Naltrexone, Suboxone, Methadone: How Medications Treat Opioid Addiction

Is willpower alone enough to beat opioid addiction, or are we fighting a medical disease with the wrong tools? In this episode of the Recoverable podcast, we shift the paradigm from shame to evidence-based science.

Find mental health and addiction treatment near you: https://recovery.com/

Host Terry McGuire sits down with Dr. Steven Klein, MD, PhD, a triple-boarded physician in pediatrics, genetics, and addiction medicine who serves as full-time faculty at Caron Treatment Centers. Dr. Klein brings a deeply authentic perspective to the table as a professional in long-term recovery himself, diving into the raw mechanics of Medications for Opioid Use Disorder (MOUD). We break down the crucial differences between traditional Medication-Assisted Treatment (MAT) and OUD-specific options like Suboxone (buprenorphine/naloxone), oral naltrexone, and the game-changing shift toward monthly long-acting injectables.

Dr. Klein directly confronts the intense societal stigma and the ongoing debate within 12-step recovery groups like Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) over whether using addiction medication means you are truly "sober". He shares the striking clinical data regarding the low number needed to treat (NNT) for buprenorphine compared to other lifelines in modern medicine. Beyond the blocking of withdrawal symptoms and cravings, we uncover the profound psychological "why" behind substance abuse—looking closely at trauma, identity, and the heavy sense of disconnection that fuels severe opioid use disorder. If you or a loved one are trying to navigate rehab options, outpatient detox programs, or sober living rules, this conversation offers data-backed hope. Subscribe for Part 2 next week, and leave a comment below with your thoughts!

Chapters:
00:00 – Changing the Paradigm of Addiction Recovery
01:11 – Dr. Stephen Klein’s Personal Recovery Journey
03:36 – What is the Difference Between MAT and MOUD?
05:12 – The Opioid Class: From Prescription Pills to Kratom
07:05 – Is Abstinence Always the Goal of MOUD Treatment?
09:28 – How Do We Measure Success in Addiction Recovery?
11:34 – How Suboxone and Naltrexone Block Cravings
14:56 – Navigating Stigma: "Replacing One Drug with Another"
21:16 – How Monthly Injectables Change Compliance and Self-Stigma
23:55 – The True Medical Risks of Untreated Opioid Withdrawal

Questions the Video Answers:

What is the difference between MAT and MOUD in addiction treatment?

How does Suboxone (buprenorphine/naloxone) work for opioid addiction?

Can you use naltrexone for both opioid and alcohol use disorder?

Why do 12-step programs like AA and NA stigmatize Suboxone users?

How do monthly injectable addiction medications like Vivitrol reduce self-stigma?

What is the Sinclair Method for treating alcohol use disorder?

Is a person on MOUD considered truly sober and in recovery?

What are the side effects of buprenorphine vs untreated opioid withdrawal?

Does health insurance or Medicaid cover long-acting injectable opioid treatments?

Why is kratom considered an emerging and dangerous opioid alkaloid?

How do trauma and deep emotional disconnection cause substance abuse?

How can family members support a loved one starting buprenorphine?

#OpioidAddiction #SuboxoneRecovery #AddictionMedicine

Transcript

SPEAKER_00 0:00

Addiction is a high morbidity, high mortality disease. The risk of not taking MOUD for severe opioid use disorder in the most extreme is death from overdose. Dr.

SPEAKER_01 0:10

Stephen Klein, who specializes in addiction medicine, joins us to discuss innovative treatments, including the role of GLP1s in substance use disorder recovery.

SPEAKER_00 0:20

I actually don't think there's anything lazy about being on bupenorphine. I use the word heroic a lot. My patients are incredibly heroic and incredibly courageous.

SPEAKER_01 0:46

And in part two, next week, we will shift focus to the frontier of science as we investigate the emerging role of GLP1s in curbing cravings beyond just metabolic health. It's an essential conversation about shifting the paradigm from willpower to evidence-based clinical treatment. Dr. Stephen Klein, a prominent figure in the field, is going to join us in the studio and share his expertise on the topic. Welcome. Thank you for having me. Thank you for being here. Before we dive into the internet's top questions, I would love to know a bit about you and what it is that propelled you into this field of all the things you could have chosen.

SPEAKER_00 1:21

My background is actually a little bit unique for someone who practices addiction medicine. So from a medical perspective, I've had a lot of training in different areas. For example, I'm an MD and a PhD. My PhD is in human genetics. That means I did medical school and graduate school, both of which were at UCLA. My PhD is in human genetics, and I followed that to then study pediatrics and medical genetics at the Children's Hospital of Philadelphia. I was really growing that career in pediatrics and genetics, but then really had a change of heart, which I'll talk about a little bit, because more than all of that training to that date, I was also a person in recovery during that time. So I got sober during medical school after the trials and tribulations of everyday life and some things that happened in my personal life really started to compete with my scholarly activities. I found myself heavily addicted to drugs and alcohol, and then found sobriety through Alcoholics Anonymous, a few other channels in recovery. And that was happening in the background of all of that training. So I went to the children's hospital of Philadelphia, set on doing a career in pediatrics and genetics, and about six years into it, I realized that something was missing in my career and I wasn't doing everything from a place of passion. And that's where I tried to be. So the last kind of act of authenticity for me was to bring my recovery into my full-time career. So two and a half years ago, I made a switch and started practicing addiction medicine. I did a fellowship at care and treatment centers. Now I'm there as full-time faculty, and I absolutely have loved it. So the whole field is that I'm a triple-boarded doctor in pediatrics, genetics, and now addiction medicine. And I practice addiction and recovery from addiction science all day. So that's what I do pretty much day in and day out. At Karen Treatment Centers specifically, I work with the young adult population and also men who have had multiple treatment episodes, what we call the return to use population.

