Addiction Medicine Made Easy | Fighting back against addiction

Breaking Barriers: Creating Patient-Friendly Addiction Treatment

• Casey Grover, MD, FACEP, FASAM

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Dr. Amy Swift, Deputy Chief Medical Officer and addiction psychiatrist, shares insights on creating healthcare systems that better serve patients with addiction through reduced stigma, trauma-informed approaches, and greater accessibility. She brings a unique perspective as someone who oversees medical care while remaining deeply connected to patients' experiences, emphasizing the need to understand addiction as a brain disease rather than a moral failing.

• Psychiatry and addiction have historically been separated, with mental health providers often telling patients to "get sober first"
• Understanding executive functioning challenges in addiction helps create more flexible, accommodating healthcare systems
• Stigma against addiction is pervasive in healthcare and actively prevents people from seeking life-saving treatment
• Person-first language and creating welcoming environments are crucial steps in reducing stigma
• Virtually all patients with addiction have experienced trauma, requiring trauma-informed approaches to treatment
• Different trauma responses can drive different patterns of substance use – numbness often leads to stimulant use while hyperarousal leads to depressant use
• Family involvement and education are essential components of effective addiction treatment
• Youth education and prevention efforts are critical, particularly around cannabis and newer substances perceived as harmless
• Healthcare leaders must recognize addiction as a brain disease requiring the same compassion and quality of care as other medical conditions

If you're interested in improving addiction care in your healthcare system or community, focus on reducing stigma, implementing trauma-informed approaches, and creating flexible systems that accommodate the unique challenges faced by those with addiction.

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 Dr Amy Swift, who is an addiction psychiatrist on the East Coast of the United States and, in addition to taking care of patients with addiction herself, she's also a deputy chief medical officer, meaning that she oversees the medical care of the patients in her health system. She and I had a great conversation on how to improve healthcare for patients with addiction, as in how can we make healthcare more accessible and friendly for people with addiction, and, given her role supervising a healthcare system as a deputy chief medical officer, she had a lot of great insights. I am hoping that healthcare executives could take a listen to this episode, as she has a lot of great insight to share and it sounds like the institution that she has a lot of great insight to share and it sounds like the institution that she works at is doing great work With that let's get started, all right. Well, good morning my time, good afternoon your time. Why don't we start by having you tell us who you are and what you do?

Speaker 2:

Thanks so much. I am Dr Amy Swift. I am Deputy Chief medical officer of a freestanding psychiatric hospital in New Canaan, connecticut, called Silver Hill Hospital. How did you get into that role? Services at Mount Sinai and I lived out here and so I approached them, I told them what I do and they created a position for me to help create a dedicated effort of treating addiction on this campus in both our inpatient and residential settings.

Speaker 1:

So I tend to focus on the micro stuff, because I'm a doc seeing patients in clinic and you're zooming out and seeing more of the system and you've obviously practiced before. Which do you like better Boots on the ground or seeing the whole system?

Speaker 2:

Well, that's. The thing is that I am somebody that sits above the system and sees all the boots on the ground. So if you ask me how many patients are assigned to me today, I'll say zero. If you ask me how many patients I've seen today, I'll say 10 to 15. It is the idea that you can't make changes in a hospital system without knowing who's in your hospital.

Speaker 1:

So I go to the patients.

Speaker 2:

I see them, I do it all.

Speaker 1:

Do you want a job in California? I like your approach already.

Speaker 2:

Listen, I'll talk to my family about it.

Speaker 1:

Yeah, yeah, Okay, we talked a little bit before we got started. I got a bone to pick with psychiatry and I'm going to pick on you and it's obviously not you. I'm trying to be funny. My daughter is, I'm sure, rolling her eyes because of my bad dad humor, but I'm really curious. A lot of times my patients go to get mental health services and they get told get sober and then I'll see you. And as an addiction doc it's all mushed together and I don't get a chance to pull it apart and a lot of what I do as an addiction doc is a mix of pharmacology and psychiatry. Do you have a sense of where that history comes from of mental health services saying get sober and then I'll see you?

Speaker 2:

I think it is a discomfort with understanding what addiction does to our mental health and it is the reason I got into addiction originally is I never wanted to be somebody that said go do something else with someone else until I can treat you. If you don't know how to treat addiction, then you can't be a comprehensive psychiatrist because they are intermingled. So I think it's just a historic discomfort with the stigma that rests with addiction.

Speaker 1:

Yeah, I have a number of therapists locally that I refer to and they tell me whoa, we don't do addiction and I'm thinking I'll manage their alcohol use disorder, but minus prescribing medications I can't fix their PTSD. You do the PTSD part, I'll take the rest and actually I'm really grateful they're going to host me for an in-service so I can do some education on that. But yeah, it's a frustrating problem. What was your experience in your psychiatry residency around addiction?

