Addiction Medicine Made Easy | Fighting back against addiction

What Every Doctor Should Know About Addiction: Buprenorphine, Naltrexone, and More

• Casey Grover, MD, FACEP, FASAM

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In this episode, we discuss the fundamentals of treating opioid and alcohol use disorders with medication-assisted approaches. We review how to understand addiction as self-regulation with substances and how healthcare providers can leverage familiar medications alongside specialized treatments to help patients recover.

We also discuss

• Addiction fundamentally involves helping patients shift from self-regulating with substances to self-regulating without them
• Distinguishing opioid dependence (physical brain chemistry changes) from opioid use disorder (psychological addiction)
• Buprenorphine as a partial agonist that blocks other opioids, reduces cravings, and decreases overdose risk by 70%
• Three FDA-approved medications for alcohol use disorder: disulfiram , naltrexone, and acamprosate
• Off-label medications like gabapentin and topiramate can enhance alcohol use disorder treatment
• Understanding the fentanyl crisis and emergence of counterfeit pills containing dangerous synthetic opioids
• Addressing stigma through person-first language and recognizing addiction as a disorder of executive functioning

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. Today's episode is on addiction in general, as well as on buprenorphine and the medications that are used to treat alcohol use disorder. We are really working in my area to educate all of our doctors on the basics of how to treat addiction, so I gave a lecture on this topic to some of my primary care doctor colleagues and I recorded it to share with all of you care doctor colleagues, and I recorded it to share with all of you. The focus was on how to understand addiction, use buprenorphine and also how to use the three FDA-approved medications for alcohol use disorder acamprosate, naltrexone and disulfiram. I got good feedback from my colleagues that attended the lecture, so I hope you find it helpful. Here we go. Hope you find it helpful. Here we go. Well, I think I will get started. So I think I know everybody on the call. So my name is Casey Grover and I am currently in recovery from emergency medicine. I practiced emergency medicine for 14 years and I actually had to leave the specialty because I was diagnosed with post-traumatic stress disorder from the emergency department and I now do full-time outpatient addiction medicine. And to my primary care colleagues on the call, I respect you immensely because I now do things like return to work and disability and have a different respect for the clinic workflow than I used to when I was in the emergency department. So very pleased to be able to talk about medications for opioid use disorder and alcohol use disorder. So we're going to go through three things, which is understanding how to diagnose alcohol use disorder and opioid use disorder, and then using buprenorphine for opioid use disorder and then medications for alcohol use disorder. So I'm going to stop here before we really get into the slide deck and just talk a little bit about what addiction is and really what we need to do. So I believe we have primary care and one psychiatrist on the call and many of the medications that you already use are effective to treat addiction.

Speaker 1:

So let's think about someone who's using alcohol. They have a reason why they consume alcohol. Right Alcohol, you have to drive to get it or pay for it to be delivered. You have to pay to consume it, and then there are the consequences of using it, like getting sick or having hangovers. In other words, there's a cost that the person incurs when they go to consume alcohol. For illegal drugs, that cost is even higher. Right, so you got to find a dealer. You have to risk exposure to law enforcement in getting the drug. You use the drug, you're at risk of overdose. You may be incarcerated. Your dealer could rob you. There's a lot of cost that my patients incur when they buy drugs.

Speaker 1:

So the question I always ask them is what does this substance do for you? In other words, they're clearly spending their time and money to get the substance for a reason. What is that reason? Let's say they drink alcohol because they're anxious. Well, gosh, primary care and psychiatry treat anxiety all the time. Let's say someone uses cannabis because they can't sleep. Same thing Common medications we know around sleep are in all of our wheelhouses and a lot of times it's trauma, it's post-traumatic stress disorder, and a lot of what I do, particularly with victims of sexual assault, is help them to understand how their trauma, which they may or may not recognize, affects their brain and leads them to seek substances.

Speaker 1:

At the most fundamental level, what I do as an addiction doctor is I take people who self-regulate with substances and I help them learn to self-regulate without substances. We might use medications and with things like cognitive behavioral therapy and mutual support group meetings and developing emotional resilience, they may get to the point where they don't need any prescribed medication. In fact, for many of my patients that's the goal. So we're going to talk about buprenorphine for opioids and the three FDA-approved medications for alcohol addiction. But I want you to realize that you already probably have more skills around treating addiction than you may realize. So the simple question of why do you use? Is usually what I lead with once I get to know the patient and then I really focus on figuring out what unmet need they have. In fact, my number one prescribed medications are usually probably clonidine, a selective serotonin reuptake inhibitors, hydroxazine for anxiety and trazodone, which I know are medications you all are familiar with. So I just want to give that context and that caveat that we're going to talk about addiction-specific meds. But there's actually a lot more primary care and psychiatry in what I do than addiction medicine sometimes. So with that, I hope that context is helpful.

Speaker 1:

Let's talk about opioid dependence. So opioid dependence is the idea that when we use opioids regularly, our brain chemistry changes Right. It's usually about something like a week to two of sustained exposure to an opioid throughout the day, and this is from any opioid right. Let's say one of our patients has a hip replacement and is on oxycodone for three weeks. They will develop opioid dependence. Let's say one of our patients is using fentanyl, buying it on the street.

