Alex Danvers, MD (Host): Hi! Welcome to Behind the Miracle, the Sierra Tucson podcast, where we talk about the stories and science underlying the work we do here at Sierra Tucson. Today, we have with us, Kristina Cabalfin and Luke Peterson. They together have put together a harm reduction program for addiction here at Sierra Tucson. And I'm really excited to talk to both of them about that approach and the good work they've been doing in the last several months. Welcome, Kristina and Luke.

Kristina Cabalfin: Thank you.

Luke Peterson, MD: Thanks for the invitation.

Host: Yeah, I'm really excited to dive into the topic, but I usually like to start by asking a little bit about what drew you to this. Kristina, would you like to start maybe by telling us a little bit about how you became a nurse specializing in mental health and now doing work in addictions?

Kristina Cabalfin: Sure. I actually started out as an emergency room nurse, and I found myself struggling with a mental health patient. So, when I decided to leave, I went to a facility in Tucson that has a court-ordered treatment where I really got to know some of the people there. And really, what I saw broke my heart, so I just kind of developed a passion for mental health. And then, I ended up as a nurse manager at a methadone clinic. And that's how I really got involved in addictions. And now, it's definitely my passion.

Host: Yeah, that's great. And so, when you were in this court-ordered setting, that was when you started to realize that the mental health was an important component of this, and the addictions was an important component of what you were seeing.

Kristina Cabalfin: Absolutely.

Alex Danvers, MD (Host): That's great. And Luke, you specialized from your bio on the website in addictions in medical school. Can you talk a little bit about what led you to be interested in that and into that specialization?

Luke Peterson, MD: Yeah, sure. So, I am board certified in Family Medicine. And during my training, it was really clear that our health system is pretty siloed. There's not only like medical and psychiatric, but also within medical, everybody's kind of siloed into different body systems. And it became pretty apparent that a majority of patients in primary care have some level of a psychiatric need that are oftentimes not being met, and I've always had a bit of an affinity towards helping people with mental health illnesses from my upbringing. And I, in medical school, had noticed that a lot of physicians don't know how to treat folks with substance use disorders. And that specialty started to interest me because there's this intersection between primary care and psychiatric and medical and behavioral and society when someone's engaging in substance or alcohol use. And so, there's just a really complex combination of these different specialties, and I just became very interested in it and realized that very few people were really getting help in the hospital systems and the primary care clinics in regards to their addictions. They were oftentimes driving a lot of why people are accessing medical treatment. But yet, you know, we'd be great at treating the pancreatitis. But then, we'd wag our fingers and say, "Stop drinking" and then send them on their way without actually giving them the resources that they needed to treat their addiction.

And yeah, so we became passionate about learning more about that. I met a mentor, was a family medicine and a psychiatrist kind of dual-boarded physician. And she gave me great pointers on some societies to get involved with. And from there, it became, you know, a fellowship. And now, that's all that I do. So, it's a really rewarding field to work in and also to educate other providers in.

Host: Yeah, I think that's really important and maybe foreshadows a little bit of what we're going to be talking about, the idea that addiction touches so many aspects of life and so many other aspects of medicine. And it's really nice to be able to go a little bit upstream because as you say, if you can kind of get a handle on this, it can have a lot of positive effects on other aspects of health and well-being. So, maybe we can start with a little bit of a discussion of the addiction program at Sierra Tucson. So Luke, I know you are Director of the Addiction Program here. And Kristina, you're primarily working in the addiction program here. What kinds of patients do we see? What kinds of people do we see coming to Sierra Tucson for addiction?

Luke Peterson, MD: So, we see lots of different types of people coming to Sierra Tucson. We have three primary tracks. We have a mood track and a trauma track and then the addiction co-occurring track and patients who end up in the addiction co-occurring track are oftentimes folks who do have co-occurring disorders. So, it's alcohol, opioids, stimulants, cannabis, benzodiazepine, or sedative use disorders. So, there's a kind of a primary addiction that's driving a lot of problems in this person's life. And they also have depression or anxiety, PTSD or other medical problems. So, they're oftentimes quite complex in how they're presenting. And I would say, for the majority, we are treating alcohol and opioid use disorder, but we'll also have a smattering of other types of addictions that show up including non-substance addictions. So, whether it's a behavioral impulse disorder addiction, whether it's gambling or shopping, shopaholicism or sex or something like that, we will oftentimes also see patients with just primary behavioral addictions showing up as well.