Speaker 2:

acute and the patients that were really suffering. So I learned early on how to manage acute agitation, withdrawal, post-acute withdrawal, all the things that come up for patients that are struggling with addictive disorders, and so it was ingrained into how I practice psychiatry in general. So that's where the trajectory started. But I do as I became further in my career and I was actually the program director for the Addiction Psychiatry Fellowship I learned as I took fellows from other places. Some residents had zero exposure and knew nothing. So it really varies across the country in how psychiatrists are trained to manage addictive disorders.

Speaker 1:

Do you think your residency training is what pushed you into doing a fellowship in addiction psychiatry?

Speaker 2:

Absolutely Many people go into addiction because they had personal experience with it or a family member. I went into it because it was hard and I was going to do the hard thing. It was the patients that caused the most kind of ruckus. They were the most complex, they were the hardest to navigate. The personality constructs, the irritability, that stuff. And that's the thing that I think really allowed me to pursue the field is being exposed to it and then feeling like I could master this.

Speaker 1:

Yeah, I think the other thing that makes people pull away from treating patients with addiction is I've learned to think of addiction as a disease of executive functioning right. It's managing a calendar, it's showing up on time, it's deciding to buy groceries or whatever substance. And I have to say some of my patients are really frustrating because they're always late or they always get the wrong day. In fact, the other addiction doctor in the practice, the very beautiful Dr Reb Close, who is my spouse, she just does walk-ins on Mondays, like that's all she does. Come sometime on Monday and I'll see you, and it actually works fairly well. What has your experience been around people being frustrated by the lack of executive functioning in patients with addiction?

Speaker 2:

manage the rigid requirements for the reasons you described. So that's why we see the attrition rate. But the other thing is the reason that I describe to patients about why I recommend rehab is because their decision-making is coming from a different part of their brain due to the use of substances, and I tell them that we need to get a break from that part of the brain driving the car so I can get it back to the front part that actually drives the car with executive function. So I think that both parts are important to understand from our provider perspective, but also from the patient perspective.

Speaker 1:

I'm going to try to be funny again here. I mentioned I have bad dad humor. I keep thinking, wow, dr Swift really knows what's going on in addiction. As we're talking and I realized, yes, you're an addiction psychiatrist, of course you know what's going on, anyways. Okay, so now tell me what was it like transitioning to a leadership role? How did you have to zoom out and see the system?

Speaker 2:

The thing that I think is most important about seeing a system is being able to understand what the problems that different people will have within the system.

Speaker 2:

So, exactly like you're saying, in terms of looking at it from the scheduling perspective.

Speaker 2:

So the person that's getting the call from the person looking for a service that they say, okay, I'm going to come in for detox at 9 am we now have to know that that detox that's scheduled at 9 am is going to show up somewhere between 9 and 12.

Speaker 2:

We have to account for that, right, and so we have to put systems in place to be flexible to accommodate these patients. But also I then have to go to the person that's going to see the patient and give them some kind of scenarios If this person shows up intoxicated. Here's our two options, right, so it's being able to lay frameworks for people that aren't as skilled in knowing what addictive disorders can do to the presenting patient, to give them a narrative on how to manage it, how to interact with an intoxicated patient that comes in and is incredibly high on opiates, or if they're using Trank and they just look so sedated they're nodding, telling them how to manage that so that it doesn't become a panic and then a triage to some other setting that maybe we could have managed them here.

Speaker 1:

Yeah, so my first career was in emergency medicine, so I have to keep things really simple, because that's how my ER doc brain was trained to work. So what I'm getting from you is you're trying to make addiction care more patient-friendly. Does that sound right?

Speaker 2:

Yes, it does.

Speaker 1:

So you mentioned scheduling and protocols when someone comes in intoxicated. What else can we do to make addiction care more friendly?

Speaker 2:

I think that also de-stigmatizing it.

Speaker 2:

When I tell somebody that they're considering what to come in for, I give them personal kind of anecdotes about what they might experience when they come in and how it applies to the person in front of me.

Speaker 2:

So, for example, here in our setting we're in the middle of a very affluent community and nobody realizes it, but I detox so many moms from our community and they are. Every time one sits in front of me we have some of the same conversations how am I going to go back to the community and everyone's going to be having a wine at lunch and I'm not? How do I? Where do I tell them? I am for four to seven days, and so when I'm talking to somebody about what addiction treatment looks like, I explain to them that it's not just the discrete episode of coming in, it's how to navigate everything after, because you're starting a new journey, you're starting a new path and I don't want them to villainize this one episode and keep it secret, because all it does is a trickle-down effect of nobody else feeling comfortable coming in. I think that the idea that addiction affects a person that is defective in some other way has to be dispelled, and it has to be dispelled on multiple different fronts.

