 Hi everyone. Welcome to the Addiction Recovery Channel or ARC. I'm Ed Baker and I am your host producer. Today, we're very fortunate indeed to have with us two distinguished guests. We have with us Dr. Todd Mandel, who is a board-certified psychiatrist with a specialty in addiction psychiatry. And we have Cam Laufe, who is a certified recovery coach right here in Vermont, presently working with the Turning Point Center of Chittenden County in a number of roles and we'll probably hear about all of them today. Thank you gentlemen so much for being on the show. This is a two-part series focused on the American Society of Addiction Medicine's expanded definition of addiction. In 2011, ASAM released its definition of addiction, which was mainly focused on brain circuitry. Since 2011, the American public for the most part has come around and began to understand that addiction is not a moral weakness, it's not a character flaw or a criminal personality, it's a medical disease. The 2019 definition is meant to expand on that, the idea of brain circuitry, and also to include some very important dynamics, the dynamics between the person and the environment. I'll read from the commentary, the ASAM commentary. They say that this definition, the new definition, recognizes that people do not develop the disease of addiction in a vacuum. The updated definition underscores the complex interplay of unique biological, psychological, and environmental factors. And by environmental factors, what they mean is what we call adverse childhood experiences or ACEs, hunger, poverty, difficulties with employment, difficulties with housing, that these types of environmental stressors can interact with brain circuitry in ways that both can cause the beginning of addiction, perpetuate addiction, and also either thwart or encourage recovery. I'd like to begin there with my guests. I'd like you both to think about your careers, think about your interactions with people with substance use disorder and addiction, and comment on the way that you have observed the environment interacting with brain circuitry, causing stress. I'll just start, can't start. I can speak a little bit about my own sort of path through recovery, and I can also speak about what I've witnessed in my work in the emergency department. My father passed away at a very young age. My mother had cancer at around the same time, so I was pretty stressed out. There's a lot of stuff happening all at once. And then throughout the years, I kind of had different outlets, which gave me sort of that reward. I'd get that kind of dopamine response from like playing sports, going to school, getting decent grades. I was never a good student, but I did okay. Up until the point where I started using substances where I had this sort of relief. So you can say that the environmental factors of my father passing away, my mother having cancer, all these sort of tragic things happening in my life sort of lead the pathway for me to become vulnerable to developing this disease. And what I see in the emergency department too is I see sort of like a compounding of factors, where you can have the genetics that lead up to it. You can have the environmental factors, and you can also have the traumatic events. And particularly the traumatic events is what I've seen sort of lead to this progression of this disease. So we'll see people coming in, possibly for their first time in the emergency department, where they're struggling with use. And then we might see them about a year down the road, and we see the progression. Where it might have started with maybe a mild substance use disorder to the point where now it's progressive. So their use is now problematic, and they're using past those consequences. You have those negative consequences which are arising in their life. One of them could be entering the emergency department. And then they're still here. They're still sort of resurfacing. Well, you know, let me take a second because that's a really interesting point. One of the other major points that ACM makes is they differentiate, which is what you're doing, between mild and moderate substance use disorder and addiction proper. They reserve the term addiction for severe substance use disorder, which means that the brain is compromised in ways that causes the person to continue in addictive behaviors in spite of consequences. And I think it's really interesting that you made that point because they make that same point. What about, Todd, what about your career? What have you observed? Very similar to what Cam describes, folks coming to treatment, bringing with them a variety of issues depending on whether it's their first time around, or having been in made attempts at treatment and recovery many times over the years. The part of recovery that seems to be a challenge for many people is how do I learn to cope with all of the emotional and environmental factors that are going on around me as I'm trying to get sober when I've used my less healthy outlets as a way of coping? And the issues are still there. As a person stops using or moderates their use or moves back along the scale, those issues are still present, or may still be present. They still may be hungry. They still may have not a safe place to live. They still may have someone in the family whose health is compromised or who's dying and coping with it without their outlet is very difficult. So a person can become abstinent, but that's when some of the more difficult work begins. Would you agree with that? Sure, certainly. I think that what we're touching on, and one of the main goals of the American Society of Addiction Medicine with the expanded