Melanie Cole, MS (Host): Welcome to UAB MedCast. I'm Melanie Cole and we have a thought leader panel for you today and this is part two of our two part series on 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, an associate professor in the Department of Anesthesiology, 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 as we're doing part two and we learned so many interesting things in part one. Dr. Potru, what role do social determinants of health play in substance use disorder and treatment? How do you address them? And do you feel like things such as psychological trauma play a big role here?

Sudheer Potru, DO, FASA (Guest): There's no question. We know very well from our current literature that social determinants, as well as psychological traumas and challenges are both significant drivers of substance use. So when we say social determinants of health, for anybody who is unfamiliar with that term, we're talking about economic issues, education access and quality, healthcare access and quality, neighborhood and environment as well as social and community environments.

And when we say psychological issues. We could be talking about depression, anxiety, and then post-traumatic stress disorder, something that goes with substance use disorders in a fairly substantial way. Number of the patients that I see and evaluate who have SUDs, of course, I treat veterans.

I work at a VA so I see a lot of folks with post, with post-traumatic stress disorder. But a number of the folks I see even or I have seen who aren't veterans have traumas that are certainly contributing to their challenges.

Host: That's so interesting. Now, Dr. Godlewski, based on what Dr. Potru was just speaking about, can you speak about strategies that are effective in engaging and retaining patients in treatment programs and why it's so important for that continuum of care?

Chris Godlewski, MD, MSHA (Guest): Sure, I think, in the other piece we discussed, the multi disciplinary, multi strategy treatment approach to these people, and especially when you're starting out, it's a very long road up, and it can feel very difficult, bleak, and hopeless, and the relapse rates can be high.

I think what's fundamentally important is that, as you alluded to previously, making it personal for people. We don't want to come at them saying they have to be clean just because they have to be clean. They, there has to be that buy in that we discussed, seeing this as, and it's not just addiction or SUD, it's really any disease process because that's what, that's the model we're operating under when we approach this now.

It's like we said, it's not, moral turpitude. It's, your wiring is altered, just like with any other disease of compulsion or obsession, really tailoring it to the patient in a palatable way that will, get them on board with it, get them coming back, making them feel like a relapse isn't a catastrophic failure, that it can be part of the process and that they just need to keep going with it until they sort of get over the crest of that big hill, I think that's really part and parcel to this.

I think there's other things, whenever the law is involved or things like that, that can be mandatory, i. e. and we'll talk about this in sort of the more treatment strategies, but, mandated drug testing, drug contracts, things that are employed by methadone type clinics, those can be a little bit more rigid ways of enforcing these things, but I think really for it to be something that the patient will carry through successfully is they really have to embrace it and accept it and not do it for a family member or because they think they have to or because their boss is telling them or, these can be good reasons to start the process, but ultimately somewhere in the process for it to stick, there has to be that buy in and I think that's the critical piece.

Melanie Cole, MS (Host): Dr. Potru, how do you handle patient relapse within the framework of a long term recovery plan?

Sudheer Potru, DO, FASA (Guest): Yes, that's a fantastic question. And relapse is something that's very frustrating for patients, for medical practitioners, because patients and we, and us, providers in the medical system, we work very hard to try to prevent it. But for a lot of folks, unfortunately, it ends up being inevitable. We have to look at addiction, a substance use disorder as a chronic relapsing remitting disease. Much like some people say you would look at multiple sclerosis or something of this nature. We know that there are going to be times and triggers and stresses that will probably result in substance use and relapse. It's just a matter of kind of getting really back on that bicycle to make sure that you're continuing to do the things that, really aided in your recovery to begin with. So when we're looking at actual relapse prevention models, what we're doing is looking at triggers primarily. That's the biggest thing saying, all right, well, is it a place that you went where you used to drink alcohol?

Is it some people that you used to hang out with whom you used to inject drugs? Is it you know, a family member who was doing some problematic things that you used to see all the time when you were young and that's where a lot of this began. A number of the strategies relate to counseling in that particular vein, in that relapse prevention model to help patients identify and avoid those triggers to reduce the likelihood of relapse.