Speaker 1:

So let's put a quick pause in stigma because there is so much there. So I mentioned the other addiction doctor in the practice is my spouse. We actually just recruited two additional doctors so we just doubled our workforce over here in California doctors, so we just doubled our workforce over here in California. But my colleague and spouse, dr Reb Close. She practices addiction medicine on the street, in the jail, in juvenile hall and then she also has a clinic practice. The executive functioning and lived experience of somebody who's been incarcerated or unhoused is very different than a suburban mom in an affluent area. How do you approach those two patients differently?

Speaker 2:

So the first one you described was the bulk of my career before this, and now I work with a pretty different population and all the same principles apply. Every single one can be relevant to each other. The difference is how long it takes for the addiction to push them into treatment. The unhoused person gets picked up a lot quicker. The suburban mom I'm seeing her when her kids go to college Interesting.

Speaker 2:

And when she no longer has the ability to hide behind the tasks and everything comes out. So the difference between their disorders is when they present to treatment and when there's a lot going on in the background they can hide. When there's not much, it really pushes them into treatment earlier. But what I will say, the difference for me is on the backside In New York City, in the middle of New York City, with a population that had less resources. It was a lot harder for me to put things in place, the guardrails, to achieve sobriety here. If people have means and motivation, there's a lot we can do to get them a path that will hopefully work more successfully.

Speaker 1:

Makes perfect sense. Coming back to stigma, so I lecture professionally on stigma. So a few years back we were trying to do a hospital initiative around addiction and one of the goals was to do education on stigma. And we reached out to our national speaker provider I guess it's like a speaker bureau and there was no one to lecture on stigma. So they said hey, grover, you do it. There was no one to lecture on stigma. So they said hey, grover, you do it.

Speaker 1:

So I've learned through the National Library of Medicine and reviewing articles on the topic. I think, based on what I've learned, stigma affects addiction more than any other illness, fully being aware that stigma casts a very wide net epilepsy, urinary incontinence, psoriasis, depression but I think addiction is the most stigmatized and you and I both know that in the setting of addiction, stigma kills. In fact, my lovely bride and colleague, dr Reb Close. She and I had a gentleman we were working with at a syringe exchange and he was injecting and he got a fever and called Dr Close and she's oh my gosh, injection, drugs and a fever. You got to go to the hospital and he said no, they're going to judge me. And he died of stigma, with a secondary cause of death being sepsis, and so it's something we've done a lot of work on in our community. But I'm curious, since you and I talked about wanting to bring this up as a topic how does one, from the top down, work on stigma?

Speaker 2:

I think there are a couple of ways that we can really do it. One is a community presence where we comfortably are able to talk about these disorders in a way where we are approachable, we are not whispering it. I had a patient actually come up to me on the campus. I was walking the other day and she came up to me. She had been deciding between two of our residential programs and I had told her I thought she should go to our one for substance use and she had chosen the one for personality disorders. And it was really interesting because she came up to me on the campus she said, dr Swift, I want to go to the one for to Scavetta, the one for substance use. And I asked her, I said why. And she said she whispered to me she goes. Well, I'm borderline and I was like you don't have to whisper it, we don't hide diagnoses here.

Speaker 2:

But it was interesting because she was actually attaching more to the substance use piece and hiding the personality component more. And I think it's because of the way we have it on our campus. It's we don't do that with personality disorders but we're so open and accepting of substance use disorders that she wanted to be part of that population. She saw that house and saw how connected they were and she's like're not going to judge you, they're not going to stigmatize you. You are actually part of a group that is welcoming as opposed to isolating, and that's the message that we have to say is that when you realize that there are people out there that understand you, you won't feel as alone. But what I will say is that we come up against. People do stupid things when they're intoxicated, and so we have to separate the idea that that is a known effect of the drug as opposed to a characteristic of the person, and that's where we can do more separate stigma.

Speaker 1:

Yeah, what we ended up doing is a person-first language campaign and a push to ban terms that have inherent judgment, particularly dirty urine it just drives me freaking nuts, they're not dirty. So, yeah, we tried to do a person with opioid use disorder, a person with diabetes, a person with asthma. And then the one that really gets me is when psychiatrists call people crazy. Oh, that really makes me upset. Give the diagnosis Crazy is just a judgmental term.