SPEAKER_01 3:25

There is nothing the field needs more than highly educated and highly passionate people. So thank you for both.

SPEAKER_00 3:31

Really my honor to be of service to the people that I'm able to help.

SPEAKER_01 3:34

Your lived experience helps a lot, I'm sure. Definitely. So let's clarify some of the terminology we're going to be using. We used to say M-A-T or medication-assisted treatment. Now the field is shifting toward M-O-U-D. Tell me a bit about the thought process behind that change.

SPEAKER_00 3:50

Sure. So I actually like both terms. M-A-T ends up being a really umbrella statement. So MAT medication-assisted treatment. I think it's really important what letters we capitalize in lowercase. So for MAT, I keep the A lowercase and the T capital because it's really medication-assisted treatment, treatment being wraparound clinical services, what's available to patients, really the other parts of recovery at CAREN treatment centers, those are things like meeting with a therapist, having really intensive group experiences. The medication ends up being a smaller part of that. I think the change to MOUD is to give it a little bit more specificity. And that stands for medications for opioid use disorder. So in the umbrella of MAT, MOUD is a subset. Okay. There's also medications for alcohol use disorder and a few others. I think it's to make it a little bit more clinical. And I think the real battle cry with that is to destigmatize all these aspects of treatment. We have really great medications that we're going to get into for opioid use disorder. And I think those medications, well, maybe some people's only avenue to recovery or to treat their addiction. So I think that moving away from MAT was a way to kind of make these medications stand on their own as medications for a medical illness.

SPEAKER_01 5:12

So when we talk about opioid use disorder, what specifically are the drugs that we mean by opioids for people who aren't familiar with that? Sure.

SPEAKER_00 5:20

So when we talk about the opioid epidemic, we are really talking about the widespread prescription of pain medications in the opioid class. So things that patients have probably heard about and that listeners have heard about. So oxycodone, hydromorphone, those were things that really got out and had a public impact because it really affected huge portions of the population. Also within that class are some illicit drugs. So things like heroin, now largely fentanyl. And potentially most dangerous that we should mention in this class is something like Kratom. So kratom is actually something that's available in gas stations and smoke shops, but it's an opioid alkaloid and it works pretty much the same way. And those are now an emerging issue in many of the patients that I serve as they become addicted to those things, in addition to the ones I've mentioned. And did you say they can be more dangerous? So danger is relative. Okay. I think they can be more dangerous because they're appearing in more and more parts of the population. For example, I live in downtown Philadelphia. A Kratom drink shop just opened up down the street from me. So they sell kava and kratom mixed into what is billed as a health drink. So people are buying these things, potentially being unsuspecting that they're taking opioids. I think people would feel very differently if they were drinking, you know, turmeric-infused heroin. But these are marketed in a way that they're fully natural and all of that. All of the opioids, everything in the in the class, um, is a derivative or a synthetic derivative of opium. Opium comes from poppy seeds. That's really the base of this class. And all of the derivatives just affect people differently as far as potency and half-life and all of those things.

SPEAKER_01 7:05

Is the goal of medication for opioid use disorder always abstinence?

SPEAKER_00 7:11

So it's a really great question that requires a little bit of nuance. I think for abstinence, we have to be really careful about meeting patients where they are. For opioid use disorder, it's pretty hard to imagine a world where people are casually doing something like heroin or fentanyl. Those drugs have really profound effects on quality of life and people's ability to interact with society, to maintain jobs, to do things that they want to be doing. So abstinence from their drug of choice, whether that be heroin or fentanyl, is I think certainly the goal of most interventions. I would say as a field in addiction medicine, really our first goal is to decrease morbidity and mortality. So, how do we really stop people from overdosing? So that's a public health initiative that we see things like now naloxone, the nasal sprays, really stopping people from having severely negative consequences from their use. I think as far as abstinence, it depends on whose definition of abstinence we're using, because some of the medications that we'll talk about have a stigma of people not being abstinent because they are, in fact, other forms of opioids. So that can be a little challenging. But I would say overall, the goal is to first reduce morbidity and mortality. Secondly, allow people to start re-engaging with their lives, with their community, with their work so that they can have some agency back in their decision making.

SPEAKER_01 8:43

And let's talk about agency for a minute, because that is critical to the whole discussion we're about to have. Yeah.

SPEAKER_00 8:48

So agency for me is the ability to make decisions that align with your value system, not the value system of medicine, not the value system of a corporation, not the value system of any marketing, but really your value system. I think when we talk about addiction, it's a real loss of agency. So you're no longer making decisions based on your values. You're making decisions based on the need. With opioids, the need is real. Withdrawing from opioids is very painful, very uncomfortable. A lot of patients at the end of their addiction are using just to maintain the feeling of normalcy and avoid withdrawal. That's not a place that aligns with many people's value systems.

SPEAKER_01 9:29

So when we look at like success markers of the effectiveness of the medications that can be used to help with addiction, what are some of the other markers of success? Is that reintegration with family? Is that employment? What are the markers?

SPEAKER_00 9:43

Unfortunately, those two that you mentioned are incredibly hard to measure. So now we really get into in my mind where I think about the treatment of addiction and the real instillment of recovery. Those are not always synonymous. I think for addiction, we have measures like morbidity, mortality. Those outcome measures are going to be decreasing overdose, retention in treatment, things like that. For those, we have really effective interventions and we can measure those because we have somewhat simple outcomes, very important, but very simple. The other questions I think get into the camp of recovery, which is how now are we getting at what's behind the drug use? How are we actually treating addiction? I would make the statement that a lot of the medications that we use treat the symptoms of addiction, which are drug use. But as far as treating the addiction itself, which is the drive to pathologically use drugs, that requires a little bit more nuance and a little bit more work.