Host: Yeah, I think that's really important to realize that we have such a wide variety. We can deal with not just substance addiction, but with also these kind of process addictions, which I know people do ask a lot about now. I think there's more awareness of that as a potential problem.

Kristina, you work with a lot of folks who come through Sierra Tucson and the addiction program. What do you think of as kind of a typical trajectory for these folks? Where are they when they start and where do we try and leave them once they've come through?

Kristina Cabalfin: When I used to admit them in Copper Sky, you know, I would usually see them, they would either come in under the influence or I would be helping them with their detox process, which is usually very miserable. Sometimes they want to give up, they want to leave, and I worked really hard to try to keep them here, get them through. I used to say, "I just got to get you through tonight," because they did at night. And then when I get to see them closer to when they're discharging, it's like it's a totally different person. They're smiling. It's an incredible turnaround. That's probably some of what gives me the greatest joy in working with addictions, is seeing that turnaround, seeing the changes. They're still obviously going to be working on it. It's a process and a journey, but you can definitely see some changes.

Host: Yeah. So in terms of addiction, I think the process, it's a long-term journey is a really good metaphor. Are there things that you say, "This is what we can do while we're at Sierra Tucson. And these are things that you'll need to kind of follow up on and continue to work on as we leave"?

Kristina Cabalfin: Yes. Yes. I'm always trying to encourage them that it is a journey. And it's something that they're going to have to work on continuously definitely when they leave. But I think it's a journey. I try to tell them it's not just an event or a journey to become sober or abstinent. It's also a process and a journey on that person you become on the other side.

Host: Yeah. I think that's a really important thing.

Luke Peterson, MD: Yeah. When people are here at Sierra Tucson, we have multiple interventions that we use to support them in this recovery journey that they're just getting into, or maybe coming back to. And I tend to think about treatment in kind of three different buckets. We have biologic or medical treatments that we use to help with withdrawal. There are medications that help with abstinence and recovery rates and cravings. And so, we're intervening with medications at times. We are intervening with psychological interventions, including individual counseling, group counseling, psychoeducation, just kind of teaching about what's going on. I do a neurobiology lecture series where we talk about the changes in the brain and try to demystify and destigmatize addiction and apply the neuroscience to recovery. We also have really great groups, peer support groups that are led by phenomenal residential therapists who both provide education, challenge patients, and facilitate group therapy. We have trauma therapists who can start working on trauma with our patients. We have a very high number of patients who have traumatic experiences, whether it's in the military or other traumatic events. We also have a lot of patients with developmental traumas that have occurred over a lifetime that need sorting through. And so, patients will be getting a lot of psychological interventions.

And the last bucket is social interventions. Addiction is so isolating that, this is a quote from Johann Hari's TED Talk, "But if addiction is in some way isolating," and it's a paraphrase, "then the treatment and the intervention should also then be connecting." And so, we have social interventions and encourage mutual support while patients are here, whether it be through peer groups or socializing or, you know, we have group movement activities and like things like AA and SMART Recovery. And so, those are the typical kind of interventions that we're doing. And usually, the first week we're stabilizing medically and then people are getting into these other interventions and seeing improvements. We're addressing their mood, their medical while they're here so that they can have the greatest chance of success. And then, at the same time, we're also talking to them and their case manager and building a treatment plan for when they go home, because this is a chronic disorder of the brain that cannot be cured in 30 days. It's something that we can stabilize and get people a kind of a foundation to move forward after they get discharged. And so, connecting to support programs back home is another crucial part of their recovery efforts while they're here with us at residential.

