[00:00:00] This is Mayo Clinic Talks, a curated weekly podcast for physicians and other healthcare providers. I’m your host, Darryl Chutka, a general internist at Mayo Clinic in Rochester, Minnesota Substance use disorders are chronic and often relapsing conditions associated with compulsive substance use. They result from a complex interaction of chemistry within the brain, as well as genetics and environmental issues.
Common substances include alcohol, stimulants, sedatives, and opioids, opioids commonly prescribed by healthcare clinicians. Substance abuse disorders often occur with other chronic conditions such as chronic pain, depression, anxiety. An early identification of patients and care coordinated with behavioral health specialists is the best approach to improve patient outcomes.[00:01:00]
The topic for today’s podcast is Addiction Care and Empowering Nonspecialists, and my guest is Dr. Benjamin Lai, a family medicine physician from the Department of Family Medicine at the Mayo Clinic. You’re listening to Mayo Clinic Talks. Ben, welcome and thank you for joining me today. This is gonna be an interesting topic.
Daryl, thanks so much for having me. What a treat to be here. Well, I’m gonna start by asking you to define some terms that are related but not equal in terms of what they mean. I’d like you to describe substance abuse, dependence, and addiction. Yeah. Great. Great question. I’m gonna start by talking about what dependence is.
When we think about dependence, Daryl, we, we typically think of a physical dependence. So we think of the phenomenon of tolerance, so somebody requiring more and more of the same substance to achieve a certain effect. And then at the same time with dependence comes withdrawal. [00:02:00] So if we were to abruptly stop somebody’s opioids or, or even caffeine, we’d go into withdrawal, and that can be a very unpleasant, anywhere from mildly unpr- unpleasant to really, frankly, terrifying sensation.
And that’s really what physical dependence and what we think typically of dependence is. When we think about substance abuse… In fact, the, the term abuse is not encouraged anymore. Abuse is considered stigmatizing by m- many of the main bodies, including the American Society of Addiction Medicine. And so we replace that now with something called a, a mild substance use disorder.
Substance abuse was used initially when we were still using the DSM-IV criteria. So that’s the Diagnostic and Statistical Manual version four criteria, which was used traditionally to diagnose somebody with a substance use disorder. And so it’s now replaced with mild opioid use disorder. Addiction is the term when we really think of [00:03:00] somebody with a psychological and not just psychological but physical dependence, right?
So that is a more We think about of, of moderate to severe opioid use disorder as defined by the DSM-5 criteria. And so it’s characterized by what I think as the four C’s in addiction, the loss of control to use a substance, cravings to use a substance, a compulsion to continue to use that substance, and importantly, use despite negative consequences.
So given the similar exposures, why do some patients develop addiction and others don’t? Yeah, Daryl, that just speaks to the complexity of addiction. Addiction really can be defined as a biopsychosocial and spiritual condition, and as such, we really need to look at that and when it comes to diagnosis, management, and treatment.
Let’s take, for example, genetics, right? So that’s the basics of, [00:04:00] of the biological component. You know, a recent studies published in two thousand twenty-three in Nature Mental Health actually show that there are multiple genetic loci that, that are significantly associated with substance use disorders.
I’ll give you an example. If both my parents have alcohol use disorder, I am seven times more likely to develop alcohol use disorder if I were to be exposed to alcohol. And so family history is an important component, and that’s backed up by older identical twin studies saying that if one twin has a substance use disorder, the other identical twin also is much more likely to, to experience the same thing.
But that is not a defining feature. The environment, and so the, the social component can really either trigger or buffer us from developing a substance use disorder. So I think about things like social support, having the right family, the friends, social network, having stable housing and transportation, [00:05:00] any adverse childhood events.
We know that individuals who were exposed to adverse childhood events, be it physical, emotional, sexual, or a combination thereof, are much more likely to develop a substance use disorder later on in life. And then psychological, if a person has underlying depression or post-traumatic stress disorder, and importantly now, especially post-COVID, loneliness We know that those are major triggers and associating factors to developing a substance use disorder.
And then finally, spirituality. When I think about spiritual, it does not just mean participating in a religious event. It means a lack of direction, a lack of purpose in life. And so that combination can really predispose an individual to developing a substance use disorder or an addiction when they are exposed.
