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 Healthcare Provider Substance Use Disorder and Recovery. Joining me is Dr. Christopher Godlewski. He's a Board Certified Anesthesiologist and Associate Professor in the Department of Anesthesiology and Perioperative Medicine at UAB Medicine, part of the Acute Medicine Pain, and Regional Anesthesia faculty, and a physician that's been involved in recovery for over 11 years.

And Dr. Sudheer Potru, he's a Triple Board Certified Anesthesiologist, Interventional Pain Physician, and an Addiction Medicine Specialist. Doctors, thank you so much for joining us for this part two. And Dr. Potru, I'd like to start with you. Since treatment requires multiple different approaches, let's talk about some of those approaches.

In part one, we briefly mentioned yoga, meditation, these complimentary adjuvant therapies, but I'd like you to speak about some of the latest advances in pharmacotherapy for addiction recovery. How do you integrate, how do you integrate medication assisted treatment, which we're hearing so much about today with these behavioral therapies, especially when we're talking about healthcare providers?

Sudheer Potru, D.O., FASA: Yes, thanks Melanie and thanks to UAB and to everybody else for having me here. I think the most important thing when you think about medication treatments for recovery, is you have to think about the pharmacology of the actual substances that are being used. A lot of people don't know that there are only three substance use disorders for which we have FDA approved treatments, which are alcohol, opioids, and tobacco. So that means that there are a bunch of substance use disorders out there, cocaine, methamphetamine, many other things that don't have FDA approved treatments. And so we end up using all of our ancillary behavioral mental health treatments to assist with those to some extent. The reality is that medication treatments are very, very effective, particularly for opioid and alcohol use disorders. To the point where they have done studies in the past where they took a look at certain types of medications, for instance, buprenorphine for opioid use disorder, and they compared it to, so, just one group with opioid use disorder that have buprenorphine, and one group that had buprenorphine plus a variety of ancillary, psychosocial and behavioral treatments, and what they essentially found was that the retention in treatment and the risk of relapse, was the same between them, meaning that the most important factor in all of those patients recovery and maintaining them in treatment, preventing relapse, was the fact that they were on medication treatment for their opioid use disorder. So when you think about the receptor pharmacology for the actual treatment substance, right?

So for instance, buprenorphine and methadone are actually both opioid agonists that we use to treat opioid use disorder. Naltrexone is an opioid antagonist, an antagonist of the mu opioid receptor, that we use to treat opioid use disorder. So, based on the actual pharmacology of the substance, those three things are acting directly at the places where other opioids, whether they're injected illicit opioids or prescription opioids, are having an impact.

Similarly, in the case of alcohol use disorder, you have things like acamprosate, you have disulfiram, and you have naltrexone, actually, which is also used for AUD as well as OUD, and interestingly, the naltrexone functions on the dopaminergic pathways to eliminate that euphoria or that high that patients get when they drink a significant amount of alcohol.

Disulfiram functions as an aversive agent, meaning that it makes you feel hungover if you take the pill and you drink alcohol immediately afterwards. Kind of an older treatment that's not really used as much. And then acamprosate has been shown to basically just reduce heavy drinking days. So, it's interesting that there are many mechanisms by which these drugs work, but at the same time, looking at the process of recovery and initiating those ancillary treatments, even though they're not necessarily as strong from the evidence standpoint, is still very important in maintaining particularly long term recovery.

And the sad reality, unfortunately, is that a lot of the patients who end up on some of these medications end up on them for life because number one, they're unsure what will happen if they come off. And number two, there may be cravings and withdrawal symptoms that may become evident if they do.

Host: Isn't that so interesting? Wow, you really just listed all those out for us so very clearly. Dr. Godlewski, what about psychotherapeutic approaches? What have shown the most promises combined with the medication assisted treatment, behavioral therapy? Speak about some of the psychotherapeutic approaches.

Christopher Godlewski, M.D., MSHA: I think that when we're talking about the psychotherapy aspect of things, it's just one piece of a larger bundle. I don't know that any factor in isolation would be effective, but a good program of psychotherapy, and this is usually takes the form of cognitive behavioral therapy, but really, I find what seems to be most effective is a holistic approach, so rehabs often focus on behavioral therapy. There can be biofeedback to elicit stimulus that triggers craving for opioids. There's family therapy that gets involved to identify any family stressors or triggers for the use disorder. Going all the way back to examining, because very often substance use disorders coexist with other psychiatric diagnoses.

So, effectively treating those as well. So in summary, psychotherapy is a hugely important part of the process, because as we keep reiterating, success is usually based largely on an individual's willingness and buy in to the process. And so the more understanding that they have of themselves and the more insight they have into things that will, once they are in recovery, potentially serve as triggers or temptation to return to the substance; the more effective they will be in the years following if they can sort of adhere to those things that they've learned and those strategies that they've taken on, which psychotherapy is a bedrock of those things and frequently PHPs will have their participants seeing a therapist monthly for some piece of time, even after going through rehabilitation services or things like that. So psychotherapy is a huge component of the holistic picture of treatment of substance use disorders.

Host: You made such a great point about that holistic and integrative approach and involving families and Dr. Potru then along those lines of what Dr. Godlewski was just saying, how important is that interdisciplinary collaboration in the treatment of substance use disorders within the healthcare community?

I'd like you to speak about some of the best practices for fostering in it. What role, if any, do colleagues, primary care, psychiatrists, addiction specialists, such as yourself, play in that coordinated treatment plan.

Sudheer Potru, D.O., FASA: Well, the interesting thing about addiction medicine is that it is practiced by numerous clinicians. People who have an anesthesia or pain background like me sometimes. Physiatrists, family medicine doctors, internal medicine doctors. All sorts of people. And understanding that a lot of these patients in recovery will need specialists as well as a central source to really kind of care for them and sort of act oftentimes as their primary care physician while treating their substance use disorder as well, in association with that, is very helpful.