Speaker 1:

The other thing we did and it's a podcast episode I've recorded but I haven't had a chance to edit and release yet but in addition to practicing medicine, I also help run a nonprofit and the executive director of our nonprofit is a gentleman named Jesse and there's a firefighter on Jesse's crew named Evan, because Jesse's a firefighter and Evan got addicted to opioids while he was a firefighter and actually Evan came on my podcast and told his story, which is why I can speak about it. And Evan's this big, burly firefighter, big old handle mustache, and I'm 6'1 and I work out all the time and Evan has PTSD and is in recovery from opioid addiction and I have PTSD from the ER and I had anorexia, bulimia, and I engaged in self-harm when I was in college and what we've tried to do is go into communities and educate as leaders, only to reveal our own vulnerabilities once the session begins. To help people realize that even the people that look successful can have their vulnerabilities too, and that was sorry go ahead.

Speaker 2:

I was going to say. I think that what people don't understand is that people aren't seeking these substances to get high. They're seeking it to remove negative emotional states. So they are trying to come in from their cold. They're not on the top of the ski mountain and enjoying the ride down. They're skiing in shorts and a t-shirt and they're desperate and they want to get in and they're uncomfortable and they can't stand the state they're in right now. So they're really just trying to distract. It really is a maladaptive coping mechanism and many of them and I sit there and I talk about.

Speaker 2:

I talked about it with this young girl. She was probably like 24. She had an opiate use disorder and I said to her I was like you just can't sit with the thoughts in your head and she's I really can't, I really can't. She had a traumatic upbringing. She's like all the things that come into my head, I just I can't tolerate them, I don't want to think about it, and I was like, listen, I. So we have to do two things we have to help you manage how you triage those thoughts and discount the impact that they can have on you right now. And we got to work on this opiate use disorder. Right, we got to cover those receptors. Physiologically your brain is firing in a way, saying you need this, but psychologically your brain is crying, saying don't expose me to that. And so it really has to be a two-pronged approach for people that have trauma, which honestly, by and large, is most of our patients that seek substances.

Speaker 1:

All of them, yeah. The point I was making about the firefighter and I, though, is that we're trying to use people who seem like successful leaders, and when we show our vulnerabilities, it breaks down some of that stigma, because people don't look at me and see an eating disorder, and when I reveal it, they will think differently about an eating disorder. Haven't gotten to know me, so that's one thing we've been trying to do just to break down stigma. But, to your point, explaining to people how their brain works, to realize that, no, addiction is not a moral failing and no, you're not a bad person.

Speaker 1:

I say this all the time to my patients. Let's say I'm seeing Bill. This is not a Bill problem, this is a human problem that Bill has. We do this all day long, and, to your point about trying to make addiction care really welcoming, we have peer support specialists in our practice, and it just. People come in and they get hugs and high fives and smiles, and even if they've had a relapse, let's come on, come in and see me, you're not in trouble. Let's get this figured out, and we've really tried to create a welcoming space, and I'll have some patients just honestly come hang out with us for the day.

Speaker 2:

It's something that we have talked about a lot here. Is that the impact of having alumni, like you're saying, people that have successfully recovered from a low point in their life or some illness whether it be, like you said, eating disorders, addiction, even acute mental health crisis, right Anything to see that they even they, will tell you when they were in that low point that they did not think that they were going to get to where they are today, and being able to come back and say, hey, like I'm sitting where you were, I was sitting where you were sitting. I never thought that I would come out the other side. It's inspiring.

Speaker 2:

I mean, we had this one patient. He literally went to 50 rehabs and then he's been sober for 10 years. And I said to him I was like I really want you to come back and talk to our patients, because when they tell me I'm not going to go to rehab again for the third time, I want to say any time can be the last time. It doesn't matter if it's three or 50. The opportunity is always available.

Speaker 1:

How long did it take you to create a culture where the patients felt more safe, sharing their addiction history more than their mental health history? That's pretty exceptional.

Speaker 2:

I think that it honestly has been. It was born here before I was here. This hospital is rooted in giving addiction treatment. Some people thought it was primarily an addiction hospital and they don't realize we actually do primarily mental health. But we just are really addiction friendly, meaning that we intermingle people. When you detox, you're on a psychiatric unit, so you're on a unit with everybody else. You're on a unit with doctors, lawyers, whoever else may be here for other things with everybody else. You're on a unit with doctors, lawyers, whoever else may be here for other things. But it really creates a culture where people feel comfortable actually saying both. So mental health gets stigmatized too. So it has the dual function of the people that are here for a near lethal suicide attempt can say that, along with the mom that told everybody she was going to some spa and she's here detoxing. So I think we've just created this culture of being able to allow people the space to be who they are, without any apologies.

