Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole, and we have a thought leader panel for you today. This is part one of our two part series on patient substance use disorder and recovery. Joining me is Dr. Sadeer Potru. He's triple board certified anesthesiologist, interventional pain physician, and addiction medicine specialist, and Dr.

Christopher Gudlewski. He's a board certified anesthesiologist. She's an anesthesiologist, an associate professor in the Department of Anesthesiology and Perioperative Medicine at UAB Medicine, part of the acute pain and regional anesthesia faculty, and a physician that's been involved in recovery for over 11 years.

Doctors, thank you so much for joining us today. And Dr. Potru, I'd like to start with you. Can you tell us a little bit about substance use disorder, the prevalence in our society and what you've been seeing in the trends?

Sudheer Potru, DO: Yeah, absolutely. Thank you for that kind introduction. So, in the substance use disorder world, first of all, the one thing that I should clarify before I even do anything else is to differentiate dependence on a substance, meaning physical dependence, from a true substance use disorder.

So, physical dependence is in the absence of using something, in particular, you sustain withdrawal symptoms. Whereas a substance use disorder is notable for the pathology. It's important because it basically messes up your life in some way in search of using a particular substance, meaning that you mess up family relationships, you lose your job, you're unable to pay your mortgage, you have legal problems associated with this, and/or other notable symptoms like cravings, withdrawal symptoms, and things like this.

So, for better or for worse, the number of overdose deaths that we're sustaining recently here in the United States has kind of leveled off a little bit. Unfortunately, we are still getting substantial numbers of overdose deaths, meaning over 100,000 a year and a lot of that is driven by fentanyl as well as a new alpha-2 agonist that we're seeing a lot of, which is Xylazine. And unfortunately, when patients overdose with fentanyl and Xylazine, we can use naloxone or Narcan to reverse the fentanyl overdose, the opioid overdose. But Xylazine does not have an FDA-approved reversal agent. And so, there are a lot of patients, unfortunately, who are still sustaining issues as a result of this.

In addition, what we're seeing now is substantially more stimulant use, specifically cocaine and methamphetamine use disorders that are becoming much more common and much more prevalent, particularly in the West as well as in rural areas around the country. And unfortunately, there are no FDA-approved medication treatments that is for either one of these. And so, that's created some problems amongst not only individuals who are older, but as well as teenagers and young adults as well.

Melanie Cole, MS: Thank you so much for that. And Dr. Godlewski, I'd like you to I want to jump in here as we're talking about the key differences in treating these and Dr. Poitrou described the differences. Tell us a little bit about some of the bigger issues treating patients with these disorders and who are in recovery. What are some of the challenges that we're seeing now?

Chris Godlewski, MD: It's three main things in my experience, and I think the things that these patients are facing everyone who has an SUD, is addicted, that sort of thing. And I think, number one, one of the biggest barriers for everyone involved is the heavy stigma that still is associated with the substance use disorders. Just by way of example, I told my parents that I was going to be doing this podcast as a physician in recovery. Both of them are retired medical professionals, have been in the field. And their first question to me was, "Do you think this is a good idea? What if UAB finds out and they fire you, or they don't promote you, or this kind of thing?"

So, in my mind, that was exactly the reason why we need to be doing this. There's still so much lack of understanding, lack of education, stigma associated with it. I think, overall, due to a number of reasons, defunding in the '80s, just the role in medical education, we are still somewhat in the dark ages when it comes to the Scarlet A of addiction as opposed to a lot of the other psychiatric disorders that we're seeing. So, what people tend to not understand, it's hard for them to have empathy for, this lack of understanding and empathy can often result in fear for the physician, the treating physician, and as well as the public. It causes shame in the addict, and this just sets off sort of a spiral that makes it very difficult for these people, even the ones who desperately want to get sober. It's a tough road for them. And I think that all those hurdles sort of contribute to a lower success rate than we'd probably like to see in these people.

Just by way of example, Alcoholics Anonymous is probably the biggest and most well known support group for addiction and substance use treatment. It's about 100 years old now, close to. And if you look at the name of it, the fundamental title is Anonymous. And the reasoning behind that, they say, is because they want to place people or recovery over specific people. But also, again, it's the feeling that you need to hide, that you're ashamed, that you have weak will, or it's a problem with your moral fiber, all these other things.