Speaker 1:

Regular opioid use leads to opioid dependence. It really happens in every human being with sustained exposure to opioids and it's really frustrating because once opioid dependence develops we really only have two ways to treat it. We either give people back an opioid so they don't withdraw, or they kick. They go through withdrawal and my patients find medications like methadone and buprenorphine very frustrating because they do all the work to stop using fentanyl or stop using heroin and they're like I did it. I got on Suboxone, but how do I get off Suboxone? And they oftentimes get really mad at methadone and buprenorphine, which is the medication in Suboxone, and methadone and buprenorphine are not the problem. It's opioid dependence that is the problem. And I remember going back, you know, 10 to 15 years ago in the emergency department. We did not recognize this as doctors. How many people came to the emergency department said I need more Norco and I said no, they just would go withdraw. So really, where medications for addiction treatment in opioids shine is that they allow people to function without withdrawal, and that's really what we're going to talk about today around buprenorphine. All right, next slide.

Speaker 1:

Okay, now on the other side of the opioid equation, from opioid dependence is opioid use disorder, and the older name for this was opioid abuse or opioid addiction. But opioid use disorder is a kind of the best way we have right now to describe a person who psychologically has a problem with opioids. And there's basically three components to addiction or a use disorder Compulsive use, cravings, or an intense desire to use, and consequences. So compulsive use would be trying to stop and you can't. Cravings is a fixation on the substance and not being able to think about anything else until they use, and then consequences could be physical, interpersonal or legal, and so I think this is the part of opioids that people find to be much more challenging to treat, and that is because, in my opinion, addiction is a disorder of executive functioning.

Speaker 1:

So what is executive functioning? Executive functioning is how to keep a schedule, deciding to save money instead of spending it, being on time to pick your kid up from school, knowing that you have a doctor's appointment, and calling ahead because you can't make it. It's the organizational, decision-making part of life, and so what I find with my colleagues is, when they look at someone with addiction, they go well, why would you do that? And I myself say that all the time. What made you think that was a good idea? And that's addiction. Addiction is a disorder of executive functioning and that's why they get compulsive use. They want to stop, but they can't. Cravings they know they need to go pick up their kid from school, but they can't stop thinking about the drug. And then they get consequences because they can't actually make rational decisions. So again, opioid use disorder is the best way to describe an opioid addiction and again I think of it as a disorder of executive functioning.

Speaker 1:

This is very common where people have an opioid use disorder, so they use the drug regularly and they get dependence. The vast minority of patients with opioid use disorder will binge. It's really more consistent use because withdrawal is so common and it's unfortunately a major contributor to drug overdoses in America. Next slide, please. Now, as I was mentioning, there's opioid dependence and there's opioid use disorder. There's a spectrum where some people are pure addiction. Others are, for example, on chronic pain meds and they're not addiction. But, as I mentioned, anyone on planet earth who takes opioids regularly will get dependence. Not everyone develops an addiction or a use disorder when they're exposed to opioids, but some will.

Speaker 1:

So an older term we used to use was drug seeking. Bad patients drug seeking, they want oxycodone. That's a very imprecise term, right? That's like saying oh, the definitive diagnosis is nausea. Well, why are they nauseated? Drug seeking is the pursuit of of a substance. Is it withdrawal? Is it a use disorder? Is it untreated pain? So I think it's really important when assessing people to understand exactly what's going on, and I usually find that most of my patients have some semblance of a use disorder and also dependence, and I have to make sure to address both of them.

Speaker 1:

Next slide, please. Okay, so this is something I'll go through fairly quickly, because I have to look this up every time. But how do we diagnose an opioid use disorder? There are 11 criteria. It's in the DSM-5. I don't know how much all of you know and love the DSM-5, but I'm sure, dr Blaine and I do. But yes, it's basically 11 criteria for addiction. You ask the patient the questions. If they have two to three criteria it's a mild use disorder. Four to five it's a moderate opioid use disorder and six or more it's a severe opioid use disorder.

Speaker 1:

In my line of work I don't actually do this. If they come to see Addiction Medicine, it's usually a bad problem. But if you want to get into the nuts and bolts you can actually do this. As an example, I had someone who was identified as having a problem with alcohol and they need me to sign off on forms going back to work and in that case I got into this specific criteria. But usually if someone comes to me and said, hey, doc, I need help, they definitely have a use disorder.

Speaker 1:

Next slide, please. All right, so let's go ahead. This slide is out of order. Okay, so here are the criteria for opioid use disorder. And again, it's compulsive use, cravings, consequences Opioids are taken in larger amounts for a longer period of time.

Speaker 1:

People want to cut down but they can't. People are doing a lot of activities to get the drug or recover from the drug. They have cravings. They're not fulfilling their obligations at work, school or home, they continue to use the opioid despite having problems. Next slide, please. And then they're giving up activities because of the drug. They're using it when it's hazardous, they know it's making their health worse and they continue to use. And then, because of persistent use, they develop tolerance and withdrawal. So that's the basic criteria and again, I would encourage you, if you want to look them up, truly, just Google DSM-5 opioid use disorder criteria and you'll be able to look them up. Truly, just Google DSM-5 opioid use disorder criteria and you'll be able to look them up. All right, next slide, please.

