 Hi, everyone. Welcome to the Addiction Recovery Channel, or ARC. I am Ed Baker, and I am your host producer. Today, we are privileged indeed to have as our guest Dr. Todd Mendel. Thanks for having me on. Thank you, Todd, for being on the show. Pleasure. Dr. Mendel is a board-certified psychiatrist with added qualifications in addiction psychiatry. Todd has a lot of experience listening to people with mild, moderate, and severe substance use disorder. Todd has over 30 years experience in the field of addictions, both providing direct services to patients and also in the administration of programs and projects, specifically focused on this population. Dr. Mendel also enjoys the distinction of having co-founded the Northern New England chapter of the American Society of Addiction Medicine. I guess the way I'd like to begin the show is to give you an opportunity to share with the audience what it was about this particular population, people with addiction, that caused you to dedicate your career to working with them. It was actually very interesting. A supervisor of mine during my psychiatric residency had said to me, Todd, addiction psychiatry is where you need to go. And I said, why? He said, you're going to have a huge opportunity to work with a very diverse population and to help people. And you'll be able to see that take place over the years. And as it turned out, the job offers that I had after residency all involved programs that had a psychiatric component and an addictions component. And the rest is the 30 years. Yeah. So you've something resonated and you grew into it? Yes. What's it been like for you? Has it been a rewarding experience? I would say very rewarding overall. There have been a lot of frustrations, policy frustrations, people not having access to the treatment they need, the stigma that we continue to talk about in all areas of addiction. And when we lose patients, it's a heartbreak. But overall, I've seen patients have come up to me many years after we worked together and they said, I'm getting a doc. And it does my heart good. Yeah. Sometimes you'll see them with fruitful employment, wonderful families, physical health, mental health. It's a beautiful thing. You get to see that. I find you get to see that if you live like I was living in a very small town where I also practiced. And you just see it. You see the fruits of your labor. That's a beautiful thing, Todd. So I'd like to begin now by setting up like a context for the show. The U.S. mortality rate has gone up three consecutive years. Converse to this, our life expectancy has dropped for three consecutive years. Most of the top 10 causes of death in America are declining year over year. However, the third leading cause of death, which is unintentional injuries, has climbed both in rate and rank. This is profound. Driving this are deaths due to drug poisoning, drug overdose. 72,000 Americans in 2017 roughly. 70,000 Americans in 2018 roughly were taken by drug overdose death. Annual deaths due to drug overdoses presently exceed those from motor vehicle deaths, gun violence, and the HIV epidemic at its height in the 1990s. This is addiction in action. Today's show will focus upon the American Society of Addiction Medicine's recent revision of their 2011 definition of addiction. It's important that we understand what addiction is. So I'll begin by reading the definition and then we'll begin discussing it. This is the 2019 definition, quote, addiction is a treatable chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual's life experience. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. So with that, Todd, you know, I'd like to just ask you to elaborate a little on that definition. What do you think is important for the general public to understand about that definition? Well, I think the fact that it's become much more multifactorial in terms of just the description of the disease process. At one point, I think it was in 2011 that we talked about, we really talked about the brain changes, and that's quite real. However, it's not all, that's not the only explanation. And the fact that ASAM now talks about life experiences, the environment, genetics, it's much more multifactorial than just the brain changes. Even though the brain changes, as I said, are quite real. So there's like a strong emphasis on the environment, including, and I'll read again, because I think it's important to get it out the way that ASAM is explaining it. The updated definition underscores the complex interplay of unique biological, psychological, and environmental conditions that have a role in any one individual's addiction. Genetics can determine how brain circuits function in a person predisposed to addiction, and stressors, and this is really the crucial point I think that you're underlining, stressors such as adverse childhood experiences, lack of healthy social supports, and limited prospects for employment or stable housing can exert significant pressure on the brain circuitry of individuals at risk for addiction. So it's capturing, I guess it's called the epigenetic dynamic. Can you elaborate on that a little bit? I think one of the examples that I give very frequently is if someone is hungry, no matter how motivated they are to work on their recoveries, because we talk about mental health issues and substance use issues, so I use an S at the end of that. If they're hungry, it's going to be very difficult for them to stay focused on the work they need to do. If they're living under a bridge, it's going to be very difficult. Likewise, no matter how motivated they may be at that time. So what are the stressors that a given person is trying to manage at the same time as they're trying to manage their treatment and their recoveries? So it's very easy to look at this conglomerate, which is a really nice way of describing it, but how does it affect each given person? And everyone's unique, just like everyone else. So how do you help a person deal with all of the rest of the factors that are going on and maybe working against them