Why do we treat addiction so differently than we do all other chronic diseases? That's a question that Dr. Joe Sepulveda has been asking for years. A board-certified psychiatrist specializing in addiction treatment at the Family Health Centers of San Diego, he founded the organization’s medications for addiction treatment (MAT) program. He urges primary care providers to embrace addiction treatment as they do diabetes, hypertension, and other common chronic diseases: without bias or judgement.
Why do we treat addiction so differently than we do all other chronic diseases? That's a question that Dr. Joe Sepulveda has been asking for years. A board-certified psychiatrist specializing in addiction treatment at the Family Health Centers of San Diego, he founded the organization’s medications for addiction treatment (MAT) program. He urges primary care providers to embrace addiction treatment as they do diabetes, hypertension, and other common chronic diseases: without bias or judgement.
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Why do we treat addiction so differently than we do all other chronic diseases?
That is a question that Dr. Joe Sepulveda has thought about for years. A psychiatrist specializing in addiction treatment at the Family Health Centers of San Diego, he founded the organization’s Medications for Addiction Treatment program. At a recent webinar for the Center for Care Innovations, Sepulveda urged primary care providers to embrace addiction treatment as they do diabetes, hypertension, and other common chronic diseases: without bias or judgement. Here’s why.
hello and welcome everyone. we'll be talking about addiction as a chronic disease. So the agenda for today, we'll talk about stigma versus health genetics, and the role it plays in addiction, the neurobiology of addiction and how this, um, addiction is, uh, in general is a treatable condition and access to care and how all of you play an important role for, for this
So let's start up withan anchor question here, and I'm going to read this to you to start stimulating some thoughts about the discussion we're going to undertake, but the question is what are some things you offer to patients with chronic diseases, such as diabetes, asthma, or CLPD to help them manage their conditions and why isn't this offered to individuals who have addiction. why is it that we treat addiction so differently than we do all these other chronic diseases?
So the first thing is that, um, addiction has historically been fought with stigmait's, it's long been known that stigma is a big component as to why treatment for addiction has suffered. it's because of this stigma it's traditionally been approached as a social problem, not a health problem, but the reality is that it's, it's an actual chronic disease. So let's start with genetics, the basic building blocks , of everything we know from twin and adoption studies that genetics plays a role in addiction. So, and based on those studies, we know that about a half to three quarters of the risk of becoming addicted to a substance comes from just genetics alone.
We also know thatidentical twins have a higher tendency to display a genetic predisposition to addiction than dyzygotic twins. What does that mean? It means that if you have a genetic predisposition for an, uh, developing an addiction, those twins that have identical genetic codes will have a much higher rate of developing an whereas those that do not, um, have the same genetic code will have different, uh, rates of developing an addiction. And this is a very strong factor. It appears that this genetic predisposition has stronger drivers and environmental factors for initiating substance use, particularly at a young age.
Sepulveda explains that both substance use disorders and traditional medical diseases such as hypertension, diabetes, and adult-onset asthma have strong genetic components. For example, the genetic predisposition for hypertension is 0.25 to 0.5, while the genetic predisposition of developing alcoholism is 0.52.
And you can see they’re pretty comparable. It's no different if you really compare the genetic predisposition of developing hypertension, diabetes, asthma, compared to someone, uh, developing an addiction.
So when we, I think of addiction, we got to think of this as a chronic brain disease. And the question I always get is, well, how do you know it's a chronic brain disease? Well, there's an, there's two things. One is the, whenever you have a brain disease, you have a behavioral expression of that illness. And that's how, you know, you have a disease. That's how you diagnose a disease. So for example, if you have Alzheimer's, the classic presentation for Alzheimer's is going to be memory loss. Now there's a range, right? There's early on, there's early memory loss and there's advanced memory loss for advanced memory loss.
In opioid addiction, Sepulveda says, the behavioral manifestation of that brain disease is cravings, which leads to uncontrollable compulsive use.
But before you get these behavioral expressions, what really happens is you get fundamental long-term changes in the biological structures, such as the brain.
we know the neurobiology behind addiction. This has been well mapped out for years, and we know how it works. So there's three areas that I'd like to bring your attention to in the brain. The first one is the reptilian brain. Okay. That's the underlying structures that are prime for survival instinct, um, reflex and dopamine plays a big role in this, an example that I'll give you as a crocodile crocodiles, don't have a developed brain like humans. Obviously they have this reptilian brain, hence why we use “reptilian brain”. And what they do is they react to things. So if something comes across a crocodile, they will snap at it. The reason they do that is because they know if something moves and they snap at it, the chances that they will have food and sustenance to survive is significantly higher.
