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Robin Kish (Host): The struggle to overcome addiction can seem insurmountable for individuals and their families. The good news is, that drug addiction is treatable. We'll explain the science behind addiction and the brain on this edition of Here For Your Health. Welcome to the Health Care District of Palm Beach County's podcast, Here For Your Health. I'm your host Robin Kish.

Our guest today is Dr. Marc Schlosser, an addiction medicine physician, and former provider with the Health Care District of Palm Beach County's CL Brumback Primary Care Clinics. Dr. Schlosser is one of the few mentors in the State of Florida in the area of addiction medicine. Welcome Dr. Schlosser.

Marc Schlosser, MD (Guest): Good to be here with you.

Host: There's so much stigma in our society surrounding drug addiction. In fact, the word addiction comes from the Latin root meaning, enslaved or attached to. What are some of the misconceptions about drug addiction?

Dr. Schlosser: I think the first misconception, which has been around for decades is that somehow addiction is a choice or somehow a moral failing. We now know, that addiction is a medical condition. In fact, it is a very complex bio-psycho-social chronic relapsing medical condition, and it is, should be and should be considered a medical condition and should be treated as such and not as a moral failing.

So, as you stated,

Host: So, as you stated, science shows the drug addiction is not about having the willpower to just say no. Right?

Dr. Schlosser: Correct.

Host: It's a chronic disease of the brain. Can you explain how the receptors in the brain work when someone has a drug addiction?

Dr. Schlosser: Yeah. So, in the middle of the brain, we have an area called the limbic system and in the limbic system is the reward pathway and the reward pathway is there so that we can repeat pleasurable behavior. And behavior that would allow the species to continue. So, the three always cited are water, food, and sex. Unfortunately, when the reward pathway was evolving, we didn't know about opiates or amphetamines and these substances can hijack this pathway and cause this automatic area of the brain to take over and kind of out rule the cerebral cortex, which is the area of the brain that we do our executive thinking and our reasoning.

So reason and executive thinking goes out the window and the limbic area just kind of runs on its own. So if we think of it as a tug of war, the area behind the forehead, the cerebral area, where we do our thinking and reasoning is in a tug of war with the automatic area in the middle of the brain. When the cerebral area wins, you're in recovery. And when the automatic area wins, you're in active use.

Host: And this tug of war goes on all the time with someone who has a drug addiction?

Dr. Schlosser: Yes. So we know that once someone's limbic region is hijacked by opiates or illicit drugs, that that is probably something that will always be there probably for the patient's life. But we do now have medication and ways of treating so that we can help people get into recovery.

Host: That leads me to the next question, which is a two-parter. What is the definition of opioid use disorder? And then what are the treatment options for opioid addiction?

Dr. Schlosser: Right. So, opiod use disorder is really defined when someone's use of opiates is continued in spite of it doing harm to them or people around them. So, dependence can happen without addiction. We could be dependent on things like caffeine. I like to have my Starbucks. If I don't have my Starbucks, I'm not happy, but I would not break into a Starbucks to get my coffee. If I would do that, that would be behavior that is harmful.

Host: So, that would be an addicts fix?

Dr. Schlosser: Yes.

Host: And -

Dr. Schlosser: We don't like to use terms like fix, but that would be a use disorder.

Host: And then what medications can alleviate or treat that disorder?

Dr. Schlosser: So, we have three different FDA approved medications for opiate use disorder. And the three different medications are naltrexone and naltrexone is a complete antagonist, meaning it blocks the opiate receptor. It does not activate the receptor at all. It just blocks it. And that has somewhere around a 50% success rate. Then we have buprenorphine which is a partial agonist. Meaning that it activates the receptor only to about 40%. So, when I say activate, think of it as a dimmer switch and naltrexone does not turn the dimmer switch on at all, it just blocks it. Buprenorphine will turn it on 40%. And then the third medication is methadone, which is a full agonist, and that will turn the dimmer switch on 80%. And these medications have been around now for many decades and are quite effective. So, naltrexone is about 50%. Buprenorphine is around 60 to 70% effective and methadone is about 80% effective.

Host: And these medications would be used in a form of medication assisted treatment for opioid addiction?

Dr. Schlosser: Yeah. We either refer to it as medication assisted treatment, MAT or medication for opiate use disorder, MOUD.

Host: How do you know which medication works best for each person?