And that, I suppose, can differentiate between somebody who are exposed, similarly exposed, but that not everyone ends up [00:06:00] developing an addiction. So it’s really a very complex, multifactorial issue that goes together and interacts causing this problem. Ben, do we have information about what’s actually going on in the brain in terms of pathophysiology and neurotransmitters and so forth?
Does, do things ch- physically change? Absolutely. So, you know, when we think about neurotransmitters, Darrell, the main key neurotransmitter we think about is dopamine. You know, dopamine is that neurotransmitter that gives us that reward sensation, right? And we know that drugs of misuse and abuse significantly hijacks that dopaminergic s- system.
It starts at the level of the basal ganglia. It really, it causes an exaggerated response in that, those parts of the brain. I’ll give you an example. Methamphetamine, for example. Somebody who takes methamphetamine who’s genetically predisposed, they are releasing 1,000 times higher the [00:07:00] amount of dopamine as they would after eating a normal meal or at baseline.
And so with that rewarding sensation, it then modulates other parts of the brain, including the memory centers of the brain. So we think about the hippocampus or the amygdala as well, and that drives the motivational centers of the brain to continue using because what we wanna do is to remember the good times when we were taking drugs, but also try to forget and not remember and escape those bad memories when we’re not using drugs.
And then it modulates the prefrontal cortex, that part of the brain that tells us, «Don’t.» And so the whole cycle continues Let’s talk a little bit about the opioid crisis. This is a very important topic, and it’s, it’s evolved over the past several years, especially in primary care. So from your perspective, how has this evolved and where are we at right now?
Daryl, it really has come a very long way. I would say even 15 years ago or [00:08:00] 10 years ago, at least where I practice in the upper Midwest, we are still concerned about heroin. Heroin is largely not used anymore or not used very frequently anymore. Many of my patients are using synthetic fentanyl. Fentanyl is very potent, 50 to 100 times more potent than morphine, and they can purchase this easily on the street and online, and they’re pressed into little pills that look almost identical to prescription oxycodone.
And so these individuals are taking, either snorting them or smoking these pills. And as, because they are so potent, they’re much more likely to overdose. And unlike heroin, nowadays we actually need to use multiple doses of intranasal naloxone, so Narcan, in order to reverse somebody’s overdose. So we’re seeing individuals who require anywhere between six, seven, eight doses, sometimes even more, of naloxone to reverse that overdose.
Importantly, we’ve seen fentanyl now laced into other drugs like cannabis [00:09:00] and methamphetamines, so individuals who don’t intend to use opioids end up becoming dependent on opioids and also overdosing on opioids. Emergingly, over the last several years, Daryl, we’re seeing animal tranquilizers, so things like xylazine and medetomidine that are laced with opioids like fentanyl as well to enhance its effect.
But unlike opioids, xylazine and medetomidine, they don’t respond to na- naloxone, and so using naloxone alone is inadequate. More worrying nowadays is the use of kratom. Kratom is a supplement that can be sold in many parts of the country, in gas stations, online. It’s sold as an energy booster or mood lifter.
Kratom is an herbal extract that was originally grown in Southeast Asia, and it’s promoted to help relieve stress and relieve anxiety. Now, at low doses, it actually has a stimulant-like effect, but in higher doses it actually has an [00:10:00] opioid effect. And so now we’re seeing more and more individuals, especially younger individuals, purchasing kratom online or locally and then presenting with opioid-like withdrawal symptoms when they’re not using it Ben, I recall maybe two or three decades ago, I had a surgical procedure, and I was discharged with a, uh, bottle of a strong narcotic, and there were 100 tablets in that bottle.
I mean, my gosh, that would’ve been enough to get me through for three weeks. Are we, as clinicians, becoming more aware of this issue and maybe dispensing opioids more judiciously? Yeah, and, and we have done a tremendous job over the last 10, 12 years or so, and we have been more judicious in our opioid prescribing in general.
