Cheryl Martin (Host): In a recently released survey on
drug use in America, more than 20% of those aged 12 or older said they used
illicit drugs in the past year, and more than 9 million Americans said they
misused opioids. What tools do substance use disorder clinicians have to treat
addiction? Up next, we get the answer to that question and more with two
experts on the front lines here at Bergen New Bridge Medical Center.

Cheryl Martin (Host): Dr. Anthony Accurso, Medical
Director of Addiction Medicine and Michael Paolello, Chief Clinical Officer of
Substance Use Disorder Services. This is Wellness Waves, a podcast from Bergen
Newbridge Medical Center. I'm Cheryl Martin. Doctor, let me begin with you.
What impact did the pandemic have on substance use disorders?

Dr. Anthony Accurso: The pandemic had an impact on
substance use disorders and opioid use disorder in particular. We know that
national death rate from opioid use disorder and overdoses increased to over
100,000 for the first time in history during the pandemic. We can't say for
sure what caused this, but possible ideas. The pandemic triggered a remarkable
wave of loneliness and panic among people which may have served as triggers.
Often people say that the opposite of addiction is connection and when people
were lying by themselves, at staying at home during the state of emergency, a
lot of people felt this sense that of the end of the world coming.

Notably during the pandemic, there was often separation from
prior stable treatment, so people weren't able necessarily to come into the
drug treatment programs from which they were deriving strength previously. Many
people were separated from in-person peer support, and not all of them had the
digital know-how to join virtually. And coupled with that was the background of
the increasing presence of fentanyl in the drug supply, which continues to make
the street product more unpredictable and therefore, more potentially fatal and
we now know that fentanyl is nearly ubiquitous in the opioid drug.

Michael Paolello: I'd like to add to the pandemic, the
fentanyl questions are more in Dr. Accurso's area. But, during the pandemic,
almost immediately, programs just closed down. They shuttered or, some of them
went virtual and some of them didn't have the time to go virtual. There was
just a panic. Nobody knew what to do, and programs were closed down and our
clients had really nowhere to go in the middle of active addiction to get the
treatment they were seeking.

So, fortunately here, we were the only one in Bergen County, we
did convince our senior administration to keep all of our addictions programs
open, including our outpatient. So that was definitely important because people
that are in early recovery really need to hear from other people that are going
through things similar to what they're going through. And they share what's
worked for them, what some of the barriers are, and having that live in person.
there's no virtual platform that can replace that.

Host: So what substance are you seeing patients struggle
with the most?

Michael Paolello: Definitely heroin. In the last, few
years, and again, Dr. Accurso can add to this, but we're seeing more heroin.
along with using cocaine. Definitely an increase in benzodiazepines like your
Xanax.

Dr. Anthony Accurso: We can look at the decade from the
2000 to 2010 as sort of a decade of pain and pain treatment, during which, you
know, we now know that, makers of opioid pain medications actively marketed,
them to patients who are experiencing chronic pain. But we can look now perhaps
that we may be entering something that's more of a decade of anxiety. The
current pandemic climate, the, increasing impacts of social media. All of these
things can contribute to just a generalized feeling of anxiousness, anxiety.

And that is something for which patients will sometimes turn
to, benzodiazepines such as Xanax or Klonopin. And so we're seeing patients
seeking treatments for those, but the background continues to be opioids, in
terms of medications that tend to lead patients, down a difficult path. And we
can't forget also that at least within the withdrawal management facility,
we're still seeing a consistent background of patients who use alcohol, which
share some characteristics with both the benzodiazepines like Xanax as well as
opioids like, fentanyl or heroin.

Michael Paolello: And that's a great point. In the
beginning of the pandemic, we almost immediately saw twice as many admissions
for alcohol withdrawal management as we had prior to the pandemic.

Dr. Anthony Accurso: I'd like to take a moment to point
out that the pandemic did actually have some silver lining in terms of our
approaches to treatment. Of note. During the pandemic and during the state of
emergency, federal guidelines on the provision of medications for opioid use
disorder, including buprenorphine, brand name, Suboxone, or Subutex, as well as
methadone, and specifically for the first time buprenorphine was permitted to
be started via telehealth via telemedicine.

