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Scott Webb: As most of us have heard over the past few years, we've had an opioid epidemic in this country. And joining me today to discuss the signs of addiction and the intervention and treatment options for people who are suffering from addiction to opioids is Dr. Larry Cowan. He's board certified in addiction medicine and general practice with Genesis.

This is Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. I'm Scott Webb. So doctor, thanks so much for your time today. We're going to talk about addiction and, as you and I were kind of speaking about before we got going here, these are some heavy questions, some loaded questions. But it's great to have your expertise today, and especially as we talk about opioids. So as we get rolling here, how do people get addicted to opioids? Because we've heard so much about that, the opioid epidemic and crisis, addiction and so on. So how does that happen?

Dr. Larry Cowan: There's several things that lead to addiction and I'm sure a lot of people are familiar with them. And one of the main ones is drug experimentation, which often with our opioid patients starts at a very young age and usually, believe it or not, prior to age 14. And it starts with usually some experimentation with marijuana, alcohol, just a little on the weekends and then they just look for more and more. And usually around age 16 to 20 is when they are introduced to opioids by a friend or even a family member and it takes off from there.

Another source of addiction, and some people may be familiar with this, is a physician prescribes appropriately an opioid for a medical issue or often an orthopedic issue. A person is in an accident and this can occur at any age, a car accident, a sporting accident, or just something that occurs at home. They break a bone and they're started on an opioid in that situation. And a week or two is really not usually a problem. But if it extends beyond 30 days, that prescription for the opioid, then the person is at distinct risk of becoming habituated.

And,

Lastly, mood disorders, undiagnosed and untreated mood disorders facilitate people's route to becoming addicted to a drug. They will go to a party. They have an anxiety disorder or something like that. They're usually very shy. They don't talk to people. And suddenly, they're exposed to some sort of drug at a party and suddenly they become, you know, a great socialite or there's a person that has bipolar disorder, which is depression with mania, and that's one of the highest risk disorders, bipolar disorders, as far as getting people into an addiction mode, because they're very apt to do things very impulsively and also to try to treat their mood disorder, which is depression in that case. Or people with depression who are untreated, they will seek drugs to treat their own depression. "I'm not going to see a psychiatrist, but I know what's best for me and I'm going to do this." Those are the big ways people become addicted to opioids and other drugs as well, of course.

Scott Webb: Yeah, for sure. It's good that we're having this conversation. And wondering, are there ways that we can prevent ourselves or our loved ones from becoming addicted?

Dr. Larry Cowan: Yeah, I guess it's to be educated to some extent about the potential. Of course, people think that marijuana and alcohol are the so-called gateway drugs, but actually nicotine is the classical gateway drug to addiction. So even starting with that particular thing is, a lot of times, one of the routes that young people especially take and especially with the ease of getting these vapor nicotine devices that have nice flavors and things that are not just like smoking a cigarette anymore, that's a big thing.

Having people, having a good relationship in their family is important, but that's not always easy to accomplish. But if you have a loved one, that you'd like to prevent, like your child, honest conversations, having a good relationship, communicating well, those are all, I guess, obvious things, but sometimes difficult to accomplish. I mean, I have four children. There's no handbook on raising kids. But having an honest relationship, you know, tell them, "Listen, you may try a drug. and it's going to make you feel better than you've ever felt in your life. But then, it's just going to be downfield from there." No one ever plans on being an addict. No one ever foresees themselves becoming addicted to any drug, but it happens.

Scott Webb: You know, as we're talking about our kids or other loved ones, what are some of the signs or red flags maybe that they're using or that they've actually become addict?

Dr. Larry Cowan: Poor hygienic behavior, suddenly their grades are going down if they're your kid or, in this case of adults, poor work performance. They're missing work. They got fired for some reason. And they say, "Well, I got fired because they're laying people up." Well, You may want to check into that a little more and just find out why they really were fired and is because they've been sleeping in or they've been "sick." And that's another thing, just, you know, strange behaviors, secretive behaviors. You can tell something's wrong a lot of times, but everyone's busy with their own lives, and sometimes you're just not paying attention, and you don't want to think about it or think that that's what's going on. But if the person's having those signs of those characteristics of addiction, where they're just letting everything else slide, that's the hallmark.

