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    Opioid and Other Substance Use Disorders

    Oct 12 2022

    Today, Dr. Marc Fishman helps us better understand Substance Use Disorders (SUDs), the impact of Opioid Use Disorder (OUD) and other SUDs on the country and the public health landscape, and the steps being taken to treat patients, enhance the quality of care delivered, and improve lives. Dr. Fishman, an addiction Psychiatrist, is the Medical Director of Maryland Treatment Centers and an Associate Professor at the Johns Hopkins Department of Psychiatry.

    *This episode is brought to you in collaboration with the Addiction Medicine Practice-based Research and Quality Improvement Network (AMNet).

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    Transcript for Audio

    Christopher Chun-Seeley: Hello. Welcome to Mentally Healthy Nation, a podcast of the American Psychiatric Association Foundation. I'm today's host, Christopher Chun-Seeley.

    Christopher Chun-Seeley: Close to 25 million people are affected by substance use disorder in the USA. Additionally, 40 million people are affected indirectly, including the families of individuals with substance use disorder. The US is facing an unprecedented opioid epidemic. There were an estimated 100,306 drug overdose deaths in the United States during the 12-month period ending in April 2021. Opioid use disorder is often a chronic relapsing condition associated with medical, social, legal, and employment problems. There are many paths to recovery and effective treatments are available, which include counseling, cognitive behavioral therapy, contingency management, and structured outpatient and residential treatment.

    Christopher Chun-Seeley: In addition, there are FDA approved medications that effectively treat opioid or alcohol use disorder. Self-help approaches are also helpful to many individuals. This episode is brought to you in collaboration with the Addiction Medicine Practice-Based Research and Quality Improvement Network, and we are joined today by Dr. Marc Fishman, who really is truly an expert in this area. And we're really excited to have this very open and critical conversation today about substance use disorder and what is it and what we can do about it. So Dr. Fishman, again, thank you again for being here. We're really excited about this conversation.

    Dr. Marc Fishman: Thanks Chris, for having me today and engaging in this rich conversation that I expect we're going to have. My name is Marc Fishman. I'm an addiction psychiatrists and I'm sitting here in Baltimore, Maryland for this conversation. I have a number of different roles in my professional life. I do clinical work with patients, with substance use disorders and co-occurring psychiatric disorders across the lifespan. I have a particular interest in young people, adolescents and young adults, but the full range of ages. I have an academic life doing research in clinical outcomes for substance use disorder treatment. Lately I've been focused on young adults with opioid use disorder as a particularly vulnerable population that needs special attention according to their developmental vulnerabilities and needs. And then thirdly, I have a clinical and administrative leadership role in a medium sized behavioral health organization, a community, SUD treatment program in the public sector in Maryland where we run programs across the full continuum where we do outcomes research in the patient population where we do training and teaching of residents and the like. And mostly treat patients and hope some of them will get better even.

    Christopher Chun-Seeley: To throw you, you may be a bit of a softball, but for some of our listeners who might not know what substance use disorder is, what is substance use disorder?

    Dr. Marc Fishman: Right. Great question Chris. Well, to begin with, it entails the use of substances. Now that itself is not uncommon in the broad population. Lots of people use substances sporadically, recreationally, without considerable impairment, without loss of control. But a substance use disorder is something different, is something that involves the progression of substance use to the point of significant impairment, to the point where a person loses control over the deliberate use of substances for intermittent pleasure and it essentially takes over their life. And you see the devastation that this produces along a spectrum from early initiation to then some people who have this relapsing remitting course or unfortunately even non-remitting course over decades, even to the point of considerable morbidity and even mortality. And so we see impairment from use of substances in all realms across the loss of function, whether that's in terms of the development of medical morbidity, psychological problems and co-occurring psychiatric problems, legal problems, ongoing use despite clear and progressively devastating consequences.

    Dr. Marc Fishman: And so that's what the disorder is. It's this progression to habitual, relentless use without stopping, despite consequences and with loss of control. We ask, well, if it's that bad, and many of us have had the experience, it's so common in a family member, in a patient, in people we've known. We estimate that maybe 40, 50 million people are affected across this country and of course many more internationally. So it's well known. Many of us have seen, even if we haven't had our own personal experiences, we've seen others suffer. If it's that bad, well why don't they just dang stop? And this is so hard for non-professionals folks who haven't actually experienced this torment and this suffering. It's so hard for people to understand. If it was just a matter of rational decision-making, right? Red and black ink on the spreadsheet, the patients I treat, the loved ones that people encounter with this problem, of course, they'd stop.

    Dr. Marc Fishman: It's ruining their lives. So many bad things have happened. Why don't they just say no? And that is of course an area of very interesting research as we understand or try to elucidate in more detail over time, the mechanisms. Mechanisms that are biological, that are psychological, that are behavioral, that are spiritual. But at the end of the day, it isn't just a free choice for patients who have developed the disorder. And that's why it's so important to identify that it is a disorder and that it has such multi-component, overdetermined, different etiological cause that cause people to be constrained, that cause people to be enslaved, such that they can't just make this simple decision to stop because they're so caught up in it and they have such loss of control.

    Dr. Marc Fishman: But anyway, very interesting as we have this conversation to try to get people to appreciate that because it's a natural thing for people to wrestle with, and it's hard for people to understand. And one of the responses in addition to compassionate concern for people suffering, which is of course what we hope for in any disorder, is distrust and anger and concern that the person is misbehaving and doing so many things that might affect a loved one or might get them in trouble with the law or might ruin them their lives. And so this is part of the interesting conversation. How do we get people to be more sympathetic and appreciative of how this is a disorder and a treatable disorder?

