Addiction Medicine Made Easy | Fighting back against addiction

These Shots Save Lives - Using Long Acting Injectable Meds for Addiction

• Casey Grover, MD, FACEP, FASAM

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Dr. Casey Grover interviews fellow addiction medicine physician Dr. Jason Giles to explore how addiction specialists approach treatment using long-acting injectable medications as tools for recovery.

We discuss:

• Dr. Giles shares his personal journey from anesthesiology to addiction medicine after developing his own dependency on fentanyl
• Addiction as a disease of executive functioning that impairs decision-making ability
• Recovery requires building new neural pathways - learning to manage emotions without substances
• Long-acting injectable medications (Sublocade, Brixadi, Vivitrol) , and how these medications reduce cravings and provide protection while patients develop new coping skills
• The process of stopping buprenorphine
• Individualized tapering approaches help patients transition from daily medications to occasional use
• Creating a safe environment where patients can be honest is essential for successful 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 is an interview with fellow addiction medicine physician, dr Jason Giles. We connected to discuss how we, as addiction medicine doctors, think about treating addiction, with a focus on using long-acting injectable medications. A few clarifications before we get into the interview. In the world of addiction medicine, there are three medications which can be given as once-monthly injections. The first is naltrexone and the brand name is Vivitrol. It is used to treat opioid use disorder and alcohol use disorder. The second is buprenorphine. There are two different products. One is called Sublocade and the other is called Brixati. They're made by different companies and have slightly different characteristics and, just to clarify, I have no financial ties to any drug companies. Dr Giles and I focused our discussion for this episode on Sublocade and Brixati. With that, let's dig in. All right, why don't we start by having you tell us who you are and what you do?

Speaker 2:

Thanks, doc. I'm Dr Jason Giles and I am an addiction medicine doctor. I've been doing that job for about the last 20 years and my specialty is taking care of patients in residential and post-acute residential so they call it PHP or aftercare step down, add to drug and alcohol treatment centers across the country. We also in our group we do psychiatry as part of incidental services, but we're also in mental health primary facilities. But that's my job Telemedicine, addiction medicine.

Speaker 1:

How did you get interested in addiction medicine?

Speaker 2:

Well, my first inkling of it as a thing probably goes back to when I was a kid and my own father struggled with alcohol, went into a recovery program himself, ultimately got it. And so I was aware from a single digit early age that people people had trouble with substances, that sometimes the things that we sought, that we seek for relief, become problems of their own. So I, I knew, I knew about that from before. I didn't have interest in pursuing that in in school or in in training until I was forced to get some education in it when I myself developed a problem with substances on the tail end of my residency in anesthesiology. My particular substance wasn't alcohol. It was well when I used to say this. I would have to repeat it because this is 25 years ago. People would say what's that? But they don't say that anymore. But the substance that I got tangled up with is called fentanyl, and now everyone knows what that is. So it was a pioneer in that sense, a trailblazer, but it's what was around.

Speaker 2:

There are a lot of reasons why I went that way, perhaps genetic, maybe there's a genetic component because of the family history, but for whatever the reasons were, I wound up as a patient needing help, dealing with my own dependence and then getting into the deeper reasons. What was behind that, why a nice guy like me was in a place like that. And as I learned more about this problem or malady, or some call it a disease I don't like that word, but whatever this thing is that you and I deal with all the time, it became endlessly fascinating to me, not just from a personal standpoint of wanting to make sure that things didn't go back the way they were, but also it's a, it's a whole frontier in medicine. That is the most exciting, most interesting, endlessly fascinating field of medicine, because you're dealing with the decisions that people make. You're dealing with the choices that they make and how can we favorably influence their choices, how can we keep them on track.

Speaker 2:

So I, I, I'm like the fish who flopped off of the dock and back into the lake. I felt like I was home. So my training is in anesthesiology. I did cardiac anesthesia. I did a fellowship in pain medicine. That's probably part of where I started to get interested in the medical interventions and also the management of emotional pain, not just physical pain no-transcript.

Speaker 1:

One thing you said when you talked about the decisions that people make the way I'm describing addiction to family members is addiction is a disease of executive functioning, and executive functioning is the ability to keep a calendar, to know when to save money versus spend it when something's a good decision or a bad decision. And it's really challenging for family members to understand this that the actual ability to make good decisions is very impaired in addiction. I'm just curious how that resonates with you, given your both lived experience and professional experience.