in their efforts at recovery? Yes, and what I've noticed about this is that some of the factors that can contribute to the development of addiction are the same factors that contribute to the perpetuation of addiction and that also feed into making recovery so difficult and sometimes impossible. You know, I know you've seen it because you've been in the field for a long time and so have I, that we would have people who would be discharged from a residential treatment program with no drugs in their system and in the very beginnings of the possibility of brain healing discharged into a community where drugs were prevalent and some of them didn't even have a referral for psychotherapy. There was not a lot of AA and NA around and there certainly were no recovery centers. So these people were kind of discharged back into an environment that was almost overwhelmingly in favor of relapse. Well, certainly at the time of discharge from any type of long-term program is a high risk time for relapse, potential relapse, overdose, and potential death. So it's a particularly scary time or a risky time for a person and handing someone a referral, a paper, a card with a referral name on it isn't really enough. We call it the warm handoff is much better and modeling to patients how they can advocate for themselves with a new provider. We don't give a name of a cardiologist for a person with heart problems and expect them to call themselves without a referral. There weren't many resources available for substance use disorders but now that there are more of them, how do we help with the better handoff so that the person betters their chances of getting to their first appointment? Yeah. And then retaining them? Yes. Well, retention is a tough one. And I think this is the basic thrust of the revised ASAM definition is to underscore exactly what we're speaking about. That resources must be allocated that will affect the environmental conditions that people find themselves functioning within. Housing is huge. People being released from incarcerated, you know, time incarcerated, if they don't have adequate housing, what are they supposed to do? They're in a tough spot. Right. Medications for addiction, counseling for addiction, recovery coaching for addiction. All these basic inputs need to be funded at an increased rate over time if we're going to make lasting progress in this particular area. I agree with you. The having resources at the type that is needed by that given person at that given time. We talk about having enough beds. Well, it isn't always beds. What is the treatment that this particular person who's coming out of a residential program or out of incarceration needs at that time? It may not be a bed, but it may be an outpatient treatment, intensive outpatient day treatment. But being able to put those resources together for that given person's needs is that's a tough, that's tough. We're having to cobble together things for folks and relying on public transportation potentially. And there are other forces, for example, if they leave incarceration in their own probation parole, whichever one it is, and they have the expectations of the legal providers and how many urine tests and how many appointments they have to go to, as well as the rest of the recovery work. It can be very challenging for a person to get to all their appointments that they need to get if they don't own a car, if they don't have a stable place to live. Realistic expectations is key also. And I think one of the things, and that, again, is well put, I think one of the things that we're seeing today, especially in Vermont, and I think Vermont is a little bit different than a lot of other states in America. One of the things we're seeing in Vermont today is like an acute new awareness of this idea of addiction being a brain disease and that we have to respond to it in very certain ways or people are not going to get better. Now, I know that you served as the medical director for the Office of Alcohol and Drug Programs here in Vermont during a very formative period when the opioid epidemic was beginning. I think you were part of rolling out methadone and buprenorphine and certainly expanding treatment opportunities for people. What's happened since then? And I think you laid a lot of the groundwork for what's happened since then. What's happening since then is actually profound. And on many levels, we have recovery supportive housing now. We're expanding that. People are being licensed so that the housing is the best possible quality. We have the Agency of Transportation looking at ways to get people to AA meetings and NA meetings and appointments. We have recovery-friendly workplaces being developed so people can actually secure meaningful employment. We have just so much going on in Vermont today. And I think it's in recognition of the profound nature of addiction. And I'd like to go into that a little bit, that what the ASEM is calling addiction specifically a brain disease that develops in the later phases of substance use disorder. So we have three phases of substance use disorder, mild, moderate and severe. And the American Society of Addiction Medicine is saying, we want to use the term addiction for the more severe manifestations of substance use disorder. We care to comment on that. What is it that occurs in the brain at those later stages that differentiates addiction from mild substance use disorder? Well, first let me comment that I think that giving the scale, the sliding scale of severity is a really important piece. It used to be not all or nothing, but it wasn't as descriptive as it is now. And they called substance use disorders to remove some of the stigmatizing words from the definition. Yes. Someone who may be using substances at a recreation level that may be too much and they start to suffer consequences from it and change their behaviors tend to be in the milder and they haven't had the brain changes, which we talk about the, and I know Dr. Brooklyn previously has talked about the Pleasure Center and the Reward