And this led to market outreach to patients often in rural areas
where there was no buprenorphine wavered physician nearby. And this led to new
delivery models. Which as publications begin to come in describing these
delivery models, they seem to show, an uptick in the use of buprenorphine
without any adverse effects from the telemedicine model. Similarly, from the
perspective of methadone maintenance treatments, during the pandemic, there was
a market relaxation of the regulations on opioid treatment programs or narcotic
treatment programs, allowing them to give patients take home doses much sooner.

And increasing the flexibility of the dosing schedules. And
this increase in patient-centeredness was well tolerated by the patients and
much appreciated. And what's going to be interesting to watch in both the
buprenorphine and the methadone spaces is, come May when the DEA declares the
public health emergency over. Are we gonna see reversion back to the now two
decade old methadone regulations, or are we going to see a continuation of the
more patient-centered approaches, which could potentially allow methadone
treatment for more patients?

On the front with buprenorphine, we're gonna have to see if
telemedicine is going to continue to be permitted. And at the time of this
podcast, the current plan, from the DEA is to allow 30 days of buprenorphine
via telemedicine after which an in-person visit is going to be required.

Michael Paolello: I mean, so Dr. Accurso paints a
perfect picture of the advantages of the virtual platform of telemedicine. and
those advantages are very valid, but that does not replace the combination of,
like Dr. Accurso referred to the opposite of addiction is connection. So
there's that critical importance of patients being with each other, right?
Helping each other, in a group setting, along with the telemedicine options for
medication assisted treatment, and the relaxation in, some of the regulations
that should continue.

Host: Have you seen a return to group activities now
that the pandemic and its impact has slowed considerably?

Michael Paolello: Well, what the good news is we never
saw that slow down. In fact, we saw it increase because nobody else was really
open. And patients that really were motivated. Yes, you have some patients that
are maybe going to treatment because probation sent them, or their job sent
them. So the virtual platform was easy for them. So they liked that. But then
you had a great deal of patients that really wanted, they were motivated to get
better and they wanted to be in group. And they came and they thanked us for re
remaining open. They had no other options, and since then, yes, we've seen an
increase because surprisingly, many of these other agencies that went virtual
have remained virtual.

Host: And there is something with coming together
physically in a group.

Michael Paolello: There's a universality, there's a
common bond that they have. group of people with addictions helping one another
get better, of course, with professional counselors and providers. But, yes,
being in the same room, with each other, with that population has proven to be
the best setting.

Host: What do you see as the barriers to getting help
that you see most often with your patients now?

Dr. Anthony Accurso: For years, the biggest challenge
with buprenorphine treatment was simply getting in to see a provider who could
prescribe it. We've seen market progress on this during the pandemic in the
following ways. Number one, the ability to use telemedicine to meet people
where they are. Both literally and figuratively at the moment at which they're
ready to make behavior change has been an extraordinary practice improvement.
And then secondly, with the omnibus bill that passed in January of 2023. We
have a change in the buprenorphine prescribing laws. The quote Xing of the X
waiver.

So previous to this year, in order to prescribe buprenorphine
providers had to complete an eight hour training and then present a notice of
intent if their desire to prescribe buprenorphine. As of 2023, any doctor who
prescribes any controlled substance is registered to do so. Can now prescribe
buprenorphine. What we hope is that this will cause more and more providers to
agree to prescribe it and increase access for patients in need of the
medication. What will be interesting to see is whether the relaxation and the
regulations will in fact change provider behavior, and I think we all need to
watch that space.

Host: You've touched on this somewhat, but what do you
find is the most successful treatment for those who seek care at the medical
center?

Michael Paolello: I think to begin with is the wider
your continuum of care is, the better the prognosis for the patient. Because
when they come in we have something called a no wrong door policy, which is
basically a patient comes in and they may think they need short term rehab or
intensive outpatient or withdrawal management. And when they come in, they see
a professional, they go through a very thorough, comprehensive assessment and
it may turn out that they need another level of care.

So the two advantages we have here is that we provide the
entire continuum of care as defined by the American Society of Addiction
Medicine, and we don't have barriers to placement. We like to call it low
barrier, no barrier. So if you come in and you thought you needed, let's say,
withdraw management, but as it turns out, you really could benefit from
short-term rehab, like a 21 day rehab unit, we can very easily pivot and have
that patient admitted to the program that they would benefit from. Of course,
it's their choice. All programs are voluntary.