    Christopher Chun-Seeley: You touched on a couple of things and one thing I think is interesting is that there are a lot of substances out there that we don't necessarily even think of as, I have a cup of coffee here in my hand and that's a stimulant. But sometimes that's to me an easy equation to help people understand that, would you give up your cup of coffee every single morning? How easy is it for you to say no to your stimulant every single morning that picks you up. And how easy is it for you to think about how late you are sometimes to work because you have to wait in your Starbucks line because you need your Starbucks directly to impact your work sometimes, or how fast you have to speed after you go and get that cup of coffee because you're five minutes later than you would've expected.

    Dr. Marc Fishman: Well, those kinds of analogies are very useful in trying to get the uninitiated and the non-expert to try to appreciate what some of these features must be like. And even the experience of the pursuit of intoxication is a very common near universal phenomena of the human experience going back tens of thousands, hundreds of thousands of years. Consider four-year-olds that like to spin around and get dizzy. It's so much part of the human experience to want to seek that enrichment, that euphoria, that being in a different consciousness. But for most people, it's intermittent. For most people, it's occasional. For most people, it's a use it or give it, take it or leave it kind of enrichment. The same for alcohol, which is nearly ubiquitous, say in US culture. Many people have a beer at the football game or a glass of wine with dinner. It's no big deal.

    Dr. Marc Fishman: Take it, leave it. Sometimes yes, sometimes no. It enriches life, but if it doesn't happen this weekend or next weekend, well that's not the end of the world. And your analogy for caffeine and it's pharmacologically reinforcing properties, many people experience that. But the difference is the loss of control to the point of impairment and having the experience become predominant to the exclusion of the full richness that most of us experience in our lives. And the person who becomes addicted, who develops loss of control is part of a disorder. Their lives narrow, the repertoire of the richness of their lives' experience such that the substance becomes everything. And from intermittent, it becomes habitual, and from habitual it becomes compulsive, and from compulsive, it becomes all-encompassing. And boy, that's hard to appreciate.

    Christopher Chun-Seeley: Yes. Dr. Fisherman, you touched on the fact that substance use disorder impacts anywhere between 40 to 50 million people in the United States. Are there any other stats or statistics that you can provide our listeners that kind of encompass the seriousness of substance use disorder in the United States?

    Dr. Marc Fishman: So maybe 25 or 30 million people with a substance use. If you talk about the reverberating ripples of people affected, maybe that gets to 40, 50 million. As I said, so many of us, maybe everybody knows somebody has a loved one, has a family member, has a patient, if we're talking about medical professionals. And so the reach is so universal. Some of the most severe consequences as with any disorder, are thinking about the mortality. And you quoted a chilling statistic that recently we passed the threshold of a 100,000 opioid overdose deaths for the first time in this country's history. And boy is that just so tragic, the loss of life. And opioids are certainly very, very terrible. And the immediacy of an unpredictability of an opioid overdose death is so tragic. But thinking about other substances, there's also a great deal to be concerned about. There are probably 140,000 or 150,000 alcohol associated deaths in this country every year.

    Dr. Marc Fishman: They're maybe not as dramatic and instant in the sense of an overdose, but all the morbidity that occurs from chronic alcohol use disorder is a number even bigger. And although we don't often think about smoking tobacco and nicotine with the urgency that we think about, say opioids or alcohol. A nicotine use disorder is probably associated with about 400,000 deaths every year in this country. Now that doesn't kill you in one puff or one use episode the way opioids do. It might be decades in terms of the chronic morbidity, but still those numbers are chilling. And so lots of ways. And nevermind death, which is of course at the end of the severity spectrum, the loss of productivity, in terms of employment, the carceral system and its punitive historic approach to adding to the damage in terms of substance use disorder and the involvement of people incarceration or not in criminal activity, the progressive medical morbidity and psychiatric morbidity, the devastation to families. So, so many ways in which people are affected.

    Christopher Chun-Seeley: Well yeah, and I think that unfortunately substance use disorder, the crack epidemic of the '80s and what is continued to occur in even sentencing discrepancy in powdered cocaine versus crack cocaine. And in the criminal justice system, what we've really done is continued to criminalize substance use disorder in such a very unfortunate vicious cycle because we don't provide them any support or any connection to treatment. We slap them on the wrist because they've used a substance, but we don't get to the root cause of why they might be using that substance in the first place.

    Christopher Chun-Seeley: And you touched on the opioid epidemic and a few weeks ago I actually got the chance to go to the US Virgin Islands to deliver one of our school-based trainings to a school there and talking to the staff about substance use. One of the things they mentioned was how they didn't have an opioid use disorder. And that might be because they don't have a hospital or they have one medical professional for the whole entire island. And access to some of that might not have been the case, but my wheels kept spinning about they have all this other substance use disorder, but opioid addiction hasn't necessarily reached the island like we've seen here in the mainland of the United States.

    Christopher Chun-Seeley: So how did we get here? What factors contributed to where we're at within the opioid use disorder tragedy of how many deaths we've had, that threshold that we crossed?

    Dr. Marc Fishman: Well, certainly the opioid crisis of the last couple of decades has been devastating and we read about it in the newspapers across the spectrum and so much, so many different factors. A perfect storm of precedents and antecedents that led us here. Just before we get into that, though, as you mentioned, so important to keep in mind that although we have such a public policy and media attention on the opioid epidemic as the crisis of the day, it's easy to forget that cocaine continues unabated and the number of methamphetamine and cocaine associated deaths continue to climb. And alcohol hasn't gone anywhere and nicotine hasn't gone anywhere but fades into the background because it's ever present. But the opioid epidemic and crisis of the last few decades has been fueled by so many factors. One is that in the prescribing practices of the American house of medicine, we've had a preoccupation appropriately enough with pain and thinking about the undertreatment of pain.