Center and neurotransmitters less likely to have occurred at the lower level of severity. On the other hand, there are people who use crack cocaine a couple of times and they start to have changes pretty early on and the compulsion comes up pretty quickly. Other people as you, we talk about kids of college who unfortunately use a lot of substance abuse, substance use, let's say, at college and someone gets an ultimatum from their family, I'm not going to continue to pay for your education unless you straighten up and they do. Some people are not as fortunate, but as the disease progresses for whatever substance and they're different in terms of how they progress, but when the brain changes occur, it's not so much something that I could say, I'm putting this down anymore, no matter what the ultimatum may be. It can happen, but often there's a lot more treatment, a lot more resource that's needed. Yeah, and I think that's such an important distinction and I like the way you further distinguish that that process can accelerate at different rates depending on the person and depending on the drug and it's not just one size fits all, it's very, very complex. So when we generalize, we get ourselves in trouble when the general public receives information that's generalized, the perceptions that they begin to adhere to tend to be not accurate and very often can lead to stigma. You know, one of the things I heard you say was, okay, so we'll take the college student that's with a falling grade point because of, let's say, alcohol use or alcohol and marijuana use. Not studying, not getting enough sleep, using drugs too frequently. So the person's parent says, you know, your grade point is going down, it goes down another two points, you're out of there. We're not going to pay for your tuition, your room and board, you're going to have to come home and get a job. So it's the prefrontal cortex, really, the executive function of the brain says, let me weigh out the consequences, the rewards, the punishments, my options and let me choose whatever the best route is for me, rationally. The person makes the choices and says, okay, I have to stop, you know, I have to decrease my involvement with drugs. I can't succeed at college unless I do. And they have the wherewithal to do that because their brain isn't yet compromised by addiction. That's really important for us to understand because I think part of the misunderstanding that's occurring is that someone with addiction, someone with severe substance use disorder where that whole prefrontal cortex has been impaired and they're sort of victims to their own impulses, they can hardly resist impulses in spite of consequences that we sort of think or uninformed people will think that people with addiction can just think their way out of it or decide their way out of it without treatment. This, I think, is a dangerous misconception. I think you're quite right about that. I will harken back to an experience I think we've discussed in preparing for the program is that I once testified in a different state at a Senate hearing and as I came up to the podium to give my spiel about the need for medication-assisted treatment to continue in the area, I was told before you start, Dr. Mandel, don't quote a science. I said, what else is there? Isn't that the core of the definitions? We're looking at a brain disease. They said, stop talking about science. I said, well, what would you like me to talk about? They said, decreasing the expense of substance use treatment in the state. Wow. So I couldn't even get to the other issues that ACM has so elegantly put down. Not only is there a brain changes, documentable brain changes, but all the rest of the factors that they talk about, there was nothing left to say. I came away from the podium really frustrated. I said, why am I being asked a question like that when we don't cut off funding for people with cardiac problems, people with seizure disorders that may have relapsing conditions, may have courses of their treatment, diabetes. What youngster who comes down with diabetes doesn't want to eat cake and goes and has a problem. And wants to know, well, will. Well, often until things square away with them and they realize that they have to take responsibility, which they can do. But it was very frustrating to me to be told not to quote science. It was based, don't say that the studies will show. Yeah, not shocking. It was how do you cut down the expense. And I was, to stick with that point for a second, I was really recently asked by someone who said, well, Todd, how come they, you don't give people two shots at this and then they're off. I said, do we do that for any other part of medicine? Or anything, two shots? How could you possibly, and he said, I guess you're right. I said, people, give people here that are dying because of this disease. And you want to say two shots? Two shots of treatment? Very frustrating. We need to regroup as a culture. And I think that's happening because of the widespread nature of disease and lethality in America today, that there seems to be more and more attention being paid to it. There's grass root movements. And I'm a little bit, like, tunnel-evisioned because I spend my time in Vermont. And if you live in Vermont, you feel, actually, you feel optimistic. Like, we do have some hope with this, but I know it's not the case for the rest of the country. You know, the, ASAM goes on with one last sentence. And I think you touched on it just now eloquently. They say that prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases. So do you care to elaborate on that a little bit? Well, let's look at the use of antibiotics. Who of us or has taken their full course of antibiotics and not left half of it in the medicine chest after you felt better? So medication compliance across the board in medicine is not 100%. It's not even close. So how can we expect folks that have this constellation of risk factors and brain changes to be perfect? We're all human. We all make mistakes and we all have setbacks. So the