Dr. Schlosser: We look at it as like levels of care. So, naltrexone is not an opioid and is a complete antagonist. It is not a controlled substance and it is easiest to prescribe. So, that is kind of level one. If you need the next level of care, then that would be buprenorphine because buprenorphine can be prescribed by physicians in their offices. If they have the X Waiver. And it is a opioid, but it has a unique property of being, of having a ceiling effect, meaning that the more you take will not suppress respiration. So, it's a safer medication. It has fewer drug drug interactions, and then methadone would be the highest level of care and that medication can only be dispensed at an opioid treatment program. And opioid treatment programs, are in a lot of areas of the country, difficult to find. So, there are a lot of regulations that surround the using methadone and it's usually daily dosed. So, patients have to go to the opioid treatment program on a daily basis. So, it's much more difficult on the patient.

Host: So how committed do patients need to be for these various medication assisted treatment programs?

Dr. Schlosser: You know what, we, we operate now under harm reduction and harm reduction means that we are trying to meet the patients where they're at. So, you know, patients struggle with addiction. And, many times it has caused them to lose connections with people, with family. It causes homelessness and it's difficult for patients to be able to participate in these programs. And there are a lot of regulations that go along with this. So the patient has to want to show up, but once they show up, then I really feel it's incumbent upon us to figure out how we can help them and how we can help them more if they are struggling.

Host: You once described an airplane landing on a strip when you spoke about addiction and the brain. How does that analogy apply?

Dr. Schlosser: That analogy is referring to the mesolimbic pathway in the midbrain. And as a airplane lands each time on a runway and causes damage, the analogy is every time someone uses an illicit opiate, it also causes damage to some pathways in the midbrain. And the more use, the more damage. The good news is that these pathways can heal with time if we can stop the illicit drug use and keep someone on medication so that the brain can be stabilized and has the opportunity to heal.

Host: It sounds like there's a very strong partnership involved in the process of treating someone who has an opioid addiction.

Dr. Schlosser: Yes. You know, it is, it is, you know, really important to look at it as a partnership and to, to have the, the patient believe that, you know, our. Is Justin helping them. You know, a lot of patients have not had the greatest of experiences when they interact with the medical system. Stigma is something that is, you know, found in all areas of all addictions. I mean, we have, uou know, 21 million people in this country with substance use disorder, 15 million of those have alcohol use disorder, which is the most common, 3 million have opiate use disorder. And then the other is amphetamine use disorder. So, it is really important that we engage the patients when they're ready and help them with the psychosocial and medical part of their, of their struggle.

Host: Which means in addition to medication assisted treatment, there are other social links that are shared with the patient so that they can help the patient in other ways, whether it's housing, whether it's assistance with food, whether it's peer counseling. Am I missing anything?

Dr. Schlosser: Yeah, no. And, and, and you're right. And if we look at success rates, then and you look at physicians who have had substance use disorders, you know, their rate of recovery is in the high 90%. And a lot of that is because they have so much support and they have, um, you know, with success, they can get their license back and continue to practice or return to practice. You know, a lot of patients just don't have that luxury. And so it is just much more difficult and housing has become a major issue for people to be able to remain in recovery. If you don't have a place to sleep and feel safe, then it's very difficult to maintain recovery over a long period of time.

Host: Dr. Schlosser, how safe is medication assisted treatment for women who are pregnant?

Dr. Schlosser: Medication assisted treatment is recommended during pregnancy. That's the consensus of the American College of OBGYN, the American Society of Addiction Medicine as well as the American College of Pediatrics. The reason is that the pregnancies are much more stable. The pregnancies tend to go to full term and the neonates are usually born without withdrawal symptoms. If there are withdrawal symptoms, then they are usually mild and can be handled with just rooming in with the mother, breastfeeding and swaddling. The mother, it is recommended, stay on medication assisted treatment throughout the first year postpartum or what we are now calling the fourth trimester. The reason being the number one cause of maternal death is relapse and fatal overdose.

The postpartum period is a highly stressful time and it is recommended that the mother stay on the medication assisted treatment to stabilize and help during that stressful period.

Host: Can patients ever overcome drug addiction and is it passed on from generation to generation?

