Addiction Medicine Made Easy | Fighting back against addiction

Busting Myths, Building Trust: Communicating with Patients

• Casey Grover, MD, FACEP, FASAM

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Dr. Casey Grover welcomes Dr. Sarah Nasir, an addiction medicine specialist, for an insightful conversation about effectively communicating with patients and addressing common myths in addiction treatment.

• Personal journeys into addiction medicine that transformed both doctors' understanding of substance use disorders
• The science behind medication-assisted treatment and why it's not "trading one addiction for another"
• How the body adapts to chronic opioid use through three key mechanisms: reducing natural chemicals, decreasing receptors, and increasing metabolism
• Why recovery takes time: "It's easier to break something than to fix it"
• The critical connection between trauma, PTSD, and addiction
• Integration of life coaching principles into addiction treatment
• Creating authentic connection as a cornerstone of effective recovery
• Addressing stigma around medications in recovery communities and sober living facilities
• The difference between dependence and addiction in patient education

If you're a healthcare provider treating patients with addiction, thank you for your life-saving work. For everyone else, thank you for taking time to learn about addiction – it's a fight we cannot win without awareness and action.

To contact Dr. Grover: ammadeeasy@fastmail.com

SPEAKER_03:

Welcome to the Addict 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 a conversation with Dr. Sarah Nasir. She is an addiction medicine doctor, like me, and we connected for a podcast episode to discuss how we communicate with our patients most effectively. We actually discussed a few of the common myths in addiction and the strategies and specific phrases that we use to give our patients the best and most accurate information to help them make the decisions that they need to make about their treatment. We covered a wide variety of topics, including adverse child experiences, also known as ACES, post-traumatic stress disorder, and her work incorporating life coaching into her addiction treatment plants. Overall, we had a fantastic conversation, and I'm really glad to be able to share it with you today. The only issue is I had some issues with my audio recording equipment. The audio of me speaking was a little rougher than usual, but fortunately you can hear Dr. Nasir perfectly. Here we go. All right. Well, I'm so grateful to be speaking to you today. Why don't you start by telling me who you are and what you do?

SPEAKER_00:

Sounds good, Casey. Thank you so much for having me on your show. I'm Dr. Sarah Nasir, and I am a board certified addiction medicine specialist, and also I specialize in family medicine. And currently I'm working in a methadone clinic as a medical director. I also have extensive experience in working in a clinical environment, taking care of chronic care along with substance use disorder.

SPEAKER_03:

How did you pick addiction medicine?

SPEAKER_00:

I feel like it picked me.

SPEAKER_03:

Who would you tell?

SPEAKER_00:

So I when you're in residency, you have to know what you want to do when you go into residency. But when I was doing residency addiction medicine and this stuff was still not very as much talked about. So like in medical school, I was working in rural Princeton, West Virginia for OB rotation. And my first exposure that I think about it was there. We were in the nursery, and there was a baby that was born to a mom who was using meth and opioids while she was pregnant. So I didn't see the mom, but I saw the baby, and the baby was crying uncontrollably, so uncomfortable. It was very heartbreaking to see. And the nurses were standing there trying to console the baby and just having a real anger towards mom in many ways, even though mom wasn't there at that time. The commentary that heck I even joined into like, how could the mom be like so selfish to the baby suffering because of her because she couldn't keep herself together? She chose the drugs over the baby, and now the baby's the one that's suffering. And at that stage, I think even dealing with babies with neonatal abstinence syndrome was not very commonplace. So the poor baby was suffering. That was my first exposure. Fast forward to residency after medical school, and I'm now in Elmira, New York, and apparently this city was in the it sat on the belt that went from Mexico to Canada for the fentanyl and heroin transportation. And additionally, that town was very famous for having a pill mill. And so we were seeing all this at that time, it was heroin, like significantly heroin dependence or prescription pill dependence. And so I was taking care of this gentleman, a young gentleman, and his elder father was there. And we were trying to get him on vivitrol or naltrexone. For that, you have to be off of all opioids for a good, solid week. Otherwise, it basically makes you feel really bad. And this gentleman just couldn't do it. Like he would relapse, and his dad looks so disheveled, like looks like he has probably lost weight and lost, doesn't take care of himself, worried about his son all the time. And at that time, I went in to discuss the case with my attending, and I told him, I can't believe why he's so selfish. Why can't he just stop using? If he can just stop using, we can get him on the vivitroll, give him a shot in the butt, and then he'll be good for a whole month. Why can't we just get past these seven days? Oh my God. And it was at that moment that I felt like it clicked because my attending said, Sarah, you do know that this is not just because they're a bad person. This is because addiction actually changes your whole body, it changes your brain. And I've never had anybody tell it to me that way. And that was a moment of questioning yourself. Oh my gosh, what have I been doing all this time? What have I been believing in all these years? That can't be true. So I told my attending that, you're kidding. I can't believe that. But then that's where it started, like that that confrontation in a positive way of me having to look inward. And I started to question. And then the story continued on one of the doctors that was a pill mill in town, he left his DEA caught up with him, took his license away, and he was not allowed to prescribe. And then there were so many patients of his. Like, I'm gonna, I know people who are gonna take care of you. And after that, the whole ER basically was like, you need to know, you can't be threatening our doctors that way. But like now, thinking back, like I do feel for her. She probably was trying to come to safety instead of going to the streets looking for heroin. So yeah, that's going back to the question why addiction medicine? I feel like there's just been so many incidences in my life where it feels like I need to re-evaluate and take care of my impression of people because I'm in medicine to take care of people to serve, right? And I need to fix my impression first. And that way, these people who need help, because they're people, they're not diseased, they're not like bad apples. Sometimes are the words that I've heard being used out there, who just deserve it. They deserve help, they deserve guidance, and I have found it to be so gratifying to see somebody go from the addicted lifestyle, weight loss, dishevel, family, personal affairs all over the place, living in the streets, to becoming somebody who has a business, who now has kids, and they look healthy, they have healthy weight. The gratitude that people have when they get their lives back. Oh my gosh, it probably feels like tring cancer, if I may say that. Like I often think about it that way. It feels as satisfying as if I could cure cancer or something.

SPEAKER_03:

Funny you mentioned that because when I'm asked what's the worst disease out there, I can come up with three that are the most destructive addiction, schizophrenia, and cancer. And when I think of how many years of productive life those illnesses take away, that's why I consider them the worst. And yes, I could not agree with you more. I similarly had to learn that people with addiction, it was not a choice. There are some profound changes in the brain. And actually, I was at a school this morning educating the kids on drug and alcohol use, and I shared my own story. The icon that is my podcast is a painting by a patient of mine. And I took care of him in the ER when he had an abscess on his arm, and I had to lance it. And I didn't know anything about the addiction at the time. Sounds like I was in the same boat as you. Yeah, sure, they could stop. Whatever. Yeah, yeah, yeah. And I took him to coffee afterwards because he told me so much interesting stuff about his lived experience with addiction. And that was when it clicked for me. I was just like, oh my gosh. I go to a school and ask these kids what do they want to be when they grow up? It's a soccer player, social media influencer, politician, astronaut, race car driver. No one says seeing Dr. Nasir or Dr. Grover. Like seeing us as addiction doctors is on no one's bucket list. Right. And yes, I love the term recovery because people get their lives back. And yes, it is so incredibly beautiful. People come in, the tears come down their faces they're like, doctor, I have a savings account. Yeah. Which substance are you seeing the most of in your practice?

SPEAKER_00:

So I work mainly in the methadone clinic right now. So it's definitely fentanyl. Everybody has fentanyl. Some people get a little heroin. Very few are just pure heroin. And then oftentimes it's combined with methamphetamine, cocaine, benzodiazepine, but more so than the cocaine, the benzo, and the alcohol is i see ecstasy. And not only patients are going out interested in doing ecstasy, but I think they're cutting the meth with it because they're both in that stimulant arena. And when I tell them, they're like, no, how did that get in there? And I'm like, Well, we're not even like checking for all the different seasonings they're putting in your stuff. These are just a few things we're checking for. So that's definitely another education conversation because another big obstacle being a doctor and taking care of patients in healthcare is the mistrust or maybe distrust in the FDA and the big pharma. And just recently I was told that I want to keep my patient on methadone because I'm getting paid by the big pharma. The patient totally understands I'm just doing what I'm told to do. So that like really rubs me in the in a saddening way when I hear that. Is here we are, we're trying to help you, we're trying to advocate for you, and you can't even tell apart who it is that's trying to help you and who it is trying to hurt you. So I take that ecstasy presence opportunity to talk about this is the difference between your dealer and your doctor, as well as the pharmaceutical companies that are making it, because they're having to report every single thing that they're doing, and the FDA is keeping track of it. I understand your distrust in FDA, but it came about because it wanted to protect consumers. I think that was Grapes of Wrath, was the book, wasn't it? Where they talked about the formation of FDA. I had to read that in like high school.