Speaker 2:

I agree with you completely. I think that's exactly on point. You can make analogies. It's like having your steering wheel on your car obey you, sometimes, ah, that's a good one, but not all the time I'm going to steal that. So you know, here we are, the the arrow's green, it's time to turn left. And you, you start pulling hand over hand as you, as you accelerate, and the car says you know, actually we're going to go straight and maybe, and maybe into another car, maybe into the island, or maybe, you know.

Speaker 2:

So it's not that the decisions are always bad. That would be fine. We would just become conserved. We would say I can't make decisions anymore. And you know that that's a, that's a thought disorder, right? So you don't course connected with the real world of how things work. So we're not going to let you make decisions about yourself anymore. To protect you, the trouble is it's faulty. So sometimes it works and sometimes it doesn't. People hold up their strengths and say look I just, I had my best quarter ever, my best year, or I won the, I'm the valedictorian, or I you know something, something great in their life. But but it's not consistent, right? It's keep a calendar, it's, it's exercise self-discipline through the difficult periods. But yeah, it's, it's, it's impaired decision-making is is is the heart of it. I agree with you completely.

Speaker 1:

I think also, you pointed out something really useful to pause and consider, which is that sometimes it works and sometimes it doesn't. To your point, someone with schizophrenia cannot understand reality and may require to be living in an institution where they have someone to make decisions for them. But I like what you said about sometimes they can make decisions and sometimes they can't, which I know for my families of my patients they really struggle with, because that's where trust becomes. Such an issue is that you did great today, but not tomorrow. When can I trust you? So I talk a lot about trying to be consistent when things are good and bad for my patients when they communicate with their families. Have I had a good day today and I had a bad day today, but I am totally going to give you credit for that. My next visit I have with a family member.

Speaker 2:

There's a neuro anatomical explanation for why that's true. So another way of thinking about addiction is learning. So it's like it's learning and we all everyone learns. We learned how to walk and we learned how to speak and we learned. Most people about 96% in America learn how to ride a bicycle and even if you don't ride a bicycle every day, most people don't forget how to ride a bicycle Because of all the repetition and because of the practiced building of an automatic routine to keep you balanced on the bike, which is what riding a bicycle is balancing. Keep you balanced on the bike, which is what riding a bicycle is balancing. That routine that you spent all those hours learning, usually as a kid, is still there and you can access it later when you get back on a bike.

Speaker 2:

It's the same with using substances to change the way you feel. It's just another loop. So I feel scared, I have a drink, or I feel I feel, you know, ineffective and I have some cocaine so that I feel powerful, whatever, whatever the the substance habit loop is, we learn if I smoke weed, I'm not bothered by my parents, or I'm not bothered by my wife, or I'm not whatever, whatever the thing is. So we, we develop this shortcut loop of when I do this, I can control my feelings. Well, that is like learning to ride a bike, and you don't forget that. So when the circumstances come up later, and until you've built another, stronger automatic loop which is when I feel scared stronger automatic loop, which is when I feel scared I talk to my buddy Casey.

Speaker 2:

When I feel uncertain, I ask for help. That is usually something we're not very good at in the beginning, and so, as people say, well, is this a situation where I'm going to have a drink or is this a situation where I'm going to raise my hand and ask for help In the early stages? Sometimes it's flip a coin for which one of those things is going to win, because one's built more robust, more automatic, feels more comfortable. It's scary to ask for help, and so it looks like I can't tell how he's going to act. Well, he can't either. That's the anatomical basis for the faulty decision-making is. You've got these competing structures. And also why relapse sometimes happens way down the road, because if we don't maintain the new system, it atrophies and then the other one might pop up and it's confounding. But it's just learning. It's just learning.

Speaker 1:

It's confounding, but it's just learning, it's just learning. So I want to pause there and unpack what you just said, and I mean this as a compliment. You truly understand addiction. I came out of taking my addiction medicine boards and went it's about the naltrexone, it's about the acamprosate, it's about the methadone. It was about the medicine. And the more I do addiction medicine, so much of it is not the medicine. And here's the fundamental way I think of what I do as an addiction doctor. People learn to self-regulate with substances and I have to teach them how to self-regulate without substances. Bingo, I know how I came to it, which was just sitting there and listening to my patients over and over and over again. How did you learn that?