I think part of that was triggered by the Centers for Disease Control and Prevention’s guidelines for opioid prescribing. Its initial version came out in 2016, and it [00:11:00] provided guidance on how best to prescribe and manage opioids, both in the acute and the chronic pain setting. There were things like days limit recommendations, morphine milligram equivalent recommendations.
The intent of this was very good, but I think it also created some unintended consequences in that some providers ended up adhering very strictly to these guidelines, and regulatory bodies also enforced these guidelines too rigorously. And so we saw a number of patients actually being abruptly discontinued of their opioids or abandoned by their providers as well.
And that was the, the trigger to revamp these guidelines in 2022, really saying that clinical judgment, shared decision-making needs to be had with the patient as well. But certainly, there has been a significant attention to opioid prescribing and opioid stewardship across the country, so it would be more rare these days to see 100 tablets of- Mm-hmm
[00:12:00] opioids being prescribed post-operatively. Yeah. So why is primary care such a critical setting for treating substance use disorders? Daryl, the primary reason for that is because primary care is much more available to our communities and our patients. There simply aren’t enough addiction specialists to go around.
Up until 2023, one person died of an overdose every five minutes in our country, and if you use that statistic, there simply are not enough specialists to go around. Pair that with the fact that going to an addiction specialist, going to a psychiatrist, there is stigma associated with that. It is also more challenging sometimes insu- in terms of insurance coverage.
Take, for example, in the state of Minnesota where I practice, in order for a patient to see somebody who is addiction boarded, an addiction specialist, and who has government insurance, they actually require a comprehensive chemical dependency assessment, and [00:13:00] that assessment can sometimes take time to get.
So coming to primary care makes sense because they’re able to see me more easily, less barriers to access, and there’s less stigma involved. Well, identifying patients who have a substance use disorder or who are at risk for one, are there any effective screening tools that we can use in primary care?
For sure. We really think about the SBIRT model, right? So the screening, brief intervention, and the referral to treatment model. So screening can be done as easily as just asking patient one or a, a, a, a few questions. In our institution, we use a questionnaire called the EMPOWER TAPS-2 tool to screen patients on chronic opioids for opioid use disorder.
Now, this tool is a, a three-item questionnaire, yes or no, and the patients can complete it themselves. It was designed by Dr. Dok Young Yoo and Dr. Sean McKee of Stanford University and was [00:14:00] published several years ago. It asks three simple questions. Did you use a prescription opioid pain reliever not as prescribed or that was not prescribed to you?
Yes or no. Have you tried and failed to control, cut down, or stop using opioid pain relievers? Yes or no. And then finally, has anyone expressed concerns about your use of an opioid pain reliever? Yes or no. A yes to any of those questions is considered a positive screen that can trigger more screening, more questioning from the provider.
How should we approach a patient where we are concerned about a substance use disorder with opioids, but they don’t identify it as a problem? That’s a wonderful question, and, and I think that is one of the reasons why providers oftentimes are hesitant to bring up this topic. I’d say the first thing is to, A, manage our own emotions.
When we are concerned, when we are upset, [00:15:00] for example, that a patient may not be complying with therapy, right? Maybe asking for early refills, we may unintentionally bring in judgment and use less than neutral language, and that can sometimes lead to the patient becoming defensive. So I think going in with an open mind and trying to elicit the patient’s own perspective I think calling it out, your own concerns out aloud can help as well.
Using caring language, like, «I’m concerned, I’m worried about your substance use. I’m concerned that you may be taking more pills.» I always try to think about why patients use, for example, opioids or benzodiazepines. Is it as intended, or are they taking it for a secondary purpose? I’ll give you an example, Daryl.
Some of my patients tell me that their opioid medications are the only medications that can relieve stress for them, or the only medications that can bring their blood pressures down. And that, for me, is a flag for, to say, «Well, [00:16:00] perhaps we have more than just a chronic pain condition going on, and we need to do- delve f- further.»
And explaining that to the patient can sometimes really open their eyes. Sometimes instead of calling it out as an addiction or an opioid use disorder or a substance use disorder, I use more subtle questions. For example, things like, «Have you ever tried to give up opioids altogether? Why, and what happened?»
You know, «If your family member were here and I were to ask them about your pill use, what would they say and why? Do you ever wake up promising yourself that you’ll only take a certain number of pills, but then you end up taking more?» Asking about things like social isolation. Are they skipping out on important family events and social events?