definition, is to kind of tease out some of the nuances of addiction, that we can't expect if we look at people and just say, your addiction is a manifestation of brain circuitry. We'll help you to change around brain circuitry, but then you'll be in the same environment that fed into causing your addiction. Maybe there'll be problems with poverty. Maybe there'll be problems with housing. Maybe there'll be problems with employment. Maybe there'll be unresolved trauma. How can we expect people to just stop using drugs and not have an environment that welcomes them and continue to be abstinent from drugs? So the idea then is that this new definition would begin to inform the public so we would enact legislation and programs that would begin to deal with adverse childhood experiences, lack of employment, lack of housing, things of that nature, and mental health. I mean, what have you seen in your practices that speaks to that, like the absence of resources in the environment that sometimes cause a person to resume the self-administration of drugs? Let's say the early 90s, we didn't address co-occurring psychiatric disorders until the person had been sober for X number of weeks. The tricyclic antidepressants were much more toxic, and if someone relapsed into alcohol or other substance use on top of that, there could be more critical problems with the advent of the SSRIs and realizing that you can't do treatment sequentially. You have to do it in a coordinated manner. Even parallel treatment doesn't work. So you can't send a person's addiction to an addiction specialist and their mental health issues to a mental health specialist. You have to deal with the whole person. That's becoming more the norm. It used to be co-occurring, dual diagnosis, then it was co-occurring, and much more we're talking about a complex patient who may have a variety of issues that need to be dealt with simultaneously. That's been a big change over the last 30 years. In Vermont, I know because I'm a licensed alcohol and drug counselor, when we adopted licensure, part of the requirement for licensure was a master's degree in mental health. So in order to get a licensure for dealing with people with alcohol or drug issues, you had to also have a master's degree in mental health so that integration began to occur there. What about, have you made those observations also? Particularly when you're looking at individuals, it's sort of like this process of, here's your laid out path to what treatment might look like for you, but unfortunately they have to return to that same environment. And it's also asking a lot for them to, can you just up and leave everything to go to a residential care facility to get stabilized on medication to engage in programming? So do you have the finances in order to give up 28 days of work or 14 days of work, however long this day is? Do you have care in place for your children if you have children? Also like, are you going to be able to afford rent? Are you going to be able to pay for food for your family if you're the sole provider? So it's asking a lot for people to do that. And then whenever they leave the treatment center and they've completed their treatment and their programming and they're stabilized on medication and they've returned back to that environment, they're still amidst everything. They still have the barriers in place, they still have the financial stressors and everything there is just significant for them so that to continue the next step it's difficult because they have to dive back into work, they have to make up for the past month's losses to get back into the financial black. Yeah, there's a lot of obstacles, roadblocks, barriers, things that you've mentioned. One of the things that's happening in Vermont now that's very encouraging is that there's movement in housing, there's movement in transportation, there's movement in employment, all to educate significant leaders about the nature of addiction and the nature of recovery. Recovery support of workplaces is something that's being discussed and defined and different conferences are going to be looking at that. Recovery support of communities. There are a few communities in Vermont where there are really integrated avenues supporting recovery. So as a state we're moving forward. It's always an uphill kind of a movement but we really are moving forward. One of the things I wanted to touch upon was this is national in nature but it speaks to this idea of moving forward. This is a resolution by United States Representative Ted Bud that was introduced on November 19th. It's a house resolution. One point I'll quote it, one point will be to start recognizing addiction as a treatable chronic medical disease involving complex interactions among brain circuits, genetics, the environment and an individual's life experience. So that's taken directly from the ACEM medication. The resolution will also support evidence-based treatment along biological, psychological and social lines. And the third one, which I think is really important and which I'd like to speak to, it will support efforts to prevent and destigmatize substance use disorder and addiction. So this is a national effort. This is a house resolution that embodies exactly what we're talking about today. It's not a cure for anything but again it's one small step uphill but in the right direction. Let's talk a little bit about that. When we look at the environment, one of the environmental dynamics that people with addiction face is stigma. Would you care to comment on that? So with medication, medication-assisted treatment, it has a name, right? Medication-assisted treatment, but why isn't it just