Joey Wahler (Host): It's a very common and serious problem in this country, so we're discussing alcohol and drug addiction and its treatment. Our guest, Dr. Sandeep Mann. He's an Addiction Medicine specialist for Dignity Health. This is Hello Healthy, a Dignity Health podcast. Thanks for joining us. I'm Joey Wahler. Hi there, Dr. Mann. Welcome.

Sandeep Mann, MD: Hi, thanks for having me, Joey.

Host: Great to have you aboard, Dr. Mann. So first, in a nutshell, what constitutes addiction compared to, say, a strong habit or urges?

Sandeep Mann, MD: All right. Well, certainly habits and urges are part of addiction, but it doesn't really define it as an entity. Within Psychiatry, they have the DSM-5, which is a manual that essentially is a diagnostic criteria for various psychiatric diagnoses. One of those is substance use disorder, which is what we call addictions basically in medicine nowadays. So, that would include things like how it's impacting the rest of your life. So, you know, are you hearing from your wife that you're drinking too much or using too many pills? It's adversely affecting your job. You know, you're getting into accidents, getting DUIs, you know, the way that it impacts the rest of your life is kind of the diagnostic criteria for addiction on top of the physical dependence as well.

Host: Gotcha. So, what addictions do you treat most?

Sandeep Mann, MD: I'd say alcohol is still the biggest addiction in our country in terms of morbidity and mortality. You know, there's so much in alcohol. It affects pretty much every cell in your body. There's not a single cell in your body that sees alcohol and is like, "Oh, thank goodness." So, it affects everything from the liver to your kidneys, to your eyes, to your skin, it's everything. And it's the most widely available and socially accepted. So, I would say alcohol is still king. Fentanyl obviously is getting most of the news nowadays. To be fair, it is killing the most people, especially since the pandemic. But I would say the most common addiction I treat is still alcohol.

Host: Okay. So, how does someone typically become addicted to alcohol or other substances? We know it can be genetic, right?

Sandeep Mann, MD: Right. Yeah, you know, alcohol is probably the best studied addiction that we have, and there has been some studies that suggest some genes are implicated in forming alcohol or alcoholism. You probably know as well as me and everybody listening that if you have a grandfather, a father, a grandmother, an aunt, an uncle, and they're all alcoholics, you have a pretty high chance of being an alcoholic yourself. So, those with a genetic predisposition are facing an uphill battle.

Host: Understood. So besides those with that family history of it, who's typically impacted by addiction and its complications? Who's most at risk here?

Sandeep Mann, MD: I would preface that by saying addiction doesn't discriminate. I treat everybody from every walk of life and socioeconomic status. So, I would say the socioeconomic group that is most adversely affected is our Medi-Cal population, those low income, maybe unemployed, maybe unstable housing. That population is probably the most affected by addictions, but by no means are they the only ones who become addicted to things.

Host: Between alcohol and drugs, you mentioned alcohol is the more prevalent addiction. Is one or the other harder to treat from your standpoint? And which particular drug addiction would you say is toughest to address?

Sandeep Mann, MD: Well, that's a great question. As of right now, there's only two addictions that we have, any medications that are FDA approved to treat. And that would be alcohol and opioids. So, I guess the default answer would be anything that's not an alcohol or opioid addiction. Things like stimulants, they're so prevalent, especially in our area here in the Central Valley. And they're so often tainted with fentanyl that treating these methamphetamine or cocaine or crack cocaine-addicted patients, it's almost as important as treating people who are only using opioids, yeah, I would say pretty much every addiction besides alcohol and opioids can be trickier just because there's no FDA approved medications, but there are options that we can use off-label.

Host: Okay. So, you led me beautifully doctor into my next question. What are the latest treatments these days for be it alcohol or drug abuse?