    Dr. Marc Fishman: But we got ahead of ourselves in terms of our knowledge of the appropriateness, or as it turns out, the inappropriateness, of using opioid analgesics, which are fantastic for treatment of acute pain and still morphine or another opiate is one of my three desert island drugs. I want an antibiotic, a steroid and an opiate if that's all I can have. But for chronic pain and for enduring treatment of pain, they turn out not just to have a considerable side effect burden like people developing tolerance and dependence and then an opioid use disorder, but they turn out not to be that effective and they lose their effectiveness. But this was a memo that much of the house of medicine missed and we got there in terms of overprescription on the part of well intentioned medical professionals. And then of course, there were the factors of the manufacturers of these medicines pushing the agenda of trying to push uptake of a medication that the sales of which were quite profitable.

    Dr. Marc Fishman: There was the promotion of the idea of opioid analgesia as a quick fix by some of the regulatory agencies in terms of oversimplifying the idea that all you need to do is put more oxycodone in the water and suffering will be alleviated. And that of course turns out not to be true. And then there is the fact that supplies of heroin initially imported from Southeast Asia, but now more so from Mexico. Supplies became more plentiful and cheaper over the decades. And as part of the commercial plan for the distribution of these substances illicitly, supplies became more and more potent. The concentration of the heroin supply became enriched. Just to give you an illustration of that, if you go back to the '70s with the last wave of an opioid epidemic before this one, typical street supplies of heroin might have been 3% or if it's really good 5% pure.

    Dr. Marc Fishman: But in recent decades in this wave of the opioid crisis, purities of heroin got to be 50%, 60%, 70%, even 80% pure in some metropolitan areas. Of course that has implications for overdose risk. But what it also meant was that nasal insufflation or sniffing or snorting became an efficient means of use. So jumping from prescription opioids to injection use would present a barrier, especially for young people. Injections is off putting, most people are hesitant. But if you can just sniff it, that seems less in terms of a perception of harm. And so it meant that either by smoking more on the west coast, sniffing more on the east coast, these regional patterns of use, there was a generation or two generations of young people that could initiate very severe problematic street heroin use. And then once addicted, the leap to injection was perhaps a shorter leap.

    Dr. Marc Fishman: And then, just maybe since 2013 or 2015, this next chapter of the opioid epidemic, the advent of bootleg illicit fentanyl, imported first from China, now also from Mexico. And the advantage if you're a gangster is that it's so potent that moving supplies and smuggling it is that much easier. But because it's so potent, the overdose death risk is so high because even the most experienced user can easily miscalculate a dose. And despite thinking they've got a good handle on this and despite thinking that I know what my dealer's got and I'm assured that I know what the supply is, nobody can have such assurances and it's easy to make a mistake, take too much and in just one use episode to have a fatal overdose.

    Christopher Chun-Seeley: I think what you mentioned too about how potent the heroin had become on the street is so important, A, because of what you just mentioned about the use of fentanyl and kind of the street use of that. But I think more because I think when families and individuals think about the typical signs of a heroin user, they're thinking of track marks, right? They're thinking of those needle marks that are in the arm in between the fingers. They're looking for these signs that if that's a little too late. You need to be thinking about if they're ingesting through nasal or they're smoking it by adding it to a cigarette or just something else, that the way that they're getting introduced to it is much sooner. Are there signs for families to think about looking for any kind of substance use, but in particular when you're thinking about opioid use disorder, because I think that trajectory in that path can be so scary and dangerous and deadly.

    Dr. Marc Fishman: Well, now we are increasingly seeing a phenomena where fentanyl is finding its way into the non-opioid drug supply. So in many urban centers on the east coast and west coast, for example in Baltimore where I do some of my practicing, almost all the heroin or what had been called heroin is essentially predominantly or exclusively fentanyl. And as pursued by people who are opioid addicted and looking for opioids, that's perhaps more expected, still a huge problem and easy to miscalculate and overdose. But now we are also seeing it being introduced into the supply of cocaine, of methamphetamine pressed into fake pills, counterfeited as oxycodone or Xanax or Valium or other kinds of things. Even found on plant cannabis where people will think they're smoking marijuana and instead in an addition also be getting an unanticipated surreptitious dose of fentanyl.

    Dr. Marc Fishman: And as you can imagine, that's a dealer strategy to try to get people initiated and to reinforce the use of fentanyl and to get people addicted and to broaden market share. But what it means so dangerously is that somebody might never have any intention of using opioids, might not have previous experience of opioid use or opioid use disorder. And with just one ingestion thinking it was cocaine, thinking it was a benzodiazepine, thinking even that it was cannabis have a fatal opioid overdose with fentanyl.

    Dr. Marc Fishman: Now you ask a great question about what should people be looking for in their loved ones, in young people in particular, the typical age of initiation for substances and then progression to substance use disorder tends to be mid-second decade of life in the teen years with peak prevalence at the end of the second decade of life, beginning of the third decade of life that is in the young adult, late teen, early twenties years. And of course people are vulnerable across the lifespan, can happen at any age, but those are the ages where it has peak prevalence and peak vulnerability.