SPEAKER_01 10:42

And that's what we tend to think of as the why behind the addiction. Does that mean that in addition to whatever medication, which we'll get into, um, therapy is still essential?

SPEAKER_00 10:52

I believe so. Um, I think my favorite expression to say with patients while they're in my office is that drugs and alcohol are not the answer, but they make us forget the question. I think therapy and interlongitudinal aftercare are really big, big things that take a lot of resources, aftercare, therapy. These are these are huge initiatives that are not accessible to all patients. But I really think that's where we get to the why, the question behind the drug use. What's the question you're looking at? Why are we as people who use drugs and alcohol problematically? Why are we so uncomfortable with who we are? What are we running from? And what's the maybe trauma or past events that we don't want to look at?

SPEAKER_01 11:34

One of the top questions from the internet are what are the main medications used to treat opioid use disorder?

SPEAKER_00 11:40

Yeah, it's a great question. So the main medications to treat opioid use disorder, there's actually three major medications, those being now trexone, buprenorphine, and methadone. Okay. Methadone is a full opioid agonist. Uh, I'm not going to speak about that a lot today just because the treatment center where I work doesn't use methadone. It's more accessible to some patients than buprenorphine, but it's not something that we use at CARIN treatment centers. The first is potentially the easiest to understand. The first is something called naltrexone. Naltrexone is the same molecule, same kind of medication that's in naloxone. Naloxone is what we give people when they're having an opioid overdose that you spray in someone's nose. It blocks all the opioid receptors and can reverse opioid overdose. Okay. Naltrexone is an oral version of that. So it's a pill that you take once a day. It keeps the opioid receptors blocked. So, in essence, opioids stop working. So it's not just a kind of protective mechanism, but what the data also shows is it decreases use and return to use. So you start that blockade and then patients use overdose, be basically the markers that we talked about early, those outcomes all increase. One of the issues with that medication is you have to be completely detoxed from the opioids that you were doing. Okay. So you need seven to 10 days off of all opioids, or else you risk going into precipitated withdrawal. When you give someone naloxone who's overdosing on heroin, they actually wake up feeling awful because all of a sudden they've gone from being in the extremities of euphoria and high to immediate withdrawal that's kind of everywhere in the body. It can be pretty terrible. They patients describe it as feeling really truly awful. So we have to make sure that whole detox period happens. That's actually one of the biggest barriers to using ntrexone. It's a really hard, high relapse potential time period. So that's that's a tough requirement. The other main class of medications is the buprenorphine products. So those are things that go in kind of not many people have heard of buprenorphine. Many more people have heard of suboxone. Yep. So suboxone is buprenorphine. It's combined with naloxone, and that's because it makes it so you can't divert it. So it's something that you put under your tongue and it delivers buprenorphine. The naloxone is so you can't either put it in your nose or more importantly, in your veins because it blocks the opioid receptor. So it's an overdose diversion mechanism that basically protects the medication. The buprenorphine products are partial opioid agonists. So they partially activate the opioid mu receptor, but not fully. And most importantly, they have a respiratory effect sealing. So it's very, very hard to overdose on something like suboxone. So the difference with suboxone is you can initiate someone who's in active withdrawal on suboxone. It needs to be done carefully. But we normally wait till patients are in moderate to severe withdrawal. We initiate them on buprenorphine. They feel better right away because it really cools off the body. It decreases opioid cravings, and outcomes are incredibly good on buprenorphine.

SPEAKER_01 14:56

Under what circumstances does someone start that kind of treatment? Is it usually I am just ready to be done with this? This has caused all kinds of harm in my life, or is it someone saying, you've got to get this under control?

SPEAKER_00 15:09

So I really don't take advice or I don't take guidance, I should say, from anyone besides the patient. So normally I meet patients in a residential treatment facility. It's a pretty high level of care. So of the ASAM levels, there's different. They go basically from outpatient, which is just maybe maybe meeting with a therapist a few times a week, all the way to residential uh detoxification, which is the highest. The highest level is four. That's called 3.7. The numbers don't really matter. But, you know, when I meet somebody, my first job as an addiction medicine doctor is to stage the severity of their use. So I ask them the 11 DSM criteria. By that, they can be mild, moderate, or severe. After that, I really offer everyone with opioid use disorder buprenorphine products when they're at my level of care. This they are the gold standard. Okay. I think they're incredible. The way that we judge effectiveness of medications is something called NNT, number needed to treat. That's the number of patients who must receive a medication for one patient to have a benefit. The number needed to treat for buprenorphine is somewhere between two and three. Very, very high effective, very, very low number needed to treat. Now, trexone for opioid use disorder and alcohol use disorder is about 12. Still pretty good for context. Um, the number needed to treat for something like statins to avoid one cardiovascular event over a five-year period ends up being greater than 30. So we're getting a much bigger effect. These medications really are amazing. And when I'm when I'm sitting with somebody in my office, I really tell them, you have a life-threatening condition, which is opioid use disorder. I have a medication that can treat that. Unfortunately, that's not where the conversation stops. Bupenorphine, especially, has a lot of stigma surrounding it. Many patients come in saying, I will not be on Suboxone. It's not in keeping with my value system and it's not in keeping with my understandings of recovery. And that's where the longer conversations start. You know, it's almost like someone who has a cancer saying, I don't want chemotherapy. And this is where that line will always exist that addiction is a stigmatized disease. And sometimes our interventions are hindered by that stigma.

SPEAKER_01 17:22

I'm having a little trouble with someone who doesn't have uh an addiction to understand you already have an addiction and are using drugs and to say, I won't use drugs. Explain that to me, please.