Speaker 1:

So buprenorphine is one of the medications that we can prescribe for opioid use disorder and opioid use dependence. Okay, this medication used to be restricted and now, if you have a valid license in DEA, you can prescribe it, which is great. It's a very interesting molecule. The generic name is buprenorphine. It comes in several preparations. There's sublingual, which is suboxone or subutex. It comes as a patch called butrans. There's some other formulations, like Zubzolve, that are different proprietary formulations, but the basic idea is that it's buprenorphine that's doing the heavy lifting.

Speaker 1:

Okay, buprenorphine binds tighter to the opiate receptor than anything else we know of, so it has a very tight binding affinity at the opioid receptor, but it's not a complete agonist. What does that mean? It will out-compete other opioids at the opiate receptor to bind and it's less euphoric and doesn't cause respiratory depression the way other opioids do. So let's say, one of my patients is on buprenorphine and they use fentanyl Because buprenorphine binds so tightly at the opiate receptor. The fentanyl is largely inert. So that's one of the reasons I love it as an addiction doctor is, once my patients are on bup, I do this. Oh, thank goodness. Right, if they have a relapse, they're protected.

Speaker 1:

Now the activation of the opiate receptor by buprenorphine it's only a partial agonist. It's enough to treat cravings and withdrawal and help with pain, but it doesn't really have euphoria. Again, there's what's called a ceiling effect where you really can't overdose on it. You can just keep going up on the dose and people will not get respiratory depression or overdose the way we do with other opioids. Next slide, please. So it is a schedule three medication, so it is something that requires a certain amount of oversight and monitoring. And it is FDA approved for both opioid use disorder and pain, and let's just take a quick minute here and talk about pain. So if you don't know the other part of my addiction medicine practice is with some of the local pain physicians. You guys probably know Sular Deldar, so he's one of our local pain docs. We're in the same practice. So I actually have a disproportionate number of pain patients in my addiction practice.

Speaker 1:

Full agonist opioids like hydrocodone or oxycodone or morphine change the pain sensitivity over time. Here's how I think of it. Pain is protective. Right, If I go to put my hand down on my desk and my desk is hot, I need to be able to pull my hand away so I can protect myself. The brain does not actually like being on opioids because it realizes it cannot protect itself if pain is present and just to level set.

Speaker 1:

Pain is meant to be an acute response. Chronic pain is non, it's non-functional pain. It doesn't alert the body of any tissue damage. So our response to chronic pain is somewhat maladaptive because we keep thinking tissue damage, because we're used to acute pain. So chronic pain is a special thing that is addressed separately. But basically the brain thinks, uh-oh, opioids are making me not able to feel acute pain. I better dial up the pain sensitivity so I could protect myself if I need to.

Speaker 1:

So these poor patients on full agonist opioids end up with worse pain over time. It's called opioid-induced hyperalgesia. It's a fancy way to say. Your pain goes up over time due to increased pain sensitivity with chronic opioid use. There are two opioids that we know do not do this to the same extent as other opioids, and they are methadone and buprenorphine. So in our pain practice we don't start really anybody on oxycodone or norco or morphine. We really start everyone on either methadone or buprenorphine. So it's actually more effective than other opioids for pain.

Speaker 1:

Next slide, please. So we talked about some of the unique things about buprenorphine. We talked about how it protects against opioid-induced hyperalgesia Because it blocks the effects of other opioids and protects against respiratory depression. It absolutely saves lives in people with opioid use disorder. People's risk of dying from opioid use disorder through overdose once they're on buprenorphine is down by 70% compared to if they're not on it. Very effective, and then, as I mentioned, it does not cause euphoria and we can talk about the dosing.

Speaker 1:

Next slide, please. As I mentioned, this used to be something that was restricted by the DEA and that is now completely gone. If you have a valid DEA, you can prescribe it. Patients tell me all the time oh, the doctor said they couldn't prescribe it. Thank you, joe Biden. All politics aside, under the Biden administration they got rid of this requirement in early 2023. Next slide, please. Okay, when should you use buprenorphine? Well, we've been talking about it. It's very effective for opioid use disorder the addiction side of things. It also is an opioid, so it will keep people out of withdrawal, so it manages opioid dependence, and it also can be used for pain, both acute and chronic. Next slide, please.

Speaker 1:

There are a couple of contraindications. Like other opioids, if combined with multiple sedating substances, it can result in overdose. Buprenorphine by itself is really unlikely to cause an overdose because of that ceiling effect. Again, it only opens the opiate receptor partway, which is why it doesn't cause respiratory depression. But if you mix it with alcohol or benzos, the downer effects of the different classes can add up.

Speaker 1:

Buprenorphine is metabolized hepatically. There's some older literature that showed that it was causing people's LFTs to go up. We still don't fully know yet and that's probably overblown. But if somebody has cirrhosis you need to choose another medicine and, as I mentioned, should be avoided with heavy alcohol use. But if you think about it, given that buprenorphine does not cause respiratory depression, if you have a patient with alcohol use disorder who is in pain. Buprenorphine is going to be safer than, say, oxycodone. Next slide, please. All right, dosing.

Speaker 1:

So there's a ton of different formulations of this stuff. I'll keep it really easy. 90 to 95% of this medication is given in the sublingual form. It comes as a tablet by itself. Buprenorphine is called Subutex. And then there's another product where naloxone is mixed in the naloxone doesn't do anything. It gets excreted in the stool. But if somebody tried to snort it or smoke it or inject it they would get withdrawal. So I actually don't care. They taste a little different, they dissolve differently in the mouth. I let the patient choose.