Speaker 1:

Do you guys have a particular approach to language or who you hire, or you want to hire people in recovery? Do you have a sense of what's the secret sauce?

Speaker 2:

I don't. I mean people in recovery definitely seek us for jobs. I will say that, but what we do is we try to have this approach of, when we do hire people, that we start, we introduce them to what is our Silver Hill culture, meaning that there is no judgment here. Right, when you've walked on this campus, even if you have your personal preconditions of what you think is right or wrong, that needs to stay outside. Here we are an environment where everybody is coming to us for help, and it doesn't matter what we assess of the situation they're in. We need to provide a measured treatment for the symptom that's bothering them.

Speaker 2:

It becomes tough, though, when you see somebody that's of privilege and is coming in and they've got three kids at home and they've got two nannies, and somebody else is essentially raising their kid, but they still can't be present. Addiction has taken over their life, for example, and they're still not there to do the fun things, to go to the games and these things. You have to really find an understanding and sometimes explain to staff that this is a brain disease. They're not choosing this. They don't want to be the mom that missed their kid's soccer game because she was drunk and didn't get to the 7 pm start. That's not who they want to be. But for people that don't have addiction training, sometimes it's things you have to explicitly say and huddle the team together and say, hey, listen, we call it in psychiatry our countertransference. The countertransference to this patient may bring up some stuff. It's like when you see a pregnant patient in detox. You sometimes huddle the staff and say, listen, mom didn't choose to be this way, she wouldn't knowingly harm her baby.

Speaker 1:

The way I explain it is. I go to a lot of schools to educate kids about drugs and alcohol use. I ask those kids what they want to be when they grow up. None of them say addicted. So what do you think your experience would be like as a deputy medical officer at a general hospital, as opposed to your specialty hospital around addiction, stigma against addiction and access to addiction care?

Speaker 2:

So when I was medical director at Sinai in the city, we were a general hospital, we had psychiatry and we had addiction, but my interface ended up with touch points in our med-surg service and ED and I got into a lot of fights with people about the way that every patient deserved equal opportunity and they weren't contentious fights, but I definitely had to go to bat. I did a lot of grand rounds for the med-surg department on how to approach the addicted patient. One of my grand rounds was entitled Is this Bad Behavior? Because it looks just like they're the addicted patient. A lot of one of my grand rounds was entitled is this bad behavior? Because it looks just like they're a difficult patient. It looks like they are, you know, medication seeking or they are being disregarding the rules, things of that nature, and so a lot of it was around training other providers how to manage these patients in an equitable way where everybody got the opportunities to be afforded the same level of care, regardless of the contributing factors to why they were there.

Speaker 1:

How many patients in America with addiction do you think actually get discriminated against because of their addiction when they seek medical care?

Speaker 2:

At some point, 100% I would agree. I mean, I don't think that you could find somebody that said that they have had an overwhelmingly welcome response every time they've sought care for addiction or have had addiction brought up in their care.

Speaker 1:

Yeah, we've had the same issue here is there's no detox in our county, so none. Send them to the ER and hope.

Speaker 2:

Do they give them one dose and send them out? Give them a banana bag?

Speaker 1:

It depends. It's a little bit of a. If they're sick enough to have alcohol withdrawal, they'll get admitted. In my hospital we have one family practice doctor who is board certified in addiction, who's been practicing addiction medicine longer than I've been alive, who occasionally admits. But sometimes the hospital gets really full and those admissions get viewed as less urgent, which I would disagree. But and then we're told we can't admit for those it's. There's not a good system here and the county to the east of us has one tiny little hospital. I am the first doctor ever to practice addiction medicine in that county. All of our residential treatment programs send people to the ER just as like a screening, just to make sure their withdrawal is not too bad. We struggle with access here, even though I've been practicing medicine in this community for about 11 years. We just we don't have a lot of resources for acute detox.

Speaker 2:

When I was I don't know, I don't know how many years, probably a decade ago I had a patient that came to our unit and was detoxing on our psych unit. We gave him 72 milligrams of Ativan in. I think it was maybe over 36 hours or something. So people got uncomfortable, sent him to the medical side. They found out he had a pending rape charge and they sent him right back because they didn't feel comfortable with him on the medical side and I said all right, you know what? Who cares how many milligrams of Ativan this is. We're still going to do it here because they're discounting his need for medical treatment because of the contributing factors to something that may have actually honestly become a product of intoxication. He's out as a freestanding citizen. Some court has said that this is fine for this man to be in the community, so we're going to treat him. But it spoke to the fact that it didn't matter that the medical necessity was there. They didn't want to. So we detoxed him on site and he did fine.