Because, the process of a substance use disorder frames a number of different things. Thesubstance use disorders can cause all kinds of physiologic problems. It can mess up your liver, it can mess up your kidneys, it can screw up your lungs, your brain, unfortunately, many, many sub, systems, I should say, can be effective, affected. But the most important interplay is that of the individual in recovery with their individual medical practitioners, as well as their associated recovery groups, because those elements have to function hand in hand and work together, which actually has created some friction, unfortunately, amongst, say, 12 step groups, and individuals who go and obtain these medication treatments for their substance use disorders.

The 12 step program was created a long time ago, back I believe in the 1850s or 1860s, when a lot of these medication treatments either didn't exist or weren't popular at the time. And, unfortunately, created some stigma for the individuals who have gotten medication treatments, because the belief is, from the 12 step standpoint, is that all those medications essentially shouldn't be used. And that success in treatment should come from belief in a higher power and a few other things. So while there are different elements that can be at odds within the actual treatment recovery system, the most important thing a patient or a family member or a treating clinician can do is to make sure that the patient with a substance use disorder is getting coordinated treatment from the various places where they need it.

And the most important point as we alluded to last time, is that has to be personalized because not everybody needs exactly the same things. Not everybody necessarily needs medications. Not everybody will benefit from a 12 step group. And so understanding that and coordinating that care in an appropriate way will optimize treatment for the patient and basically improve their chances of recovery the most.

Host: That is so interesting. And while you were speaking about that, I was having thoughts of bariatric surgery and the stigma around that in the similar way that the weight loss community looked at this as not a tool, not something to really help the process, but an easy way out. And so that's very interesting that you brought that up. I'd like to give you each a chance for a final thought. This has been such an interesting conversation in this two part series and Dr. Godlewski, I'd like you to speak about advancements in telemedicine, digital health tools, how they're transforming the recovery practices, and any key research areas that you feel need more focus to improve outcomes in substance use disorder recovery for colleagues in the healthcare community.

Christopher Godlewski, M.D., MSHA: In terms of telemedicine, it can effectively really broaden the reach in every one of the areas that we've discussed. So it would facilitate potentially access to somebody like Dr. Potru. You could have people talking to a psychotherapist or a psychiatrist through telemedicine, perhaps if they're in a place where they don't have transportation, can't afford transportation, et cetera, all these sort of circumstances of life that prevent people from getting effective treatment, I think telemedicine can really open those doors quite a bit.

I think in terms of advances, I think overall the most important thing that we can do is continue to educate people on these things and to de-stigmatize substance use disorders. I think that that stigma is still very real, though it is getting better, as Dr. Potru has said. Encouraging people to make use of the resources that are out there and feeling comfortable in doing so and not feeling discouraged or ashamed of having to do that.

I think that first and foremost will probably make the biggest difference. I don't know that there's anything new on the horizon with psychotherapy that is really gonna be a game changer, but I think access is also actually a huge barrier for a lot of people because a lot of these treatments can be very, very expensive.

The cost of an inpatient stay for rehabilitation even with quality insurance paying for it, is astoundingly high. A lot of insurance companies, the last time I checked, weren't fully covering a lot of these medication assisted treatments that Dr. Potru was speaking to. So, there's all these barriers in terms of access and stigma that I think if we can overcome those and educate people and break down a lot of those barriers, would probably be more effective than any single one advancement in one of the arms of those treatment strategies.

Host: That's exactly what we're doing here with this series. And we've done a part one and part two of substance use disorder series among the patient population and this one among healthcare community setting. Dr. Potru, last word to you on these really lively discussions we've been having on substance use disorder. Where do we go from here to do a better job with our colleagues building and expanding a little bit on what Dr. Godlewski was just saying. Where do we go now?

Sudheer Potru, D.O., FASA: I really appreciated all of Dr. Godlewski's comments here. They're all spot on. We know that many, many people, probably 85 to 90 percent of people with an active substance use disorder got specialty substance use disorder care within the last year. And this is true year after year after year, all the studies and survey studies demonstrate this.

When we think about our colleagues who are struggling with a substance use disorder in medicine, in nursing, in pharmacy, in whatever medical specialty they're in; the most important thing, as Dr. Godlewski alluded to, is that they have to seek help and it's so difficult to seek help when you haven't been used to seeking help, when you've been succeeding by all measures, whether it's in medical school or residency, wherever it might be.

You're so used to doing well and not asking for help that you continue to try to struggle through on your own and you don't ask for it. And if there is a healthcare practitioner out there who is listening to this, or a family member who is listening to this, encourage your loved one to get help, because resources are out there.

And while there still might be stigma, while there still might be some challenges with accessing treatment, we know that those exist. The reality is that if you seek treatment as a healthcare professional, the likelihood of you getting better is so much higher than it is in the general population that you will most likely improve substantially and be able to go back to doing the things that you love, taking care of people and helping them live better lives on a daily basis. And so, I think that's the most important thing I can say.

Host: Wow. Thank you both so much. What a discussion we have been having in this really four part, but two part series on healthcare community and two part series on the general population and substance use disorder and recovery. You're both such amazing guests and I can't tell you how much I appreciate how candid you were with us today and really the amount of information that you've given us is so much to think about.

So thank you both so much for sharing your incredible expertise with us today. And that concludes part two of our UAB Medcast series on provider substance use disorder and recovery. Be sure to check out part one, if you missed it. And for more information, you can always visit our website at uabmedicine.org/physician. I'm Melanie Cole, and thanks so very much for joining us in this series.