Speaker 2:

probably the same. Probably there's now thousands of patients that I've looked, looked after in the last 20 years and you and you pick up their patterns, their, their stories from what used to be the most painful, most embarrassing, 25 years ago before, before I was able to get help with for my problem. I certainly wouldn't lead with that conversation. I wouldn't say, hey, you know I'll be your doctor today and just so you know, I used to have a problem with fentanyl. That's not how I would start a conversation. But with the substance use patients having the common experience of having been through it, it actually puts us on this even footing. They know I'm not judging them, which is a big piece of their defensiveness, of course, and also I mean, if a knucklehead like me can get through it, then maybe there's hope for them. I see them processing that like, wait, there might be life after this. So some of it is just having hope that there's a way out. But your question about how did I come to this? I don't want to go back to what my life was before. Okay, I've got to learn all about this so that I can control it. But the way the way to control it is to not try to control it. The way to guarantee or give yourself the best shot of staying in recovery is where it just becomes your life. Of course it's. It's, it becomes second nature. It has to be for a person to to get it and stay on the good side, on the on the non-substance use side, of auto-regulation. It has to be. Before you realize it, you've already texted your buddy to talk about what is actually happening in your life. You're not even you just sort of come to in the middle of asking for help, in the middle of being engaged in honest conversation with somebody who gets it and can help you, the same way that people wake up hungover and forgot how they got to the bar, that the automaticity of managing their feelings with substances has to be replaced with the automatic. I just raised my hand, I just make a phone call, I just go to a meeting, I just talk to my doctor, and that's when you well and truly changed. We're not even thinking about it.

Speaker 2:

William James talks about second nature, right? Second nature. So we have a nature. Our nature is to avoid pain, seek pleasure, get through, get by. But second nature is our habits, and so keeping a calendar becomes not something you have to rigorously concentrate on and it's difficult, it's just. I'm a guy who keeps a calendar, I'm a guy who goes to the gym, I'm a guy who gets to bed and gets as much sleep as I can, and you start to see yourself differently and then that new habit takes over. It takes time right, it takes time, takes over. It takes time right, it takes time. So the medications can be helpful in the early stages until you've got the automatic dance steps of living a different kind of life.

Speaker 1:

I have to say our practices are very similar. We employ peer support specialists in my practice to help with that peer-to-peer relationship, and it's almost like you heard me speaking in clinic yesterday to my patients. Medication is a great way to help the brain work better in the early stage of recovery while people build their skills Absolutely. So you and I today we're going to talk about long-acting injectable medications my practice. There are two doctors in the practice the very lovely and very beautiful Dr Reb Close, who happens to be my spouse, and then me, and we've largely developed our own way of doing things, mentored by a local physician around here who's been doing addiction medicine longer than I've been alive. But we really like the long-acting injectable medications. They're very effective and just to level set for everyone.

Speaker 1:

There are three long-acting injectable medications. They're very effective and just to level set for everyone. There are three long-acting injectable medications we use in addiction medicine and no financial ties to anything here. There is naltrexone, also known as Vivitrol, and then there's the two forms of buprenorphine. One form is called Sublocade, the other is called Brixati and there's a little bit of nuance to each. So the one that my patients have the most interest in is Sublocade.

Speaker 2:

Talk to me about how you're using Sublocade in your practice. So yeah, these are super, super cool tools that can help be that bridge. So I like analogies we're talking about the steering wheel earlier. I think of these medications like a cast for a broken ankle. So if you break your ankle, it hurts, you can't put weight on it. You go see the doctor. They said it, maybe it needs surgery, Maybe it doesn't, but you get a cast.

Speaker 2:

And how long would you leave the cast on? Cast on Rest of your life? Probably not right. You're going to get problems from that. You're going to get atrophy, you're going to get arthritis on the other side. You're not mobile. Eventually you probably get skin breakdown and so forth. So you wouldn't leave a cast on for the rest of your life. In the case of a broken bone, six weeks, eight weeks, four weeks, depending on how high and how complex the fracture is, maybe longer. In the case of a substance use disorder that takes years to develop and then in many ways feels like it's taken on a life of its own, probably six weeks is not enough. Probably six weeks is not enough to develop a new automatic habit system. So even though the cast analogy is apt in terms of a temporary support. It's probably not in terms of the timeline it takes longer.

Speaker 2:

The other thing that I say and this didn't used to be controversial at all, but there's a, you know, some people think that you should be on opiates the rest of your life. I don't think anyone is born opiate deficient. I don't think you come into the world two quarts low of endorphins. I don't think that's how it works. So, and to that end, I'm not a fan of lifelong opiates or even opiate blockers. I think they they're helpful, but I think their utility wears off over time. So I like what you said about using them as offset. We had a little chat before the the pod about using them for people who have been on maintenance for some time, and that has to do with pharmacology. They wear off in the. It's like the finest wear off you can. You can imagine.