Speaker 1:

For someone who is opiate sophisticated meaning they have a history of opioid dependence, they've been on opioids or they've got opioid use disorder I usually start them on somewhere between about 8 to 24 milligrams a day. For someone who's opioid naive, it's more, like you know, 2 to 6 milligrams a day. For someone who's opioid naive, it's more, like you know, two to six milligrams a day. So let's say, for example, I, you know, have to have shoulder surgery next week. I would probably take something like one to two milligrams of bup three times a day. But if 10 years down the road I've developed a fentanyl addiction, then I would probably be on something more like 24 to 32 milligrams a day. It also does come as a once a month injection for those with addiction, which we do all the time in the office. It's absolutely wonderful.

Speaker 1:

Next slide, please. The only other thing I would point out on this is that if people do swallow buprenorphine it really doesn't get absorbed. It's only like 10 to 20% of the dose. So if people are starting it, we have to instruct them to take it sublingually. And we talked about dosing. All right, next slide, please. It's important to realize that it's a very potent opioid, which is why the dosing is so low. For opioid-naive patients. One milligram of sublingual bupe is about 30 to 40 morphine mill equivalents. So that's pretty potent. And in the era of fentanyl people have such incredible opioid tolerances that are just through the roof. Buprenorphine is actually one of the only opioids that is a potent enough agonist to keep them out of withdrawal. Even methadone some of my patients get put on these ridiculously high doses of methadone and they're still in withdrawal. I think we covered everything on this slide. Next slide, please.

Speaker 1:

Okay, so let's say you're thinking about putting a patient on buprenorphine. What would you want to do before you start? Well, if they have obvious signs of liver disease, as in you can see it from across the room on physical exam they are not a candidate for bup and, sorry, we abbreviate buprenorphine as bup. So if somebody has significant, significant liver dysfunction, choose another med. It's recommended to check LFTs periodically. I have dozens and dozens of patients on this. I don't check LFTs Lee Goldman, for context, maybe does it once a year. The risk of it causing liver dysfunction is overstated. And then it's important to know are they using other substances? Are they using meth? Do we want to address that? Are they using cannabis? What other substances do we need to address while we're working on getting them on bupe? Next slide, please.

Speaker 1:

Pregnant patients can get opioid addiction as well, and the treatment for opioid addiction in pregnancy is methadone or buprenorphine. We dose it almost identically. In terms of buprenorphine, it used to be that we only used the monoproduct, the buprenorphine, or Subutex, in pregnancy, but it's now been found that both suboxone, which is the buprenorphine naloxone, and buprenorphine by itself are both safe in pregnancy and essentially you dose them until they don't feel cravings and they don't feel withdrawal. It is recommended that we do not taper people off of opioids during pregnancy because there is an association with preterm labor and opioid withdrawal.

Speaker 1:

In terms of youth, we treat youth with buprenorphine all the time. I think our youngest on bup is 14. In the practice the dosing is fairly similar because most kids by about 14 are pretty close to adult size and it's important to know that any child 16 and older can consent to bup without parental consent. I know parents and addiction. It's a difficult population. The parents have obviously high expectations for their children. The teenage brain is not super responsive to insight, it's still growing, so that can be a difficult population. So kids can get bupe on their own. 16 and older. Next slide, please.

Speaker 1:

Common things in terms of side effects it's an opioid. It's an opioid agonist. It's a partial agonist. So you're going to get the same stuff you get with opioids constipation, nausea, drowsiness when we give the once a month shot. It's called Sublocade, that's one brand and Brixadi is the other. It's essentially a shot where they don't take medicine every day, they just get a once a month shot. So compliance is great. They usually get an injection site reaction.

Speaker 1:

And then we are unfortunately seeing that there's increasing literature that sublingual buprenorphine in either the subutex or the suboxone is associated with dental carries. So I've got a couple of folks that have come to me and said I got to get off this stuff, I'm losing teeth. I didn't know about that until recently. Really disappointing because it works so well. If that is the case, if it's a pain patient, you can transition them to the transdermal, the Butrans, which is FDA approved for pain and it's for opioid use disorder. You can use the patch off label. But we might need to transition that patient to the sublocate or the brixati, the once a month injection. So if you're having trouble with somebody on bup and they're having dental caries issues, absolutely you can refer over to Addiction Medicine and we'll see what their options are.

Speaker 1:

Next slide, please. Okay, how do you start this stuff? If buprenorphine had a kryptonite it would be this For an opioid-naive patient. You can just start it right. So let's say one of your patients has an upcoming surgery and you want to start them on buprenorphine in advance of surgery. Go ahead and write, for you know two milligrams of Subutex or Suboxone, you know a half to one three times a day for pain, or four times a day for pain, no problem. Now for people that are dependent on opioids. They have to be in a period of withdrawal before they start buprenorphine, and it's a major problem and frustrating. Here's how this works In my brain. This is how I understand it. Let's imagine that we're driving a car and that car is fueled by opioids A full agonist opioid, meaning it activates the opioid receptor.