So we explained to them, all right, so you don't need
withdrawal management say, because let's just use an example. You know, you're
using amphetamines and so you wouldn't need withdrawal management for that. But
certainly we don't want to just say, all right, go home, you don't need to be,
detox from their withdrawal management. We refer to withdrawal management,
instead of detox, which, Dr. Accurso can explain very well. But the point is,
instead of saying this isn't for you, and then having them go home, we can say,
this doesn't really fit, but this does. And make sure there's no barriers for
them to get from point A to point B.

Dr. Anthony Accurso: And offering several different
levels of care within our system has been a big benefit for the patients. So it
really allows us to meet patients where they're at. You know, for example, some
patients may have nowhere to stay. Or where they have been staying may be so
conducive to drug use that they just need to get away for a while. And for that
we offer residential rehabilitation services here. And we also have a good
network of other residential facilities throughout the state to which we can
refer patients.

On the flip side, if somebody's housed in a supportive
environment and simply needs medication to stay off of opioids, and doesn't
really have time to engage in other services, then that may be sufficient for
that patient, but not for the first patient. So we try to meet people at every
stage of the treatment continuum and, we're uniquely positioned to do that
because we have all of the levels of care under one roof.

Michael Paolello: Another good point. I just want to
point out the long-term rehab. So we talked about inpatient rehabilitation as
part of our continuum here at Bergen New Bridge, but we also are partners with
Integrity House, which has longer-term rehabilitation. So really no barriers to
somebody that may begin in short term and want longer term or may want longer
term to begin with. So the partnership with Integrity House has certainly
proved to be a benefit.

Dr. Anthony Accurso: I'd like to speak more about the
recommended treatments or the most effective treatments, which I believe is the
question. So the treatments for different drug classes vary, and all listeners
to this podcast have to understand that the medications that we have for opioid
use disorder in particular are profoundly effective. And so those include
buprenorphine, as well as methadone. And in some cases, extended release
Naltrexone. Brand name to Therol medications can also be used for alcohol use
disorder.

We have, again, naltrexone, either by mouth or by injection, as
well as Acampersate, and we have other medications that are sometimes used.
Five in total. So if patients haven't been offered these options, it's a big
myth in terms of their recovery. What's interesting is not every patient wants
to be on medication, and we all have to understand and appreciate that there
are multiple roads to recovery. And so when people come into our facility, we
do our best to ask patients, what are your goals? What is your interested
medication? What is your entrance in counseling services?

Are you interested in both? Do you participate in peer support?
12 step? These are things not everybody has to do, but anybody who is
attempting recovery should probably. I think of note, the one class of drugs
for which we really do not have a medication are the stimulants. So cocaine or
methylamphetamine, Adderall. The stimulants are drugs that really don't respond
to any medical therapy. The one thing that seems to work is treatment called
contingency management, which is basically an offering of small rewards for not
using, and we have a pilot program, from grant funding that we received to
launch this new but evidence-based approach to stimulant treatment.

Michael Paolello: And we are in the early stages and it
seems to be working well. We see our treatment adherence, certainly increase
for the, person with stimulant use disorder. Going back to one of Dr. Accurso's
points, for example, 12 step programs what we're seeing now more than ever, as
everybody knows with our patient population, is all these young kids that are
just unintentionally losing their lives because of the fentanyl that's in the
heroin. Or The way it is now, really just fentanyl that they're getting.

 Today is National Black
Balloon Day. And so yesterday in recognition of that, we had something called
the Black Poster Project. And, Dr. Accurso spoke to a very large audience, on
many of the topics we're speaking about today. But what we also had was people
from the 12 step Community that have recovered or are recovering from their
addiction. And they spoke about the hope. So on the one side of our exhibit, if
you will, we had the over nearly 600, what's referred to as black posters.
These are people that have really often very young kids, very vibrant looking,
that have lost their lives.

But, their loved one will put this what's called black poster
together to kind of celebrate the life. And it was just an overwhelming,
display. I mean, you can't imagine six hundred posters of, individual families
putting pictures on them and writing about their life. The point being when
patients are done with treatment, Okay. There needs to be a place for them to
go. And like Dr. Accurso said, there's no one place, but what we do see very frequently.
And we see this because patients that are now in longer term recovery come back
to help patients that are new to recovery.