SPEAKER_02:

It's been many years since I read The Grapes of Wrath. Yeah.

SPEAKER_03:

So we talked about before we got started on the podcast ways that you and I as addiction medicine doctors can communicate effectively with our patients. So let's let's maybe do some myth busting here where we'll we'll we'll share some myths that our patients have about addiction and we'll see if we can straighten things out. So the first one is Suboxone and methadone are not good medicines because you're just training one addiction for the other.

SPEAKER_00:

That is a myth I have to face and resolve like every other patient, it feels like, every other person that I talk to. So methadone and suboxone, these are evidence-based medicines. They're very, very good at treating opioid use disorder. And the way that I try to talk to my patients is that those years of opioids that you've been putting in your body, what that does is it messes with your body's natural balance because people love to talk about like body's natural ability to take care of itself. And so I go from there is that you're when you're putting in these chemicals that don't belong in your body, your body changes itself to keep you alive. And so it starts to pull away the normal functions and it disables your system, so your balance becomes off. And I like to talk about how it does one of the three ways to protect your life and keep you alive because your body wants you to live, whether you like it or not. The first one is it will make less of your natural chemicals, your natural hormones like the endorphins, the enkeins that are natural occurring opioids that lead you to feel good with the dopamine release that makes you feel happy. Now, the bad thing about having too much dopamine is that it makes you want to breathe less, like those chemicals, they go and they make your brain not have the respiration drive anymore, right? So that's one of the reasons why people are dying, is because you're not breathing, because no breath means no life. The second thing your body can do is it can pull away the receptors where these chemicals bind to, and that's where tolerance develops, because you will have to use more to get the same effect. This is a protective mechanism that's kicking into your body to protect you. The response ends up being that you need more and more. A third thing I've seen happen in many patients, and especially if they have the genetic predisposition for it, is increased metabolism of the chemical. So, for example, with methadone, we have patients who will have a gene that makes them metabolize the methadone much, much faster. And so it's cleared out of the body. So, you know, it's not around long enough to make you overdose on it. So, three ways your body is doing its job, trying to protect you, making less of its natural chemicals, pulling away the receptors, and increasing the clearance process. So, when you don't have this outside chemicals in your body anymore, your body is basically at a very disabled state. So imagine if you're standing on the ground like a normal person, and after exposure to these chronic opioids, when they're not in your system, it's like you're at the bottom of a hole. And where we're coming in with the methadone and the buprenorphine is we're trying to also artificially close this gap, make your body feel stable. So it's moving from a survival phase to a healing and rebuilding phase because the body needs stability to focus on the next thing. And so having everything in the methadone and the suboxone platform allows us to then guide you in a safe, controlled manner. So your body heals and what and you build a lifestyle that's going to sustain sobriety afterwards. And when you're done, we'll guide you to slowly taper off and train your body to come off these chemicals so you can eventually be free of us. You go be happy in your life. We want you to do that.

SPEAKER_03:

I love that. Well, let me tell you how I handle it. Yeah. So people will come in and let's say they're trying to get off Kratum, and they'll tell something like, oh my gosh, I don't want to be on Suboxone. It's just it's so bad, and then you can't get off of the Suboxone, and I go, whoa, whoa, whoa, leave Suboxone alone. Suboxone is not the problem here. The problem is opioid dependence, right? No one on planet Earth, no matter how many years of fellowship you or I did, can fix opioid dependence quickly. You either get back on an opioid or you kick. There's nothing else. And so we have to realize that unless you want to be really horribly sick, we have to give you back a safe, effective treatment. And that's going to be either methadone or suboxone. Particularly in the Kratom community, too. I know we talked about this a little bit. The Kratom community is so divided on whether or not Suboxone is a good idea that they have to have separate social media accounts. The pro-suboxone and the anti-suboxone.

SPEAKER_00:

That is that is a hoot. I feel like I'm not surprised. After having lived through the COVID era, I'm just not surprised.