    Dr. Marc Fishman: So what do you look for? Well, one of the things that we know is that many young people have very low perceptions of harm, don't think it's a big deal. These days, cannabis for example, "Ah, it's not a drug. What's the big deal? What are you fussing at before? Everybody does it." Well maybe everybody you know, but it isn't everybody. So there's some kind of openness about use. And so it might not be a secret to parents, to loved ones, but on the other hand it might be, and whether it's out in the open or not, looking for indicators of change in function. Are people not the same person that they used to be? Are they changing their function? Are they slipping at work or at school? Are they getting emotionally dysregulated, more depressed, more anxious, more irritable? Are they erratic in their behavior? Are they not showing up in areas where they used to show up? Are they losing their enjoyment and their participation and their pursuit of activities that used to be a standard part of their repertoire?

    Dr. Marc Fishman: Anything that just makes you wonder, "Something's not right." There are many things that can lead to that, including other psychiatric illness like major depressive disorder, et cetera. But you have a high suspicion for substance use and substance use disorder and getting an evaluation, referring somebody to get help, asking them to get seen, to go see a professional. "Well, you're going to send me to rehab. I don't think it's that bad." "No, not saying that. Just go talk to someone. It could be your primary care doc, it could be a counselor at school, it could be anybody in any helping profession including a religious advisor. But go talk to someone and get a second opinion." And then we can try to pursue it.

    Dr. Marc Fishman: But one of the key messages here is that these are treatable problems. These are issues that are amenable to approaching in the medical and the helping professions. And we need to get these issues out of the shadows, out of the shame and stigma where they've traditionally been buried because nobody wants to have that person in their family and nobody wants to talk about that and be shamed among their friends and relations because somehow it's impugning as a moral wrong. Now I hope that that's changing and I am hopeful that the culture is shifting. And so more and more we should be encouraging people and I see that people are taking this to heart, that this is something that you can speak about openly and that this is something that we can say to people, "Yeah, it's bad for you but get help. Yeah, it is devastating and maybe there is some bad feeling and embarrassment you have about it, but that doesn't mean that you shouldn't go and get help because help can make this better." And we do have successful treatments and it starts with evaluation like all medical disorders.

    Christopher Chun-Seeley: And before we get into more specific conversations about treatments because they are out there and they work. And I want to go back to an earlier statement that you made about how some people can have fun recreationally with substances, other people they can't. They develop these substance use disorders. So I come from a family of addicts, I know that there's a family history of substance use and that's why it's something that I have to be very cautious about personally. And I'm wondering why do some people develop these substance use disorders and then others don't?

    Dr. Marc Fishman: Yeah. Oh, it's so interesting. I wish I really knew the full answer to that question. And if I did, if I could tell you, I'd win a big prize and a free trip to Stockholm. But we are zeroing in increasingly on the range of vulnerabilities and there's no one answer. You raise one very important factor and that's familial risk. We know that this disorder runs in families. One statistic is that the son of a father with alcohol use disorder might have as high as a 40% risk of developing the disorder. So the genetic determination is very high, higher than many other disorders we commonly think of as genetic. And so part of the heritability is something about how people are wired, why some people are vulnerable to the reinforcement that substances bring if you will, as sledgehammers that overtake the brain's natural reinforcement system. There's also a kind of familial experience of the normalization of substance use by learning and by experience and by example. Kids tend to do what you do more than they do what you say.

    Dr. Marc Fishman: And in families where the experience and the behavior of substances are front and center, that also is a mechanism of transmission for sure. And the same goes not just for the family but for the community and for the neighborhood and for the peer group, especially important. So the affiliation with peers that are involved in substances and other disruptive or deviant behaviors, antisocial behaviors, those are risks. Another big risk is having a concurrent psychiatric disorder. We know that for example, past year, major depressive episode incidents increases the risk of initiation in young people by four to eight-fold depending on which substance we're talking about. And for adults, the same risk is there. If you've had major depression, you're much more likely to progress from casual recreational use to the loss of control and development of a disorder. It's interesting, we don't know which comes first for everybody. Chicken or egg? Is it the psychiatric comorbidity or the substance use disorder?

    Dr. Marc Fishman: But for sure, they are mutually exacerbating and worsen each other. We know they go together. Another big risk is what we sometimes talk about as emotion dysregulation or affective dysregulation. And by that I mean, some people in the normal course of their developmental maturation trajectory are growing up a pace and their ability to manage their emotions, their ability to exhibit executive function, inhibitory control, the kind of judgment that enables us to make strategic planning about the future. First of all, these are functions that take time to mature and most individuals are not mature in their emotion regulation and executive function until well into their 20s. But there are some members of the population in the heterogeneous mix across individuals who are even more immature or who are even more behind in terms of their milestones for these aspects of developmental trajectory. And those people are particularly at risk.

    Dr. Marc Fishman: Some studies have even been able to identify kids who will later be at most risk for substance initiation and progression to substance use disorder in infancy and toddlerhood just by looking at their problems with emotion regulation. That kid who was the tantruming one, that kid who wasn't able to manage perturbation of environmental stressors and is the one that can't self-soothe. So that's another big risk factor.

    Dr. Marc Fishman: So anyway, there's many different risk factors. We know a lot about them and if we can intervene early, that's a good message for prevention. And if we can tell people who have heightened risk factors, "Yeah, lots of people are doing it and anybody can develop a disorder, but you particularly have a special vulnerability and that's a message why you maybe shouldn't be like everybody else and need to put breaks on it."