Scott Webb: Yeah. And whether it's our children, loved ones, friends, whomever, let's assume that we've spotted these signs or these red flags, right? Then what do we do? What are our next steps?

Dr. Larry Cowan: Yeah, that's a great question. If you have a primary care physician, a lot of times going to them and to tell them what's going on. But, you know, there's of course privacy matters concerning that. You can tell a physician something about a patient, but a physician is obligated not to say anything to you about the patient unless you are on their medical release that allows them to communicate about that individual back to you. If it's your child, you are allowed to have that information to a certain extent. But the HIPAA laws in the United States, which are appropriate, you know, prohibit us from knowing each other's medical details unless permission is given by the patient. You can go to the person and have that conversation with them. You can go to your clergy member and ask them for their help if the person is attuned to whatever that clergy member represents. You know it depends. Everyone, as we grow older, we sometimes diverge our religious beliefs and principles and that may actually, you know, kind of backfire.

The best thing a lot of times is to sit down with the person and ask if they're all right, "What's going on? Are you having trouble, you know, with alcohol or something else? Just tell me, I'm not going to be mad at you for telling me. I just want to help." And the problem with the whole thing is the person has to be ready to recover, who has the addiction, they have to be ready. And it's awful to say, but unfortunately, a lot of people have to suffer enough to finally call an end to this thing that's controlling their life and that's our biggest barrier. Unfortunately, it's a disease that the person oftentimes doesn't even know they have the disease or is unwilling to admit they have the disease. It's a very unusual disease. The person doesn't want to necessarily get better from the disease. And with our opioid patients, and this is terrible to say, a lot of times, once they are down in that valley, they have to be down in that valley suffering for as much as five to ten years before they finally want to emerge from the valley. And, you know, the horrible thing is right now is that fentanyl is so out there and it's difficult to dose. These people that are distributing fentanyl aren't exactly biochemists. And you would think they don't want to kill their customers, but it's happening because it's hard to control the dosing. And these people are dying of overdoses before they have a chance to realize that they need to come out of that valley of suffering that's involved with the addiction.

Now at first, the addiction, you know, they're having a fine old time. And then before they know it, they say to me over and over, people that are recovering tell me, you know, "Finally, I realize all I'm doing now is just trying to not go through withdrawal." They'll spend years doing this they tell me. And then finally, they go, "I just can't stand it anymore." Now, if an individual says, "Listen, I need help," then you call your family physician, but you can also call something like a reputable recovery system, such as what we have at Genesis here. We have a great staff that will welcome people in. And we have a couple of programs there, several types of programs, including medically-assisted therapy for drug addiction, which of course I take a great part in that. But we have amazing counseling and other services and intensive outpatient treatment program for people that come to us. But getting that person to call that number is a lot of times a very hard barrier to get by. And they can call the number, they can set up an appointment, but then they have to show up for the appointment.

Scott Webb: As we get close to wrapping up, let's assume that someone has come out of that valley of suffering, that they've called that they've actually shown up, what are the treatment options for people who are addicted to opioids?

Dr. Larry Cowan: There are several. But to be honest with you, the number one standard for opioids is buprenorphine therapy, which is commonly known as Suboxone. And there's so much stigma associated with the name Suboxone, which of course is just the trade name or the commercial name for the drug buprenorphine/naloxone. It's actually a combination of two medications. That is the number one accepted treatment for opioid addiction. Of course, for years, we've had methadone since I believe the '40s. But methadone, in my opinion, is a little bit outdated to a large extent. It's a much more complex treatment program. They have to be seen every day at the methadone center. And then, after some number of months or years, they are allowed to have the medication and take it at home. But it's not the same thing as buprenorphine therapy, which is, like I said before, commonly known as Suboxone, buprenorphine doesn't really get the person high. It doesn't give the person a full opioid effect. It is an opioid, but it is a very atypical opioid. Methadone is a full opioid. It will give the person the full opioid effect. And it's effective and we've had use for it for years. But like I said, the buprenorphine just gives the person more of an effect where they will almost always tell me they just feel normal. They feel like they just don't have any cravings. They don't have any desire to use drugs.