medication? So there's one instance right there. So changing the language and the terminology, understanding that it's medication. And this is a disease where, just like most chronic diseases, it's not just one treatment fits all. You need to sort of take into account the environmental factors, the adverse childhood experiences so that everyone's own sort of presence of addiction in their life could be different from another's. So that what my treatment for the same sort of, you know, what would be a chronic disease might necessarily not be the same for somebody else's chronic disease. Exactly. So I might have some allergies to some medications where you get the gist here. And it was brought up earlier just in a conversation that we had sort of like a microcosm or some macrocosm of what stigma looks like. And so I can speak, from my experience of stigma in the recovery community, particularly to a 12-step fellowship, that there is significant stigma facing towards individuals who use medication that's derived from those who are this strictly abstinent base recovery path. It's sort of like a sense of, you know, elitism that comes from it. This sense of purity, you know, I don't really know because I can only speculate to the experience, but I've seen it. I think this is a really important area so why don't we just stay in this area for a while. So what you're talking about is a stigma placed on people with addiction who are receiving a medication for addiction treatment. And the stigma is coming, nonetheless, from people who are also in recovery, but are more in recovery based on an abstinence-based program. You care to speak to that, Todd? Well, it's been an evolution as most parts of recovery have been. The fact that methadone is probably the most highly studied medicine in all the pharmacopoeia of medicine doesn't mean a lot to a lot of people. And yet it saves lives. It helps buprenorphine when it was released to say, right, you don't have to go to a clinic necessarily. You can go to a doctor's office that has the proper training. The efforts to train, and it was only allowed by physicians to use it initially. Now it's been open to MPPAs, nurse practitioners, physicians, assistants to be able to prescribe it. How to recruit folks to be able to use it was a large effort. And Vermont did a really nice job in leading the country and training the number of providers that have the buprenorphine license. It was interesting that this is the first medication, buprenorphine, that requires an eight-hour training. Most medicines you read you read a little bit about it and you discuss with a colleague and they jump on ahead. So who is going to be providing it? Who's patient is it? That's your patient, Todd, people would say. You have that patient, you do that. Well, how about the fact that they have hypertension, they may have diabetes, they may have a mental health issue that needs to be on medication. How do we coordinate that? Your patient. So now it's becoming more of an hour patient. And that's representative representative Bud's issue is he says very clearly in that document, people with addictions might not present for treatment because they're afraid of the stigmatization that they may experience when they come in. So it's within and without of the recovering community and it's a slow process but representative Bud made a really nice start with that. Putting it on paper is unfortunately different than having people absorb it and to practice to not be stigmatizing. We all have our blind spots but how do we learn to work past them and how do we not exclude people from the treatment that they really need. Exactly and well said by you both the fact of the matter is that stigma costs lives and the general public needs to be gently educated about that. Stigma causes people with severe substance use's order to be reluctant to reach out for help when they don't reach out for help the disease progresses and in our society with some of the drugs that are available on our streets today that can very often lead to death. I have a quote from the Betty Ford consensus panel on recovery and one of their criteria for recovery is what they call sobriety and I'll just read you the footnote because it bears directly on what we're saying. The Betty Ford Foundation says the consensus panel agreed that individuals engaged in medication assisted treatment who meet the other criteria for sobriety would meet consensus definition of sobriety. So what they're saying then is a person who's receiving buprenorphine or methadone will be considered in recovery if they're adhering to the prescription and the way that their medication is supposed to be taken and this is again the beginning of the expansion of consciousness to include people. To me and I know a lot of people in recovery to me it's heartbreaking that someone with such a dangerous disease opioid addiction would first have to battle the stigma of you know I'm not even going to say the word but you are a so and so you know you choose this you made your bed sleeping it that's the initial stigma that they face then if they're lucky or fortunate enough the resources and they get into treatment and they're on buprenorphine or methadone they're met with the feeling of you're still using your medication is opioid based so you're still using how how are that's we are the environment this is part of the environment that we create what what can people do what can the general public do to change that environment around how can we how can we change that I'd actually like to hear from you Cam about the role of the recovery coaches and how basically you're helping folks walk through that shepherding them