    Christopher Chun-Seeley: I'll repeat something that you said earlier too about stigma around some of this, especially within families and family secrets, especially around substance use disorder and how that might matriculate from across the family span and how it might get talked about. That's really important. I want to emphasize that talking about these things because if you know that it has happened in your family or occurs in your family, sharing that with your son or daughter, especially as they get older, helps them to make a more informed decision. I think that's really important. And then also I think the learned behavior. And this is a man coming from Wisconsin where there's more bars per capita than grocery stores where that is the norm that we grow up in. You get done with work, you go to the bar. The bar is always the place to socialize and to get things done, and it's very easy to see even how community culture can influence how a substance like alcohol gets treated and then gets overused just as in our community.

    Dr. Marc Fishman: And it's easy to dismiss it because it's so socially normative. That's right. No big deal. And now that's becoming the case with cannabis. Well, one of the prevention messages that I like is to teach young people about delaying initiation. And it's not always successful, it's not always digestible. One of the ways we try to make it more digestible is to say that there's a difference between adult use and child or adolescent use and that the adolescent brain is not fully formed. And I sometimes like the metaphor of executive control in the frontal cortex as a force field that helps protect you, but your force field's not fully turned on until you're 25 or 21 or 18 or whatever number it is you want to choose. So let's wait till you've exercised that muscle a little bit. It's not going anywhere. You can always try a beer later, but how about delaying it? And sometimes that can be effective rhetoric.

    Christopher Chun-Seeley: I wish I would've had that one. I've worked in the residence halls and had to do conduct meetings with students who would overuse and mine was the diminishing point of returns. Let's make an informed decision. If you're going to use then I'm not going to tell you not to, but let's make informed decisions. So that's a wonderful, I love that developmental kind of conversation and really helping them to understand what they can be and the force field. That's wonderful Dr. Fisherman. I love it.

    Christopher Chun-Seeley: So you were talking about treatments and I want to go back to that because as we talked about, maybe 25 million people are impacted directly by substance use disorder and then more people, by their families and the community members who are impacted by it. And there are treatments out there. Substance use disorders are treatable. So what are those treatments? What are out there? What can community members look for?

    Dr. Marc Fishman: There are effective treatments. That is the take home message that treatment for substance use disorder is effective, but you got to try it and you got to do it in order for it to be effective. And it's hard because you didn't develop this disorder overnight and it's not something that is amenable to surgical cure. Hollywood sometimes fools us into thinking that, well if you go away to rehab then you come out of the oven at the other end fully baked and you're fixed as if it were a surgery and I wish but no such luck. So it's a marathon, not a sprint. That's an important message for families, for potential patients, for policymakers. But with that caveat, there are great treatments and there are both behavioral and psychosocial counseling style treatments and there are medical treatments where we have an enriching and expanding tool chest of medications that can help with cravings and with relapse prevention.

    Dr. Marc Fishman: And we're increasingly exploring that in very, very important research. Just to give you an overview, standard treatment includes a full continuum of care across different levels of care, whether that be outpatient or intensive outpatient or inpatient rehab or long-term residential. But for each person, there's a match, a treatment matching, just like with any medical disorder in which some people need outpatient services, some people need to be in the hospital. So that's one of the elements. What's the right level of care? And then depending on which substance we have, as I said, medicines, we're very lucky for opioids in particular to have very effective medicines. There are three FDA approved medications for opioid use disorder, methadone, buprenorphine and extended release Naltrexone. Those medicines have now been available for decades. They are very well studied, they are very effective, they have very high effect sizes and good outcomes.

    Dr. Marc Fishman: Unfortunately, many people drop out and as I said, they are not curative, you got to stick with them. The same I would say would be true for treatment of diabetes, hypertension, and major depression. We don't have cures. People have to stick with these treatments for what are essentially chronic remitting relapsing disorders. But thank goodness, we have this technology. We also have some FDA approved medications for alcohol use disorder. And although not FDA approved, as I said, there's increasingly optimistic results of research that shows us that other medications are available and we're learning more about their effectiveness, even if not officially approved by the FDA use off label, for cocaine use disorder, methamphetamine use disorder, cannabis use disorder. Oh, I forgot to mention, we have great FDA approved medicines for nicotine use disorder. So there's lots of technology available.

    Dr. Marc Fishman: You mentioned earlier a treatment called contingency management. It hasn't been disseminated in broad clinical use quite the way that we'd like. It hasn't had the uptake yet. But essentially the idea is we sometimes call it by the way, motivational incentives. And the idea is rewarding people for non-use, rewarding people for abstinence and sobriety. That reward might be direct cash payments for example. Now that may not be sustainable over a lifetime, but at least to get people jump started on a competing reinforcer. Since substances are so rewarding and so attractive, this is to provide an alternative. And the research is very, very strong in support of that kind of treatment. We have mutual help and support. We sometimes think of that as self-help or mutual help rather than official treatment. So Alcoholics Anonymous, Narcotics Anonymous, Smart Recovery, Rational Recovery and a variety of other approaches. So valuable in terms of creating a community of support among people with substance use disorder to be able to create a new community of sobriety to help them with new pro-social peer group.

    Dr. Marc Fishman: So anyway, that that's just a brief summary that there are many more. You mentioned cognitive behavioral treatment, motivational enhancement therapy, many psychosocial treatments. But the bottom line is lots of treatments, treatment work, but we got to get people to treatment. We have to get people in a pathway of a medical treatment utilization system that starts with screening and identification and then gets people to these resources, which is hard to do. But increasingly, I think as resources get allocated and as the message is out, I think we're seeing this become less stigmatized and more a standard.