Speaker 2:

So these medications for the, for the listeners who don't know, they're injectable and they're in formulations that cause them to be absorbed very slowly. So some shots when you get a shot, you want it to be absorbed quickly. If you get a shot of antibiotics, you want it to be absorbed quickly. If you get a shot of antibiotics, you want that to be absorbed quickly. But there's actually some antibiotics you want to be absorbed very slowly because they've got to kill a certain germ and they need to be around for a long time. Penicillin is one of them. It's mixed in a certain depot form that takes a long time to be absorbed to kill a certain infection.

Speaker 2:

In the case of these long-acting opiates, they're mixed in substances that when they stay in the body, the body can't get access to all of the medicine at the same time, and so the body's macrophages, the little cells that clear away foreign material, they go to work on these things and as they do, the depot of medication is slowly revealed and it's slowly dissolved. And what's nice about that is the tapering function, or the tapering aspect is so gentle that you never get dropped from a high level of opiate support to a low one, so you don't get the withdrawal feelings. So they're wonderful off-ramps to a maintenance or to a long-term substance. But, as you said, what I heard you say is when I was doing my boards it was all about the medications. But if that were the case, then we would just put people on Suboxone and they'd be fine, they wouldn't have a problem.

Speaker 2:

The thing is when people come in for treatment. The upfront concern is the substance use disorder. But the real issue is why they were using these chemicals in the first place. There's a term, mat medication-assisted treatment. It's not medication instead of treatment. It's not that the medicines do all the work. So in our practice what we use them for is people who are at the tail end of a substantial period of time. No-transcript is two reasons. We'll set Vivitrol aside because it's sort of a special class. The reason we use these medications comes from Niswander's work on methadone.

Speaker 2:

If you are driven by the cravings to go score and to go get opiates, then your life is dysregulated. You're caught up in the merry-go-round of getting drugs and getting money to get the drugs and the addict lifestyle. If you're not compelled to go get drugs because there's enough opioid around in your system that you don't have cravings they figured this out in the 60s that that helps people. That's the so-called methadone maintenance and that idea is actually even older. That goes back to the old days when people got on heroin and morphine was what they drank all the time and they carried around and they just stayed on it. That's Halstead, if you know the famous surgeon Halstead. He had an opiate problem and he just stayed on opiates for his entire career. So that was his. His maintenance strategy was staying on opiates.

Speaker 2:

Methadone is better because it's longer acting. Suboxone, which is the drug that's in sublocade, is long acting and it's a cool drug because it blocks the effect of other opiates. It even blocks the effect of itself. So you take a lot of sublocate. It's like you took a certain amount. It has a speed limit, if you will. It's got a block of itself and of other opiates. So if you feel like you know what I need to get some fentanyl today and you have a shot of sublocate on board, then the fentanyl doesn't really work. You can overcome it with massive amounts of fentanyl, but you're largely protected from the effects. You're protected from the effects of the fentanyl. So these long-acting medications do two things they reduce cravings and then they also make it so if you use you don't get the effect and it protects you from something really bad happening happening from overdose. But they are not a substitute for getting to the heart of the matter, which is this faulty decision making.

Speaker 1:

Well said, yeah, I think the way I've learned to describe it to my patients, and I love the speed limit analogy because I use it myself. Opiates and substances that cause dependence are unique because we have essentially two issues right. So a person uses a substance regularly, you and I both know their brain chemistry changes and then when they stop using, they feel sick and sometimes that withdrawal syndrome can be life-threatening. So it's almost like when someone comes to me as a new patient, step one is we have to address their dependence and withdrawal while we build the foundation of understanding why they use, what their triggers are, how bad is their PTSD, et cetera. And so I've been very active in learning about Kratom and shout out to my friends at the Kratom Sobriety Podcast for interviewing me.