SPEAKER_03:

Yeah, yeah, yeah. A funny, funny thing I heard on a podcast, there was a gentleman that was being interviewed about the COVID vaccines, and he he said this and he was trying to be funny. He goes, I want to figure out who nature's PR person is because nature has been trying to kill us. It gave us measles, it gave us diphtheria, it gave us cancer, it gave us hurricanes, it gave us rattlesnakes, and yet everybody wants to do it naturally. And I thought that was really funny because this idea that the human body has been, you know, has worked it all out. Well, our life expectancy was like 45 until the era of modern hygiene and medicine. So I understand the whole thing, like, I want to do it naturally, I want to be healthy, but that's why we have doctors as well. Okay, next myth around addiction. I get this one a lot. Someone will have been using opioids, and we stabilized them on either methadone or buprenorphine. They're a week into their recovery, and they're like, Doc, I gotta get off this stuff. How do you handle that?

SPEAKER_00:

Yeah, I say, well, you're feeling good now because remember that bottom of the pit that I talked about? You're now feeling stable because we have artificially came come in and poured all that artificial chemicals in there to stabilize you. Now, if you come off of it, basically what's gonna happen is you're gonna go back at the bottom of the pit again because you haven't given your body the time to heal and retrain it to come back to the surface. So oftentimes it ends up being going over my little three phases of treatment and pathophysiology of opioid addiction and recovery again.

SPEAKER_03:

How long do you usually keep people on medications for opioid use disorder?

SPEAKER_00:

The maintenance phase, that's the second phase, that's the one we recommend doing for at least one year. And if the patients are following up in the early phase, normally we're at the therapeutic dose within the first two months. Methadone takes a little bit longer because of the safety concern there. And so the buprenorphine is a lot faster. However, what I've found is that the when somebody's on a really high dose of fentanyl, it's a lot harder to control with buprenorphine. And this is where I think methadone is a very powerful tool in our arsenal because we are able to give more and and close that gap. And and that's basically what I look for is do you have 24 hours of coverage or basically because some of the medicines you can take it three times a day or two times a day. So basically, you need to have no withdrawal symptoms or cravings from one dose to the next. And as soon as we get there, that means the gap has closed, your body is running on smooth surface. Now our second phase starts. So the first phase is induction, finding the therapeutic dose, closing that gap. The second phase is the maintenance phase. That's one I recommend doing like at least a year, unless somebody has been on it for just a year. I like to also put in perspective. It's a lot easier to break something than it is to fix something. And more time. So when people are like, man, that's a long time, I'm like, what else do you have left to do with your life? I mean, you're I'm asking you to take time and you know, it's it's like your time for your time. You're gonna invest in your time to get more time out. Would you rather do that? Or do you want to keep coming back and through this revolving door? Because another thing I hear is that I've done it before. I know what I'm doing, I can do it again. And this is where I I what is it like play the ad devil's advocate here again? Is that if you had done it right the first time, you wouldn't be talking to me right now. Like the an unpleasant reality in their phase. And so the last phase of this three-phase treatment process that I educate patients about is the taper phase. And that's where you drop the dose a little at a time so your body gets trained to climb back up towards normalcy. It's like you don't want to go from couch potato to bench pressing 500 pounds. One is the it's just not safe, right? You need to like slowly train your body and acclimate it to be able to do that.

SPEAKER_03:

I'm stealing it's easier to break it than to fix it when it when it when we're describing recovery. That is beautiful, and I'm gonna use that next week in clinic.

SPEAKER_00:

Okay, please go for it.

SPEAKER_03:

Okay, next one. I love this one, is don't worry, Dr.

SPEAKER_02:

Grover, I'm gonna be okay. I trust my drug dealer. You got me you got me there.

SPEAKER_00:

Wow.

SPEAKER_03:

So I so this is this is where the story came from is so in my office we do extensive liquid chromatography mass spectrometry testing. And this one patient, as we've expanded our panel, is we now include isotinidazine and acryfentanyl and acetylfentanyl and paraflora fentanyl and xyrosine and all these horrible synthetic contaminants. And she kept testing positive for all these weird fentanyls. And I'll never forget this. I love her. She is the sweetest lady. She was just like, Dr. Grover, I really can't trust my drug dealer. And we had this moment of, well, you know why drug dealers do what they do. I mean, it's all about profit. And so, anyways, I've had a number of patients that are like, Dr. Grover, I just I really can't take medicines. I don't trust them. I'm really worried. I'm like, but you trust your drug dealer. There's there's a huge misunderstanding as to what's the right thing to trust there. Have you had that come up?