Host: Yeah. I really liked the description that you did of this kind of integrative complete person care. And I think it kind of connects with what Kristina was saying, is that you're also discovering yourself, you're discovering who you are when you're not using. And so, it's not just about the brain pathways. It's not just about detoxing. It's about finding those social interventions. Yeah, I'm glad you mentioned Johann Hari. I just read Lost Connections this year. And I think that was really an interesting take on things.

Let me dive a little bit more into kind of the core here of what you've been doing recently, which is taking a harm reduction approach to addiction. So, I pulled up a description of what the harm reduction approach is on Psychology Today. And maybe I'll just read that out and then you can kind of tell me if that resonates or if there's like other pieces that you think are important to include. So, what they write is that instead of judging, shaming, or punishing a person for their addiction, harm reduction programs believe in compassion and acceptance. They try to meet the addict where they are at by developing individualized programs to reduce the negative consequences of substance use. Harm reduction drug treatment takes a realistic view of addiction while simultaneously acknowledging the individual's ability to change for the better. So, how does that strike you? What does harm reduction mean to you? Are there other kind of core components to the way you think about harm reduction in addiction?

Kristina Cabalfin: Well, first and foremost, especially with the groups that I'm doing right now. It's saving lives, trying to keep people alive so that they can continue that journey, that recovery journey. And it's also reaching out to them as a person. There is a lot of stigma and sometimes they do come to the medical community. They get stigma from them, the people that they're asking for help. So, that drives them away, and harm reduction and public health, that's again trying to repair those relationships, to build trust, help them with medical health as well, not just the substance use, any kind of social work needs.

Alex Danvers, MD (Host): Yeah. And I think, Kristina, when you did like a presentation that I attended on, your approach, you maybe mentioned like how even earlier in your career, you had been around people in medical fields who hadn't taken a kind of more charitable or compassionate approach. I don't know if there's anything that you want to share from like how hard it is to change that or how difficult it is to get people into that mindset as opposed to kind of a more maybe punitive or blaming mindset.

Kristina Cabalfin: I could share a story from my ER days, which I usually share in group with people because it was so mind-blowing. It was a definite example of that stigmatism. So, when I was working in the ER, we had an incoming code blue, where they were already getting CPR in the ambulance. And as they came into the room, we have a team ready to help and take over. So, we had a doctor in there and, you know, he was asking questions, getting report, telling us to give this medication, do these labs. We're all in there working on this. And the ambulance person said, "And we saw needles on the floor," and his whole face just stopped. And he turned around and walked out. And I was so floored.

Host: The doctor walked out?

Kristina Cabalfin: The doctor walked out. And I'm just standing there going, "Um, does that change? We're not going to try to help this person? They don't deserve to be saved?" So, that was one of my first experiences to the stigmatism by the medical professionals. It was horrifying.

Host: Yeah. That's really scary. But I think certainly growing up, it's easy to take that approach of, oh, this person has made bad decisions, and so we just can kind of dismiss them or we don't have to worry as much about their wellbeing. Yeah, but it is scary and pretty jarring to hear a medical professional having that response.

Luke Peterson, MD: That is certainly horrific. And when I think about harm reduction, it does very much encapsulate this kind of facing our own stigmas and bias about substance use. We all carry something about that, whether it's from our family of origin, our personal experience, or society's view about substance use. We all carry that. And so, harm reduction to me is a philosophy more than a treatment regimen. It's a philosophy that we take that we're checking our own stigma and bias at the door. And we're acknowledging that substance and alcohol use is a reality for people. And that severe addiction is a reality for people. And not everybody who's in active use is in the action stage of wanting to stop. Many people, in fact the majority of people, are actually in a pre-contemplative, contemplative, or a like a planning stage of change. And so, harm reduction is a philosophy that we can use when we're looking at the spectrum of willingness to change.