helping them assisting them through those issues and I'd like to hear more since it's fairly new I'd like to hear more from you about how you and the other folks at your work would actually manage that help folks manage it I should say of course so really it depends I mean I'm I'm glad you brought that up because I I don't necessarily agree with that to set parameters around somebody else's kind of experience you know and and what's true to them and what is subjective to them I feel like that does a disservice to that person and and sort of you know not and what we do as recovery coaches we help align sort of parameters and expectations for individuals and what is reasonable for them to accomplish so helping them sort of come up with motivation helping really create a sense of autonomy through just dialogue and having an open dialogue session with them at various points of intervention we sort of create this sense of belief that you know I might not be able to do this right now but I can do this so it's kind of inching the person towards this larger goal of what might be their understanding of sobriety because for me to say well you know what according to Betty Ford this is what sobriety is and you're not living up to it therefore you're not sober you know like it's kind of a weird sense Betty Ford the consensus panel on Betty Ford is that you are considered sober even if you're on buprenorphine or methadone whereas one of the general stigmas that we're seeing is that most of the recovery community are saying you're not in recovery if you're on methadone or buprenorphine which I get 100% and I agree but there's another level to it so outside of medication there's also use of other substances although not the same substance that's causing the sincere problems in the person's life so if somebody uses IVU's heroin every single day and they're able to get to a place where they're not but they're smoking weed or they're using benzodiazepines or they're using crack cocaine it's not as problematic as it was in the past so from their understanding they are in a better place so that is it's working it's sort of a harm reduction approach applied to getting to a person to a place where they feel comfortable enough to kind of see like recovery this is my lifestyle that I'm living now it's a tall order to have sort of this expectation of you know committing to a sense of sobriety for the person when they're not in the place I see what you're saying and you know it gets really complicated but I'm with you Betty Ford is one resource and I think they've made progress by stating that people on opioid based medications can be in recovery if you look at William White in some of his writings he kind of addresses part of what you're saying it's kind of a harm reduction idea he will differentiate three stages of recovery one is partial which is what you're referring to people are still maybe harm reduction or the recurrence of use they're still struggling the next phase is full where people are abstinent from all dangerous psychoactive chemicals and they're leading rewarding lives improving their health improving their participation in the community and then the third really is beautiful it's enriched where recovery has shaped them in ways that enable them to give back to the community of people who are using substances and fighting for recovery helping them to move forward so I think that that is a very rich kind of way to define stages that we can't really see things in black and white and I think that's what you're talking about is the human and gradual movement forward and respecting the person no matter where they are in that process is that kind of what you're saying? yeah, 100% I don't like to give it labels because it would be subjective to each person but I wholly agree and I think and I understand like along the process I can't say this is kind of like a recovery coach sort of quip here I can't say I'm the expert on somebody else's they're the expert on their reality so when we work with people whether it's in an inpatient setting if they're admitted to the hospital or if it's in a recovery setting and if they're throughout the various stages whether in there sort of that partial all the way up to enriched as you stated earlier it's really a similar process where you have sort of this understanding that they're where they're at right now where they're at and provide them with the support so that they can continue well I mean that really answers my initial question about what can we do to reduce stigma and help people to move forward in recovery if we can spread that kind of attitude a little more to the general public by educating them then that's really what we need to do over time thank you Todd? well educating the public but also providing the support and education within the community of folks who are working on recovery so that they don't fall victim to this stigma and whether it's that I'm on methadone and I'm not being accepted by NA or I'm on I use alcohol and I am on antidepressants which didn't used to be allowed in or wasn't as as that rather than saying that wasn't as accepted by all meetings so how do we negotiate that and how do we help care providers negotiate that have a better understanding about what it's like to face to be afraid to ask for help what it's like when you're judged in an emergency room how do we help someone manage that and avoid use in semantics the tiniest things can make a difference and saying that someone has an addiction difficulty as opposed to being an addict opens up a door in a different way how do we use the better vocabulary the more accepting words more support how can I help you