SPEAKER_00:

So I have never had anybody tell me they trust their drug dealer. Oh, I've had plenty of, I don't trust the doctor, I don't trust the system. Normally, when I'm when I'm talking, like and doing my explanation, at the end of it, I'm talking, I'm your doctor, I'm not your drug dealer. I care about you being alive, I care about you being healthy. I'm absolutely okay with being out of a job because you're out there, everybody's out there just living a fulfilling, healthy life, and there's no need for doctors. That is a really good reason to be out of a job. However, your dealers, they only care about your money. And I mean, just look at it like if you can't pay them, they will make you sell or they'll let you suffer. They're really sweet and nice when they're getting you hooked for the first time. That's like they're really good at marketing and sales. So fortunately, I have not had to hear that heartbreaking sentence. I think it would really, it would really make me feel really sad. I mean, it was one thing to hear my patients say that I'm employed by the pharmaceutical industry, so my job is to keep them on the methadone. To, yeah, well, I'm sorry you had to hear that.

SPEAKER_03:

It actually went up happening is the fact that we expanded our drug testing panel. I was actually able to show a number of my patients that kind of no one knows what they're getting, including their dealer. We also work very extensively with peer support specialists in my clinic and the folks with lived experience. We'll sit them down to like walk. I had a dealer too. This is how this works. And I think it also depends on where a person comes to addiction from. They talk about people with so-called high rock bottoms, people who didn't ever lose their job or didn't ever lose their house or didn't ever lose a child to child protective services. My folks that are unhoused and they're in the thick of the really drug-infested homeless encampments, they they are they don't trust anyone. And that's actually on the flip side, it's hard to get them to trust us. And so that's really what we work on is just creating you are safe in our office. Come in and hang out. If you want to see the doctor, great. If you don't. So I think I get it on both sides. I think the folks that are dabbling in buying drugs, kind of like, well, I have a dealer, I'm gonna, that's my dealer, I'm gonna trust my dealer. But the ones that have really had difficult, difficult, difficult life arcs with addiction really don't trust anyone, and they've learned not to trust their dealer either.

SPEAKER_00:

And one of the things I'm finding working with this population is that they have immense aces. Like sometimes I have to tap out and be like, I just need to go and catch my breath because it was just an intense thing, just listening to their story for an hour versus they've had to live through this for gosh, 40, 50, 60 years of their lives. And it's just I'm like having people flash in front of my eyes as I'm talking about this. Those people I can see will have a really hard time trusting, especially if when we show up in front of them as just take this medicine and just do this, do that, as that like authoritarian person rather than holding that safe space for them to share their stories. I've I've found like that is the thing that I like to really focus on during the maintenance phase of the three-phase treatment process, because that's what I say. If I recognize that someone has trauma before we get into that education phase, I say, this is what you need to do. You need to now heal around that wound that you have, because that scar is not going away, but you're growing around it. And this is the time when you're supposed to figure out what is the support system you need, what is the healing you need to go through, what are the coping mechanisms you need in place so when you are facing these triggers again, because I guarantee you life will keep it keep bringing it back to you until you learn how to basically shut it down and move past it. But so this is what this phase is about. Take the medicine, let your body heal, and you focus your mind, your brain, all your resources on healing from whatever it was that pushed you into this in the first place and keep push keeps pushing you in into this hole. So I find those are the patient population that have like even a harder time trusting us.

SPEAKER_03:

So yes, I I will actually do uh an average childhood experiences or ACES score on a number of my patients. There's one on MD Calc that I use. And yeah, most of them score very high. For me, I got diagnosed with PTSD last year from my 14 years in the emergency department. And when I start to bring up trauma, I lead with that. And I let them know I know how they feel. And I have to say, PTSD is miserable. Oh, it it is, it has been the most educational thing I ever could have gone through as a doctor to understand PTSD was to live it. And it's horrible. And so, yes, my niche in addiction medicine has become the intersection between PTSD and addiction. And with most of my patients, it's only a matter of asking the right questions. And you find the childhood trauma, abusive father, sexual assault, abusive relationship. It's just, oh my gosh.

unknown:

Yeah.