And you see a very common theme. And that theme is they
participated in a 12 step program. They got a sponsor, they went to meetings
regularly. So that is certainly something we need to focus on. What do we do
when they're done with treatment? Because we want to prevent anybody else from,
winding up on that black poster.

Host: What are some of the warning signs that loved ones
should be looking for if they suspect substance use disorder? Especially
parents. You mentioned young children now on these drugs.

Michael Paolello: I mean, a change of peers, immediately
you'll see that, unfortunately missing items in the house. To support a habit
as they often refer, it costs money. .

Dr. Anthony Accurso: We often call that what's called
acquisitive crime. This is a tough one. the specifics of addiction are role
failure, craving, used despite adverse consequences. And I think that that view
of addiction is probably the best way for parents to look at this, if they're
expecting their children are using. You know, a change of behavior, a change of
friends, just as Michael pointed out. But I think, for instance, if we see,
their role as a student or their role on a team starting to slip, if there is a
sense that the child is using, if they are unable to stop using, despite
adverse consequences.

That's where you know immediately that, that is addiction. that
is not used. This is a tough call because people use drugs and they have been
using drugs for a long time and to just circle up children and say drugs are
bad and then end the discussion is probably not gonna be very effective. I
think better is that if children know that they have a good connection with
their parental figures, a trusting relationship and one where the parents
listen and listen without much judgment, then the quality of the information
they get from their child will be better.

And then it's a little easier to see, is this child,
experimenting in a one-off kind of way? Or has this child lost control of their
use?

Host: How young are you seeing children, take let's say
fentany or other drugs?

Michael Paolello: I normally say you really don't see it
until after high school. And for the longest time that was true. But when I
refer to the people that had passed away the black poster project I refer to,
we saw people that were 15, 17, that had died it's infrequent, but we do see
this, younger population now using opioids. Whereas a few years back it was
really after high school that you started to see that you may, there may have
been some prescription drug abuse, while they were in high school, but when you
started to see them using heroin with the fentanyl in it, that was typically,
around age 20 or 19.

But to see these, my evidence being the young kids 15, 16, 17,
that have passed away from an opioid overdose. Certainly leads you to believe
that they're using at a younger age now than they were in the past.

Host: We talked about the warning signs that loved ones
should be looking for, but how can loved ones support the treatment and
recovery process for those diagnosed with a substance use disorder?

Michael Paolello: Education, I always say is a critical
first step. You've heard of enabling. So a lot of loved ones are, enabling the
behavior to continue, but they're not really at fault because they don't know
they're acting out of love

Host: And how are they enabling?

Michael Paolello: They're enabling by believing, say
lies. I need money for. Whatever that the child may say. And the reality is, if
you really think about it, it doesn't make sense. But they're trying to help
or, I mean, there's a lot of creativity, but, you'll see the lying and
dishonesty will certainly increase, or it may have just started. You may have a
very honest child, who starts to be dishonest. The addiction does create a
serious, significant behavior change. And sometimes, just may be doing
something that you think you're trying to help, when with education, you would
realize, no, I'm just enabling and not really helping.

Dr. Anthony Accurso: So, enabling is a term that has a
history that decades ago, family members were encouraged to confront, the
family members who were using to have an intervention, to cut all ties, to push
abstinence only as a condition of housing. I'm not certain that that's always
the best answer. I do think someone who is in chaotic drug use is motivated to
get roughly the same amount of drug product as they used the day before. And if
they are separated from a prescription for it or if they never had a
prescription for it, they will often have to resort to buying it in a
non-prescribed way.

And as people build tolerance, it means they have to spend more
and more money each day just to feel normal. So this is to say if they don't
get a certain amount of money each day, they won't be able to function. And if
viewed that way, the actions of someone in chaotic drug use, be it from
borrowing money from, selling the jewelry in the house, while it's not what we
would want to see somebody do. if you put yourself in the shoes of the user,
it's a very logical course of action. So for the family that finds themself in
that situation, locking down the jewelry, changing the pin numbers on the
accounts is probably a good idea.