So, I think that's first and foremost, is that we need to do a better job. We've done a really good job in the modern era, taking the shame out of a lot of things and bringing them into the spotlight with social media, pop culture, big pharma. You know, obesity is being talked about frequently now, as is diabetes, depression. We have people like Simone Biles and Lady Gaga coming forward. And we applaud them for bringing mental health to the forefront, and rightly so. My question is always, why aren't we doing the same thing with substance abuse and addiction? And I think on a more granular level, going back to medical training for physicians in terms of the education that we receive on this topic, it's by no means expansive, broad, or anything to even close. We tend to learn about it in a roundabout and distant way, don't have much hands on experience with it. And that's why it's so important that we lean on people like Dr. Potru, who have that education to redo the way that we view these things so that these people aren't so marginalized.

So, for me, stigma and understanding is number one, Better education is number two. And then, I think, three, something that plagues all the mental health areas is reimbursements for mental health treatment are very low. It's not a very attractive field for a lot of practitioners in the '80s, the massive defunding of mental health. We don't have a great infrastructure for treating these people, and it's terribly expensive. And so, those are the three main things that I would say are really the massive obstacles in dealing with these people and these patients.

Melanie Cole, MS: Dr. Potru, I'd like you to jump in. But before that, Dr. Godlewski, thank you so much for sharing, because I think it's important. What you're doing is to highlight that stigma, which was going to be my next question. It's so important that we look at that. And as you mentioned obesity and things like that, there's a stigma around that, diabetes, all these things, but there seems to be just a different darker one for substance use disorder. And I just really thank you for bringing that out because, for providers listening, that's one of the most important points we're going to make here in this particular podcast, is how they can help their patients get past the fear of that stigma enough so that they can get help. And Dr. Potru, what do you think about this?

Sudheer Potru, DO: Yeah. Everything that Chris highlighted is critically important. We know that It's only between 11-14% of patients who likely had a substance use disorder in the past year actually were able to get specialty SUD care for it, which means that these patients are not accessing the healthcare system, and in large part likely due to stigma, as well as possibly due to economic challenges, social challenges, whatever it might be. It's really not in question how we have treated some of these people and, we being the healthcare system, how we've treated some of these people. And it's time for us to start making a change.

I think a lot of that will of course be education, and understanding that substance use disorders are neurobiological diseases, right? In addition to some behavioral diseases, there's some behavioral components to them, obviously. But we know that certain circuits, for lack of a better term, are kind of broken or go a little bit haywire in the brain. Specifically, the reward pathways in the mesolimbic system, which is a smaller part of the actual limbic system. And we know that those dopaminergic pathways are basically altered and ultimately corrupted by repeated substance use, which basically changes the entire scope of how the brain works and alters judgment, alters executive functioning and planning over the course of time, meaning that basically the brain is wired to look for a substance as opposed to doing other things that would allow it to survive and allow the body to whom it belongs to survive as well.

So, I think part of that, understanding that this is truly a physiologic or pathophysiologic problem as opposed to just as Dr. Godlewski referred to just a weakness or a moral failing or a whatever kind of picture that's previously painted will go a long way in helping us educate our fellow colleagues about how to treat this better. You know, we talk so much about hypertension and diabetes and all these things as chronic diseases. Well, patients who have chronic diseases, they don't get turned away. They get treated with medications. They get treated with other various lifestyle modifications and things like this. The reality is that any chronic disease, including a substance use disorder, which is also a chronic disease, can't be effectively treated with a seven-day detoxification or a 28-day rehab program or things like this. Patients who are in recovery are typically in recovery for a lifetime. There's some evidence showing that patients, if you show them an image of a drug that they've used even more than 15, 20 years ago, the reward centers in their brain will still actually kind of light up if you do fMRI studies, meaning that there's still some circuitry that is challenged even so many years after they've been in recovery. And so, it's a consistent process for them to remain in recovery. And there are many strategies that we use to try to assist with that. But at the end of the day, we have to make sure that we're doing the right things for these people, encouraging the process of recovery and decreasing stigma.

Melanie Cole, MS: Well, I certainly appreciate that. And Dr. Potru, I'm going to stick with you for just a minute since we are doing a part two. I'd like you to speak now about the multiple different approaches, the multidisciplinary approach. There are so many. As we've mentioned, AA and groups like that. What are some of the latest, most exciting advancements in pharmacotherapy, behavioral therapy? Tell us what's going on in the world that you find most encouraging.