SPEAKER_03:

With some of my patients, I've even stopped working on the substance because they're still so in fight or flight mode with their PTSD that I just need to give them some emotional safety so they can actually start the work of getting sober. And maybe that's the wrong approach. I should do it the other way, but I felt like I was prescribing naltrexone and it wasn't helping their PTSD, so they they were still drinking.

SPEAKER_00:

I think you bring up something that I'm now moving into because I just feel this is this is an augmentation we really need. So obviously, I'm not coming from the field of psychiatry. Maybe they have a little bit more experience in dealing with it than family medicine doctors of being able to give that motivational interviewing, cognitive behavioral therapy. But I became a coach, like life coach, because what I found is that as a doctor, I'm able to support with knowledge and chemicals, better words, right? I'm able to stabilize the body. But then there's this part of this multidimensional human being who's sitting in front of me that is trying to like process and and continuing to not succeed in closure, obtaining that closure and gaining that strength and moving on. And this is where I'm finding the coaching arena to be very, very powerful, which is taking what you have with trauma and or or whatever the weaknesses are, and then creating the plans to move on to the next phase. A lot of folks don't have that because they're so stuck in that trauma loop, that PTSD, that it's really hard to get out of it, really hard to think beyond that same scene, those same feelings, just keeping you trapped in a cage. And in that situation, I'm finding that when I'm putting on my coaching hat, I'm able to help them come out and and have a plan to go towards safety, which is something that they did have initially. So I'm really glad you brought that up.

SPEAKER_03:

So are you doing coaching for your patients or no, the the medicines I started prescribing changed. So I came to addiction medicine through the practice pathway. So I did emergency medicine as my primary specialty, and then I was doing so much Suboxone and education and alternatives to opioids. And we were seeing so much addiction in the emergency department. I was trying to improve care for that, that eventually the other addiction doctor in the practice, the beautiful and extraordinarily intelligent Dr. Reb Close, who is also my spouse, she and I were doing it together in the emergency department that we went through the practice pathway. And so I came to addiction from a very, it's almost like learning a language from a dictionary rather than learning how to speak it. And so I was like alcohol, maltrexone, opioids, buprenorphine, benzos, benzotaper. And as people would be under my care, either the medicines would work or there'd be a relapse or something was missing. And now probably my most commonly prescribed medications are propranolol and clonidine for triggering, raisicin for nightmares, and then SSRIs, which are useful for all sorts of stuff. It's just, I find that people come to me and they're like, oh, doc, it's the alcohol. And then when I can't get them sober, I'm like, yeah, we're missing something. And then we start digging into the trauma. And one of my patients, I've shared her story anonymously a few times. I could not get her sober. She'd go for maybe a month on naltrexone into pyramid, and she did okay. And then I was just, I am missing something. And I said, Do you do you have any light traumas? And she's like, no, no. I mean, my my stepdad was verbally abusive to me my whole childhood, and I nearly died in a car crash with a police officer. And I was in the hospital for three weeks, but nothing bad. And I remember thinking, like, hmm, okay. Do you get nightmares? Oh, gosh, every night, Dr. Grover. Do you get flashbacks? Oh, gosh, all the time, Dr. Grover. And so we pivoted from naltrexin and to pyramate to Sertaline for Pranolol and Prazosin. And I got about five months of sobriety from her before finally she got overwhelmed again and had a relapse, but she really was realizing that it was around the stepfather who had been verbally abusive. And when he got in her face, every memory in the book came back. And then we're working on it. So I don't really come to it from a coaching standpoint, but I do have our peer support specialists in the office with limped experience. Most of them have some form of BTSD from prison, addiction, whatever it's going to be. And then I'm very aggressive with trying to get people into therapy. And then we do offer mutual support group meetings in our office that are just come here, share your feelings, be safe. And we're looking to put together a women specifically trauma group since I have probably 15 women who have just been unspeakably mistreated as human beings. And we're going to put together like an afternoon where they all come see me, they all come see peer support, and then we have a meeting just for them. But I'm curious, so that that's that's it's all organic. Like that's that's what I've come up with on my own. Tell me what's different about coaching or how coaching plays in.