Oftentimes that can then clue the patient in. They may initially not acknowledge it, but then many times they will c- go back home, they will think about it, and in future visits they will say, «Maybe I do have a problem and I do want help.» And I think this is also a reason why [00:17:00] this is such an important issue for f- primary care clinicians.
We have the opportunity, and we typically establish a long-term relationship with our patients going over many years, many decades, in fact, and that gives us a chance to build a trusting relationship with them. And I think they will tend to accept what we say when we’re concerned more than, you know, uh, maybe a surgeon who sees them once.
You know, I think that trusting relationship is important. I entirely agree with you, Daryl. I think that continuity of care really gives us the therapeutic advantage of having these difficult conversations with the patients. And you know what? Especially in family medicine where, uh, the, the field that I practice, you know, we’re literally seeing patients from cradle to grave.
We deliver them. We may take care of multiple generations of the family. Sometimes I know the patient’s social history and family history better than they do, and so I know how the family dynamics work. Well, let’s turn to management [00:18:00] now. What does successful treatment look like, say, beyond abstinence?
Daryl, it goes back to that biopsychosocial spiritual model of addiction and substance use disorder. Abstinence is important, but abstinence may not be achieved by some individuals, at least in the early stages. Our goal initially is harm reduction. Are you coming to your appointments? If they’re prescribed a medication, an anti-craving medication, are they using it?
Because by taking those medications, it reduces the cravings, reduces the chance of relapse, and essentially reduces the risk of dying. That’s the early stage. What we ultimately want is for them to find their purpose again, to reintegrate these individuals back into society, to becoming productive part of the society, and to have them have a fulfilling life.
So working on addressing their underlying psychiatric comorbidities, helping them and guiding [00:19:00] them through navigating our social system, getting job retraining, finding housing, transportation, all that is important, and then connecting them with individuals who are also in recovery. You see, patients with a substance use disorder, oftentimes their social circle is also composed of people who also use drugs, and so bringing them into a different social circle, people who have been there before c- can provide support, is extraordinarily important.
I’m pretty sure I know how you’re gonna answer this next question, but is the management of substance use something that can be accomplished purely in primary care? Is it more effective to refer to a specialist, or is it best to work as a team? I would say that many patients with substance use disorders can be managed in the primary care setting.
That being said, I think it also depends on the comfort level of the primary care [00:20:00] provider and the level of support that the primary care provider can have. What I have available to me at Mayo Clinic in Rochester, Minnesota, could be very different compared to somebody practicing in a more rural setting.
I think, like you said, Daryl, before, that because primary care providers are able to provide that continuity of care, that gives us that therapeutic advantage. Many of the medications that we use to treat, for example, opioid use disorder or alcohol use disorder are well within the scope of a primary care provider.
That being said, though, if an individual continuously relapses, if you have tried but they continue to not do well, then I think intensifying their treatment, for example, referring them to an addiction specialist or having a shared management model with the specialist would be a very good approach. We are very fortunate in that we do have a lot of resources available where we work, but you mentioned an issue.
How about the [00:21:00] smaller resource-limited clinics? Can they realistically manage this? Yeah. That certainly can be a lot more challenging. What I would say is that since COVID, the adaptation of telemedicine has really, really become widespread and commonplace, and so we are able to reach patients even to more rural and underserved settings using telemedicine.
So I think providers working in more l- resource-limited communities can realistically utilize telemedicine to help many of these folks and also connect them with behavioral health providers who may otherwise not be available in that area. There’s a really good federal government website called findtreatment.gov that really you’re able to type in your own local zip code or community, and resources like methadone clinics or other behavioral health treatment centers will pop up The great thing is that in 2022, the [00:22:00] opioid settlement funds w- started to be dispensed.
Now, the opioid settlement funds, for those un- unfamiliar, is a result of a settlement of lawsuits from big, giant pharma and pharmacies from around the country, and they have decided to settle for– to give over $50 billion to states and local governments and tribal nations all around the country over an 18-year period.