fact that ASAM is trying to perhaps normalize the substance use disorders into routine medical jargon to say this is just like any other disease. We have to work on prevention. We have smoking prevention. We have DWI prevention. What's the difference? We don't ever say to someone you only get two shots or two chances to have your asthma or your emphysema treated. Okay, I'm sorry. Radiation, chemo. If you don't stop. I get excited with talking about addictions. It's a very important point. We don't put that kind of limit on anybody else. Why should we put it on folks that are suffering from addiction, substance use disorders or addictive disease who also may have a mental health issue? Or medical issues that go along with it that may also be barriers to their getting better. Why would we put that kind of artificial limit on exposure to treatment? The answer, the most obvious answer is stigma. You and I today are mightily fighting against stigma by bringing out information that is accurate and timely for the general public. And a lot of the general public seems to be catching on. But still, stigma is alive and well in America today. And I'm sure we're all too painfully aware of that. I'd like to just focus a little bit more on the commentary on the definition. They say, asem says, we will not be able to punish our way out of the crisis. And we must face the reality that stern talks about drug use will not treat a devastating disease. Blanket punitive policies including incarceration without access to evidence-based addiction treatment medications ignore science. We have no evidence that a felony charge or a time in jail cell addresses the underlying disease. And the consequences of incarceration only add further pressures that make it more difficult to manage the illness. So it seems like they're really trying to get at the fabric of what is perpetuating, you know, addiction in America. This misunderstanding that a stern warning or punishment or the war on drugs, like that's going to work, it's just not going to work. And they also begin to look at profound cultural and societal arrangements, you know, adverse childhood experiences, poverty, difficulties, you know, seeking and acquiring meaningful employment. I mean, they really begin to focus on some of the underlying societal conditions that set people up for addiction. Do you care to talk about that a little bit? Like, what is your, do you have hope that the American culture, the American society can really begin to get real about this and not just focus on the symptoms and focus on the fatalities, but at the same time, without taking resources away from people with addiction, focus on some of the underlying causes. Well, let's back up for just a moment and look at the stigma that exists within the treatment provider networks. Okay. One of the things, one of the tip for substance abuse, substance abuse, SAMHSA, talks about is that someone showing evidence of their substance use behaviors, for example, a positive drug screen does not mean they should be discharged. And that's been an uphill battle for some programs is that one positive drug screen, and we don't say dirty anymore, dirty or clean, one positive drug screen means you're out of treatment. How does that help the person when they're just exhibiting symptoms of the problems that brought them into treatment? Of course. So even within the treatment network, we still have our own baggage to clean up. And at the same time, we're asking the greater populace to say we would like very much for you to understand that folks with substance use disorders need treatment. It may be a chronic nature. The duration of someone, for example, being on buprenorphine or methadone is strictly an agreement between the provider and the client. There's no set guidelines as to when someone ought to come off it. There's no set guidelines as to when someone needs to come off their dilanthin, if ever, for a seizure disorder. And I tend to use the seizure disorders more than the diabetes model that people talk about. They're both very applicable. But how do we, what is SAMHSA is trying to do, to mobilize or embrace addiction, substance use disorders into the medical model, into the medical, into general medicine? And I think that as providers, we need to set an example. So along those lines, you can have a provider's office, a physician's office with a waiting room, maybe a group practice with five physicians in a waiting room with maybe 10 people in it. And two of those people might be there to see their doctor for a urine drug screening and to have a buprenorphine prescription updated. And they're just in the waiting room with everybody else who has some sort of medical condition and it's just seen as the same. Nobody knows why anybody's there. It's all confidential. You're here for buprenorphine, you're here for this medication, you're here for a checkup, whatever. It's all just part of the American health landscape. That was the original intent of the release of buprenorphine. It was office-based treatment, just like any other person coming in for any other problem. Just a little bit more training because we know no other medicine has required eight hours of training to be able to prescribe it. But that was the point. It was office-based treatment to normalize as opposed to, and some people have trouble with going to a methadone clinic. Some people have trouble going to AA, so it's trying to match the treatment approach and setting for the person, not just the medicine. All right, and I think that profession, ASAM, social workers, certainly licensed alcohol drug counselors, licensed mental health counselors. There's a lot of private practitioners out there. There's a lot of programs and projects focused on this that are all kind of moving this ball forward. And a lot of the attention today, rightly so, I do believe, is moving toward the underlying conditions that persist in the American culture that sets the stage to make people more vulnerable to addiction. Now, you know, how do you have hope about