Joey Wahler (Host): Opioid addiction continues to plague many often leading addicts and their loved ones. Wondering where to turn. So we're discussing saving lives and dispelling myths related to this dangerous and scary condition. This is Mountain Medicine, the official podcast of Northern Inyo Healthcare District. Thanks for listening. I'm Joey Wahler. Our guest Dr. Anne Goshgarian, emergency room physician for Northern Inyo Healthcare District. Dr Goshgarian, thanks for joining us.

Dr Anne Goshgarian: Thanks for having me, Joey.

Joey Wahler (Host): So first as an emergency room doctor, how much of what you see involves treating opioid addicts?

Dr Anne Goshgarian: Well, as an emergency room doctor, I was seeing a lot of the complications of substance use disorder of all types. So we were seeing overdoses and we were seeing increased numbers of overdoses in the community, as well as complications like withdrawal from medications or, patients who were unable to get a prescription. Narcotic medications from their regular doctor for one reason or another. So we were seeing a lot of these complications in the emergency department and that sort of correlated with a study that was done out of Yale, which demonstrated that if we start treating opiate addiction or opiate use disorder in the emergency department, those people are more likely to be retained in treatment at one month and six months later. So that was sort of the impetus for us to start treatment program here at the rural health clinic within Northern Inyo Healthcare District.

Joey Wahler (Host): Gotcha. So we mentioned dispelling some myths about this type of addiction. What are some of those that come to mind?

Dr Anne Goshgarian: Well, I think one of the things that I've been working really hard to de-stigmatize in our community, is that substance use disorder and opiate use disorder in particular, isn't a moral failing. When we think of addiction, it really is a brain disease that leads to people being unable to control their use of substances, such as opiates. So that's one of the biggest myths that we're working hard to dispel because there's really a neurochemical process and biochemical changes that occur in opiate use disorder.

Joey Wahler (Host): Now at Northern Inyo, you use something called MET. Medication for addiction. What do we mean by that?

Dr Anne Goshgarian: So there are FDA approved medications to treat opiate use disorder that are effective. But up until relatively recently, they hadn't been widely utilized. So right now nationally, we're in the midst of an opiate epidemic. We're seeing a great deal of complications from opiate overdoses and substance use in general. The number of people who have an opiate addiction has increased dramatically over the past 10 years. And so, as a result, there's been a really big push to increase access to treatment using approved medications that are effective, for patients who are struggling with this disease.

Joey Wahler (Host): So now some may be surprised to hear that medicine is used to treat people that have an addiction to certain medicines. So how does that work exactly?

Dr Anne Goshgarian: So it is kind of Interesting because, when we think of any other disease process, what we're doing as physicians is treating the changes that occur because of the disease. And the same thing is true with opiate use disorder and with addiction. So when we have an opiate use disorder, our brain chemistry changes slightly. And, we see decreased levels of naturally produced dopamine, which is a neurotransmitter that helps us feel good, feel motivated to do things. And so some of what we do replaces those changes that have occurred over time with opiate use disorder. So the medications helped to reduce cravings, to use and help to rebalance our brains biochemistry.

Joey Wahler (Host): Interesting now the MAT program, as I understand it also involves behavioral health therapy, both individual and group sessions. Right?

Dr Anne Goshgarian: Exactly. Yeah. What we recognize for opiate use disorder treatment is that we want to treat the person as a whole, we call it a bio-psycho-social approach. We treat the biology with medication, but we also treat the psychologic impacts of the disease process itself using behavioral health therapies. And then we also focus on some of the social implications that occur with opiate use disorder. We often see that, we struggle to help treat someone's opiate addiction if they are also homeless, or if they don't have transportation to get to the doctor, or if they don't have insurance to pay for their medication. So we kind of work with the patient and we provide whole person care.

Joey Wahler (Host): And speaking of which your weekly support groups, I believe include a warm meal as well. I presume because often these addicts aren't eating properly, right?

Dr Anne Goshgarian: Yeah, exactly. Plus it helps get people to come.

Joey Wahler (Host): Everyone likes a free meal or a free anything for that matter. Right?

Dr Anne Goshgarian: Exactly.

Joey Wahler (Host): So what's the biggest challenge when someone with this addiction first comes to you, there's obviously, and we've touched on it a bit, a lot going on both medically, psychologically some of these other outside distractions that come along with this type of a situation, where do you start?