    Dr. Marc Fishman: One of the things that we've seen be very problematic is that substance use disorder treatment has been so divorced from the rest of the medical treatment utilization system. And so lots of people wonder what is this mysterious thing that people do in addiction treatment? And they sit around in circles and talk about their feelings and have a secret handshake. And sure, there might be special methods that might seem mysterious to people, but having substance use disorder treatments increasingly located within the house of medicine in standard medical practice settings, beginning with primary care, beginning with hospital based care, beginning with emergency departments, say at the point of discovery of an overdose or of a medical consequence of substance use. Making those linkages, as we are, I hope doing increasingly is such an important advance to be able to increase uptake of treatment broadly.

    Christopher Chun-Seeley: I want to emphasize one more thing before we jump onto the barrier conversation because I think relapse is a part of the process and I think unfortunately it just reminds me of a conversation of someone who is going through their own addictions journey that I just had the conversation with. And I just wanted to remind them again that it was like, "Hey, just to let you know, there is no failure in this process. There is relapse that might happen. That's not a failure. That's just another step in this process because that's going to continue to motivate you to do better the next time and continue to push you forward." And I think family members sometimes forget it that it's a really hard journey.

    Christopher Chun-Seeley: Like you said, to get people to engage and to get people connected to the care. And what we kind of talk about with staff members in schools is that you're going to walk a student to the door 15,000 times sometimes, but it's up to them to cross that threshold and to engage in that support services. But like your job and your role is to get them to that door, it's on that person to really step across that threshold and engage in those support services. But as you alluded to, there are these barriers to treatment and they differ, obviously depending on the substances. But what are some of those barriers to treatment, and what are those potential ways that we can overcome those barriers?

    Dr. Marc Fishman: One big barrier is one that you mentioned that is the broad attitude that we expect people to be miraculously fixed from their first presentation to care and that we are disappointed and, understandably so, if they struggle, if it isn't a unilinear trajectory to recovery and cure, that people relapse and there is a stuttering course. But on the other hand, that is the course and people need increasingly to be realistic about anticipating that intermittent progress, three steps forward and two steps back is the rule, is the norm rather than the exception. And that's okay. We might wish for miraculous cure, but we don't really expect anything different in other chronic remitting relapsing illnesses. Take depression for example. Most people have multiple episodes, most people have times where they don't seek care when they ought to. Most people have times where they stop their medicines or have problematic adherence to their medicines.

    Dr. Marc Fishman: And this is also a feature of substance use disorders and to think otherwise is to set ourselves up for disappointment and failure. So that's one barrier and it's important to be imbued and to imbue the patients and the family with a sense of, what I like to call, therapeutic optimism. We're going to move forward, we're never going to give up. If it takes multiple episodes of relapse and trying again, well of course, that's not what we wish for, but that's not going to deter us from welcoming people back into treatment and promoting another round. One of the things I was talking to a patient the other day about is getting them to see that although that they've had multiple episodes of relapse, the time in between relapses has grown, elongated with greater duration. Something's going right because they're figuring out the recipe for how to keep it going a little bit longer each time, hopefully trying something different, not doing the same thing again and again and expecting different results, but adding new elements to the treatment plan, trying new things, being willing to come back again when you're struggling and not be ashamed.

    Dr. Marc Fishman: And one of the things that both family and treatment providers need to do is to have an optimistic view and a welcoming view. "Thank goodness you're back. Let's try again." Another barrier we've already talked about is shame and stigma. So we need to think about the appropriate ways of encouraging people to take the plunge no matter how shameful they find it or how embarrassing. There is, unfortunately, a bit of a cultural divide between some proponents of mutual help, for example, in the rooms of Alcoholics Anonymous and Narcotics Anonymous, and the medical approaches of using what we call Medication-Assisted Treatment, MAT or Medications for Opioid Use Disorder, MOUD. Just to throw around a little jargon. But unfortunately there's some opposition there in which members of the mutual help recovery movement have been opposed to the use of medications and criticizing it perhaps as not being real recovery or as being only a crutch.

    Dr. Marc Fishman: And that unfortunately dissuades some people from seeking out those medications, that medical technology, which can be so life saving. I look forward to a day where there isn't that tension in which both of those approaches are integrated more universally because I think they're compatible and where I see them integrated, you get the synergy of both at once. It shouldn't be choosing between one approach and another. They go well together. I certainly see the use of these medications as being as real as any other recovery. Listen, there's a big tent, there's many pads. There's not one that's right or one that's wrong. It's about what gets you first to the starting line and then gradually across the finish line, many different flavors. Just to use the metaphor, listen, if you break your leg, you want a crutch. What's wrong with that? Use the tools, they're available.

    Dr. Marc Fishman: Thank goodness, we live in an era where these tools are available. So I think the medical delivery system has been a barrier. There aren't enough slots, there aren't enough pathways, there isn't the ability to find the resources and the path in when a person or a family member has a problem, but where do I take them? Does my primary care doc know how to evaluate this? Is there a clinic nearby? How do I get my insurance to sustain me in these treatments? So those things still are big puzzles for us, but increasingly, I'm optimistic that we're connecting the dots and doing a better job. And recently with the opioid crisis, there has been an infusion of resources that I see as very helpful.

    Christopher Chun-Seeley: And I guess, not to put you on the spot here, but is the Addiction Medicine Practice-Based Research and Quality Improvement Network, AMNet, that's the acronym there, are they working to educate more primary care physicians about substance use disorder? As you said, if your primary care physician isn't educated about the signs and the symptoms and then the pathways of connection, you might not have that trust or that distrust is kind of built within the system because maybe you've had a poor experience in the past. Is there work being done around that from AMNet or the APA or any of these larger bodies to address that issue in particular?