But decrying that family member as worthless, as morally
broken, as a bad human is probably going to make things worse because again,
the opposite of addiction is connection. And someone who uses drugs who's been
cut off from their family or friends, is going to feel even more isolated and
likely use more. I have heard from families that feel regret for the amount of
confrontation that they did after the overdose results in mortality. They say,
I wish I could have done something differently.

So I think it's a balance. Of note, the thing that family
members can do to keep people with opioid use disorder alive is to encourage
them to stay on medications for opioid use disorder, such as buprenorphine or
methadone if those medications are working for the patient. I think the thing
that scares me the most as a prescribing provider is when I hear a patient say,
I'm doing great on buprenorphine, but my family says, when are you gonna get
off? Because that moment when they come off is an incredibly dangerous few
weeks or months.

Michael Paolello: And the message, for example, from
Families Anonymous or your 12 step family groups, NARANON, Alanon, Family
Anonymous is almost exactly what Dr. Accurso is saying. It is still love the
person that is using. But the education is definitely, important. Referred to
as a family disease for good reason, an entire family suffers when just one
person in the family abusing, substances. So really that education and their
own involvement in 12 step fellowships that are focused on families that have
loved ones that are using is certainly critical.

Host: What's the impact of co-occurring conditions on
treatment?

Dr. Anthony Accurso: A co-occurring behavioral health
disorders, can interface with substance use disorders. And sometimes it's a
little tricky to tease out does somebody have a behavioral health disorder,
something like anxiety or depression, which is improved by heroin and fentanyl.
Or does somebody have primarily a substance use disorder, which has caused so
much, chaos in their life that it is triggering a secondary depression or
anxiety? Strong programs will attempt to treat patients for both.

It is a good moment to note that in our country services for
behavioral health, and services for substance use disorder are regulated in two
different ways, and many programs will only be comfortable providing one of the
treatments or the other of the treatments. And going forward, we would do well
to reform our system to make it easier to create an integrated behavioral
health and substance use disorder treatment program.

Host: Just in wrapping up, anything else either one of
you would like to add about your program or just words of encouragement for
those who have loved ones who are struggling with recovery or substance abuse?

Michael Paolello: I will say that it is important we
have a patient population that comes in often at lowest point in their
addiction and in their lives. And their self-esteem at that point is pretty
shot. And I think it's really, really important that the people that work with
our patient population, believe in them, believe that they can get better, and
encourage them to get better. And it is genuine because patients know when you
really care. And having said that, having a medical namely Dr. Accurso, that
has a passion, a belief, thinks outside the box, does what you can to help this
population. Those patients respond like I've never seen before. And patients
come back and it is very common they will say, I didn't really believe I could
do this, but I saw that you believed in me. That's what we're trying to do.

Dr. Anthony Accurso: I think the biggest thing I would
emphasize, number one, is that addiction does not define people. Many of the
people who have substance use disorders are talented, wonderful, colorful
people, and the substance use disorder defines one aspect of their life, and it
will be a relapsing and remitting condition. It will come and it will go away,
and it will come back and it will go away, much in the same way that diabetes
or hypertension are chronic diseases that will occasionally manifest as being
out of control. And then with treatment and medications can be brought under
control. I'll note, working with patients with addiction is amazingly
rewarding.

If you look at somebody when they come into withdrawal
management, they look really ill, and three to seven days later when they come
out, they look markedly better. I think an important aspect of the work that we
are doing at Bergen Newbridge Medical Center is really trying to apply a
principle that Michael taught me, which is the no wrong door principle. And we
want to meet people wherever they're at, and be a knowledgeable group of clinicians
and physicians and mid-level providers who can literally sherpa patients with
addiction around the many treatment options that exist within our state of New
Jersey.

Host: Well said. Dr. Anthony Accurso and Michael
Paolello. Thanks so much for educating us on the latest treatment options, but
also for offering hope to those seeking recovery. Thank you so much. To learn
more. Visit Newbridgehealth.org and select the substance use disorder tab.
That's newbridgehealth.org. If you found this podcast helpful, please share it
on your social channels and be sure to check out the podcast library for other
topics of interest to you. Thanks for listening to this episode of Wellness
Waves, a podcast from Bergen New Bridge Medical Center.