Speaker 1:

It's funny you mentioned that I mentioned my lovely spouse and colleague, dr Close. Yesterday we were chatting. She, as I mentioned, practices medicine in the jail and there was a gentleman that she was seeing and his attorney said do you know what his charges are? In this kind of menacing way, like he's such a bad guy and she's like that's not my department, that's yours, I do the medical care, you do the legal, and then ordered him some buprenorphine.

Speaker 2:

Oh, that's a whole other scenario. Mat for opiate medication, assisted therapy for opiate use. It sort of saves lives. There's absolutely no reason to restrict it. Zero, zero reason. It's also cheap.

Speaker 1:

Stigma.

Speaker 2:

Yeah, but it's. I mean, there really isn't. I think that one of the things that I have brought to this hospital because Connecticut's definitely different than New York is the idea that Suboxone should be something that we should consider. For anyone that has ever struggled with kratom or opiate use disorder, it is something that saves lives. It allows people to function. I tell it to people.

Speaker 2:

I mean, I see you're wearing glasses, I wear contacts, I get up and I put my contacts in my eyes every morning because I want to see the world a particular way. Could in my eyes every morning, because I want to see the world a particular way. Could I function without them? Sure, will it be hard, absolutely. Is it safer for me to drive and do other things with it? Yes, the same thing for buprenorphine. If it's something that helps you function and it makes it safer for you to be out and about doing your things, do it. There's really, honestly, there should not be stigma attached to it, especially now that we have injectable formulations where you don't even have to be taking something. Nobody has to know. It's like getting an allergy shot once a month.

Speaker 1:

So you had mentioned that many of our patients with addiction have trauma. I'm going to channel Dr Gabor Mate and say that everyone with addiction has been traumatized. So I came into addiction medicine. I went through the practice pathway. I didn't do a fellowship and I was like, oh yeah, it's all about penaltrexone and the acamprosate. I was really med-focused and I have to say the single most enlightening thing that happened to me was to get diagnosed with PTSD myself. I had no idea the profound changes that my brain would go through and it really helps me to understand what my patients go through. And I've started to try to make everything trauma-informed. Like I have a CrossFit coach that works with me and my family. She has been through a lot herself and I send my young female sexual assault victims to her. I call it trauma-informed fitness. So how do we make addiction care trauma-informed?

Speaker 2:

So that's it's funny because we at our hospital we're really a trauma-informed fitness. So how do we make addiction care trauma-informed? So that's it's funny because we at our hospital we're really a trauma-informed hospital because we have a trauma-based residential program which is, I think, the only one in the country. But so it was already happening here. But I was happy to see that because it was really consistent with the way that I practice addiction. You cannot practice addiction without being trauma-informed, because even if you hadn't identified what the direct or indirect trauma was coming into your addiction, once you're already using an addictive substance, the chances that you've been in another traumatic instance after that are, like you're saying, 100%. So even if you can't figure out what some indirect trauma was coming into it, it's going to be compounding trauma. You're now a vulnerable population.

Speaker 2:

So I think that there are two things that we really try and be explicit about is not villainizing people. You can't blame the victim, right? Many people are very shameful about the situations they've been in when they've been using substances, and we have to kick that out the window. But the other thing is, as I spoke about before, is identifying what are the key things that are so hard to sit with, because if we could try and address some of that in a therapeutic manner then the alcohol or whatever use could diminish. We had one patient that came in, went to our substance use program, went out drank. Went to another one of our psychodynamic programs, went out, drank. It wasn't until this person did the trauma program that the drinking stopped. Because that's what it was. We were seeing the tip of the iceberg, but it was just the symptom that was visible. All the other things we needed to address first to have that iceberg go back under the surface first to have that iceberg go back under the surface.

Speaker 1:

So just to level set around who my audience is some of them are healthcare providers, some of them are not. Can you explain what a trauma-informed approach is and then give me an example of, let's say, a program or a modality that is not trauma-informed and how you make it trauma-informed?

Speaker 2:

So one of the things that is really important first, like first blush looking at a patient is that you have to understand that asking somebody direct assessment questions of whether or not they've been a victim, have you ever been sexually assaulted those sort of things People are going to tell you no or they're going to tell you yes, but it's not a way to inspire conversation about how we can address it. So it has to be a conversational assessment to begin with, about just towing the water of have you felt unsafe before? I'm not validating whether or not your assessment of your safety was real. I just need to know if you feel like you've been at risk before of being vulnerable, because that's where the conversation starts.