Right? And that dopamine is what drives that reward. I snapped out something, I ate it and filled my belly. That's a pleasurable experience. I have dopamine surge. So they're going to do it, their prime to do it over and over again.
Sepulveda then turns to the amygdala, the core of a nervous system involved in memory consolidation.
I'm going to focus on the amygdala here because that's your memory centers and that's, what's going to have you remember what that experience was like. Was it euphoric? Was it non euphoric? And if it was euphoric, then it's going to drive you to seek more and more of that. And then you have your higher level of functioning executive areas. That's what us, that's what distinguishes us humans from a thing like a crocodile, our deductive reasoning, our executive functioning, our ability to say no or reason.
However, there’s a catch: These functioning executive areas are overwritten and shut down when the reptilian brain is driven.
And we've seen this in imaging studies. So in essence, what I'm saying here is that a person that has an addiction really doesn't have control over their decision-making process or use patterns. It's a disease, it's an illness
So the other thing that we need to understand is that addiction can happen to anybody. It's not just the genetics that I talked about or the neurobiology, but everyone is susceptible to a certain degree of developing an addiction. And the reason I bring this up is because that's how we got into the, the opioid epidemic in the first place was the over prescribing of prescription opioids and the fifth vital sign and needing to treat the fifth vital sign. We thought it was okay to give opioids for an extended period of time. Well, what we found out is that if you actually give people chronic opioids, you can have as high as a 50% prevalence rate for developing an opioid use disorder over time.
We also know that it's not just time, but it's also dose or strength of the opioid. That's gonna, um, that's gonna make it more likely for you to develop an addiction.
Sepulveda discussed another study looked at opioid therapy that last more than 90 days and involved doses higher than 120 morphine equivalents, which he called “a pretty hefty dose.” Researchers found that people who met that criteria were 100 times more likely to develop an opioid use disorder compared to people who did not. And still another study found that people prescribed opioids for acute more than five days were more likely to be on opioids three years later.
And that's why the recommendation is now that if you have acute pain, you should not take these opioids for more than a week.
Now, one of the things that I used to hear, and it's still here occasionally, but people are a lot more savvy to this now --but w I used to hear, wait a minute, addiction. It was a choice they chose to try for the first time. So it's their fault. Why should I care? Well, involuntary, uh, initial voluntary misuse does not make this condition any less a result of a disease. And we know this, right? If you chose to have a poor diet, or if you just, weren't the type of person that liked to exercise, and, you know, you like to watch TV and stay still, or you have a job that requires a lot of hours where you're sitting, you're going to be more likely to develop a health condition, whether that'd be a heart issue or Alzheimer's, um, diabetes, the list goes on and on nevertheless, the doctor or the physician, or whoever's treating that patient is still going to treat the condition because they know that is an illness.
It's a disease, even though there were some personal life choices that may have major risks higher for developing that yet we don't really see addiction in the same light.And I I'd like to echo this again, when we're dealing with addiction, regardless of whether you were prescribed chronic opioids by a well-intended physician, you chose to try something at a party and you became addicted to it. Uh, or any other avenue that, you know, a person fell into and developed an addiction -- addiction by definition is involuntary compulsive use, right? Cravings can not be controlled. This person does not have control over this. They need assistance. And this is an imaging study that I really want to highlight. We have a patient who has an addiction, is being shown in nature video They're perfectly fine. But just by simply showing them cues of someone, either using or showing the substance that they're addicted to, you will get a lot of lighting up of the amygdala. In this case, it was cocaine that lighting up of the amygdala and then is going to drive that circuitry that I described earlier. So again, they don't have control over this.
What's the best way to describe a craving. And I've, I've tried several ways to describe this in the past one was, if you break an arm and you put a cast on, you have a iche, you don't think of anything until you can scratch that itch, right? That's, what's driving you. But I think the best way to describe a craving is to actually use a patient example. And this was in USA today. And what is a craving and compulsive use feel like, imagine yourself with this person, who's shaking their head and trying to hold back tears. And they say, it's like, God tells you that if you take another breath, your children will die. And then she goes on to say, you do everything. You can not to take a breath, but eventually you do. That's what it's like. Your brain just screams at you. Now. I think all of us can relate to this, right? Try not to take a breath. It's impossible. Your brain overrides your as much volition as you have, as as much intent, you have not to take a breath. Your brain is going to override that, and you're going to take a breath. This is what it feels like to have an addiction.
Sepulveda is equally troubled by the judgmental attitude many patients have toward patients who relapse. To him, it is part of the harmful stigma surrounding addiction and drug use both in and outside of the medical field.