SPEAKER_00 17:33

I I wish I could. It's it's a really challenging paradigm that exists for really all medications that are in this kind of gray area of agency and also autonomy. You know, I think the same conversations happen around the country every day relating to SSRIs.

SPEAKER_01 17:51

Yeah.

SPEAKER_00 17:52

So people are really reluctant, even though they may be drinking or doing things to treat their depression. They view SSRIs either by what they've heard or now, more likely what they've read to be problematic or they're worried about a side effect. I think about that being a really important part of my practice, which is not forcing someone to come over to the way that I see the world, but educating and really making part of that motivational interview process to see where patients are. And I use a lot of analogies. And really, I think the cancer analogy is an important one. I actually think if you looked at the number needed to treat for some of the best chemotherapies, they'd be much higher than buprenorphine. So I think it's an ongoing conversation, but it's also one that's shaped by society. And I think, you know, one of the biggest helps that we offer patients when they leave treatment is mutual help groups, 12-step recovery. And there's been a lot of back and forth and a lot of tension between those groups accepting the use of buprenorphine, especially.

SPEAKER_01 18:54

When you are meeting with someone who has primarily been in treatment, correct? And is considering the next step, how does that conversation usually go?

SPEAKER_00 19:04

So it happens in phases. I would say the first step is kind of day one. I knock on somebody's door and I wake them up in what feels like a hospital room, because that's where our residential detoxification happens. And the first conversation is really forecasting what's going to happen. So if I know someone has been doing opioids, it's my job to forecast what the next few days are going to feel like and what to expect. What we know is that opioid withdrawal is incredibly uncomfortable. It's not life-threatening. So it's not something that you can't get through. Uh, and we do lots of things to treat the symptoms of opioid withdrawal. We have great medications that can make patients feel better and help them tolerate that time period. I do start the conversation early that when our bodies and minds are craving something, it's really, really hard to think about anything else. So I also use that time to really set the stage that they're with us for 28 to 30 days. I really want those days to be focused on the inner work and not their cravings and not their withdrawal. And that's when the conversation starts about buprenorphine in the kind of the first two to three days. And that's when either patients say, I'm ready, I would like to start as soon as I can, and then we talk about what that looks like, or I have a lot of work to do. You need to talk to my family, my network, things like that. And then it's a longer conversation. I would say for patients who go and buprenorphine right away, they can be on that during treatment. It it looks just like any other medication. They come and they get it at our facility from the nursing staff. And then what's great and even better, and where we can kind of turn the conversation as well, is now we have long-acting injectable forms of these medications. So we can now start before patients leave that injection journey, what's which is once a month. Okay. That's much better for compliance and much better and easier on patients. So that's the in the ideal scenario, that's how it kind of happens. There's many iterations of that with many different types of kind of genres of patients that come through. Some patients want to start on buprenorphine and then taper off. Some want to be on for only a day or two. Again, we we try to meet patients where they are.

SPEAKER_01 21:16

How has an injectable changed the game a month long versus having to be compliant in a way that is really time-consuming and tedious?

SPEAKER_00 21:26

Yeah, I love that question. So I think in multiple ways, starting at the most basic, you have to make 12 decisions a year instead of 365, or if you're taking it twice, double that. So I think from a logistics perspective, compliance is just not good with medications. People have busy lives, people are doing other things. Hopefully, rebuilding their lives, engaging in recovery communities, it's it's a hard thing to keep up with doing a daily medication. So from a compliance standpoint, game changing. I would say the next thing, and one of the things that I think Maybe a little more subtle and nuanced, is I really like that patients kind of forget about it. You get it once a month. It's not something that, oh, I'm, you know, feeling a little anxious. But then I take this aboxone and I even out. The data doesn't support that. It kind of reaches steady state after a certain amount of time. And at maintenance dosing, there shouldn't be too much fluctuation, but daily dosing, you run that risk that there's this kind of correlation to how someone feels. I feel like with injectables, they're they're really that fades to the background. That's my ideal for an addiction treatment, is that you forget you're taking it. Yeah. Because it really allows you to get deeper into the work. And then the last thing is coming off of an injectable is actually much easier than coming off a daily dose of Suboxone. So weaning off of Suboxone or methadone is a really hard thing to do. That it can take weeks, it can take months. This the dosing is challenging, and patients really can struggle with that process. With the injectables, what's amazing about that is they overall the patients get a few injections and then after about the fourth injection, they can stop and it slowly comes out of their body.

SPEAKER_01 23:11

You talked about stigma earlier, and I'm wondering if having a monthly injectable would reduce self-stigma, because it's not that every day I'm reminding myself I'm an addict. It's, you know, I need some medicine and oh, it's time to get it again.

SPEAKER_00 23:26

Yeah, I completely agree. I think it's, I think that's a really astute observation, which is it takes it out of the hands of the patient and it's something that's on them. And it's more that they have to show up to a doctor's office. These are inter-office administrations. And it's it's really important that they that they happen and that they that they make those appointments, and that furthermore, those are touch points with their addiction medicine professionals and times where they can check in. How are things going? Are there other things that we maybe need to tweak?

SPEAKER_01 23:55

What are the side effects or some of them of medications for opioid use disorders?

SPEAKER_00 24:00

The side effect profile is actually pretty well tolerated. Any opioid will affect the GI system in the way that it kind of slows. So GI, all opioids have a side effect of constipation. That's one of them. We recommend that everyone on Suboxone see a dentist with the sublingual versions. There's some concerns about tooth decay. Some patients kind of report that there's this idea that they're kind of, I'll use the word blunted, but some of their drive for things comes down. Um, overall, as far as like major medical side effects, we don't see a lot.