today as opposed to your drug seeking all of those they're significant but they're also very small changes that one has to make in order to have a welcoming environment so there's that and also what I think about frequently is the way the care provider or the recovery coach or the therapist or the neighbor feels inside about the person with addiction that somehow that gets communicated and that we all need to educate ourselves more about what addiction is and what people with addiction go through so we can really feel compassion and I know that both of you are still in practice you're still working with individuals I no longer in clinical practice but maybe we can talk a little bit about that the sensitivity that you experience toward people and the sensitivity that they bring into the office in my experience people with addiction by far are overly sensitive to stigma they will have feelers out and if they feel it emanating from someone that will push them away and it seems to be an obligation really for the service professionals really to deal with whatever they have to do education or therapy or consulting or supervision or whatever they have to do to get down in there and make sure that they have the right kind of attitude toward the people that they're working with do you want to comment on that I was actually hoping that you could walk us through a little scenario of someone that you're coaching who is experiencing stigma from whatever vantage point from their family from a provider and how you might help them deal with it how might you approach someone who said this has happened to me or I'm not feeling welcome at this meeting because I'm on methadone how might you help them manage it it's a relapse trigger yeah completely so what I can speak about has occurred pretty much sequentially over the course of a year and a half that I've been working in the emergency department is individuals re-engaging with treatment through the emergency department and it has been pretty rapid so it's about 3 4, 5, 6 times a month that it's occurring and every single time they're a bit less willing to engage as a result of encountering stigma through staff so it's kind of that look it's that tone it's sort of that sense they're very sensitive to that sense of well they don't want me here you know clearly I'm not going to get the best treatment and then it turns into just cognitive distortion and then it turns into a belief and it's a core belief and then they're unwilling a core belief about self and then they're unwilling to seek out treatment as a result and that's when we lose people that's when we lose lives what we do in a sense is we really provide that compassionate support for people so that where they are seeking it out in different venues having it reciprocated to the sense where they need that we'll then provide it and also what we'll do is we'll sort of we'll debrief in a sense they go to a meeting or they engage in treatment and then we'll debrief afterwards what did you hear did you take anything personal in a sense of like what came up that you felt was sort of targeted against you and then talk through it because it could just be misunderstandings it could be you take something and you misconstrue it in your own mind when I first got sober I felt everybody was staring at me I felt everybody was talking about how I wasn't speaking right and I'm from Baltimore and we have a really weird accent so and up here it's a very thick drawn out yeah I bought housing so there's this sort of you're in a spotlight and you feel like you're in a spotlight even when engaging in treatment when you first go to the emergency department you go you know there's that sense of well I'm not here for a medical reason there's kind of there's the overlap between adverse childhood experiences and addiction and children with adverse childhood experiences by and by having what's called early stress response early fear response they're like ready to bolt ready to bolt you can assume that really in my experience by practically everyone with addiction they're ready to bolt they're ready to be rejected they're ready to be misunderstood so they bring that to the setting and it takes a real inner peace on the part of the provider to engage that and de-escalate that body language it could be you know a professional that's just busy that really doesn't contain any stigma but they're busy and it appears that they don't care little things like that can cost lives and I know you're both acutely aware of that because you deal with that every day the idea of debriefing with a patient that was a little I like that do you have protocols for that you know ways that you are you documenting or you may be developing some kind of literature where you're going to be teaching people how to do that because that to me is really important we're in the process, I mean the protocol is continuously evolving as the program develops you know nothing is consistent right now especially when you work in a hospital you know it's we have the 10 day follow up which kind of turns into a month to two months however long a person wishes to work with us and when working in an outpatient setting as a recovery coach you're meeting with people at a coffee shop or the recovery center you're meeting them where they're at it's really the coach's own responsibility to kind of create that sense of support so it's you know it's up to the coach and what they wish to do at that time but they're all skilled enough to go through that process and debrief and you know I'm sorry I like the debrief, it's a reality test was this really what you were thinking your old stuff or was it just someone