 Hi everybody. I'm Ed Baker and it's my pleasure today to welcome you to the Addiction Recovery Channel, otherwise known as ARC. For those of you who may be tuning in for the first time, ARC is a TV station that is devoted to raising public consciousness specifically regarding substance use disorder. The idea being that if the general public has accurate information, they are likely to approach this particular population with substance use disorder with compassion. And we will actually be saving lives. So today it's my pleasure and my honor to welcome Dr. John Brooklyn to my show. Thank you, Ed. Thank you, John. Thanks for having me, yeah. Thank you for being here. I'd like to begin with a couple of statements about Dr. Brooklyn's career and his history. Dr. Brooklyn was licensed as a physician in Vermont in 1992. He was board certified as an addiction medicine physician by the American Society of Addiction Medicine in 1996. And he has been an innovator and a researcher in the treatment of opioid use disorder since the mid-90s, specifically leading Vermont's innovative buprenorphine program since 2002. Now, you don't find many people around who have that kind of distinguished career for that long a period of time. And that way is what drives my first question to Dr. Brooklyn. John, I'd like you to give the audience a general perspective on what you've seen. You've been here since the beginning of the opioid epidemic and you're still here now. So what have been your observations? How has this happened? So when I came here in 1989 to do my residency, I had been trained at Brown University on substance use disorders or addiction as a disease that's treatable. And so from my perspective, it wasn't anything unique or special to see people who were using alcohol or injecting heroin as a medical student. So when I came to Vermont, it just seemed like another disease to treat like diabetes or high blood pressure. So when I finished my residency, actually during my residency, I was asked to do some trainings for the other residents and even some of the attendings. And it became apparent pretty quickly that there was zero treatment for people who were heroin users, we'll say, at the time. And so when a job at the university opened up in the research wing, I took it. And so for many years, anybody who was a heroin user, the only treatment available in Vermont was through our buprenorphine studies at UVM. And so I feel like I got to see the majority of individuals who were struggling with this. And we would have 50, 100, 120 people in different studies. And it wasn't until about 1998, 1999 that we began to see a change from just heroin use to pill use. And predominantly it was Oxycontin, the long-acting Oxycodone. And primarily that was because it was being widely prescribed. So there was a shift from injection heroin use to pill use. And then in the early aughts, still a fair amount of pill use, but heroin became stronger. And suddenly we began to see people who were no longer injecting it, but were sniffing it. So you went away from people who maybe would have never used heroin because they had to inject it. Now looking at it is something that they could use because they could use it in a less difficult form by sniffing it. And when our first treatment facility opened in 2002, the Howard Center's Chittenden Clinic, we took people from who were traveling out of state because I don't know if you were aware, if the viewers were aware that in Vermont in order to get any kind of methadone treatment, which is another treatment for heroin users, you had to ride three hours each way to a program either in Greenfield, Massachusetts, or Nashua, New Hampshire, or even Albany. And so people would get on a bus at 2, 3 o'clock, or a limousine, 3 o'clock in the morning, show up at the clinic at 6, get a dose, turn around, and come home. Every day. Every day, until they were given some take-homes and they wouldn't have to travel every day. But predominantly, when the clinic first opened, the first cohort we took were those travelers. And so then we had a waiting list from the very first day we opened that program. And what happened is that over time, as people realized that there was now methadone treatment, they began to call and call and call, and we had quite a number of people in treatment. At the same time, buprenorphine became available in 2003. So all the studies that we did at UVM helped pave the way for the FDA to approve it. And so you then had a lot of physicians in the state who understood about buprenorphine because some of their patients had been in our studies, they were agreeable to learning about how to prescribe buprenorphine and began to prescribe it. So you saw zero treatment for about 10 to 12 years, and then suddenly treatment, which was available, but waiting lists everywhere and treatment demand because more and more people were looking for treatment because there was more availability of prescription opioids, heroin didn't have to be injected, and it became more and more of a problem. I think when you talk about the current day situation, what's really been a game changer is the advent of the synthetic opioids such as fentanyl and carfentanyl, which are very, very potent. And so previously someone may inject a large amount of heroin, but not overdose and dye, and now you have people injecting one or two doses of white powder that they think is heroin and it's fatal. So I think what you've seen over time is the evolution into just that much more of a potent substance that we have to be even more thoughtful and careful about trying to make sure that there's