SPEAKER_01 24:33

So tell me about what research shows about the effectiveness of medications for opioid use disorders in terms of reducing overdose deaths and other things.

SPEAKER_00 24:43

Yeah. So the the data is very overwhelmingly positive. So far and away, buprenorphine, methadone, and naltrexone are the gold standards. Buprenorphine, I would say, takes the lead in those three for effectiveness from the outcomes that you said about overdose, overdose risk, and returning to use. Again, the number to treat, we're talking about two to three. So for every two patients who are prescribed buprenorphine, one sees a benefit in one of those major outcomes. So it's pretty incredible. They're some of the most efficacious medications in all of medicine. Wow. Because they really work that well. So, you know, that that is the evidence that as an addiction medicine professional, I'm trying to portray to my patients. And, you know, they're navigating a really tough time. They're navigating their addiction, the expectations of their family, and the expectations of their community. It's my job to represent how powerful that medical data is.

SPEAKER_01 25:40

So efficacious, what a great word. So if they're the most among the most efficacious medications out there, why aren't more people using them? And is that the power of addiction?

SPEAKER_00 25:51

It's not an easy question to answer. There's multiple winds and forces at play. Overall, addiction remains a highly stigmatized condition. So at the most basic level, very few patients who need addiction care get it. That's from a self-disclosure point of view and also an accessibility point of view. Uh, I think it's hard to have addiction medicine-trained individuals in all aspects of health care. It's also just now becoming really commonplace for doctors to be talking about addiction and asking the red flag signals that they can be referred to the resources that they need. The statistics about the medication effectiveness are not the troubling statistics. It's actually about the number of patients who need them who aren't getting them. So once a patient gets the medication, I think that's where the success lies. But now it's really about lowering barriers to care, lowering the stigma around using the medication so that when offered, patients accept and want to participate in that treatment. And then also just kind of the societal shift that we're talking about addiction more openly. This isn't something to be ashamed of. This is a medical condition, not some type of moral failing. So I think those combine in a way to decrease the amount of patients who need these medications but don't get them.

SPEAKER_01 27:16

So if you're talking about the stigma of using medications to deal with an addiction, obviously there's a stigma against it being an addiction as well. Is one private and one more public? Because you had to say it to somebody. Why would that not weigh having an addiction is more stigmatized and worse for me than being on a medication? I'm just over here like this. I don't know how you're supposed to follow that.

SPEAKER_00 27:38

But certainly it's and it's multifactorial and it's different for everybody. We're talking about now these ideas of word of mouth and also kind of things that are pervasive in different types of recovery communities. I wouldn't say it's as easy to say like being an addict is stigmatized more than being a person on Suboxone. It's more how each of those shape an individual's journey. So, for example, someone could be prescribed an opioid, realize that they're taking it not as prescribed, and that they have a problem. Okay. The first stigma that they face is, you know, really asking for help. And I think that comes with a lot of courage. I think most of my patients are incredibly courageous in that they're asking for help. But that's a hard, that's a hard first hurdle. Oh, yeah. So approaching your doctor, maybe even the doctor who prescribed you that opioid and saying, I'm not using this correctly or this is becoming a problem for me. That's a type of openness that for many reasons patients may have trouble with with their doctors. I think the next step is once patients hear the potential treatments for that. And I'm not saying that everyone who problematically takes prescription opioids the first time will be on suboxone, but even the word suboxone, the word methadone carry weight. There's this idea behind them. People on Suboxone R X, people who take methadone are Y. And I think that comes to identity of patients not wanting to identify as addicts just because I inappropriately use opioids. Maybe I don't fully identify as having an opioid addiction yet. So I think those are just a few examples of how different journeys can dictate more or less accessibility to these medications and willingness to take them, which in my experience have been additive.

SPEAKER_01 29:20

So any online search of MOUDs is going to bring up a debate over whether somebody is really sober if they are replacing one drug with another.

SPEAKER_00 29:29

Can you address that, please? Absolutely. So this is something that's really woven into the recovery and 12-step communities. Um, we we actually published a piece on this that was really talking about shattering the stigma. So bringing the conversation around MOUD into this century in the 12-step communities. And it's it's interesting because we have to remember that 12-step communities are incredibly tried and true ways of treating addiction. And I say that in every sense of the word. Treating addiction is really like getting to the core and facilitating recovery. That being said, there's been somewhat of a tumultuous past with the relationship between 12-step recovery and the medical community, largely because in the beginning of, say, the founding of Alcoholics Anonymous in the 1930s, the medical view of people with severe alcoholism was you either had to be in a sanitarium or that you were destined to be in a in some type of institution for the rest of your life. That was really what they had to offer. It was, it was few and far interventions between. So I think there was a strong and maybe warranted distrust of the medical community in the beginning. That makes it an interesting stage that some of the most influential voices, like Dr. Silkworth and Alcoholics Anonymous, were actually medical doctors that started to recognize that alcoholism and drug addiction is actually a medical disease. The story with MOUD is also preceded by a story about other medications, such as medications for depression. So in the beginning, when these medications were kind of in their first wave, it was thought that maybe that these were shortcuts, that these were an easier, softer way. Crutches. Crutches, something that you were leaning on, something that, oh, you weren't ready for this part of your recovery, and therefore you need to use this, which is somewhat paradoxical. It's it was shown that Bill Wilson himself was on high doses of niacin in the foundation of Alcoholics Anonymous for depression. And furthermore, the big book even goes on to say that God gave us amazing doctors and medications and we should use them. So that's the kind of historical background. I think more uh in more in a more contemporary sense, there's this real belief that Alcoholics Anonymous and Narcotics Anonymous offer a spiritual experience. And that spiritual experience is blocked by the use of mind-altering medications. So when someone comes in on something like Suboxone, which is an opioid partial agonist, I think the fear is that they'll be blocked from doing that deeper work and having that spiritual experience. I don't share that belief. I think that the idea is that the conversation about opioid use disorder is a conversation between patient and doctor. And I think, again, the medical evidence is overwhelming that these decrease overdoses and decree and retain uh participation in treatment. So I think they they have to be used. I think where we get to this friction is really the idea that they're not conducive to the work that happens in 12-step recovery groups. I think there's really no evidence for that. There's no biologic objectivity to the idea that these people are not sober. I would say these people are sober. These people are in recovery. They're using all the tools that are available to them. And in fact, I think in many ways, the use of buprenorphine is an incredible manifestation of the first step, which is that I'm powerless. And therefore, I need something that helps me. I need something outside of myself. I need something like a doctor and a medication and technology to help me on that path. And, you know, I think the other part of it is that anytime that there's something new or that there's something that that helps patients along, I think there's a little degree of threatening that happens. If someone can do this with buprenorphine, do they need narcotics anonymous? I think the answer, as always, is a little bit more nuanced. I look at buprenorphine especially as buying patients time to have that vital spiritual experience where then they can engage in the rest of their recovery and potentially come off these medications or stay on. It's a conversation between them and their doctor, but really it they're the medications themselves. The evidence is so overwhelming that they help patients that as a doctor and a person in recovery, I don't think anyone should have limited access or face stigma for taking them.