Speaker 1:

But when folks use Kratom, which can act like an opioid if they use it enough, they go into opiate withdrawal. When they stop it acts like an opioid, and then they'll get on suboxone, which is very effective at treating opioid withdrawal. And then they get frustrated that now they're stuck on suboxone. And if you've read Matthew Perry's book before he passed, matthew Perry talked about being addicted to regular opioids like oxycodone and they would put him on suboxone and he was saying suboxone was the hardest medicine to get off of. And in my humble opinion, suboxone's not the problem. Opioid dependence is the problem, and so the way I describe it to my patients is when you use an opioid regularly, your brain chemistry changes After about two weeks. If you stop, you get sick, and there is no one on planet Earth that can fix that quickly or easily. And we have two strategies we give you back an opioid like methadone or suboxone so you're not sick, or you kick, you go through withdrawal. There's no other option. So the way I think of when I go to use a long-acting injectable medication is somebody's on Suboxone, they're not in withdrawal, they're not craving, they're going to meetings or they have a sponsor, or they're getting therapy and they're processing their reason for using. But I don't want them to be sick and I'll get them on Suboxone and they stabilize. Sometimes they forget. Or I have one my patient, who's about 10 years sober, who's a college professor, and sometimes he's off in the field with his students and his suboxone gets damaged because they're kayaking or backpacking. And so I like to transition to the injectable medications.

Speaker 1:

When somebody has a very active lifestyle, they're doing well and taking a daily medicine is difficult and their sublocate and bruxati they're both buprenorphine or if someone's not doing so well and I'm worried that they know that if they stop taking the suboxone and wait long enough, they can start using fentanyl again and it's almost a little bit like I'm going to push you into sobriety, where you really can't use for about a month, and that buys me a month of time to really intensely get you into services, get you a sponsor, consider residential, and the two products are a little bit different.

Speaker 1:

The Brixadi is very small volume. My understanding is we don't know exactly how long it lasts. The Sublocate is a bigger volume but we've had it for longer and my understanding is people, after they get a Sublocate shot, will test positive for buprenorphine for about four to six months and that goes back to this very slow tail as the medicine gets dissolved. But that's how I'm using the injectables. But what I'd like to talk about is people have learned, based on how you nicely described these shots, is they get absorbed very slowly and so someone might absorb them over several months and people found that they would get sublocate month to month to month and then stop and they raced for the withdrawal and it didn't happen, and so I'm currently treating patients with sublocate as a way to deal with that opioid dependence and get them off suboxone over several months. I'm curious as to what your experience is with that.

Speaker 2:

Yeah, I think that's a good indication for it. I think that's reasonable. Now listen, it's a tool. People come up with clever ways to use tools. Yes, they do.

Speaker 2:

If you go to the emergency room as a fentanyl overdose and you survive, your chances of overdosing again in the next week are 100%. So people who overdose overdose, and they it's just because the nature of their supplier perhaps, or their unregulated use or whatever. And so some emergency physicians are giving people sublocade in the ER after they're Narcan'd and reversed and so forth. You've already gone through the opiate withdrawal anyway, gone through the opiate withdrawal anyway, and they'll keep them on Narcan, sometimes because the sublicate is not as available, and there's a paper that came out, I think in 22, about this particular strategy. So they're getting 300 milligrams of sublicate in the ER on presentation for an opiate overdose. So if they survive, they get sent out with essentially, an airbag to protect them from this happening again, and it has enormous efficacy in the short run. So that for me is the quintessence of harm reduction. And the overdose has a whole cascade of depression and sadness and disconnection and it makes it really much more difficult for people to connect. So their cravings are mitigated and they're protected from the effects of the sublocate being an opiate blocker. So that's a clever strategy for using a medication really in a different way. There's another paper that came out in 23 about the duration of action of sublocate.

Speaker 2:

So the traditional way that we use it is we give initial loading dose of 300 milligrams and it's a cool delivery system, right, it's a liquid in the syringe and when it goes in underneath the skin it polymerizes and turns into this lump that you can feel. And the appropriate disclaimer is just because you feel the lump doesn't mean there's still sublocate around in it. So it's not correlated with how much is left. So I still feel it, so I must be okay. Is not necessarily true. Also, I don't feel it so it must be gone. Is not true either, because it could still be in there and you can't feel it. It's not perfectly correlated Anyhow.

Speaker 2:

So the way the manufacturer teaches us to use it is you get 300 to start. This is assuming somebody has reached stable state on Suboxone. You give them the larger shot and then the maintenance follow-up shots are 100 milligrams every 30 days. But what we know now is that that's a very optimistic rate of clearance. It's probably cleared faster. And then the reason for being on these medications in terms of medication-assisted treatment is to protect you from the cravings driving you to use, and there is a therapeutic blood level at which point that happens. So with the 100 milligram monthly maintenance, about a third of people fall below that safety margin.