Speaker 1:

All the way is going to take you to 100 miles an hour. Morphine, oxycodone, hydrocodone, fentanyl they all take you to 100 miles an hour. Buprenorphine, because it's only a partial agonist, takes you only to about 60, 65. You're going fast enough that you're not in withdrawal or craving, but it doesn't push you all the way up to some of that level of euphoria. So if you take buprenorphine when you have a full agonist opioid in your system, buprenorphine binds more tightly to the opiate receptor than anything else we know. So buprenorphine will actually kick those other opiates off the opiate receptor. So it's literally like going from 100 miles an hour and slamming on the brakes and going down to 65. And that's called precipitated withdrawal. So people will go into withdrawal when they start buprenorphine, unless they're already in withdrawal. So the idea would be is if they're driving 100 miles an hour on opioids as the opioids wear off they'll slow down. We have to get them like down to 30 miles an hour in bad withdrawal and then bring them up with buprenorphine.

Speaker 1:

It's a little frustrating and certainly you know you can refer to addiction medicine if you're having trouble getting someone started on this. For people who are on regular opioids, like an oxycodone or even heroin, it's only about a 12-hour wait. You can have them take their last dose of opioid or use heroin at 10 pm and then they can start buprenorphine the next morning. For fentanyl it's a much bigger problem. Fentanyl is lipophilic so it builds up in the body for days. Usually those folks have to wait even up to three days to get enough fentanyl out of their system that they're ready to start buprenorphine. It's a really frustrating problem.

Speaker 1:

Next slide, please, and then once patients get on it, their withdrawal is better. If they're a pain patient, their pain is better and then their cravings are better and essentially you titrate to the dose where if they have pain they're feeling better and if they have opioid addiction they're, you know, not craving and if they're dependent they don't have withdrawal and I let them self-titrate. I'll just say you know here's, you know up to where you could take about 24 milligrams a day. Tell me what dose feels right and people will self-titrate. Some people will take one in the morning and they're good for the day. Some people will take two in the morning, one in the evening. Almost all of my patients have a different regimen and I let them choose whatever works for them. Again, because of its incredible safety profile. If somebody starts escalating the dose on their own, I don't have to worry about them having an overdose. Next slide, please.

Speaker 1:

It is a controlled substance, so you're going to want to see your patients pretty regularly, initially until they stabilize and then, once they're stable, it's I mean, I do this once a month with some of my patients. I've got some folks that are, you know, 10 years sober on bupe and I just see them once a month, give them a high five. We chat about, you know, sports teams and we send them on their way. It's exceptionally effective for folks to stay in long, long, long-term recovery. Again, if you're, if you want to monitor liver function tests six months to once a year would be totally fine, all right. Next slide, please. And then the last thing would be just realizing that if folks do have underlying opioid addiction, relapse can happen. So making sure they have naloxone and getting them into some sort of supportive community around their sobriety is very important. Next slide, please. So once again, take-home points.

Speaker 1:

Buprenorphine saves lives. You can use it for patients with opioid use disorder. It also treats pain. It treats opioid dependence and withdrawal. Anyone with a valid DEA can prescribe it and it has unique pharmacology which means that it is protective in relapse because it blocks the effects of other opioids. But it is a little bit hard to start, as you have to be in a period of withdrawal before you start as an opioid dependent patient. Again, for opioid naive patients, you can just start it straight off. Next slide, please.

Speaker 1:

Okay, so we are now going to go on to alcohol and I just briefly want to rant about alcohol. I feel like I'm in a ranty mood today. So it's interesting. We call it alcohol and drugs like. Alcohol's not a drug, and recently we had the Pebble Beach Food and Wine Festival. For some reason we have decided that alcohol is okay and it's our one societally acceptable drug. If I asked any of you like, hey, should we go wine tasting this weekend? You might say, gosh, that sounds great. If I told you, let's go methamphetamine tasting this weekend you'd look at me like I had three heads. So in terms of what I do, alcohol is like any other substance and it's actually harder for my alcohol patients because alcohol is freaking everywhere. There are liquor stores. I think there's like three liquor stores on the way home from my office to my home. 7-eleven sells alcohol, gas stations sell alcohol, wineries, distilleries, local breweries it's just everywhere.

Speaker 1:

Number one addiction in America is alcohol. So alcohol dependence is the phenomenon where people, again their brain chemistry, changes because of regular use. It's a little harder to predict who gets alcohol dependence than opioid dependence and most often we see it in people who drink heavily, in terms of the quantity, and people who drink throughout the day. For people who are nighttime drinkers, they tend to not have as much dependence because they'll have like a 20-hour period during the day. For people who are nighttime drinkers, they tend to not have as much dependence because they'll have like a 20-hour period during the day where they don't have alcohol in their system. It's really morning, noon, afternoon, evening, nighttime drinkers that we tend to see the most dependence Dependence can develop in again about the same time frame as opioids, usually about somewhere between a week or two of heavy use leads to alcohol dependence. Next slide, please. And then again, just like opioids, we have opioid dependence and opioid use disorder. We also have alcohol dependence and alcohol use disorder With alcohol because it's not prescribed medically, it's very, very unusual to have anyone who is dependent but doesn't have a use disorder.

Speaker 1:

I'm trying to think of a scenario where some would be dependent on alcohol without having a problem. I don't know if I can come up with one, but the idea is again is that we have to treat two issues they are dependent on alcohol and then they also have an alcohol use disorder. The treatment of alcohol dependence I'm not going to cover in this, because sometimes it requires inpatient hospitalization or ICU care. But the basic idea we're going to talk about today is, once people are through their dependence, we have to work on helping them not go back to drinking. So same thing, it's those three C's with alcohol use disorder, just like opiate use disorder, cravings, compulsive use and consequences. Next slide, please.