SPEAKER_01 33:53

I understand that that is your very informed uh opinion. Do NA and AA allow people who are using opioids as a treatment to be in their programs?

SPEAKER_00 34:06

Now they do. Um NA has released more contemporary literature and pamphlets. AA has more come around to it as well. I think AA the the stance in NA was perceived by many, including myself, to be a little bit more um organized and maybe a little bit more pragmatic. Um that I think is fading away. It takes time, changes slow. And I think, especially because the opioid epidemic, and by that I mean the wave of opioid use that was precipitated by prescribing of opioids, uh, really kind of took the community and the country as a wave and it happened quickly. And now we're still kind of reeling from that as a phenomenon. So I think it's important it's important to start the cultural conversations. I think more importantly, it really gets to the point that no patient should be discouraged from using a medication by anyone besides their doctor. And that is something that I think needs to be reinforced and it's probably has a little bit of geographic variability as well.

SPEAKER_01 35:09

Do sober living homes allow MOUD use?

SPEAKER_00 35:12

I think it's a it's a variable. Um, some do and some don't. I think for uh just logistics to administer them, some I think run into logistic issues of that uh as a as a treatment center that refers to multiple sober livings, multiple aftercares. It's something that we have to judge and make sure that the right patient is going to the right setting.

SPEAKER_01 35:34

And how do we find out if we don't have you being an advocate for us? If I'm looking into treatment options and I'm currently using an MOUD to help me with my opioid use disorder, how do I know if the place is going to allow me to be there? Definitely ask.

SPEAKER_00 35:49

Yeah. That's the biggest part, I think. Also, if you're looking at navigating a few different treatment options and you are someone who's struggling with opioids, you may want to know if the treatment center that you're going to is offering MAT and MOUD. Most treatment centers do now, but that wasn't always the case. And there may be some growing pains, again, largely depending on geography and what the ideology of that treatment center is. Uh so it's something you may want to look into while doing the research and picking out the right treatment center for you.

SPEAKER_01 36:19

Do the medications we're talking about for treating opioid use disorder also help with other addictions like alcohol use?

SPEAKER_00 36:26

Yeah. So going back to naltrexone, naltrexone is actually the standard of care for alcohol use disorder, which is really interesting because you're now saying why. We talked all about the opioid receptor, but now alcohol works on a completely different receptor class. It's basically the GABA receptor. So why is it that the data shows that patients on naltrexone drink less? It's a pretty fascinating mechanism. So we have now started to understand that really the first drink, the first time that someone ingests alcohol, yes, it's GABA-mediated, but there's a euphoric feeling, what some patients describe as that like first like breath of alcohol drinking, that first kind of wave of drunkenness. Um, that's all mediated through the opioid receptor. So there's something that happens at that level that decreases cravings for opioids. Also, naltrexone is used in a somewhat interesting, going back to one of your earlier questions about abstinence versus moderation, with alcohol, there can be different outcomes and different desired paths. One of which is called the Sinclair method, which is when someone takes naltrexone 30 minutes to an hour before drinking in the hopes that it mediates the number of drinks that they have during that episode.

SPEAKER_01 37:37

Does insurance, whether private or public Medicaid Medicare, cover medications for opiate use disorders?

SPEAKER_00 37:43

Yes, largely so. It's been one of the really great successes, I'd say, of public health initiatives in the addiction medicine space. Insurance is not something that I feel like I have to contend with. I can recommend MOUD to almost anyone, also with naltrexone. These things are widely covered and their injectable forms are actually really expensive. Sublicade, Brixati, and naltrexone comes as an injectable called vivitrol. They're very expensive. Um, but luckily, addiction medicine practices have gotten really good at doing those prior authorizations and getting patients on monthly injections, probably because the number needed to treat is so low. And when we keep people away from doing substances and treating their substance use disorders, I think it's one of the great kind of public health successes in that we can really have them re-integrate into society. They have less comward issues. And overall, it's I'm not an insurance company uh calculus major, uh, but I would imagine overall the cost savings is huge for patients with addiction.

SPEAKER_01 38:48

How long do the benefits of MOUD last for people?