How about if we look at relapse, one of the things I hear too with relapses, well, you know, they relapse, they're not really committed to this, and it leads to people being kicked out of programs. Well, again, if you approach this with the lens of a chronic disease and compare it to other traditional medical conditions, you will find that it's no different than anything else that you've treated and in medicine. So let's look at drug addiction, type two diabetes, hypertension, and asthma. And you can see that if you look at type two diabetes, all the way through to asthma, you have a relapse rate of anywhere from 30 to 70%. What does that mean? It means that the patient either didn't abide by the recommendations that was given to them by the physician, they didn't take their medication as prescribed. They forgot to take their medication. They didn't need to adhere to their diet. They had a flare up that led them to a hospitalization where they needed to get stabilized and then sent back over to the primary care doctor, essentially, all the things that happen in addiction. When you treat someone that has an addiction and the relapse rate is comparable. If you look at drug addiction, it's anywhere from 40 to 60%. So again, should be treated the same as a chronic medical condition.
The other thing that I want people to realize is that it doesn't matter what addiction you have. It takes time for your brain to heal. If you take someone that uses methamphetamines on a chronic basis, you will destroy a lot of those dopaminergic areas. And even after one month of abstinence you'll see that those areas don't come back yet. And 14 months out , you'll see that those areas are coming back, but they're not coming back to the same degree that they were before.
So there is recovery that happens with someone that has sobriety, but it takes time. So you need to work with the patient over a long period of time, just like you would with a diabetic excellent forgiveness. And understanding is a big part of what we need to do when we deal with treating addiction. Because we see this in every other illness that we treat. This is an example that I'd like to highlight. Um, for example, diabetes, hypertension, and congestive heart failure. As I alluded to earlier, there's personal choices that a person makes that can either lead to a person developing these conditions or exacerbating worse than the condition that they already have. Yet. Somehow we work with the patient, we meet them where they're at. what you're essentially saying is I'll work with you. I understand it's difficult. I'll meet you where you're at, but you know, I'm still here for you. And we don't have that same kind of mentality in addiction. Someone does something that, you know, they, you told them not to do. And next thing you know, the, the trigger is I need to kick them out. I need to get them to a higher level of care when all you really need to do is what the slide is depicting.
And not only is there stigma around substance use disorders, this stigma and prejudice extends to medications used to treat addiction.
So let's talk about medications for opioid use disorder and stigma, and even stigma associated with these medications. So one of the first things that our comp you commonly will hear about is that medications for opioid use disorder is substituting one drug for another. And someone who says that doesn't really understand what this is doing or what medications for opioid use disorder is doing. And it's ill-informed. So let me walk you through this slide. You'll see that there's three different colors here. The top going from top to bottom, you'll see a turquoise, which is euphoria. Then you move to the middle, which is an orange, which is your normal physiological state. And then you'll move down to the bottom, which is a yellow, which is a state of withdrawal. When a person first starts using opioids, which is the acute use. And now we're looking at the X axis.
You'll notice that there's a squiggling line going between normal to euphoria. And when you were there, basically tells you, is that someone uses an opioid to get a euphoric effect. When that wears off, you go back to your normal physiological state, but there will become, they'll come a time when your body will adapt to that, and you get the pendant. And all of a sudden what happens is you shift from going into euphoria and normal to going from normal to withdrawal. And now the withdrawal is, was driving you to use the opioid or the substance. And many of us who treat addiction will hear this story time and time again, a patient will come in and say, doc, you know what? I really want to stop this. It's ruining my life. But what I'm doing now is I'm not taking it to get high. I'm taking it because I just want to feel normal.
And that's what they're referring to in this slide. when you Institute these medications, whether it be methadone or Suboxone or buprenorphine, is what you'll find is you'll restore them to a normal physiological state that's stable. And they can go back to feeling who they were and get their life back. And that's essentially what you're doing with medications for opioid use disorder. Again, no different than what you would do for any other condition. This is what insulin does, right? This is how you control a diabetic. This is what heart medications do. Everything is analogous to what you typically do on your daily practice.
The other question that you often get is, well, I've been on this medication for X amount of time. How long do I really need to beyond it? I want to stop, or, you know, the program is telling me that I know need to be on this for longer than a month. Well, we know from studies that the minute you stop these medications is when you are not going to do well at all. Okay? And these studies go out to 12 months. We don't have longer studies. Unfortunately they go out years and no one really knows how long you really need to be on this stuff. And before you can really think about getting off of it safely, but the conventional wisdom right now, based on the evidence that we have is that you really should remain on this for as long as you possibly can, probably the rest of your life.