Speaker 2:

As we get to know people, we can suss out a little bit more of what it looks like to build a history of if they have some of the symptoms that would be consistent with, for example, a PTSD. We can ask about hypervigilance, we can ask about nightmares. We can get some of those criteria met, but at the end of the day, I actually don't need to know so much about the specific trauma. I need to know about your response to it. I need to know how it's impacting your functioning today. And that's where when we say trauma-informed care is that we need to get a little bit of a base, but then watch and observe the patient and see how we're seeing it play out, because that's where we can start to make measured changes and customize our approach to how we individualize trauma-informed care.

Speaker 1:

Give me an example of a program that is not trauma-informed, and then how you make it trauma-informed. Let's say, a residential treatment program.

Speaker 2:

So all of ours here are trauma-informed. I would say that, honestly, any substance use program, any rehab that is not considering how to process trauma whether it be from before a substance use started or during is not going to approach. It's not trauma informed, because once you've been intoxicated and do not have your executive function intact, you are potentially a victim. You're vulnerable. Things that happen during that time A you might have not have consolidated memory from which is scary, or. B you might have memories that are kicking around in your mind as bringing up negative emotions. You don't like those emotions, you're scared of having them again and you can't quit the substance. So the potential that those things are going to happen again is hanging over your head constantly. There is going to be a hyperarousal associated with that. So to just say no, no, no, let's talk about cues, let's talk about triggers, let's talk about relapse prevention that's not going to work if you're not thinking about the things that will amplify those cues.

Speaker 1:

Let's weave our conversation together here. How do you address stigma against PTSD when people don't understand what it is?

Speaker 2:

Well, that's the thing is you have to identify it first. They don't even know what's happening. I've had patients say I just I can't calm down and I was like, oh, we have a name for that, it's called hyperarousal. But they really don't even understand that. Not everybody's living like that and there are papers written about this.

Speaker 2:

But if there was a traumatic upbringing, these adverse childhood experiences, if they were like on edge all the time, then they may have just functionally started to be quite numb. So as they felt very, very numb and then got into this adolescent age, they might seek substances that stimulate them, that bring them to life, because they've spent a whole time retreating back, that they don't really feel like they're alive until they bring something up. So our stimulants, our hallucinogens, things like that, our stimulants, our hallucinogens, things like that. The other side is the people that are constantly, constantly so scared and that hyperarousal has started early that they cannot tolerate it. They just want to break, they want to come in from the cold. So they seek the numbing substances. They're looking at the sedatives, the opiates, alcohol, things like that.

Speaker 2:

But when we remove those, the other state remains, and so that can be traumatic in and of itself. Now you're being reminded of this mood state when something bad was happening. So now something bad happened. You became numb. You started using stimulants and we tell you, it gets over. You get sober, you're back to numb, and now that's cuing you of that time period where you needed to be numb. So we have to deal with it.

Speaker 1:

It's how it all interconnects. How about, in terms of stigma, when loved ones of a person getting treatment don't understand PTSD?

Speaker 2:

So PTSD is something that you know because we've all lived through some of the wars and things like that. People really associate it with veterans. By no means is it wholeheartedly associated with veterans. That is our poster child, because almost 100%, I would say, of people that have served have some traumatic experience. But that does not discount that anybody walking around on the street can have traumatic experiences and it does not mean that you're again a defective person. It means that the emotions connected with the event created some disruption in your brain where it is no longer firing in the way that it was before.

Speaker 2:

Whatever experience, it's not a fault of yours. It's literally a brain wiring thing where your brain is now signaling be worried, be aware, let's not let this happen again. Let me remind you about this it is not a choice to make this thing impactful. It is something that happened in your brain when that thing or situation or string of situations happened. That now you cannot correct without a measured response to it Therapy, sometimes some medications, or just really being mindful of how you are responding to the intrusive thoughts that are present with PTSD.

Speaker 1:

I have to say, when I was diagnosed with PTSD I was embarrassed. I was afraid to share with my colleagues. It took me about four to five months to finally get up the nerve to tell my colleagues. And then I realized I had to own it and if I was going to break down some of the stigma around mental illness at my institution I had to share it. So I finally got up the nerve and I was chief of staff at the time. So I wrote my chief of staff letter to the board of trustees in my hospital about my PTSD diagnosis and I was really pleased. The board had a very favorable response. They thanked me for sharing and then I shared that same letter with my emergency department group and I got a lot of positive support. But I still feel like a couple of my colleagues are like yeah, grover's a sissy. So I don't know. Personally I feel like now I'm in a place where I can own my diagnosis and I can talk freely about it. But I was really scared when I first got that diagnosis.

Speaker 2:

Tough men don't get PTSD yeah.

Speaker 1:

Yeah.

