrin. So that's really an overview of what I'm seeing.

Speaker 1:

Again, this is the breakdown of the various percentages of the substances I'm treating people for and, as you heard, a lot of what I do is understanding mental health and trying to support people with their mental health, in addition to the traditional MAT medications for addiction. So I'm going to leave you with five take-home points and then, if we have time for questions, I'm certainly happy to discuss. The first is that medications for alcohol use disorder really don't work that well. We have three of them disulfiram or antibuse. A camprosate or camperol and naltrexone. Most people really don't use the brand names. Each of them has maybe a little bit of an effect, but when you add them together they can be very helpful. I also use a lot of off-label medications for alcohol use disorder and there are lots. My go-to are really gabapentin, tapiramate or topamax and then baclofen, and these are all medications that can be used in an additive fashion. Usually I start with two again to have that additive anti-craving effect.

Speaker 1:

The next issue is we must understand how trauma affects our patients and I know you all know that I'm still fairly new to this. I'm getting very interested in the work of Dr Gabor Mate. In his words, everyone with addiction is traumatized, whether that's small traumas like bullying as a child, or the more severe traumas like personal violence, assault, sexual assault. We really have to co-manage PTSD because many of our patients are just trying to numb themselves and I know that's an oversimplification, but literally yesterday my first patient of the day years and years of sexual assault in the foster care system and she said exactly, and I quote I drink alcohol to numb my feelings. So we have to address PTSD.

Speaker 1:

Number three as I mentioned, kratom is a developing public health issue. The industry is changing and making more and more potent products. Kratom is actually a leaf but you can dry it and then put it in a capsule so you can consume more. You can also chemically treat the leaf and extract the chemicals so you can get even more. And they're actually even starting to really modify the leaf and make some synthetic and semi-synthetic versions of the chemicals in kratom, almost like coca leaf got turned into crack cocaine. We're seeing the same thing in the kratom industry. So we are going to see more and more kratom, as it's unregulated and these extracts and synthetics are extremely potent.

Speaker 1:

The next is ADHD. I was always taught in the ER that ADHD is kind of a minor issue. Defer it to outpatient psychiatry. But really co-managing ADHD is important in treating addiction. If you can imagine you can't focus on your schoolwork Because you have ADHD. It's very hard to focus on the recovery work. So I am now very aggressive in treating unmanaged ADHD in patients. I use a lot of the non-addictive ADHD medications.

Speaker 1:

And then the last thing is buprenorphine. A lot of our patients don't like to be dependent on anything. I get countless people asking me when am I done with buprenorphine? The data would suggest that when people come off of buprenorphine when they're stable for opioid use disorder. Within about 18 months two-thirds will relapse, get back on buprenorphine or have an overdose. So, as we heard in the third case, being fairly liberal with small amounts of as-needed for breakthrough cravings can be very helpful. And if someone does want to come off their buprenorphine, it's a lot of regular contact to make sure that they know what to do if they're craving. And then again, for a lot of my patients, I just give them like maybe a few doses of buprenorphine a week that they can take when they are craving. So for this patient, we're going to keep her on sublocade for several months and then use it to wean her off of buprenorphine, and then I'll still keep her on just a few doses of buprenorphine a week, as needed.

Speaker 1:

Before we wrap up, a huge thank you to the Montage Health Foundation for backing my mission to create fun, engaging education on addiction, and a shout out to the nonprofit Central Coast Overdose Prevention for teaming up with me on this podcast. Our partnership helps me get the word out about how to treat addiction and prevent overdoses To those healthcare providers out there treating patients with addiction. You're doing life-saving work and thank you for what you do For everyone else tuning in. Thank you for taking the time to learn about addiction. It's a fight we cannot win without awareness and action. There's still so much we can do to improve how addiction is treated. Together we can make it happen. Thanks for listening and remember treating addiction saves lives. I'll see you next time.