As I said, we anticipate that it probably will happen at some point or another, especially for patients who have severe substance use disorders, but obviously minimizing that and getting them re engaged and linked back into treatment is the best way to ensure that their one time or two time relapse will not result in a significant problem or ultimately their death.

Melanie Cole, MS (Host): Dr. Godlewski we've learned a lot over the past few years about not working in silos and, and physicians sharing research, sharing information. And one of things that's come out of COVID was Telehealth and real digital health tools that we didn't really, that were underutilized before COVID. How do you see advancements in telemedicine, digital health tools, transforming addiction recovery practices? Do you see a role for these in beyond what we've seen just in the last few years?

Chris Godlewski, MD, MSHA (Guest): I absolutely do. I think, the way that telehealth has jumped forward because of COVID, as we discussed in the other piece, a huge limitation or hurdle that people so desperately wanting to get into recovery is access to care, And I think telehealth, maybe the patient can't afford to go to an inpatient rehab or whatever the mitigating circumstances are, but every little piece that we can chip away in this treatment model, the more we can put in front of the patient to, again, engage them and keep them bought into the process. I think it's huge. I think, especially the role of a physician like Dr. Potru or a psychiatrist, a psychologist so that somebody doesn't necessarily have to drive to the clinic or go into the city, but they can log on, you know, there's AA meetings and NA meetings online almost every hour of the day now, and that is a fantastic change, and I think access to healthcare via telehealth it could absolutely be a game changer, and I'd like to see it actually take root and even grow more than it has.

Melanie Cole, MS (Host): What a great conversation we're having. And as we wrap up, Dr. Potru, where do we go from here to do a better job with our patients? And we just were talking about digital health tools and telemedicine and the social determinants. We've brought so many aspects into this. And in our part one, you did discuss some of the exciting treatments.

Where do we go from here? Speak about any research, advancements, anything you would like other providers to take away as key messages.

Sudheer Potru, DO, FASA (Guest): As much as I enjoy talking about advancements, the key message for me coming out of this is that you can't avoid these patients and you shouldn't give up on these patients. Continuing to try to pass them to other practitioners or ignore their care, ignore their substance use, you're ignoring an important part of their health and an important part of their medical care.

And stigmatizing them for it obviously is not great as we've already discussed. I think the biggest thing also is to keep in mind trauma informed care, meaning that we want to ensure that we're looking at the entire person and looking at their past traumas and how they may have influenced current and future behavior. Making sure that we have welcoming spaces for them, making sure that we're not using judgmental language, making sure that we are not re traumatizing them in the process of actually trying to care for them. So one of the things that I have found a really, as a really good method for creating empathy, which I had to do when I started treating substance use disorders because I don't have a ton of it in my own family, was I actually visualized, you know, in my exam room or, or on my procedure table or wherever it was, an individual in my own family, because I do have one who has a fairly significant alcohol use disorder, and I kept trying to imagine how I would want him to be treated, how I want him to be looked at in the healthcare system, and how I wouldn't want him to be judged, and how I wouldn't want him to be talked down to, and I think that allowed me to really kind of create some genuine empathy within myself for the individual human sitting in front of me struggling with these very issues.

That would probably be my biggest takeaway and the thing that's been most helpful for me clinically, as I've looked at some of these patients, but just understanding that we're all human beings, that we all have challenges, that we all have struggles will take you so far in trying to actually connect with somebody who has a unfortunately really challenging refractory disease at times.

Host: I'm so glad that we really emphasized compassion and empathy to help reduce that stigma so that other providers that are working with these patients really do see the whole person and the multidisciplinary approach. Thank you both for joining us today. And that concludes part two of our UAB Medcast series on patient substance use disorder and recovery.

Be sure to check out part one, if you missed it, there was so much great information discussed there. For more information, you can always visit our website at uabmedicine.org/physician. I'm Melanie Cole. Thank you so much for joining us today.