Speaker 1:

Just one point on alcohol withdrawal, just because it is pretty important. Alcohol withdrawal is fairly unpredictable. We have some people that we admit you know with Dr Goldman who we are sure are going to have bad withdrawal not so bad. One of my patients, literally today is getting discharged. She was so afraid of bad withdrawal, was drinking 16 beers a day, minimal. I had one 19-year-old who I was sure was going to be just fine and ended up hospitalized with alcoholic hallucinosis. The single biggest predictor of bad withdrawal is previous withdrawal. So if you're talking to someone in the clinic and they're talking about stopping and you think like, yeah, I can probably give them a couple days of Valium, get them off alcohol, a really important question to ask is have they had bad alcohol withdrawal before? In which case most likely we'd want to have them assessed at the hospital, and in my career in the ER, sometimes what we do is we just put them in a room and let them metabolize and if they don't develop bad withdrawal, we know they're safe to go home. All right, next slide, please.

Speaker 1:

So the diagnostic criteria for alcohol addiction or alcohol use disorder are very similar to the ones from opioid use disorder and it's actually in the same reference, the Diagnostic and Statistical Manual 5th edition. There are 11 criteria and it's the same threshold 2 to 3 is mild, 4 to 5 is moderate, 6 plus is severe. Next slide, please, and you'll recognize these criteria for alcohol use disorder because they are exactly the same as opioid use disorder. The only difference is they say alcohol instead of opioid, so trying to cut down giving up other activities to use the substance craving is not able to manage their obligations. Consequences Next slide, please. And then the same thing using it when it's hazardous, particularly around driving, and then tolerance and withdrawal. So very similar in terms of how we diagnose alcohol use disorder and opioid use disorder. Next slide, please. Okay, so we have three FDA-approved medications for alcohol use disorder and I just want to remind you all these do not treat dependence or withdrawal. They are for the alcohol use disorder, craving, compulsive use side of things. So let's go through them. Next slide, please.

Speaker 1:

All right, so the first one is called disulfiram and most people know it by its brand name, antabuse, and this is the one, for some reason, that everybody thinks of. The mechanism of action is it blocks alcohol metabolism, leading to a toxic buildup of one of the metabolites of alcohol, and it basically makes people sick. So somebody drinks alcohol on day sulfuram, the toxic metabolites of alcohol build up and people will get nausea, vomiting, flushing, upset stomach, a general sense of malaise when they drink. I was always taught that it's fairly minor. It actually can be life-threatening. If somebody binge drinks with disulfiram in their system it can be fatal.

Speaker 1:

The toxic metabolite of alcohol that builds up is cardiotoxic, so you can get hypotension, bradycardia and cardiovascular collapse. I have seen it once. There was a gentleman that came into the emergency department as a lights and sirens code three near death ambulance run and he looked like garbage. Oh my gosh. His pulse was like 40, his blood pressure, I think it was like 60 on 40. We tanked him up with fluids and I couldn't figure out why he was hypotensive. And then I looked at my drug reference and it cautioned against binge drinking while on disulfiram. So definitely not an option for anyone who's binge drinking. And that's actually why there are contraindications of cardiovascular disease, because if somebody drinks on disulfiram it can exacerbate their underlying cardiovascular disease. It is hepatically metabolized, so somebody with cirrhosis is not a candidate.

Speaker 1:

And I put the dosing on there 250 to 500 milligrams a day. How well does disulfiram work? The answer is it doesn't. Maybe maybe in some unusual clinical circumstances where somebody's really motivated and very afraid of health consequences and they've got a loved one that's going to make them take it every morning. Be in some unusual clinical circumstances where somebody's really motivated and very afraid of health consequences and they've got a loved one that's going to make them take it every morning. For the most part, people will just stop taking it and drink. So I usually don't prescribe it. I have one patient on it right now and he's about to be kicked out by his parents. So the agreement is we watch you take your disulfiram in the morning or you leave the house. So he's very motivated, has a lot of support and it's again that regimented way of using it.

Speaker 1:

One other thing people need to be off alcohol for three days around this medication, otherwise the residual alcohol still in their system can cause those unpleasant side effects when the alcohol metabolite is built up in the system. All right, next slide, please. So the next one is one of the ones I use the most and this is naltrexone. So naltrexone is an opioid blocker. Think of it like Narcan for 24 hours. The way it works is when some people who are genetically predisposed to alcohol addiction drink, their brain releases more dopamine than the average person, dopamine being again the reward chemical of the brain that makes us feel good, and that excessive dopamine release causes endorphin relief. So they get a double high from alcohol. They get the pleasure release of the dopamine and they get the calming opioid effect of the endorphins. So what naltrexone does is it blocks the endorphins, so it actually makes alcohol less pleasurable. And interesting. What we know about craving and the anticipation of use is when somebody who has an addiction to alcohol pulls into the parking lot to buy alcohol, the brain starts to release dopamine and those endorphins in anticipation of the drug. So naltrexone makes the drug less pleasurable and thinking about the drug less pleasurable, which is how it blocks cravings.