Sandeep Mann, MD: Well, probably the most interesting development recently regarding specifically alcohol, it kind of confirmed what we were seeing anecdotally with the rise of this new class of medication, which I'm sure everybody has heard of and is trying to get their hands on nowadays. Things like Ozempic, you know, the GLP-1 analogs, the ones that are prescribed usually for diabetes and for obesity. We've actually seen a huge reduction in the amount people are drinking, the ones that take these medications. And it's hard to say whether it's just the physical, you know, you can't drink as much because that's the purpose of the medication, is to kind of make it harder for you to intake large quantities of food and liquids at once to kind of facilitate weight loss. But there's a study that came out actually in the summer of this year that implicated GLP-1s for alcohol treatment. And we really need to see a head-to-head study that really looks at things like Vivitrol or naltrexone compared to you know, Ozempic. And we'll see, eventually, if we get any funding for that sort of study. You know, Novo Nordisk is pretty tight when it comes to letting other people in to those medications in terms of using it for other things, and it's hard enough to get it prescribed for obesity or diabetes as it is.

Host: So, to be clear, you're saying that a weight loss drug could also be effective in treating alcoholism.

Sandeep Mann, MD: Absolutely. And it really gained traction around the pandemic when the rates of alcohol consumption in America were at their highest since the '60s during the pandemic. As you can imagine, you know, everyone's got free time, they're staying at home. We have apps nowadays where it's easy enough to get alcohol delivered at home, you don't even have to leave your house. So, it's easy to see how there was a huge uptick in alcoholism in America and alcohol-related comorbidities. Like, you know, I've been seeing 30-year-olds with cirrhosis in the hospital. So, it's really a big thing. But when we saw the GLP-1s come along and people were reporting that they were drinking substantially less, we all sort of looked at each other in addiction, like, did we just discover the drug that everyone is clamoring for is also effective for alcohol? It's like, what can't it do? So, that's probably the most exciting development. There are other medications which are more Classically used, and certainly FDA approved to treat addictions, things like I just mentioned, naltrexone, which is an oral tablet that also comes in a monthly injection which completely takes away the compliance issues for most patients. People have probably heard of disulfiram, which is antabuse. That's the one that makes you sick if you drink. I hardly prescribe that medication. But a lot of people, they swear by it, say it's the only way they can stay sober. And then, there's also acamprosate, which is a little more cumbersome to take. Instead of just one tablet a day, like naltrexone, it would be six tablets a day, so two tablets , three times a day, so a little bit more cumbersome. However, if people take it as prescribed, it's about as efficacious as the once-daily naltrexone. As you can probably imagine, the one that has the best data to support its use for alcohol is the Vivitrol, which is once monthly injectable naltrexone, which is given in the doctor's office.

Host: Now, coming back for a moment, Doc, to something you mentioned earlier, you said addicts are often struggling with other problems, personal, family, health, job, or other issues. So, do you get them the help that they need with some of these other things in tandem with their addiction treatment?

Sandeep Mann, MD: That's a good question. As physicians, we're trained to prescribe medications. But, you know, I just read this, it was an article, it wasn't really a study. But in the UK, or in Europe, they're basically giving people prescriptions for hobbies or exercise or like, "My doctor gave me a prescription for a gym membership." So, those sorts of things, I wish I could do that and just make it happen. But really, it's on the patient for the most part to make those changes.

Now, you also mentioned, you know, things like mental health and whatnot, of course, depression and anxiety kind of are lying on the bases of so many of the addictions that I treat. You know, it's hard to say whether or not the substance caused the mental health issues or if it was vice versa, but treating them in tandem can be so much more helpful than just treating one or the other.

Host: Sure. And I was going to ask you about that next, so you addressed that perfectly. The fact that mental health, of course, is also a common accompanying problem here, right?

Sandeep Mann, MD: Of course.

Host: A few other things. With addiction remaining such a huge problem in the United States, based on your experience, doctor, what would you say is the main obstacle for you and yours in treating the issue? What's holding back more progress in this area.

Sandeep Mann, MD: Yeah. Well, excellent question. You know, availability of the medications and the amount they're being prescribed obviously that should have a direct effect on how much people are drinking. Like, let's say if we put naltrexone in the water, for instance, or if more primary care doctors started prescribing it for people who they know have alcoholism, that's one thing that can obviously increase the amount of treatment going on.