Sudheer Potru, DO: Absolutely. So, I do like the fact that now, with greater education, more patients are trying to seek treatment, which is great. There are some really cool things happening in the substance use disorder space. I mean, we have some medications that aren't just oral or sublingual. They're long-acting injectable, meaning that they work for several weeks at a time or a month at a time. I've seen some neurosurgeons out there who are actually doing deep brain stimulation of some of the reward centers to actually treat refractory cases of substance use disorders. There's non-invasive stimulators like vagal nerve stimulators and different things like this that actually we think are having some impact on cravings and on withdrawal symptoms, which is really cool. And some evidence that transcranial magnetic stimulation may be helpful as a non invasive modality as well.

Traditionally, treatment for substance use disorders has been broken down, of course, into medication and non-medication, a.k.a. psychosocial treatments or behavioral treatments. The medication treatments, I think, are kind of fairly self-explanatory. There are several different ones which we can talk about. But, essentially, the non-pharmacologic treatments range from anywhere, something like cognitive behavioral therapy and motivational interviewing, which have evidence behind them, as well as something, fairly simple things like support groups, 12-step groups like AA.

There's also some evidence for family therapy, what we call contingency management, which is basically a method by which you provide the patient compensation, whether that's a gift card or cash or whatever it might be, for concordant or appropriate urine drug screens on a regular basis, so every week or every other week, depending on what it is they're doing. So, it would take a long time to go through every single one of these types of treatments, but there are numerous psychosocial treatments, some of which have evidence behind them, but we do know that the evidence is better for medication-based approaches. Just like it's better with hypertension, just like it's better with diabetes, these patients do better when they're managed with medications as well as the other treatments too.

Melanie Cole, MS: This is such an interesting and important conversation that we're having here. As we wrap up this part one, Dr. Godlewski, I'd like the last word to be to you. How important is personalized treatment planning when we're talking about substance use disorder recovery? And what factors do you consider most critical?

Chris Godlewski, MD: That's a really, really good question in terms of the most important or how the importance of personalized, and we'll talk about this a little bit more when we talk about impaired physicians, but I think, when I went through rehabilitation and that my process pretty much encompassed almost everything Dr. Potru has mentioned, medication, family therapy, et cetera, I was very lucky. And I think the more personalized and tailored it can be, the better chance of success you have. But again, my mind, the problem is we are fighting a disease that we don't have a lot of resources for. And I will say that I don't think the majority of people suffering from this have access to such sophisticated multidisciplinary treatment. Ideally, they would. And I think perhaps our success rates would be higher if they did. Is that the pot of gold at the end of the rainbow for all this? I certainly hope so. And I would love to see us start to move towards that. I think it's critical because I think, for me, more than anything else, and I consider myself, again, very lucky. I went to treatment with primarily other physicians, most of whom it was not their first time there, which scared me right out of the gate, to be honest with you. But I think that more than any one factor, or one component of that treatment arm is in the big book, which is the sort of the equivalent of the manual for Alcoholics Anonymous. The crux of it is such that you examine yourself and have a fundamental shift in the way you think and approach life, and that is actually the key factor that keeps you in recovery, keeps you "taking your medicine" every day. And there's all kinds of cute and trite phrases that are bandied about in Alcoholics Anonymous about your disease out in the parking lot doing push ups and that sort of thing.

But I think the fundamental factor that, fingers crossed, have kept me in recovery this long is really examining yourself and buying in wholeheartedly into the change, sort of preparing yourself for it, going through it and maintaining it, because I have seen folks go through the program, and they call it white-knuckling. It's called white knuckling, because they just squeeze the armrests on the chair to get sober or fake it till you make it. But I think long-term sustained recovery, the bedrock of that is that fundamental internal change in the way you view things, the way you interact with your world, the way you accept the things that happen to you in the world, all those sorts of things, which can be, again sort of magnified and more effectively addressed by a personalized program. I think for me, in my mind, that is the main thing that has kept me on the straight and narrow for all these years.

Melanie Cole, MS: I thank you both for joining us today. And that concludes part one of our UAB Medcast series on patient substance use disorder and recovery. Be sure to check out part two to get all the information that you need. For more information, please visit our website at uabmedicine.org/physician. I'm Melanie Cole.