Speaker 2:

We're probably not using enough or we're not going often. Enough is really the way to fix that from a pharmacokinetic standpoint is you probably should come in every three weeks rather than every four weeks. It's an expensive medication. It's expensive not just in terms of the medication itself, but has to be administered in an office by a medical person. You have to rotate locations on the abdomen so you don't want to keep giving it in the same spot. It's not just take a pill or Ozempic shot at home. It's more complicated. So, yeah, there's some wrinkles. There's some wrinkles to it.

Speaker 2:

I think the two groups that it's most useful for is setting aside the emergency room story are people who have been on maintenance, got their lives. You know. They're living like they want to live, they're working where they want to work, their relationships are tidied up, they have this support system, recovery, whatever it is that keeps them going. That group who's ready to be off Suboxone. I think it's elegant and it's a lovely way to finish. The other group is people who have compliance problems and are not fully invested in recovery and are looking to figure out how to stop suboxone. Use that as a management strategy. There's a lot of diverted suboxone in the black market. Patients use this stuff to deal with withdrawals. They use it as a bridge to methadone or as a bridge to the next time they can get fentanyl that group of less than dedicated daily suboxone users. I think that the injectables are helpful, very helpful.

Speaker 1:

So I'm going to give another kudos to a podcast I work with the Addiction Medicine Journal Club, dr Sonia Deltredici and Dr John Keenan. I've done a couple of episodes with them and they covered a paper on discontinuing buprenorphine and the data on people who get off of buprenorphine after a period of sustained sobriety on buprenorphine. Again, buprenorphine is the medicine in Suboxone, subutex. Sublocade Brixadi is that within 18 months of stopping, two-thirds will relapse, have an overdose or go back on buprenorphine. So I know what I do in my practice around getting people off of a Suboxone or buprenorphine product. What are you currently doing?

Speaker 2:

Well, let me ask you a question about that.

Speaker 1:

How long were they on buprenorphine before getting off of it? I don't remember exactly, but I believe it was something like 18 months to two years of sobriety on a buprenorphine product, and then they followed them for 18 months after successful weaning.

Speaker 2:

So this gets a little bit into the gnarly part of addiction medicine. So there's a strong contingent from the traditional 12-step based recovery world who feel that use of any of these medications is not sobriety. Now we addiction doctors, we bristle at that because we're not trying to replace lifestyle change and habit change and the rest of the stuff that you need to be a successful human being with chemicals, with even these long-acting injectables. With that said, I think it's important to listen to what the old-timers say about that. There's something about dealing with the world. Just to be extra vague, there's something about dealing with the world without chemicals in terms of managing your feelings that may speed the process of change. So we act as if giving buprenorphine is a risk-free choice, that it doesn't affect the process of learning this new habit system of self-regulation without chemicals, because we're giving it and saying it's not having an effect on your, on your growth and emotional development. But of course it is. It must have been, or you would have grown during your fentanyl phase. You would have matured out of that or learned out of that. So there are kaplan-meier curves for probability of relapse based on time. So the longer a person is in recovery, the less likely he is to return to whatever it is drinking or opiates. There's a shoulder in the curve around two years. So if you can stay abstinent for two years, your chances of staying abstinent go up to something like 70 or 80% If you can get to two years. If you can get to five years they go up to 90%. So it's pretty flat from two to five and then the data gets a little murky. But there's papers about people in AA for 10 years or more. It's never fully gone because of the learning thing we talked about, but successfully defeating it, if you will, so that they don't relapse. So I'm just throwing a question mark in there about that, which is to say, 18 months to two years without buprenorphine. We know some of the wings are still wet, right? The people don't have their lives together in a way. That's more automatic With buprenorphine. I'm not surprised that this maturation has delayed. Some of it may even be because, well, I'm not really sober, I'm still on this medicine, or the management of it, or the use of it. So, yeah, that's more complicated than it presents itself.

Speaker 2:

The suboxone crowd would say this is why you should stay on this for the rest of your life, right. The methadone clinics would say well, this is why you need opiates the rest of your life. But I still don't feel that way. Back to what I said, that no one is missing opiates, you get into the conversation about risk. So if the risk of relapse is returning to taking one Vicodin that's actually a Vicodin, then I'm probably less worried about that. You get back on track. It tells you it's feedback. You need to make some changes. If the risk of relapse is taking a fake Vicodin or a fake Percocet that's actually fentanyl and you overdose and maybe lose your life, well, now the stakes are much, much higher. So I don't have a great answer for you about that.