Dr Anne Goshgarian: My goal always when I first talk with a patient is to find out what their motivation is and what their goals are, and to really help elicit that. Because it's really hard to make some of these changes. when we talk about treating addiction, we talk about making big, broad, sweeping life changes and behavior as well as, their overall health. And so when I first meet with somebody, I love to learn about their history, find out who they are and, really focus on what their goals are for their own life and health and wellbeing, so that we can kind of incorporate that into their overall treatment.

Joey Wahler (Host): How big a challenge is it considering everything that addicts often have going on in their lives negatively. How big a challenge to get them once they're in treatment to stick with it and not succumb to some of these other distractions?

Dr Anne Goshgarian: It is really hard. And, you know, I never want to minimize that as a physician. It's been really gratifying work for me sometimes to see people really, make big changes in their lives. And so I recognize that it's a huge challenge. It's really difficult for people to change behaviors that are sometimes deep set and have a long history. It's kind of amazing to see how and why, and watch people do it. I always tell patients, I'm kind of like a cheerleader in this process. I prescribed the medication that helps balance the biochemistry, but I'm not the only influence in their whole life.

And so that's where eliciting their motivation for change And really focusing on, maintaining that, bringing that to the forefront because motivation for anything waxes and wanes. So helping to continue reinforcing that and bring that to the forefront is both, gratifying and sometimes challenging.

Joey Wahler (Host): And when you talk about that gratification and that reward for helping people get over the hump, maybe talk a little bit more about that, please, because so often. In the medical world today, depending upon the situation, of course people's contact with medical professionals can be brief. It can be sort of fleeting, but here you form a real bond with some of these people. And I would imagine that they feel as you do that, it's a life-changing experience?

Dr Anne Goshgarian: Definitely. I mean, I've been doing the work in the addiction clinic for going on over three years now. And so I have had long-term relationships with some of these patients and it has been really, fun see them make big changes. I've had patients who have really gone from the challenges of being a homeless opiate user, like a heroin user to now really succeeding both in their job and their life as a whole. And so it's really, fun to watch. It's really amazing to experience. And, really gratifying to be a part of, but I'd never want to minimize that the patient themselves has done all of that work. they're the ones who make these big changes.

And it's really neat to watch. So we absolutely formed tight bonds. And part of that is because with this treatment program, we start by seeing the patients really, really frequently, in order to help with any little thing that could come up to change patterns of behavior that have been ongoing. So with that, over time we sort of spread those visits out, but at least in the beginning, as we're trying to help patients get stabilized into sobriety, we see them really frequently and that helps build that bond.

Joey Wahler (Host): And I was going to ask you about that next. What kind of a commitment are we talking about in terms of frequency, in terms of the amount of time, what kind of a commitment does someone need to make in order to fully get back to where they need to be?

Dr Anne Goshgarian: Well, our program is really, unique in the sense that what we ask from patients is a desire to want to find sobriety. Guide the patients based on what they are willing to commit to, we offer services of all different types and levels of care. There are certainly some patients who come to us and say, I think I need to go to inpatient rehabilitation treatment. And we say, great. That is a fantastic step to finding sobriety and we help them get into rehabilitation treatment, wherever that may be. And then when they reenter our community, we provide them all kinds of support in order to help make that transition back. So really it's very patient centered patient directed.

So all I ask from patients is that they come with a desire to find sobriety, and then we work on a plan together. Whether that be what is most common for us is initial medication treatment. And. Physician meetings as well as group therapy, support and behavioral health support as well. So it really is very time intensive at first to undergo what I would call the full treatment that we have available. And some patients just don't have the capacity to do that initially, as we're trying to stabilize other factors in their life.

That would be more difficult to show up to multiple appointments per week as a person who is homeless and struggling to find food. So as a result, we kind of work with the patient individually to break down some of those barriers and help them find the resources that are available so that they can stabilize other aspects of their life and focus on their medical treatment as well.

Joey Wahler (Host): Excellent. Well, folks we trust you're now more familiar. How to help save the life of an opiate addict, doctor Anne Goshgarian. Valuable information to say the least. Thanks so much.

Dr Anne Goshgarian: Well, thanks for having me. I appreciate it.

Joey Wahler (Host): Same here now for more information about the mat program we've discussed, please visit nih.org. That's nih.org. And please also check out Dr. Goshgarian's healthy lifestyle talk on opiate addiction on the Northern Inyo Healthcare YouTube channel. If you found this podcast helpful, please share it on your social media. And thanks again for listening to mountain medicine, the official podcast of Northern Inyo Healthcare District, hoping your health is good health. I'm Joey Wahler.