SPEAKER_00:

I mean, first of all, like power to you for what you've been doing with these patients. I think one of the most important things, not just in addiction, but in medicine in general, that we need, and it I think it's slowly starting to move in that direction, is customized medicine, where it's not, I mean, yes, we have the bodies of knowledge about this is what the evidence-based medicine shows, this is the dosage for this condition, for this type of person, but to be able to hone in on the person who's in front of us and really understand what is it that they need, and then titrating the doses to their actual disease, like like looking at it as a cause and effect rather than oh, up to date says this, Hippocrates says this. So here's your prescription, right? And I think it's called now precision medicine, is what I heard, like AMA person talking about it that way. And I was like, that's what I'm talking about, customized medicine. Okay, so it sounds like that's what you did because we all have our own unique circumstances, right? Even though we look like each other, we eat the same stuff, we speak the same stuff, we experience things very differently. So I'm glad that you were able to get that patient, that six months of sobriety by hitting the nail on the head. And I relapse is part of this journey to recovery. So it's that she was successful for six months. That's what we focus on that you did it for six months, let's do it for another six months. Oh my god. Keep going until you retrain the brain to develop new neural pathways, new habits. And that's where you end up flowing and you keep going. And that's what's gonna allow me to segue into the question about coaching, because when I got the coaching certifications, like these were some of the things that I was taught. And I'm I don't know how when you go into the subspecialties or specialties of psychology and neurology, maybe I don't know how much of a overlap here is, but when I what I learned in coaching is that our brains do like one of three things with the immense amount of information that it gets through the different sorts of sensory inputs, such as generalization, deletion, or distortion, you know, and and that's where the events that actually happen to us, these events then are assigned emotions based on what the circumstances are. And when I was studying for the board exam for addiction medicine, and we came across the brain part called insula, which is where the emotions are being attached to the events. I'm like, oh, this is exactly what they were talking about. Now I actually have an anatomy to like associate with this finding. And then I learned a lot about NLP, neurolinguistic programming. And when I learned about it, I'm like, this makes so much sense because it's kind of like giving us computer science ability to program our language using the way that we take in information and telling our brain what to focus on and changing basically the algorithm in our brain on what to fixate on. So that's what I found very powerful in coaching and the way that it, I mean, it sounds also once again like a lot like there's CBT and MI involved in it, like cognitive behavioral therapy, motivational interviewing. These are very familiar. It felt familiar in that way where you're creating that safe space, building report, exercising your listening, and letting the the person talk and solve their solve their problems with you as a guide. So that's what I use coaching for is to guide the patient back to connecting with themselves. And I think going back to the part where you were talking about bringing your patients together in a support group, a lot of times our patients in this population, one of the biggest lacking is the lack of connection, the lack of connection, authentic connection. And so when we find others, and it's not just the population with addiction, I think it's a human condition, it's a human need to have connection, to connect with people who get us, who understand us. They see our work, they appreciate us, we feel seen, and so we want to do more. And I think that is what we're meant to be naturally addicted to. I heard a person with a PhD in addiction mention something so beautiful, and I'm like, I actually I'm gonna, I'm gonna steal that and I'm gonna say that everywhere. So, Dr. Sherry Candelario, PhD, she mentioned that the brain is created to be addicted. Because like we have these reward pathways there for a reason. That the reason why we're able to pursue delayed gratification is because we train ourselves to eventually go and experience that. So that's where motivation leads us from where we are to going through medical school and and surviving the trauma because we are allowing ourselves to go and draw reward from a different aspect. Otherwise, why would we do it?

SPEAKER_03:

I tell my patients all the time that we have dopamine for three reasons food, to make babies, and to have communities that can protect us. And I think that's where these support group meetings, the magic is in that you get dopamine when people are nice to you in a community setting. All right. Last myth here, and then we're gonna wrap up because we're almost at time.

SPEAKER_01:

Yes.

SPEAKER_03:

Doc, I went to an AA meeting and they told me that the meds I'm on am not sober, so I want to quit them.