But as far as your question in terms of barriers, it's kind of classic doctor's dilemma. Is trying to get these medications covered by their insurance. Luckily. In our area. Health Plan of San Joaquin, we don't need a prior authorization to prescribe Vivitrol for alcoholism. So, I have a lot of success getting those patients, Vivitrol. It's a lot harder for people with private insurance, so I wish insurers like Blue Cross and Anthem, HealthNet United, all of these other private insurers, if they got on the same page as Health Plan and some of these other Medi-Cal Advantage plans, it would be a lot easier. You know, the amount of time I spend doing prior authorizations for Vivitrol for X, Y, and Z, it's just a big time sink. And I can see why other prescribers would just give up and say, "Hey, this is too much time for my office. You know, we don't have the resources to deal with this many prior authorizations for Vivitrol." So, refer them to Dr. Mann.

Host: Understood. So speaking of which, you're saying that this type of treatment is at times covered by insurance. So, which particular ones do you accept?

Sandeep Mann, MD: Oh, you know, at this time, for addiction treatment, I pretty much have all the major insurers. The big holdout was Blue Shield for over a year, actually, but we just got that contract as well. So, pretty much everything from Health Plan of San Joaquin to Blue Cross to United to everything in between. We're working on some of the other local IPAs, Hill Physicians, I do have a contract with MedCor and AllCare. We're kind of working on as well.

Host: Great to hear. So, how can patients contact you, Dr. Mann?

Sandeep Mann, MD: Yeah. They can feel free to call our office at 209-851-2065. They can always Google us as well. My practice, I think we're listed on Google as Pacific View Recovery, which is kind of my baby in terms of my Addiction Treatment Center, which right now is just me and my doctor's office. But if you Google Pacific View Recovery Stockton, it should come up. Or if you have any questions, you can just reach out over phone. We are also able to be contacted through the website as well.

Host: How about the importance of referrals to you from primary care doctors?

Sandeep Mann, MD: Yeah. For the most part, the majority of my patients get referred to my clinic from their primary care doctors if I'm being honest with you. So, that's probably the best way to get in, because obviously we want to see some labs first. There's a few check boxes that need to be done first before I see a patient. So, we really prefer it if there's a referral included, but also we see patients without referrals too.

Host: And so in summary here, if someone is willing, generally speaking, what are the chances of effectively treating their addiction?

Sandeep Mann, MD: If you look at the overall population data, no one's done a real good study in terms of how effective is addiction treatment. They kind of look more at other metrics in terms of especially for alcohol, the one that they kind of mentioned the most is percentage of heavy drinking days, that's kind of the goal to reduce in terms of giving a patient naltrexone or Vivitrol. But if we were to just look at addictions across the board, that's hard to say. I can say for sure that if a patient gives a medication-assisted treatment, which is kind of this whole idea that I'm doing here is giving medications to assist addiction treatment. And that's thing, it's an assist. It's not the only treatment, right? This comes along with therapy. If you need to see a psychiatrist, you got to go start medications for depression or anxiety, like go to AA meetings. There's so many other things that go along with addiction treatment other than the medication, which sometimes gets a little muddled.

Patients sometimes expect a magic pill to kind of come along and cure them, which, going back to your question. If I were to estimate the total number of addictions that become successfully treated or that the patient recovers from and is in remission, I probably estimate it somewhere between 20-40%, that's complete conjecture.

Host: Okay, fair enough. Well, folks, we trust you're now more familiar with addiction and its treatment. Dr. Mann, a pleasure. Thanks so much again.

Sandeep Mann, MD: Thanks so much, Joey. Appreciate it.

Host: Same here. And for more information, please visit dignityhealth.org/stockton, S-T-O-C-K-T-O-N, of course, forward slash behavioral health. If you found this podcast helpful, please share it on your social media. I'm Joey Wahler. Thanks again for being part of Hello Healthy, a Dignity Health podcast.