Speaker 1:

Now, unfortunately, not everyone consumes alcohol for the same reason. If you consume alcohol because you're anxious, this one doesn't really work. They're not seeking the pleasure, they're seeking the downer effect. If you consume alcohol because you're anxious, this one doesn't really work. They're not seeking the pleasure, they're seeking the downer effect. If you drink alcohol because you can't sleep, this one doesn't really work. You're not trying to get the euphoria, you're trying to get the downer effect. So it only works in a percentage of patients. The two big side effects and I see this all the time is somnolence and nausea, and usually that's something that goes away with time. So I usually start people on a half dose of the oral medicine for a few days to let them get used to it before they go to a full dose, and then it will cause horrible opioid withdrawal if they're on opioids regularly. So anyone who's on opioids is not a candidate for naltrexone, and then anyone with cirrhosis should not get it as well.

Speaker 1:

It is given as an oral medication and it can be taken daily to block cravings, like I get up in the morning and I take it so I don't drink. It also can be used as needed, like I'm about to go to a wedding and I don't want to drink, I'll take my naltrexone right before. And you can do both. So daily dosing as an anchor and then as needed on top of that. And then it also comes as a once a month shot which is called Vivitrol. I give I don't know a couple of those a week. It's given as a once a month injection so people can't again stop the naltrexone and go back to drinking.

Speaker 1:

Next slide, please. How well does it work? It's okay. So the number needed to treat to reduce drinking with naltrexone is somewhere between 12 and 20. So what that means is is I have to treat somewhere between 10 and 20 people to see it be effective and that's pretty consistent with my my clinical practice most people, for most people it's just not a oh wow, doctor. Thank you, it works a little bit in most people. I have a handful of patients that have horrible alcohol addictions and they take naltrexone and the desire to drink goes completely away. It is absolutely a miracle drug for some people, but for the vast majority of people it helps a little.

Speaker 1:

So often what I do with naltrexone is I combine it with another medicine and then the anti-craving effect of naltrexone is combined with another, say gabapentin, and then the two anti-craving effects are additive. So that's usually what I do. The IM once a month shot does work better. The number needed to treat to reduce alcohol is six, and that's likely because the compliance is better. Next slide, please, oops, other direction. There we go.

Speaker 1:

Okay, acamprosate this is one that I had never heard of until I sat for my addiction boards and I didn't use. And it works great, way better than naltrexone. So what acamprosate does is it actually mimics alcohol's effects in the brain to a very minor extent. So alcohol makes GABA, which is a downer brain chemical. Alcohol makes GABA work better, which is where the downer effects of alcohol come from. And then we have glutamate, which is the brain's natural upper chemical. Alcohol makes glutamate work less well, so let's think about that. Alcohol makes GABA work better, so that's a downer effect, and alcohol makes glutamate work less well, so that's another downer effect. So essentially, alcohol is a double downer.

Speaker 1:

And so what acamprosate does is it does that same thing, but on a very tiny amount, and the best way I can describe it to people it's like you've had a half of a beer. It just takes the edge off. It's actually fairly effective for people with anxiety. That's where I've had the most success with it. Unfortunately it is renally cleared, so it cannot be used if somebody has renal insufficiency. But in people who have liver disease or are on opiates this is a great choice. I've actually not had anyone have side effects on it, but the manufacturer notes that diarrhea is the most common side effect.

Speaker 1:

Now I don't know if anyone is superstitious, but the dosing is weird. It's 666 milligrams three times a day, so it's six pills a day. Most people can't remember that. So you can dose it BID and then the compliance is a little bit better For my older patients who were already on a bunch of meds. Then I just put them on three times a day and they put it in the pillbox. How well does it work? Well, the number needed to treat to reduce drinking is between 9 and 12. So let's compare that to naltrexone, which was between 12 and 20. So it's more effective than naltrexone and it works better the longer people are sober. So if somebody gets admitted, gets detoxed and then they come out, that's a great time to start a campersate. Next slide, please. Now.

Speaker 1:

If you dig into the literature, there's been all sorts of stuff that's been studied for alcohol use disorder in terms of cravings, been studied for alcohol use disorder in terms of cravings Topiramate, baclofen, gabapentin, frazacin. There's all sorts of stuff. We just went over the FDA approved medications. There's only three of them, but I use off-label meds for alcohol use disorder all the time. The one that we're all probably the most familiar with is gabapentin, and so I usually do put people on gabapentin for alcohol use disorder. It does help with mild withdrawal and it does help with cravings. I usually dose it somewhere between 300 and 600 TID and you can take an extra dose of bedtime to sleep. If you are interested, you can certainly look up to pyrimate and baclofen on how to use it for alcohol use disorder. But yeah, I usually start either ac, campersate or naltrexone plus something else when I'm treating my patients with alcohol use disorder.

Speaker 1:

Next slide, please. Okay, take-home points here. Naltrexone makes alcohol less pleasurable, so if somebody drinks it doesn't feel as good and it makes the thought of consuming alcohol less pleasurable. A campersate works on that chemistry in the brain around alcohol and makes people less likely to want alcohol because it mimics alcohol to a very, very tiny extent. And the disulfiram is the so-called enforced sobriety of people will get sick if they drink and it largely is not very effective. Next slide, please. And it largely is not very effective. Next slide, please. Okay, couple of things just to share. You know, just in general is for our patients using opioids.