Now, a big thing that we hear, Scott, all the time, "Well, aren't you just exchanging one addiction for another when you put someone on Suboxone?" That is the biggest thing we hear. No, an addiction is when the person is playing their own doctor. They are of course committing malpractice against themselves. People are not equipped nor should anybody be prescribing themselves medications. I'm not allowed to prescribe myself any medication as a physician and neither should anyone else. But of course, you know, convincing people that it's not always very easy, but that is addiction. And of course, the person's out of control being their own doctor and their own patient. This drug is being prescribed by an authorized individual who is a physician who is prescribing the buprenorphine or Suboxone, what we call Suboxone therapy. And these people have very good prognoses when they are on that medication. They go years and years. I have patients that are 14 years in remission, still on buprenorphine. I constantly have the question, "When can a person go off of it?" Well, it is discouraged to take someone off of that medication. It is strongly discouraged. And I think, most addiction specialists such as myself feel that that's the biggest mistake made with that medication, is doctors feel obligated to wean the person off as soon as they can. The person should be on that for at least two years before you should ever consider weaning. And I would never wean a patient off unless they request it themselves, strongly request it, and only after two years. Because by then, the person has had a good chance to modify their entire lifestyle, get a job or reestablish with their family and things like that.

Now, the other treatment of course is what we call Vivitrol, which is naltrexone, which is an injection once each month. And naltrexone does not give anyone an opioid effect, but it blocks all of the opioid receptors in your brain. So if the person does desire to use an opioid or something, it will have almost no effect on the individual when they're on naltrexone. It does reduce cravings to some extent, but nowhere near the amount that buprenorphine does. And the person has to completely be weaned off of the opioid before they start naltrexone. They have to go through an entire withdrawal process before they're on naltrexone. And with fentanyl, it takes sometimes as much as a week and a half or two weeks to get that completely out of your system.

So those are the big three. And of course, we would have the person simultaneously going through group therapies and education about addiction, which is what our intensive outpatient treatment program at the Genesis Drug and Alcohol Recovery Center supplies to our patients. So those counseling measures are a very, very important part along with group therapies. And of course, 12-step programs play a role as well.

Lastly, Scott, I'd like to just mention inpatient treatment programs of which there are several in our area and elsewhere, which supply inpatient or overnight long-time stays often amounting to 30 or even 90 days in duration. These programs are much more geared towards people that are in very dangerous situations. People living in a home where drugs are being used in the house by other people or they're in a dangerous domestic situation, or they're just a person that has repeatedly failed outpatient therapy. People should not misunderstand that these are always the absolute answer to an addiction problem. I often have people that say, "Well, if we could just get Jimmy into an inpatient treatment program for three months, that'll do it. We'll force him to do it. We'll talk him into doing that." Well, remember at the outset of this discussion, I said the person has to be ready on their own to do it. It's horrible. They're in a dangerous situation. The inclination is to put them into an inpatient program. And you can try that and sometimes it will work, but unless that person's ready to recover, it's not going to happen and a lot of times these inpatient programs can be exorbitantly expensive. They could cost tens and tens of thousands of dollars to the family, and they're just basically wasting their money. It's a difficult situation. You're worried about your loved one, maybe even they're worried about themselves, but they're not absolutely ready. That's kind of the problem for any treatment for any addiction, especially with opioids.

One other thing with these inpatient programs versus an intensive outpatient treatment program, I kind of favor if I have by choice the outpatient program, because the person is able to still live at home, live in a realistic environment, go to work. We have evening programs for those who work during the days and daytime programs as well to accommodate both types of individuals as far as their work schedules. And I just like the combination of recovery occurring in a realistic environment where the person is in their regular lifestyle. But once again, the inpatient program is a very important vehicle that we have as well.

Scott Webb: Yeah, this has been really educational today, doctor. I feel like we could keep talking about this. As we sort of prefaced today, saying this is kind of heavy, deep stuff. And you've done a great job and I'm sure listeners agree. So, thanks so much. You stay well.

Dr. Larry Cowan: Thank you, Scott. You too.

Scott Webb: And for more information, visit genesishcs.org. And thanks for listening to Sounds of Good Health with Genesis, brought to you by Genesis Healthcare System. If you found this podcast to be helpful, please be sure to tell a friend and subscribe, rate and review this podcast and check out the entire podcast library for additional topics of interest. I'm Scott Webb. Stay well.