that? Having been in the field for a long time and having seen the progress that you've seen, do you think that we will actually, this time, because I've seen profound starts to do something about this a number of times during the course of my career. But I can honestly say to you that I have never seen a groundswell of compassion that has the kind of traction that this one does before in my lifetime. So I do feel hopeful. We have trauma-based education today in Vermont. We have trauma-based psychotherapeutic treatment in Vermont. People are looking at ACEs. People are looking at getting to families and giving them more support. So there are things afoot, and it's expanding these things over time, never saying, and this is the difference that I see today, people are not saying that we've done enough. People are not resting on their laurels. People are really ready to move forward. Do you have hope that over the next two decades that we will make significant progress in the underlying causes? I do, actually, and I'm aware of many what we would call grassroots initiatives by different medical societies to bring, for example, to bring medication-assisted treatment into the emergency rooms. How do you begin someone, for example, on buprenorphine when you've screened? They seem to have a substance use disorder opioid dependence, as we used to call it, and they're showing signs of withdrawal. How do we get them connected to treatment right then? How do we provide education about overdose prevention for people who are in medication-assisted treatment for substance use disorders, as well as for pain management? What are the tips we can get people to look for? And certainly, more police officers are carrying naloxone kits with them, and that was a major pushback to that in a lot of areas. Why bother having folks with addiction problems used with impunity? Why would you not want to have them have a rescuing available to them anytime that they're using? So there are quite a lot of initiatives, but we also have to remember that in addition to the medical piece, the medicine piece, what about the rest of the factors? And I'm not as involved in those initiatives. Those societal factors. Right, and I hear about them, and I'm aware of the different programs that are offered, different levels of care. How do we make treatment at the time that's needed, at the level that's needed, more available, and that includes all managing all the rest of the factors that we're talking about. Right, and not playing one off against the other, like it's either or. It must be both simultaneously if we're really to make a difference. And I think if you look at AIDS, I think AIDS, the HIV epidemic, provides a really good model because there was the urgency of people dying now, a lot of people dying now. And then there was the added urgency of needing to educate people, treat people, and then prevent AIDS. And we really, or HIV, we did that. We're pretty successful at that in America. And we also are set like a global example, and we've helped a lot of other developing countries. And that, I think, was the Surgeon General's report of 1989 that got everybody's attention along with some things that were happening in our society that really began to turn the corner. And we have today, we have the Surgeon General's report of 2016, Vivek Murthy, Facing Addiction in America that I hope will be kind of similar to that 1989 Surgeon General's report and beginning to really generate like a national effort to get at some of the root causes while treating, while responding to the urgency. Economic, very much, economics very much play a crucial part in it. But also, and I know that you're acutely aware of stigma, that when the more people understand addiction as a brain disease that anyone can get, the less stigma they'll be, and the more likely will be to take meaningful action. Let's also go back to, as we mentioned, as we discussed before, we came on the air, was that when I first entered the workforce in the addictions and psychiatry field, the inpatient programs were called dual diagnosis. And that has morphed over time into co-occurring, people with co-occurring disorders. We don't say someone has, someone is a dual diagnosis patient any more than we say that someone is a schizophrenic. We say a person with schizophrenia, a person with mental health and substance use issues. And my soapbox on that is, it's a complex person. You don't have to necessarily define them by their diagnosis. And we also used to say that you had to be sober for a period of time before you dealt with mental health issues. The sequential model didn't work and the parallel model didn't work. It's the integrated model of how we're going, the illnesses or the challenges play off each other. If we don't address them simultaneously, we're doing a disservice potentially. Beautifully put, sequential, parallel versus integration, I like that. I didn't make it up. I like that. Certainly the field today is moving in that direction. Much more. You know, well, Todd, we're growing short on time. And I mean, I'd love to invite you back on the show. I think that you're such an experienced guest and your heart is in the right place for sure. And I'd love to have you back on the show at some point. I'm in the habit of ending the show with my guest talking directly to our viewing audience. So although I hate to end the show, I think it's time we end the show. I'll give you the stage to make a comment to the viewing audience. And I really hope to have you back on the show. Thanks for having me. It's been a pleasure. I can only suggest that we keep doing what we're doing and building on the successes. We've come a long way as we've talked about, but we still have a long way to go. And it's important to build on the successes. And Ed mentioned retention. Retention in treatment is a huge issue. And how do we address that, even if treatment services are available? So there's a lot to think about and a lot to do, but I appreciate being able to be on the show. Thank you, Todd. Thank you.