Dr. Schlosser: We know that about 50% of the likelihood of becoming addicted to some substance is genetic. So yes, there are a set of genes that, that wind up increasing the vulnerability. But the epigenetic changes that occur with adverse childhood events during when a child is young and a teenager and up through adulthood can increase the vulnerability for addiction. Now we, we believe that those changes are durable and that they you know, do last a lifetime, but what we think is that the, the priority in the database, in the midbrain, with recovery, it just goes down, but triggers and stressors that happen, in life, can kind of rekindle those, the addiction issues. So, someone who has a substance use disorder will their entire life has to be aware of the possibility of being triggered.

Host: According to the Centers for Disease Control and Prevention, more Americans are dying from drug overdoses during the COVID-19 pandemic. Over 81,000 in the 12 months ending in May of last year at the highest number of overdose deaths ever recorded in a year's timeframe. What have you noticed in your practice?

Dr. Schlosser: Yeah, it's been a real struggle you know for, for patients. As John Harry said that the opposite of addiction is not sobriety. The opposite of addiction is connection. And for so many people that struggle with addiction, it's a very dark place. It's a very isolating place. And unfortunately, during the pandemic, that's what defined really the situation everybody was in.

And, you know, patients couldn't go to group meetings. They couldn't go to in-person counseling sessions. Everything was on zoom, if you had a computer, if you didn't have a computer, then it was on a smartphone. If you didn't have a smartphone then it didn't happen. So the isolation that occurred during the pandemic was a real driver to make it much more difficult for patients to stay, in recovery and treatment. So, you know, we certainly noticed that the patients struggled much more and unfortunately it is easier to get fentanyl. You can get that 24/7 whereas medications and treatment are during office hours. So it's, it's been a, it's been a struggle. And the number that you quoted is a little bit lower. The one I heard was 86,000 fatal overdoses, which is only surpassed by the alcohol use disorder. And that is about 95,000 fatalities. And that's the only surpassed by nicotine and cigarette related deaths. And that's, that is 450,000. But if you consider that, that was a comorbid condition for people who wound up doing more poorly with COVID, then that number's going to be much higher. So it is a struggle.

Host: Are things improving?

Dr. Schlosser: Yes, they are because we are now getting the connection back. You know, patients are coming to the clinic and they are actually able to have in-person sessions for the counseling. So we have seen a stabilization and we're hopeful that, that that will continue.

Host: Scientists in the US are now studying an anti-opioid vaccine to protect the brain and nervous system. What do you think of this research?

Dr. Schlosser: It is very interesting. The, the problem I see is that what a vaccine does is it stimulates the immune system to form antibodies. And those antibodies are in the system. And when they see an opiate, they run over to it and attach themselves to it. So it will no longer fit in the receptor. So the opiate cannot drive the receptor. So that's good for protection against overdose, but it doesn't address all of the psychological issues. So, it is more of an antagonist and we know that antagonist therapy is not as effective as the methadone and buprenorphine partial agonist or agonist. So it will, it will be protective against fatal overdose, but I'm not sure that it will be a panacea. It certainly will not be the magic potion.

Host: You've shared with me that the ultimate goal is to help restore patients' overall health and their lives. How often do you see that occur and how rewarding is it when it does?

Dr. Schlosser: You know, it is rewarding every day, working with these patients who are struggling with, with addiction. These are good people with a bad disease. They are not bad people. And they are, they should not be stigmatized. It is, they should not be marginalized. And they struggle every day with that. When, when we know we have success and we have a lot of success, it is very, very rewarding. And it's why I do this work.

Host: Well, thank you, Dr. Schlosser for explaining the neurobiology of addiction and for all of your work in the field of addiction medicine.

Dr. Schlosser: Great to be with you.

Host: To learn more about the Healthcare District's Medication Addiction Treatment Program call the CL Brumback Primary Care Clinics at 561-642-1000. Or visit www.Brumbackclinics.org.

If you find this podcast helpful, please share it on your social media channel and check out our full podcast library for topics of interest to you at healthcaredistrictpodcast.org. Let us know what you think. Your review helps us reach more people just like you. Today's podcast is brought to you by the Health Care District of Palm Beach County. The Health Care District is a unique safety net healthcare system located in south Florida and provides county residents access to primary care, skilled nursing and hospital care, registered nurses in nearly all of the county's public schools and oversight of the county's trauma system, which includes operating two life-saving trauma Hawk, air ambulances. Learn more by visiting HCDpbc.org.