Speaker 2:

I will say this that patients who come to a 30-day treatment program to taper off suboxone without getting on the long-acting stuff, that's usually a bad idea. I agree, because your life can't be that together if you have to check into a treatment center to get off suboxone. For those of you at home who want to come off suboxone, you drop by half whatever it is. This is how we do it. You drop whatever you're on. You can cut it in half, and that's because of the nature of the Michaelis-Menten curve, which is a fancy way of saying how the receptor binds the drug so you can cut it by half and then see how you feel. You have to give it four or five days to equilibrate. If you feel fine, cut it by half again.

Speaker 2:

At some point you'll feel icky, you'll feel withdrawal symptoms. The move there is to not cut it anymore until you don't feel the withdrawal symptoms. That's sometimes a few days, that's sometimes a couple of weeks. Now low-grade symptoms, don't put yourself into massive withdrawal. But you feel like, yeah, I'm not feeling that great. That's the time to lean on the rest of your support system and tell them hey, I've been on 16 milligrams of Suboxone. I went to eight. I felt fine. The next week I went to four and I start to feel kind of crummy. So keep an eye on me, guys. I'm going through it.

Speaker 2:

And then you wait until you're no longer going through it, so to speak, having physical withdrawal symptoms. Then you go down to two, having physical withdrawal symptoms. Then you go down to two. Now, that process can take a while, but who cares? Time is your friend in that situation. And you're transferring the dependence on the substance to the dependence on your recovery system In a treatment center, doing it in 30 days very difficult. It's not your usual support network. It's this, you know, bolted on well-meaning and professional people, but they're not your crew. And then the, the calendar is in charge and time is not your friend. So in general, I wouldn't recommend that.

Speaker 2:

If they've changed the, the way they regard themselves and how they manage their feelings, then I think sublocate or tapering are great and in fact you should. If you haven't, if there's some external pressure, if you're hearing it from your family members hey, why are you still on that stuff? You need to get off. Then those are fraught situations because you probably aren't stable, you're probably not in good shape and maybe the medication is protecting you from something bad happening. So the message I would say is to try for the clinicians, for the docs, is to try and see if you can figure out what's going on For the patients. Help them be honest with what's really happening. I don't really want to get off of this, but my wife is on me about. She thinks I'm different or whatever the details are. Does that make sense?

Speaker 1:

Yeah, I guess I have a slightly different approach, which is that and I'm going to give credit to my lovely bride and fellow addiction doctor, dr Reb Close the way she describes addiction is feel something, take something. Dr Reb Close, the way she describes addiction is feel something, take something. And so what I'm doing in my practice is, let's say, someone says to me hey, doc, I've been on Suboxone for three years, I'm tired of this stuff, I'm ready to get off of it. I'll say great, we put them on Sublocade. That's my preferred product, simply because I have more experience with it and it seems to last longer. I give them, let's say, four injections, allow the sublocate to reach steady state, and then I tell them to stop. If they get withdrawal, we give more, we work it out.

Speaker 1:

The issue is, though, to your point to riding a bike they are used to, when they don't feel good, using some sort of substance to make them feel better, and I want them to take my substances, not whatever horrible substances are out there, right? So common dosing for buprenorphine under the tongue is anywhere from, you know, in the fentanyl era, 16 to 32 milligrams, right, and what I will do is I say I'm going to give you the two milligrams, the little baby ones, and I want you to know that if you're having a bad day, you can take one. Yeah, I like that. And the idea would be is that you never say goodbye to buprenorphine. It's that you don't take it every day and you're not dependent, but while you continue to work on building your skills and building your support group and working on your sobriety, if you have a bad day, the Suboxone is like a little tiny parachute yeah, that if you take three doses a week for six months while you're getting off of it great, you didn't use fentanyl.

Speaker 1:

And then I always tell them you have to keep seeing me, even after you stop until X date, or you've got a primary doctor that you're going to work on it with, et cetera. But it's almost like Suboxone is always there as a tool. You may not need that tool, but it's always there for you, particularly as the sublocate shots wear off and the buprenorphine gets out of their system. People are often overly confident on buprenorphine because it works so well for opiate use disorder and opiate cravings and they're like where the heck do these cravings come from? Great, let's work on it. Here's your four doses of two milligrams of buprenorphine a week and I'll see you next week. That's my approach.