who was busy or when you need to go back there next time how do you advocate for yourself better I like that how do you advocate for yourself better and what about the medical profession itself I mean when doctors are trained I mean people with other diseases also can present a situation that causes like a negative response or a stigma based response our doctors how are they trained around responding to patients in a compassionate way is that part of what what goes on or is that just considered to be sort of you bring that to your role naturally well there's much more attention to the process of addiction than there had been when I was in training wasn't mentioned any more than nutrition was mentioned more than an hour in all of medical school and residency so things are evolving how how do you approach how does a practitioner in early training and all practitioners not just the docs how do you approach something that may make you uncomfortable and remembering to leave that at the door and to remember that everyone who's coming in to see you is not feeling good they're unhappy they're feeling terrible how do you no matter what the issue is it's bringing them how do you approach that in a compassionate way it's certainly an expectation we across the board as a society we could do better at it yeah well thank you for your candor about that and you know we're certainly you know motivated by powerful forces today to evaluate everything we do and get better everything we do you know the representative Bud's resolution I just want to point out was of course endorsed strongly by the American Society of Addiction Medicine because it closely reflects their definition of addiction but in addition to ASAM there were 14 other organizations that endorsed the bill and their organizations such as the American College of Medical Toxicology, the American College of Emergency Physicians the American Osteopathic Academy of Addiction Medicine and the American Psychological Association that's just a small group there were 14 so there's momentum there's force behind getting this message out to America you know and I want to thank you both I mean I think we're all part of that force and I want to thank you both for being here today we'll close the show now and as I am in the habit of doing I like my guests to close the show with whatever message they have for the viewing audience so Cam would you like to take the lead on that sure you know I like to go on to news sites on Facebook and and I like to go in the comments and I like to be a fly on the wall and kind of see the dialogue because I think you know aside from the Russian bots and you know all the other stuff that's happening the political discourse because that's where the true kind of understanding of what addiction is and that's the kind of language that is hurting people and so that's to the broader public the people who might not watch the show people who might not pay attention to the American psychiatric association they might not you know so I like to see what what they're saying and it kind of leads to the point of you know they made that choice they made that choice you know and for my experience and what I've seen and what I've lived through that there was a choice at the beginning but there was a lot of external factors playing into that choice being made so when I mentioned that my father passing away my mother having a life threatening illness me having to live with my grandparents and you know this whole whirlwind of stuff and then still this thought of cancer coming back in my mother's life and you know this sense of worry just throughout there was something that sort of kind of pushed my hand into making that choice of you know this kind of makes me feel better I'm going to keep doing this so it's like you know you make that choice to go swimming why do you go swimming because it feels better right you do it because you enjoy it but then when you're out swimming you think I got this I'm so strong I could swim against the current but now the current is taking out the sea you're in a rip tide what do I do here it's okay it's alright I can manage it you're still playing it's okay it's alright I can swim out to the side I can swim but then eventually you're 100 yards out to sea and nobody can get you an exhaustion yeah and you drown and it's it's brutal to see that so I mean beautiful description of the innocence of addiction and how it occurs over time outside the person's experience you make choices but you never choose addiction you choose relief of suffering pleasure improved self-esteem social connectedness comfort the things that drugs bring you temporarily while under the surface there's actually something happening in a cellular way in your brain and before you know it you need a drug just to feel normal and you're willing to do anything to get the drug and you have addiction yeah this is something that we need to keep talking about so people can really understand it that was a beautiful rendition of it it's kind of changed but do you get a little different do you get into it? because it can take all day sometimes I will get sucked into it yeah I'd like to have peace of mind thank you for that thank you for that very interesting swimming metaphor I liked it very much I use it small strokes, small steps small changes in language changes in legislation more support, more recognition that this is a problem we have a long way to go but we're making progress and we just have to stick with it thank you Tan thanks for having me back so thank you for joining us again for part two and we'll look forward to seeing you next time on the addiction recovery channel thank you