And that is a very different way than how we viewed addiction treatment. Because in our traditional view of addiction treatment, it's like, "Well, you need to stop using." And once you're "ready" to do that, then we will help you. And so, you'll hear that oftentimes. It's like, "Oh, they're just not ready. They're not ready." And so, we're not doing anything until they're ready, but we don't do that with any other disease state, right? And so, harm reduction is taking this idea of, "Hey, if someone's in a pre contemplative stage of change and they don't want to stop using, how can we engage in a holistic and a compassionate way to help lower the risk of that person contracting HIV, overdosing and dying, being homeless on the street? How can we engage with the person and keep them alive, like Kristina was saying? How can we lower the harm of their active use when they're pre-contemplative? What can we do? Is there anything we can do in the contemplative person who's thinking about changing, but maybe not ready yet, or fully ready? And the change might not be abstinence. The change might be, "Hey, I really need to stop injecting." And so, maybe you engage in a level of, "Hey, let's talk about smoking it instead of injecting it. Let's talk about HIV pre-exposure prophylactic medications to lower the chances of you contracting HIV. Let's treat your partners who are maybe using, who have HIV or hepatitis C. Let's engage so that you're not spreading it to one another. Let's get you some needles that are clean and not used to lower the chance of spreading both soft tissue infection and also blood-borne infection."

What's really interesting is when you engage with somebody at that level and you're providing compassionate kind of holistic care in a harm reduction way. What ends up happening is that people end up feeling like a human being again. They're treated like a human being again, right? And I think that that spurs a little bit of self-compassion and further pushes people along that stage of change to the point that they maybe want to start using again. And there's actually really good literature that if you engage with somebody in a harm reduction way, they're five times more likely to actually go into treatment. Not that that's the goal, like we're not pushing people. There's no agenda with harm reduction philosophy. It's we are meeting them where they're at, supporting them where they're at, and just by doing that alone, it moves people a stage of wanting to maybe pursue some abstinence.

Host: Yeah, I think there's some really good themes that you're bringing up here. One of them being that substance use is often a way of coping with things that are going on in life and putting in place these things that are humanizing, that are helping you, even though you are still using might actually be a better way to get people to move to using less.

And I also love this metaphor of these different stages, right? I guess those are technical terms, you know, pre-contemplative, contemplative, where maybe an abstinence-only approach would kind of ignore people that are in those stages and as you said, say, "They're not ready," but this approach would say, "Meet them where they are."

Luke Peterson, MD: Yeah. Meet them where they are. Lower the chance of significant issues with their drug use, including overdose and death. Keep them alive so that, at some point, maybe they will choose to be abstinent and maybe they won't. But either way, we're engaging and providing compassionate and evidence-based care. And just the byproduct of doing that is that more people will choose to be abstinent And want to enter into recovery programs.

Host: Right. And I think even the name harm reduction, you know, it emphasizes what's bad about using substances or addiction. It's not getting high, it's harm. It's the bad things that happen to you as a result of your use. And so, let's try and target those bad things that happen to people when they're addicted to substances.

Let me jump in here and ask a little bit about the kits that you're giving to folks after they leave Sierra Tucson. Kristina, would you want to describe what those are and how they've been put together?

Kristina Cabalfin: Yes, thank you. They are including naloxone or Narcan, which is the opioid overdose reversal medication. They also include testing for fentanyl and there are test strips for xylazine, which is something that's not as well known right now as there is for fentanyl, but it's actually a veterinary sedative used for large animals that's causing a lot of harm. It intensifies the effects of the fentanyl. It's causing terrible skin wounds.

Host: I'm hoping that you'll repeat some of the stuff that you've said to me before, but this is becoming more popular, right? Xylazine is like an increasingly popular street drug, is that right?

Kristina Cabalfin: It's actually being added to other things and people are not aware that it's in there. It's getting added to the fentanyl. It's being added to other drugs, again, trying to intensify the effects. Besides the test strips and the naloxone, we have resources. And I always point out the top one, the overdose prevention hotline, where you can go online, and it's neverusealone.com, because that's one of the ways I try to teach them, is to never use alone. They cannot give themselves Narcan if they're having an overdose. Stay safe. They need to have someone else there. So when they call that phone number, they do ask the address where they're at and then they stay on the phone while they use to make sure that they respond. If they don't, then they're going to call 911 and get some help out to them.

Host: So this helps people who might overdose, right? It could literally save somebody's life.

Kristina Cabalfin: Exactly, exactly.