Speaker 2:

I see you smiling to it. It is not something again, like you said, nobody's going to grow up and say I want this traumatic event to impact me in this way. It is not a choice we made to wallow in our sorrows of something that has happened to us. It is something that we cannot manage the impact of, for whatever reason. The chemistry of our brain did not allow us to manage it.

Speaker 2:

I think about a lot. I don't know I forget if it was a podcast or a documentary I watched but about how you could have a bunch of people, for example, in a bus crash, right, and everybody's experience or impact of it is different. And how do you predict whose is what? Honestly, you can't. You cannot predict who gets what from that same event. They all brought different things to it, they took different things away from it. But looking at it, that space and time you cannot point around and say this person's going to have a PTSD diagnosis in six months from this. It's just not predictable in that way, because it doesn't happen to people that have identified shared characteristics.

Speaker 1:

So we've talked about your work as a deputy chief medical officer overseeing substance use treatment. You try to make addiction care more friendly, such as by accommodating difficulties with scheduling when people are in active addiction because of diminished executive function. You talked about trying to reduce stigma. You talked about being trauma-informed. What else do you do to make addiction care better where you work?

Speaker 2:

informed. What else do you do to make addiction care better where you work? We have to involve families. We have to. You can't do it without. It's like fixing a car and sending it back to somebody that doesn't know how to drive. If the family around, or whoever it doesn't have to be family, the support system doesn't understand addiction. It's very hard for the person with the addictive disorder to go back out and fend for themselves. It has to be a team effort.

Speaker 2:

When I meet with patients, I actually I meet with patients and I spend a ton of time with the families because they have questions. I mean, I just did an opiate detox for a gentleman and probably spent I don't know maybe an hour and a half on the phone with his wife because she had so many questions. He'd come by the prescription, honestly, but the way that it affected his brain, he ended up with an opiate use disorder and so she really wanted to go from the beginning. How did this happen? How did this start? When did you know? Just, it was like having access to somebody to ask the questions was huge for her, and it made me realize how little access some of the general population has to these questions and they just don't have the knowledge, and without the knowledge it's hard to discount the stigma that's attached to it.

Speaker 1:

It really is. As we get to the end of our time here recording this episode, what's next on your to-do list to improving addiction care at your institution?

Speaker 2:

Well, one of the big things and we're doing it this year when I'm speaking at one of the high schools locally here is we got to get it out to the youth. If we don't start this earlier and earlier, then it's harder for me to treat it later and later we're already in the addiction field. I don't know if you're seeing it too, dealing with the kind of the baby boomers that they were the 60s 70s. Pot was not that dangerous then as it is now. They really have a different relationship with drugs and alcohol than this population here. But if we don't, youth does too. They've stigmatized alcohol in a way that's a little bit newer. But they're doing all kinds of other what they think are clean things that aren't.

Speaker 1:

Like whippets.

Speaker 2:

Exactly Like. They think there's no lasting impact of it. So this is fine, but there is lasting impact. So one of the things that we're really and I'm really trying to do is provide psychoeducation for the dangers of cannabis use in adolescents and what conversations parents should be having with their loved ones. It's about being able to be the one to say no. It's really hard in a group of teenagers to say no and to be comfortable saying no. So doing that kind of supportive interventions in the community studies show that if you target the most at-risk youth, it has a herd effect and you can disseminate it to other people. So being able to make an effort, knowing that, even if you don't see it right now, that it will be impactful later on.

Speaker 1:

Well, if you need any slide decks, let me know. I've been going to schools and talking to students and parents for about a decade.

Speaker 2:

Amazing. Well maybe I will hit you up for that.

Speaker 1:

It's actually one of the things I would encourage you to do is walk into a smoke shop. If you haven't done it already. I've done a couple of episodes on Kratom and just seeing how Kratom is sold and then taking some photos of just how vapes are sold and really targeted towards kids, colors, flavors I got plenty of slide decks, so when you're ready, reach out. It's something we've been working on for quite a while here in Monterey County. As a deputy chief medical officer, what's the rest of your day look like?

Speaker 2:

I only got two more hours of the day, so I'm going to go check on the detoxes we admitted today to make sure everybody is tucked in for the weekend, particularly the one that was using Kratom, because, listen, you got to understand what we're doing with the Suboxone that she doesn't think she needs, but she definitely needs.

Speaker 1:

I would agree. So that's my day. Okay, well, I have to say I, I would agree. So that's my day. Okay, well, I have to say I am so glad someone like yourself is leading the ship at your institution, because I can tell, in speaking to you, your passion for your patients and for what you do. Thank you so much for joining me. I have learned a ton and appreciate the work that you do.

Speaker 2:

Of course, it was lovely to meet you.

Speaker 1:

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