And so many communities in our country are now utilizing these funds to promote medications for substance use disorder, to promote mental health resources, and the like. So I think the amount of resources, even in more rural communities, is a lot more now compared to even just five, six years ago. Well, Ben, what do you see as the biggest barriers in preventive primary care in managing substance use disorders?
Daryl, I think one of the biggest barriers is our own fears and our own [00:23:00] stigma, be it intentional or unintentional. We fear, for example, that prescribing buprenorphine, which is one of the three FDA-approved medications to treat opioid use disorder, is somehow very difficult. I would argue, in fact, that prescribing buprenorphine is probably simpler to– than many other medications that we already prescribe commonly in primary care, things like insulin or warfarin.
The other barrier is our, our perception that somehow if we start prescribing these medications, we would somehow open up the floodgates to more patients coming in and seeking that type of help Firstly, if patients come in and seeking help, I would gladly offer it as a primary care provider. Secondly, the data can hardly be f- far from the truth.
The data has proven that if we were to s- start prescribing buprenorphine, there is no data supporting that somehow we would open the floodgates that everyone in town will [00:24:00] come to us. What’s important for us to know is that substance use disorder is a chronic condition, it is a brain disorder, and it’s treatable, but like many other chronic conditions, people do relapse and remit, and so we have to treat it that way.
So I think understanding that the basics, the, the fact that a substance use disorder is a chronic condition, it’s a brain condition, it can be treatable, can really help to reduce the stigma and the barriers faced by primary care. Another issue I see, since I take care of mostly elderly patients, is the reluctance to use opioids in terminal illness, even hospice care, and where the pendulum has actually swung the opposite direction, where clinicians are now concerned about prescribing these drugs, in many cases very appropriately.
Yeah, I agree, and that was one of the reasons why the CD- CDC revised its guidelines in two thousand twenty-two, [00:25:00] really thinking about emphasizing shared decision-making, clinical judgment. One cannot apply the same rules to somebody who might be in their forties or fifties, healthy otherwise, to somebody who is at the end of their life, have cancer-related pain, right, or under hospice care.
So I think really individualizing the care, but at the same time utilizing clinical judgment to screen for and then to promptly address substance use disorders is key. If you could give each healthcare provider one piece of advice about treating substance use disorder, especially opioid use disorder, what would it be?
Very simple, Daryl. Just don’t overthink it. A lot of my colleagues are scared to prescribe medications like buprenorphine because they think it’s very complicated, because they think a, a great degree of skill and monitoring [00:26:00] is needed, but don’t overcomplicate it. There are great resources out there, resources such as substance, the resources published by the Substance Abuse and Mental Health Services Administration, or SAMHSA, or the California Bridge Program.
They have algorithmic treatment guidelines to help a clinician initiate, manage, and then troubleshoot buprenorphine and medications. And of course, there are plenty of continuing medical education opportunities, both in person and virtually. I would say that one of the most rewarding things that I have done in my career as a primary care provider is taking care of patients with substance use disorder.
Because I see them frequently, you end up building a very trusting bond and relationship with these patients, and it’s really wonderful to see how many of these patients, when they first came to me just even several years ago at the worst of their life, really are now doing phenomenal. So I would say, bottom line, don’t overthink it.
Do what’s best for your [00:27:00] patient. Do what is best for our patients, correct. Well, Ben, you are very involved in managing substance use disorders. Are you optimistic about the future? Can we actually accomplish what we’re setting out to try to do? I’m very optimistic, Daryl. I’m optimistic that we will continue to beat this epidemic.
We have seen for the first time in 2024 a decline in overdose deaths. We are seeing multiple communities, societies, and organizations across our country mobilizing to improve access to substance use disorder treatment for our patients, to improve harm reduction tools for our patients, such as making naloxone more readily available, and we’re seeing things change at the state level, at the federal level, so I’m very optimistic.
We’ve been discussing addiction care and empowering non-specialists with Dr. Benjamin Lai from the Department of Family Medicine at the Mayo [00:28:00] Clinic. Ben, thank you so much for sharing your knowledge with us today. It was, it was a great discussion. Thanks for having me. You can now listen to several hundred different medical topics developed for primary care providers on Mayo Clinic Talks podcasts.
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