    Dr. Marc Fishman: Sure. AMNet or the APA broadly, the American Society of Addiction Medicine, lots of professional organizations, lots of resources focusing on overcoming stigma, increasing education, targeting primary care, targeting the criminal justice system, targeting behavioral healthcare professionals who might know about psychiatric illness but not so much about substance use disorder where there's so much overlap. This is a golden era of education, I'm pleased to say. We need to take it to the next step so that we have uptake so that education turns into action, turns into numbers of patients treated. But the point about the general medical care system is so critical because whereas there are specialists, as there are in many fields, specialists alone can't treat our way out of this. We're going to need broad application of identification and treatment of cases in the general healthcare system for us to be able to be successful. And as in any epidemic, we're not going to be able to just treat our way out of it.

    Dr. Marc Fishman: We've also got to think about prevention because we've got to reduce the pipeline and we've done some important things by reducing the overprescription of opioid analgesics. We've started to decrease the initiation among young people of opioids. The death rates have not gone down because of the fentanyl problem and its very high potency. But the new initiates have started to decrease. But we have a problem with the societal attitude that is increasingly, in my view, permissive and minimizes the harms associated with young people's use of substances. Whether that be alcohol, whether that be nicotine and tobacco products, whether that be cannabis, it gets trivialized as, "Oh, teenage high jinks. Everybody's up to it." But that doesn't take away, even if there are teenage high jinks, even if we know that young people will experiment with a variety of risk behaviors, unless we broadly take a clear stand that these are dangerous experimentations and that in a substantial subgroup will lead to progression, loss of control in the development of substance use disorder with devastating consequences, we miss an opportunity to do very important prevention.

    Dr. Marc Fishman: And that has to happen in primary care, pediatrics and family medicine. It has to happen in schools, it has to happen in family homes around the dinner table. I mean this idea that, "Oh, we did it when we were young. I'll teach them how to drink in my house where they can drink responsibly." And no, no, no, no, no. That's been disproven again and again. Age of exposure is clearly associated with increased risk. The best amount of intoxicant, cannabis, nicotine, alcohol, the best amount of intoxicant for an adolescent to be using is zero. Now I'm not naive enough to think that just because I say that or just because mom and dad say that that's what's going to happen. But it does matter that we're clear in our messaging in order to do this prevention work.

    Christopher Chun-Seeley: Well, and Dr. Fishman, hopefully I will synthesize some of these main points that you've hit on throughout our conversation today. And then I would love to just give you the opportunity to close us out with any of your final thoughts. And correct me if I'm wrong in my synthesization, I'm going to do it in our foundation notice talk act framework because that's just how my brain kind of works nowadays. But I think first notice, A, as a society that substance use disorders are real and we need to take them seriously. I think from an education standpoint, notice that we need to talk about it in a way that is both educational but also optimistic because there are treatments out there. And then as a family, I think notice the changes in behavior. I think from your point and what you said earlier is are they finding that motivation? Are they actually engaging the things that they like? Are you seeing changes in emotion, drastic changes in those emotional behaviors?

    Christopher Chun-Seeley: But really just notice any of those changes in behavior and start a conversation. And I really want to pull that talk from you as being optimistic. I'm so glad that we're having this conversation today. So glad you showed up today. All of that positive reinforcement again to counteract what we know to be true about substance use disorder. And I think the talk across the larger society is again, that this is a real problem. That this is a disorder of the brain and that there are treatments for it. Again, reinforcing some of those things. And that act is getting them to the door. Understanding that treatment and there are those barriers and how we do address them. But there are those treatments available and we need to continue to be supportive in moving our community members, our family members, our loved ones towards the doors of treatment and support because that's what's going to get them there.

    Christopher Chun-Seeley: Understanding that it might be a few times that we need to guide them there because relapse is a part of the process. There is no failure in this marathon. As you said, that it's not a sprint, it's a marathon. And that the acts from us as loved ones, as community members that care, we might have to help them along a little bit longer in the process before they really engage and they really get whatever their process is to be sober and what that means to them. So hopefully I synthesize a lot of your main points there, but it's open to some things.

    Dr. Marc Fishman: Yeah, no, you're absolutely right. Substance use disorders are real. They afflict so many people with such devastating consequences to the patients themselves and to their families and broader circles. And with that, seeing that devastation, it's unfortunately so easy for people to be pessimistic. "Nothing you can do. Once an addict, always an addict. This is a moral malevolence. There's nothing we can do anymore." And I disagree very strongly with that. And we have to encourage people to move away from that nihilistic, pessimistic view to one of what I certainly am an advocate of, which is therapeutic optimism. Treatment works. We have multiple different treatments. Not every treatment is for everybody, but we have enough tools in our tool chest that there is some approach that is likely to be effective for everybody. There are multiple paths to recovery and allowing for fits and starts with incremental progress and three steps forward and two steps back.

    Dr. Marc Fishman: And that's okay, but we never give up. Being hopeful and encouraging and promoting motivation, which by the way is not a given. It needs to be tended and kindled like a flame. It waxes and wanes. But take advantage of the motivational moment and optimistically bring people into treatment and encourage them over time. And if they drop out and if they relapse, welcome them back, encourage them back. As you say, it's not a failure, it's an opportunity to get back up and try again. That's what so many other remitting relapsing illnesses. Treatment works, more treatment. One other thing I would say, one other thing I would advocate for family members is not to be put off by what often seems like a closed family unfriendly treatment delivery system. And of course, just to give an example, confidentiality and private treatment is a cornerstone of what we do.