Speaker 2:

Yeah, no, I've done that. I've done that. It's patient to patient. I've done it with partial strips also. And listen, there's the placebo effect as well for smokers on an airplane. You can't smoke on an airplane, right, but feeling the pack of cigarettes in your coat pocket or in your in your blouse pocket, ok, I've got these. So when we land, I'm OK, and sometimes the idea of having it just in case, paradoxically makes it so that they don't need to take it. Whatever works, so long as a person doesn't go back to fentanyl and we're moving forward and don't go backwards, it's all good with me, and so that's maybe one of the best things about this specialty is you're dealing oftentimes in uncharted territory.

Speaker 2:

Well said Doesn't standardize, it's not. We always do this this way with this situation. It's true in all the medicine, right? So even the guy fixing the ankles, all the ankles are different and where they're broken is different. So it's true in all the medicine, right? So even the guy fixing the ankles, all the ankles are different and where they're broken is different. So it's true in all the medicine. Why would we think in addiction medicine? Oh, opiates. Here's the rubber stamp on what you need to do. It's not how it works. So, yes, I think creating a space where the patient can be honest is essential. The patients need to be able to say hey, you know, dr Grover, I feel scared, or I took some extra Suboxone, or I got some fentanyl.

Speaker 1:

Well, I have to say, you and I could probably geek out about addiction for at least another 90 to 120 minutes For sure. Let's wrap up here. What would you say are some take-home points that our listeners can take away from what we've talked about in terms of learning about how to treat addiction, including long-acting injectable medications?

Speaker 2:

Sure, I would say that long-acting injectable medications are valuable and useful tools. They are not magical Swiss army knives that solve all problems. We've narrowed our discussion to, in the most part, to talk about opiate use disorder. We don't have long-acting injectable medications for the rest of the substance use and the rest of the substances that people get tangled up with and the opiate use disorder. Long-acting medications are not going to keep you from drinking and they're not going to keep you from using cocaine. So to a certain extent they're limited in scope and efficacy and it's dangerous for people to say well, I'm just an opiate guy, I don't have a problem with whatever because of the phenomenon of cross addiction. Right, so you can. You can develop something else. I would say that if you're committed to changing the way you respond to your feelings and you manage them with these other strategies CBT, you know, insight oriented therapy, exercise, all the stuff that we have to help sobriety If you're doing that and you have an opiate use disorder, these long-acting medications can be very helpful. They can be very helpful. When to get off of them depends on how far along you are and how much of your life has fundamentally changed.

Speaker 2:

People do grow out of their opiate use disorder with time. How long that takes, I'm not sure. It's person to person, because the consequences can be so grave, and by that I mean literally the grave. Yes, I would rather if it were someone I loved or a patient of mine that I cared about. I'd rather that they got an extra month or two of sublocade passed when they actually needed it than stopping too soon before they're fully cooked, as the kids would say right, let them cook. And that has to do with the philosophy.

Speaker 2:

So if you believe that you've got a faulty decision-making system and you trust that it's faulty, then you won't trust your decision-making. You'll say how does this sound, casey, I am going to Las Vegas and all of my friends are going to be doing cocaine and speed balls, but I'm just going to hang out with them and I'm going to be the designated driver. Now, when you hear that plan, you're laughing, right, I'm watching you laugh. And so when you hear that plan, that's insane, right, that's an insane. You might think that's a really good idea because you're not going to use, but you're putting yourself in a dangerous environment with camaraderie and so on and so forth, and and so running your plan by another human being. It's like those bumps in the road when you start to get out of the lane, the tire running over them will let you know. So get some bumps in your lanes so that you can see when you're starting to drift off track. Otherwise you'll be the last to know.

Speaker 1:

I have to say, so many nuggets of knowledge that you have given me today will be used in clinic next week. I have to say this has been absolutely fantastic. I can't wait to get this podcast out there. So great to get to talk to you today.

Speaker 2:

I enjoyed it. I learned a lot. For me, it's a delight to talk to a wise colleague and I made this choice to abandon a very traditional specialty and to pioneer and be one of the guys in the trenches out here, and it's inspirational to me to see that there's a whole other crop that's going to take over and push the frontiers farther out. It's an endlessly fascinating specialty and I'm grateful to be here. I'm grateful for the time you spent and thanks. Really fun time, doc.

Speaker 1:

Yeah, I was going to say I mean, I think for me, the two things I love about what I do is the gratitude and the people are so nice when they're in their addiction. Sometimes they struggle, but addiction can happen to anyone. Some of the nicest people I know are my patients and I'm just grateful to be able to take care of them. 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.