SPEAKER_00 38:52

They they can last forever. I would say the limit doesn't exist. There's really the ability to be on these medications for the long term, especially with the injectables. I will say anecdotally, you know, just going back to maybe the the foundation of this conversation, there's treating the symptoms of addiction, and then there's really treating addiction. Yeah. For me, treating addiction is recovery. So I do work with men who have been sober for long amounts of time, have very um, very strong foundational roots in 12-step recovery, but then return to use. What's interesting that I see again, and I don't have data to back this up, it's more of an anecdotal observation, is there are uh men that I serve as patients that are on MOUD for the long term and come back into treatment for other substances that are actually not being blocked or activated by the opioid receptor buprenorphine or notrexone. And I think that gets to the core of, you know, we forgot the question and we still didn't answer it. And now we are getting to it by a different substance because that question is still there. So I think that the question of why was I using in the first place?

SPEAKER_01 39:57

Why what was I running from? What am I trying to feel or not feel?

SPEAKER_00 40:00

Yeah. So going back to that analogy, you know, opioids were not the answer. They made me forget the question. Yeah. I still didn't answer that question. And now I'm doing crack cocaine or methamphetamines. And I think that's still a block that's making me forget the question and or hiding me from the pains of the question. Yeah. And I think that's really where these medications potentially start to hit their sweet spot, is when at a place like Karen, we combine not just the medication, but with therapy, going back to your other question, with wraparound clinical services, that's when we get to the dream of lowercase M, lowercase A, capital T, medication-assisted treatment, treatment being comprehensive, not M O T medication only treatment.

SPEAKER_01 40:49

The why you keep bringing up, is that generally traumas? Are there what are the the main categories that fall under the why and explain why, why we start using in the first place?

SPEAKER_00 41:00

Sure. I think it's a it's a tough question. Lots has been a lot has been researched in that area. Trauma is a huge player. Um, I think for me, I I, from my own experience and from the experience that I have with my the patients that I'm honored to serve is really the why comes down to some point in life when disconnection happened. Disconnection is really the mantra for me for addiction.

SPEAKER_01 41:25

Yourself from the world, yourself from yourself. Both.

SPEAKER_00 41:28

Yeah. Both, either, sometimes all. I think that disconnection where we start to identify and start to exist in two different or three different or four different versions of ourselves. The version that experienced trauma from the version that is now in the present, the version who was, you know, for me, a young gay boy who didn't know how to integrate my sexuality into the main the mainstay of my existence to who I am now. All of these things lead to disconnection. And I think in the space between identities is where addiction can really flourish. So I think that's where we use substances to really get in and start to have the illusion that we feel okay when really we're troubled by the way that we feel.

SPEAKER_01 42:14

Feel okay or or don't feel. I mean, that was Or forget to feel. Yeah. We've talked about the side effects of using medications to treat opioid use disorder. What are the side effects and the risks of not treating it?

SPEAKER_00 42:28

The most important question, which is my statement about this, is an addiction medicine. I don't treat scraped knees. Addiction is a high morbidity, high mortality disease. The risk of not taking MOUD for severe opioid use disorder in the most extreme is death from overdose. I would say also just decreased quality of life, decreased ability to have any type of agency and return to use. I mean, the stakes are incredibly high. Luckily, we have really great medications in the realm of opioid use. And that started to help us even be able to combat the opioid epidemic, but there are still barriers. There are still barriers.

SPEAKER_01 43:10

If someone listening is thinking that medications might help them, you know, maybe they hadn't thought about it before. Maybe it was so stigmatized that they just that was for somebody else worse, way worse than they are. Um, so if for ourselves or for a loved one, we're thinking maybe this is something we should look into. What's the first step they should take?

SPEAKER_00 43:27

I think the first step is to acknowledge all of the steps you've taken to get to that point, that you've really done an incredible amount of work and that you've probably had an incredible amount of hurt by going through whatever you've gone through or what your loved one has gone through. So just to be at that point, I think takes in a huge amount of effort and is heroic. I think the first step from that point is to find a medical professional who's versed in addiction medicine who can walk you through the options. Depending on where you live, that may be easy or harder to access to have access to. We're getting better and better about providing both telemedicine, more in-person opportunities, more things that are supported by insurance, both state and federal insurances. So I think finding that, no matter what it looks like, and knowing what resources you have. And, you know, the the internet is obviously a wealth of being able to connect people, it can be hard to navigate. But really, if you need to start that conversation with your primary care doctor, your family doctor, your pediatrician, anybody to start that ball rolling who can put you in the right direction of someone who prescribes buprenorphine.

SPEAKER_01 44:35

So I'm going to ask you to go down two different paths here. So first is if someone's speaking to you directly and they say, I don't know, you know, I can't. I'm I am, I know I'm in it, right? I know I have an addiction. And I I have not considered medications before to get out of it for all the reasons somebody might not. And they're asking you, what should I do?

SPEAKER_00 44:55

The first, so anytime anyone asks me, you know, I'm struggling, I just listen. For the first part of it, I listen to what substances they're doing, what's going on in their life, how it's affecting them. As a person in long-term recovery, my idea is to really break it down and make sure that they understand that I'm on their level. I know what it's like to be a person who's lost agency. I know what it's like to not be able to control my behaviors based on my desire to pathologically pursue reward. So first I want to identify with them and make them feel not alone. As a physician, it's the idea that I'm really looking at them from, you know, how much of a risk are they to themselves? How severe is their addiction? How severe from a medical perspective, from a psychological perspective, really from a multitude of perspectives. So I think if someone's talking to me as far as like, hey, you know, I know you're in the addiction medicine space, what do I do next? It's really gauging what level of care do they need. Uh, that's something that can be informal, but is also very formalized. The idea is really identifying do they need outpatient level of care versus inpatient? Those are things that were colloquially called rehabs. We now call inpatient treatment centers. Do they need to go to a place where they're completely separated and we can mitigate all the risk factors, or can they maybe get by on an outpatient basis? That's case by case. Um many patients, I think, in an ideal world would have access to outpatient interventions. And then if they didn't do so well or progressed, they would then go inpatient. But that's the kind of runway and the buildup that I try to set up for patients, whether I'm, you know, on the clock or off the clock. Um, just the idea that there's all these resources available to them, whether it's ending up in care and treatment centers or being with an amazing outpatient addiction medicine doctor who can give them resources and medication, that's case by case.