    Dr. Marc Fishman: But sometimes families experience that as unwelcoming as a door shut in their faces. "Oh, we can't talk about this. I can't disclose." "What are you talking about? I'm paying for the treatment. I dropped him off this morning. He's on my insurance. We can either affirm or deny that a person by this name is receiving treatment. You'll hear from our lawyers in the morning." No. We want people to think broadly about family engagement, about family involvement as a potential cornerstone for enriching the effectiveness of treatment. By the way, we do that in every other medical condition, right? If granny is having trouble getting to her appointments, if mom or your son can't understand the complicated technical instructions that the doctor is giving, you go to the appointment. You try to explain it, you ask questions. If your loved one isn't taking their medicines, you remind them. You help them with the pill box.

    Dr. Marc Fishman: This is just what we do, but not so in substance use disorders where the shame and the stigma and the sense of this being in the shadows prevents that broad inclusion. So my message to families here is you can insist that you are involved, and sometimes the loved one who is the substance use disorder patient might bristle a little bit. "It's none of your business. Don't tell me what to do. Don't treat me like a baby." Fine. You need to be respectful. You need to do it in a way that is inclusive and promoting of independence. But a person who is sick with substance use disorder is not in their right mind. They are not fully capable of autonomous good judgment in pursuit of health. So they might need some help. That's an appropriate role for family to step in and be part of the conversation and ask for ways of being able to support treatment like we do across the medical treatment delivery spectrum. So just a plug there.

    Christopher Chun-Seeley: Definitely alright to plg. Dr. Fishman, again, I just want to thank you for your time and your expertise for this conversation. I really do think that we have outlined not only what substance use disorder is, but I think the current impact of what individuals in our community members who are experiencing substance use disorder and living with substance use disorder, but also the family members and the community at large and the impact that it's having on them and what the solutions are. Because again, I want to emphasize that there are solutions out there, just like any mental health disorder.

    Christopher Chun-Seeley: And if you listen to any of our episodes before this, there's not a one-size-fits-all. That's that's the really unfortunate part of mental illness. But also I think a beautiful part of it because you can really find your individual pathway and what works for you. And though it works for you, it might not work for others. But that doesn't mean that you shouldn't share your story of success because success is possible. It is out there and we want to continue to encourage our community members to seek that and our family members who are supporting people to know that success will come, but you will have those moments where you just continue to support them through whatever that next relapse might be.

    Dr. Marc Fishman: And the outcomes of substance use disorder treatment, contrary to popular expectation and pessimism are actually quite favorably comparable to other chronic illnesses. We do well with substance use disorder outcomes compared to depression, compared to diabetes, compared to hypertension. Our success is quite good. So I think that message of optimism is super important and for people to not get hung up with this sense of futility and pessimism. Treatment works, people get better, recovery happens.

    Christopher Chun-Seeley: Well, and I just want to give you the mic, so to say, for any final words, Dr. Fishman, on any takeaways that we maybe haven't hit before or anything else that you want to reemphasize for our listeners?

    Dr. Marc Fishman: Well, thanks Chris for including me in this conversation. It's been a treat. And again, therapeutic optimism is the principle that should guide our approach here. There is no wrong point of entry and we should be promoting, screening and identification and treatment across levels of care, across the different entry points of the medical treatment utilization system. And I'm so gratified that this conversation is increasingly disseminated, that it's a broad conversation, that it's getting to families, that it's getting to psychiatrists, that it's getting to counselors and social workers and therapists, that it's getting to the criminal justice system, that it's getting to policymakers because we need more resources. We need advocacy for treatment because treatment works, and again, people get better, recovery happens. So thanks for doing this.

    Christopher Chun-Seeley: Dr. Marc Fishman is an addiction psychiatrist, is the medical director of Maryland Treatment Centers and an associate professor at the John Hopkins Department of Psychiatry. He is also a part of the Addiction Medicine Practice-Based Research and Quality Improvement Network, AMNet, and we're happy to have him here today.

    Christopher Chun-Seeley: Thank you again, Dr. Marc Fishman for joining us here today. And thank you to all of our listeners for joining us for this episode of Mentally Healthy Nation on the crucial topic of substance use disorder and its impacts not only on our community members suffering from this illness, but also the family members and friends who are also suffering from the impacts of this illness. If you'd like to access any of the additional information or resources that were talked about today, I want to encourage you to visit www.psychiatry.org and in the search bar, type in addiction, substance use disorders, or AMNet, A-M-N-E-T. I also want to encourage you to check out the APA Foundation's website at apafdn.org to check out any of our free resources for where you live, learn, work, worship, or play.

    Christopher Chun-Seeley: If you enjoyed what you heard today on this episode of Mentally Healthy Nation, I encourage you to share it with your friends, family, and colleagues, as well as take a listen to some of our other episodes or go onto the psychiatry.org website and listen to some of their thrilling podcast episodes as well. I'm Christopher Chun-Seeley. Thank you again for joining us here today. And remember, we're all on this journey of wellness together.

    Christopher Chun-Seeley: The views and opinions expressed in this podcast are those of the individual speakers in their personal capacity only, and do not necessarily represent the views of the American Psychiatric Association Foundation, or the views official policy or position of the institutions and organizations with which the speakers are affiliated. The content of this podcast is provided for general information purposes only and does not offer medical or any other type of professional advice. If you are having a medical emergency, please contact your local emergency response number.