Speaker 1:

The drug market is drastically different than it was about five to six years ago. So brief history. Where did America's problem with opioids start? It started with prescription medication. So when I was in college my friends loved Vicodin. I don't know why Vicodin, but a lot of my friends use Vicodin. I had no interest in it. Vicodin is now off the market. It is hydrocodone and acetaminophen. It used to be that if you got a pill from the non-legal market. It was a prescription that had been diverted, so it would be oxycodone. That was a legitimate oxycodone.

Speaker 1:

Starting in about 2019, here in Monterey County, everything changed. Fall of 2019, specifically October, is exactly when fentanyl arrived in our drug supply. Initially we were seeing it really just as counterfeit pills. So people were buying an oxycodone and it looked like an oxycodone. Maybe it was a little more likely to crumble than a regular pill, but people had stamps they were able to press fake pills. All of it contained fentanyl. Now, unfortunately, we're seeing that fentanyl is not the worst. We are now detecting acetyl fentanyl, acryl fentanyl, paraflora fentanyl, even some weird novel benzos like atizolam and bromazolam. The illicit market changes very regularly with all these research, chemicals being pressed into counterfeit pills. The majority of my patients use fentanyl in the form of counterfeit oxycodone.

Speaker 1:

So be liberal in co-prescribing naloxone, you know, refer people for treatment and then also realizing that a lot of patients, particularly older patients, were put on multiple scheduled sedating medications at the same time and trying to come up with safer regimens can be a win. Let's say someone comes to you on fairly high-dose oxycodone and high-dose clonazepam. If you're able to wean the dose down to the clonazepam and transition them from oxycodone to buprenorphine. That is a safer regimen. So sometimes we're stuck with these older regimens, but that is a safer regimen. So sometimes we're stuck with these older regimens, but at least we can make them safer.

Speaker 1:

Next slide, please. Oh, stigma, good heavens. Stigma's really hard. Stigma is the judgment of one group by another based on a particular attribute that they have. And in medicine, stigma is what patients feel when their healthcare providers judge them. Next slide, please. And it comes up in all sorts of ways. We might make one patient wait longer because they're a quote difficult patient In academic medical centers. Sometimes they'll make the medical student see the patient with the undesirable diagnosis. We often attribute blame or intent in non-compliance to patients based on their diagnosis. Oh, you know? Oh, that patient was schizophrenia. He doesn't want to be on his meds. It's important to be very objective with our patients. We really need to check our biases and realize that we can have implicit bias about particular conditions.

Speaker 1:

There is stigma in healthcare about all sorts of stuff Psoriasis, epilepsy, urinary incontinence, dementia, addiction, depression, ptsd. Medical providers may make patients feel judged for all sorts of stuff. What can we do? There's two simple things we can do. The first is really avoid terms of the judgment. Please don't call it a dirty urine drug test, right? Think about that. We're calling the patient dirty. It is an abnormal urine drug test, right? They didn't come in here because they're using cocaine to be called dirty. They came in to be treated for their cocaine use disorder. Let's call it an abnormal urine drug test, or? Hey, their urine drug test was positive for cocaine. The other thing is let's call patients what they are, which is people. I have asthma. I am not defined by my asthma. I would prefer the term a patient with asthma rather than an asthmatic.

Speaker 1:

Simple things avoiding stigmatizing language and using person-first language, where we say a 35-year-old male with alcohol use disorder instead of a 35-year-old alcoholic, can make a big difference. Next slide, please. The other thing we have to realize is addiction is fairly common. One in seven americans will develop an addiction at some point in their lives. Our organization employs maybe like 4 000 people. That's somewhere between 500 and 600 people in our institution that could have lived with or be living with addiction. So if you make a remark that alcoholic, what's the doctor in the next office hearing? Could their best friend be in recovery? Could their wife be still in active addiction.

Speaker 1:

We had a Schwartz Rounds talking about stigma and one of our social workers reported being in recovery and how hard it was every day to hear her colleagues judge people with alcohol addiction because she had lived with it herself. Also, just even recognizing that stigma happens, and sometimes it's so built in that term dirty urine we are taught that throughout our careers. It's so easy to not realize what we are doing is stigmatizing. Next slide, please. So, yes, our words matter. I think this quote is up. Next, if we want to kill something, we call it a weed. If we want it to grow, we call it a flower.

Speaker 1:

The words we use around our patients confer judgment and convey our intent, even if it's not explicit. Just saying you know to somebody and calling them something like a junkie, oh, as such a judgmental term lets them know that they're already in an uphill battle with their healthcare provider. Next slide, please. Here are some examples of what we talked about person-first language A person with anorexia rather than an anorexic. This is my biggest pet peeve when psychiatrists call people crazy. There is no DSM-5 diagnosis for crazy. Call it what it is Psychosis, anxiety, dependent personality disorder. The word crazy just confers judgment. We really need to continue to work on person-first language and avoiding judgment. Next slide, please. I knew this quote was coming up Once again if you want to care something, you call it a flower.

Speaker 1:

If you want to kill it, you call it a weed. The words, and the choice of our words makes a big difference. Next slide, please. So yeah, addiction is killing Americans. About 750,000 Americans will die every year from drugs, alcohol and cigarettes. Bupe is amazing. It is life-changing for my patients and we underutilize medications to treat alcohol use disorder. 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.