SPEAKER_01 46:51

How does it help when you're communicating with somebody in addiction to be able to say, I get it?

SPEAKER_00 46:58

It's the whole conversation. Yeah. It really is. I would say of the patients that I have the honor of waking up at seven o'clock in the morning when they're in residential treatment, I can take them through an entire medical plan. I can tell them all the numbers needed to treat. I can tell them the medications available to them. I can lay out the field. Uh, but at the end of that conversation, I can look at them and say, if you choose, you never have to feel this way again. And I know that from experience. And I'm not saying that all addiction medicine doctors have to be in recovery.

SPEAKER_01 47:34

Yeah.

SPEAKER_00 47:35

The pretest probability that I have something in common with my patients is pretty high.

SPEAKER_01 47:39

Yeah.

SPEAKER_00 47:40

And, you know, I do think for me, on a personal level, integrating recovery into my career has been an incredible manifestation of authenticity. But it's also made me really effective. I think for me, I love having that conversation because there's two real battle cries of addiction medicine, and that's trust and hope. And trust, I feel like I can form because people know where I'm coming from and that I've walked that path. And hope I can also try to offer because I see what the other side has looked like. And that's really where I find this career to be so incredibly rewarding. And, you know, there it's it's in the the big book and the language of of Alcoholics Anonymous, but there's there's really nothing that replaces one alcoholic talking to another, one person with lived experience breaking down that wall. And and to be honest, to zoom out, I think it's because it instantaneously shatters stigma. I'm offering medications not as a representative of just medicine. And someone who's been to school and someone who has the education. I'm offering medications as someone who's walked through that path who knows that there's so much more of the journey, but this may make the beginning of the journey easier. And that to me is is the entire conversation. Yeah.

SPEAKER_01 49:11

So to a different audience, let's talk to the partners, the parents, the whomever uh who is thinking, listen, my blank has a problem. My you know has a problem with opioids. And you're saying they should take opioids to treat it. Like, how do you explain to them why you think it's a good idea?

SPEAKER_00 49:30

Yeah. I start by first acknowledging how hard their journey has been. Being the loved one of someone affected by any type of substance issued substance use disorder is devastating. Addiction is a family disease. It affects the person with the substance use disorder and everyone around them. And from that standpoint, I really start from an inquisitive standpoint of what is your fear about opioids? The idea of replacing one opioid with another when you have a grave distrust because, from your perspective, opioids have destroyed your family and your future and your loved one. I get it. I understand your fear. From that vantage point of curiosity, I open up the conversation of what do you know about these medications? Do you know anyone on them? And is there anything that I can answer about the specifics of how they're going to be used? I think in the beginning, the biggest questions are, can they be abused? And is there any overdose risk? I think those are things that can be easily talked about. But then the harder conversations is will my loved one ever recover if they're going to be on opioids forever? And is this a forever problem? And, you know, I often at that point relate to the idea that I don't prescribe medications for people's lifetime. If I had a magic wand in my office, I would offer everyone one year of abstinence from the substances that brought them into my office. I think that's the about the amount of time that it takes to start really evaluating the why, evaluating what's what are we going to need to get at the why. So from that perspective, I just try to partner, not from the sense that I'm right and you're wrong, but from the sense of your loved one is dying. Your loved one has a high morbidity, high mortality disease. As a doctor, I can help to treat that. I'm going to need your help and I'm going to need their help. Together, we have a chance. Alone, we really don't. And from that teamwork perspective, I think we have a shot. But it takes, it takes a lot. It takes a lot of alignment. It takes education. It takes follow-up. This is not a a low a low anti-game. This is something where you really need to be invested in your patients and their families. Wow.

SPEAKER_01 51:47

One more question, we'll wrap up part one here. So, what is the stigma associated with using medications to treat addiction that if you mention your magic wand, that you wouldn't most like to see eradicated?

SPEAKER_00 52:01

Really, it's it's what you were talking about, and you've mentioned a few times that it's, you know, we're treating one opioid with another. I think if we could just dispel that this idea that these are that buprenorphine-based products are an opioid and that they're somehow making patients high and that patients on them are lazy. I actually don't think there's anything lazy about being on buprenorphine. The amount of work that it's taken to break the cycle that a patient was in, get to help, and then have an honest conversation about what they need is again, I use the word heroic a lot. I think most of my patients are incredibly heroic and incredibly courageous. So I think to really honor that journey for them and break down all of the barriers, that one stigma that either they're kind of synonymous, but you're using one opioid for another or you're not sober, unclean. I think those are the two things that I would like to see just done away with. And instead being saying you're a person with a life-threatening disease who's using all the tools at their disposal to gain recovery.

SPEAKER_01 53:04

And how it ever became crutch instead of tool when we use medications for pretty much every other illness we have in our lifetimes. Correct.

SPEAKER_00 53:12

So welcome.

SPEAKER_01 53:13

And I'm looking forward to next week's conversation. Please join us next week as we continue our discussion with Dr. Stephen Klein. And this time we're going to shift to GLP1s, those diet drugs that you know about Lycosempic and Wagove. They are thought of as weight loss drugs, but they are also showing great promise in addiction treatment, and we'll be talking about those next week. Please join us. Between now and then, please take care of yourselves and each other.