And again, looking at it through the lens of a chronic illness, just like a diabetic, as long as you treat and control your blood sugars, you're going to be fine. The minute you don't treat them, you're going to start falling apart. And this is the same scenario here, right? So if you look at patients that were started on medications for opioid use disorder, and they were stopped at one to three months, three to five months, five to eight months or eight to 12 months, there's a significant drop. And within one year about anywhere from 80 to 90% of patients will relapse about two years out. You're almost guaranteed that you're going to approach close to a hundred percent. Now, you you're always going to hear that one patient says, well, I knew this one person that, you know, stopped everything and they've been sober for 20 years.
And, you know, there are stories like that. Granted, you you'll hear some, but for every one story you hear like that there's hundreds of others that did not make it. Um, so keep that in mind when you talk to the patients and they want to come off of this and use this data to, to encourage them to continue to remain on the medication, that's allowing them to, uh, restore their normal functioning.
Sepulveda talks about buprenorphine, a relatively new medication that satiates the opioid receptors that cause cravings and can be dissolved under the tongue. buprenorphine is shown to significantly reduce drug use, and. Health Affairs has called the medication “a potentially transformative tool in health care practitioners’ fight to reduce deaths from opioid overdose.”
Again, you know, this is a very treatable condition. The medications work wonders. I have yet to find a medication, just one medication that can do a such a wide variety of things from decreasing mortality to withdrawal symptoms, to reducing deaths, violent crimes, recidivism, uh, improving treatment outcomes, not just for addiction, but for all other issues that they're dealing with, whether that's hepatitis C care, their general medical conditions or mental health status as well, engaging in a treatment, restoring relationships with their families, becoming functional members in society.
I mean, this is really a medication that makes a huge amount of difference, not just with the patient, but with the patient's families and really restores them back to normal functioning. these medications really do a great job at decreasing mortality.
A really good study from Baltimore shows the effectiveness of buprenorphine. if you look at 2002 onward, when Suboxone or buprenorphine really became available in the city, you can see that overdoses decreased significantly.
So this is a great medication to use to, to, to help, naltrexone, I'll just say a brief word about this. Uh, it's another medication that you can use in your arsenal. It's um, I would, I would use this at the lower end of the totem pole. So I would think of methadone and Suboxone buprenorphine as your first two, uh, choices to go to followed by naltrexone. But nevertheless, naltrexone has a benefit. one of the take home messages from a study that looked at naltrexone was that when naltrexone alone was added this, um, standard federal probation, it led to 70% less opioid use and 50% less incarceration. So it has its merits.
Lastly, I want to talk about access to treatment. Access is very difficult for this patient population, and there's a number of reasons why it's difficult. Stigma is one, but just having this, uh, lifesaving treatment available to patients is another and primary care physicians feeling that they're not capable or knowledgeable enough to treat this condition, really limits access when you, they are more than capable and with just a little bit of training, but one in 10 patients who suffer from addiction receive any form of treatment. That means 90% of people do not get any treatment and very few get evidence-based treatment that dues get treatment. Um, this is this really, this really is a problem because if you look at it, um, excuse me, have you look at things like diabetes and hypertension, 70 to 80% of those patients receive treatment for those conditions. You know, we really need to do the same for addiction. Next slide.
And you are making a big difference here and, you know, thank you for joining CCI and for really signing up to treat this population because as you can see, it makes a huge difference and you're needed. If you look at the PR uh, project practitioner database, you'll see that 55,000 people have an X license, and then you can see the pie chart on the right-hand side, but the vast majority of those have a 30 patient cap. Well, now the 30 patient cap has been removed, right? But nevertheless, most of the providers had their 30 patient cabs, meaning they never went ahead and got the waiver for a hundred or 275 patients. But 48% of the total cohort of people who have an X license only prescribe on average to five patients. That's not going to make a dent in the opioid epidemic if we really want to turn things around. So we need more people to actively prescribe
personally, I think the biggest thing that people need to realize, and I have said this earlier is, um, we need to approach this illness with heart and compassion and the same amount of heart and compassion that we've done for other medical illnesses, uh, meeting the patient where they're at, if the patient comes in and sees you and you've identified a problem, but the patient is not really ready to Institute the amount of change that the provider wants. It's realizing that you need to build up the trust, a relationship, and that trust and relationship eventually will turn and morph into the patient feeling that they can not only come to you for what they need, but also that you have their best interest at heart and will win them over in order to effectively make change. These patients have dealt with stigma for the majority of their life.
They've been shunned away from institutions. They've been shunned away from emergency departments within, uh, they've needed help. So they, they, they have this wall, um, that for their own self protection, right. And providers traditionally have not really been that great at dealing with this patient population. And the first thing that you need to do with this population is you need to build trust. That's the fundamental thing you need to make them feel like they're, they're at a place that they're wanted they're cared for and that they can come to you for anything. And I think if you approach that in that light, whether you with motivational interviewing that empathy is really gonna win over the patient. And that's when you really start noticing change.