Luke Peterson, MD: I think one of the realities about treating addiction is that at least National statistics show that about 50% of people relapse within a year of treatment, which is a lot. I'll also say that about 50% of people with diabetes, hypertension, and asthma will also relapse in those disease states and will need further treatment. So, it's pretty on par with other chronic disorders. But relapse to substances and alcohol can be really devastating both physically and socially and mentally. And so although as a physician, I know that abstinence from the substance will bring the person the greatest quality of life and the greatest improvement in symptoms and social interactions and in health. I also know that 50% of people will relapse in the next year.

And so, we are engaging in the conversation of, "Hey, what can you do to prevent relapse?" And also if you do, how can we lower the chances of harm coming to you and things like the naloxone, the testing strips, the hotline. These are tools that can be used in the midst of a relapse to lower the risk so that someone can then turn things around much more quickly. So, this is a really different type of conversation from our normal abstinence based conversations we have with patients, because I think we do acknowledge abstinence will be the best way forward for you. And we also acknowledge that there's a chance things may not go as you are planning. And if not, these are ways to stay alive and to keep yourself healthy.

And what's interesting, some people might say, "Well, you're just encouraging people. Doesn't that increase the chances of them relapsing?" But the research actually does not show that. By engaging in harm reduction conversations, we lower the chance of harm and risk and death without increasing the chances of relapse. And so, it is a misnomer. And Kristina, you can probably speak to more on this as well, like there are other harm reduction strategies that we do commonly that I think some people think, "Oh yeah, that's going to increase the risk of something happening. However, it doesn't, right?

Kristina Cabalfin: Absolutely not. Definitely studies are showing that this is the way to try to engage, keep people safe, keep them alive so that they can continue that recovery journey.

Luke Peterson, MD: Right. I'm kind of thinking like birth control and condom usage and CP usage, like those conversations. People sometimes will say, "Well, if you talk to adolescents about condoms and birth control, aren't they just going to go have sex?" But that's not what the data actually shows. And it's the same with this harm reduction approach is that by having that conversation about how to stay safe, it's actually beneficial. We're saving lives by engaging in this conversation rather than encouraging. We're not encouraging people to use. We're recommending not using, but we're just planning for these contingencies and supporting them if they happen to relapse.

Host: Yeah. Thank you for addressing that. I think that's an easy kind of first thought, is when you hear, "Oh, we're giving these tools to people that are used for testing drugs. Well, isn't that just kind of enabling them?" But as you've said, the data does show that this reduces overall usage and it reduces the amount of harms that come from usage.

And I think maybe one intuitive way for me to think about it is actually, I think you brought up this idea of self compassion and I've Certainly had friends who it took more than one try to get sober. And I think I'm always happy that they're around for that second try or that third try or whatever try to get sober. And I think maybe it's better to think about what would you want for someone you cared about as opposed to a kind of more generic public health statistic.

Kristina Cabalfin: Dr. Danvers, can I also add that not only does harm reduction benefit the user, right? It is also benefiting public health, because we are reducing the spread of diseases like HIV, hep C infections. We are reducing the number of ER visits, which is also affecting health costs for all of us. It's also when there are, I don't know if you've heard of the term a safe use site where someone can go and use and also possibly exchange their needles, then you don't have that public use for maybe your kids to see. And you also have less disposed used needles around where they have these safe use sites. So, there are definitely public benefits to this, not just for the user.

Host: Yeah. So, maybe you're telling me, don't discount that public health statistic. That's a very important set of public health statistics to consider.

Kristina Cabalfin: Exactly. Exactly.

Luke Peterson, MD: One thing that I will commonly run into is, you know, and I think we're talking a lot about these strategies for like opioid use and things, is what we're talking about. It's the opioid overdose, the testing strips, the pre-exposure prophylaxis. But I also engage in some conversations with people in regards to cannabis, and I would say that I also take a harm reduction approach with people who are using cannabis. Now, I am always encouraging people to not use cannabis, because it increases the rates of them relapsing, it increases anxiety and insomnia and psychosis. And so, I don't think using cannabis in recovery is a good idea by any measure. However, many people are on a different stage of change with their cannabis than they are with their alcohol, opioids or methamphetamine or cocaine, and they're like, "Well, I'll just use cannabis for pain or for sleep or something," because they're seeing it's not as harmful. They may even think about that as like with nicotine as well, right? And so, I find myself very commonly engaging in a harm reduction conversation about cannabis.