SPEAKER_00:

So many times, and it's not just the meetings. What is even more frustrating is when they're trying to get into sober living facilities, and they're like, Oh, you you have to be off of everything before you can come in here. And I'm like, Define off of everything. Because here I am, a licensed doctor writing you this prescription, and you're telling me that you can't be on this medicine. So if you had diabetes and if I was prescribing you insulin, if you had heart attack, and if I was prescribing you aspirin, would they tell you to stop taking those medicines? So yeah, it comes down to trying to help folks connect the dots coming back to connection again. It's not just it's not just people-to-people connection, sometimes it's neuron-to-neuron connection. So I find that humans are creatures of context. If you have not experienced it, you will have a really difficult time understanding and grasping it. So I take that opportunity and the way I approach education then is once again, like if you had diabetes, would you question me if I tell you to take insulin? If you come to me with a cellulitis or sepsis and I'm giving you vancomycin 1,000 milligrams, will you tell me that, Doc, that is too much? I don't want thousands of milligrams of that medicine. And I've actually had a patient tell me, yes. This was the patient who said I work for the pharmaceutical companies. But most people, they get the point. They're like, oh yeah, so this is like a disease. And then I tell them, you are the expert of being the person who lives in your body, and I'm the expert of how the human body works, how these medicines work. So we're gonna work on this together. We're gonna do this in a team-based thing. You're gonna tell me when I give you the medicine, you're gonna tell me what your body is telling you. And then I'm gonna adjust the medicine. And then together we're gonna be forming this treatment plan. Like, I'm not the big man, you don't have to stick it to me. I'm here to support you.

SPEAKER_03:

Yeah, I've learned to say that addiction is the use of substances to change how we feel, and the ultimate goal is to feel good and not need anything, but medicines are the bridge in between. And for some of my patients, they're like, Yeah, yeah, okay, that makes sense, right? I need the medicine now, I won't need it forever, and that seems to make them feel better. But it's very interesting. I I wish I knew more about the history of why addiction has been seen as just weakness or that it's a a disease of the soul. And I mean, we don't tell our diabetics to go to meetings and pray. Well, we don't tell our patients with stroke, like you said, stroke. Yeah. So it it's there's it's it's almost structural stigma in the treatment community. And and what I tell patients is this if you were my patient, I would say, Sarah, if you put mayonnaise on your left ear and you told me that mayonnaise on your left ear kept you sober, what would I do? I would go buy you mayonnaise. Meaning that if it works, great. If you love 12 steps, that's amazing. If you can stay sober and work with your sponsor and work the steps and you don't need any meds, that is amazing. But if it doesn't, then we've got to reevaluate. And I would say, interestingly, in the era of fentanyl, I see more folks that need some sort of methadone or stoboxone just because fentanyl is so much more intense in how it activates the opiate receptor than other opiates.

SPEAKER_00:

I want to clarify on something because you mentioned a statement that I feel like oftentimes I have to sit down with my patients and define it a little bit better. It's about addiction, the concept of addiction versus dependence. Folks are like, oh, I don't want to be dependent on stuff. So same scenario, diabetes, high blood pressure, stroke, etc., is that if your pressure is not controlled without the medicine, if your sugar is not controlled without the medicine, then yes, you're gonna have a little dependence. You, you, your health is dependent on the medicine that you're being prescribed. That is not a bad thing. It's buying you time to get to the lifestyle that you want to have without the interventions. Addiction is when you fall apart if you don't have it, and that is the pathology. Addiction is a disease because without when it is present, your life is not functional. And that's how I take a time to define it so I can say, is your body dependent on opioids? Yes. Is your body dependent on benzodiazepines? Yes. Addiction is when your life is falling apart because of this. Um I try to say that because I feel like redefining these words gives the patients power with how they're talking about it.

SPEAKER_03:

Any last words you wanted to share with our listeners?

SPEAKER_00:

I really appreciate you doing what you're doing, Casey. Thank you for having me on the show and giving me the opportunity to share some of the words I tell my patients, and I've seen like light bulbs go off on top of the head. So I'm like, maybe if I'm seeing this consistently, maybe it's something that needs to be out there and more people need to be talking about it this way. So I'm really honored that you're gonna take some of my thoughts and share. I'm gonna take some of your ideas as well. That's the that's how knowledge is we share with each other. As for the patients, it I think the people who are recovering and going through this are some of the most amazing and strongest humans I've ever met because it's easy to climb the Himalayas, but it's hard to climb the the hole that we find ourselves in, even though we don't want to be in it. Sometimes others put us in there. So yeah. Here's the fun thing I like to say. Remember, you're a greatness in progress.

SPEAKER_03:

I love that. You are you are a greatness in progress. Gotta say, this has been great. Thank you so much for speaking with me.

SPEAKER_00:

Thank you for having me.

SPEAKER_03:

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.