Now, I'll still recommend abstinence from it. However, my conversation doesn't end there. We talk about, "Where are you getting your cannabis products from? Are you getting it from a dispensary? Are you testing it?" Because we have had some patients come here who have overdosed, accidentally overdosed on cannabis laced with fentanyl. "Are you using a loan, like Kristina had said? Do you know the different states' laws? If you're going to be moving to another state or driving through another state, what risks are you going to have? How are you monitoring your motivation level? How do you know that this is a good idea to keep doing and how would you know if it's not a good idea? What would you be seeing that would then tell you you maybe need to change? And if you needed to change, what would you do?" So, the conversation is more than just don't do it. It becomes more of this kind of more rounded conversation. And I really find that a lot of people end up saying and vocalizing, "Maybe it's not a good idea. Maybe I'll hold off for a while." And then, I'm really pushing hard on people and asking, "How would you know if you needed to consider using again? What would you be seeing?" And many times people can't come up with a whole lot of reasons. And they're like, "Well, it's probably a good idea that I don't continue to use it."

And so by using this harm reduction approach, I find that I can have a more fulsome and honest conversation with people. And I'm not just getting lip service like, "Oh, yeah, I'm not going to use, I'm not going to use." when in actuality, they're planning on going home and using because they fear my judgment if they're not going to be abstinent from it. So, it's a much more honest way to have a conversation about some of this stuff. And it doesn't always end in the way that I would recommend it ending. Some people still can plan on continuing to use, but we can just engage in the conversation, engage with the person in a more fulsome way than if we're taking kind of this paternalistic abstinent-only approach.

Host: Yeah. Even the way you phrased the question, I think, is nice. It's like, well, what would you look for, as opposed to coming in with a list of recommendations and saying, "Hey, if you see this, don't do it. If you see that, don't do it"?

Luke Peterson, MD: Well, you know, understanding human psychology and most people don't like to be told what to do. And so if you can highlight their internal motivations, you're more likely to see change than if we wag our finger at them and tell them what to do. Many times people will balk at that and actually dig in their heels and become more resistant. So, I take a motivational interviewing approach when I'm talking about these things with patients. And, you know, at times we have patients who come here who, it's maybe after a family intervention and they're pre-contemplative. They're here to placate family and they're not planning on stopping using. And really, the only way to engage with them is through motivational interviewing and harm reduction approach, because they're not planning on being abstinent. And if we only engage if they're "ready", then we're going to miss all this opportunity to have a more honest conversation and provide some education and support to keep them alive longer so that hopefully at some point they do decide to make some bigger changes and get more healthy.

Host: This has been really great. We're coming up at around time. I really appreciate you both taking some time to talk with me about this. Any last thoughts or anything you wanted to mention about this before we sign off?

Luke Peterson, MD: No, I don't have anything extra. Thanks for giving us the opportunity to share some of this way of thinking about recovery and some of the supports that we can offer at Sierra Tucson for folks who are maybe a little bit more pre-contemplative or contemplative about their substance use and abstinence.

Host: Yeah. Thanks both of you for the work you're doing. I find it really inspiring, and I really appreciate the outreach that you, Kristina, have been doing even just with our staff to make sure that everybody at Sierra Tucson is on the same page about what the harm reduction approach is. And I know you've spent a lot of time explaining to us, you know, this is how we're approaching things here and this is why it's beneficial. So, thank you both.

Kristina Cabalfin: Thank you.

Luke Peterson, MD: Thank you.

Host: All right. Thank you all for tuning into another episode of Sierra Tucson's Behind the Miracle podcast. And thank you to Kristina and Luke for being here to talk about a harm reduction approach to addiction. I'm looking forward to hearing more in the future. And please stick around as we continue to talk more about what goes on behind the miracle here at Sierra Tucson.