treatment for everybody, which we've now achieved in Vermont as we were talking about earlier. So why do you think it is that the number of people with opioid use disorder grew so rapidly? That's a great question because for decades the feds thought they were sort of on any given day about a million uses of heroin in the United States, and that number remained fairly constant, partially because unfortunately people would pass on from using heroin and new people would come and use, but I think the game changer was the prescription pills because if you think about it, if you're a person who would be unwilling to inject a bag of powder, but you got a pill that the FDA had stamped saying this amount of medication is in this pill and it came from a physician or it came from a pharmacy, there's more legitimacy to that. So I think people had this sense that it was a safer substance to use. It has a low addiction potential. Or not only that, but they were less likely to have harmful effects because it wasn't cut with anything. You knew the potency, you could stratify the amount you used, and so it was just a consistent product and I think what happened is that as people experiment, it leads to more and more experimentation. More pills are out there, more teenagers get a hold of pills, parties, whatever, and so you just have a rising tide of individuals who were exposed and now you've got maybe four, five, six million individuals in the United States who are dependent on prescriptions versus heroin, so the numbers tripled or quadrupled in terms of the total number of people who are opioid users. And then there's also, I think, data that shows that around 1994, people with heroin use disorder, their first opioid of use was a prescription opioid rather than heroin. They began with a pharmaceutical opioid, illicitly obtained, and then later on switched over to heroin, presumably because the heroin marketers began infiltrating the area with high-grade, low-cost heroin. But tell me if this is one of your observations. This is one of my observations from my private practice. This happened many times. I would get usually a male between 20 and 30 years old in my office who's either got injecting heroin or has an opioid use disorder with prescription opioids. You take a history and find out what happened with them. And I can't tell you how many times. It was because of pain that was generated from hard work. We have a lot of young people. They do landscaping, mowing, just the construction. There's a lot of people in that industry in Vermont. I cannot tell you how many people I've had in my office who were introduced to an opioid by a coworker to deal with pain, and that inevitably led to full-blown opioid use disorder. Have you seen that? Absolutely. In fact, I think when Dr. Chen was our commissioner, he was very wise in trying to identify the fact that most people actually started with a legitimate prescription, whereby you went to the emergency room or you went to your doctor and you had an injury, back injury, leg injury, or you had an orthopedic injury, and you were prescribed. And you were prescribed much too long to the point where you became physically dependent. And then the docs erroneously believe that you would have suffered no symptoms of withdrawal if you stopped abruptly. Well, we know what happens when you stop opioids abruptly after a couple weeks, and then you're out looking for pills. And the pills are more costly. And next thing you know, the dealers are around with low-cost heroin. So if you start off with Percocet or Oxycodone, and then you progress to the long-acting Oxycontin, it was going for $1, $1.25 a milligram. So if you're using 160 milligrams of Oxycontin a day, you're not going to make that money pumping gas or mowing lawns. And next thing you know, beg, borrow, and steal, heroin's around the corner. $10, $15 for a dose. And next thing you know, it's the low-cost option. So that's exactly how I would say most people, even today I still encounter people when I'm doing intakes. You know, they were on these medicines 10 years, 5 years. But inevitably it led to a situation where heroin entered, and it's, you know, quite... In fact, the other thing, just to point this out, is that one could argue that one of the reasons there was a rise in opiate use, and this may be a little controversial, is that when you raised the drinking age to 21, and you made it harder for people to obtain alcohol, there was no difficulty finding opioids or heroin because you weren't going to get carded anywhere. And so we know that for many, many years alcohol use disorder was the predominant. In fact, we used to say opiate users are just a tributary in a sea of alcohol use. That's really changed. I think two or three years ago we saw for the first time a decrease in admissions for alcohol and an increase in opioid admissions that finally overcame the admissions for alcohol. So one could argue that there was an unintended consequence by restricting access to alcohol that led... Because let's face it, our brains are wired for novelty, right? We want to do something that's fun and exciting, and if it's going to be a substance and you can't find this substance, well, let me try that substance. How harmful can it be? It comes in a pill form and I'm just going to snort it. And then there's a certain percentage of the population that tries one substance or another, maybe opioids in this case, who have inner pain. They have psychological pain. They have emotional pain. They have post-traumatic stress. We call it adverse childhood experiences. Somehow their brain is wired and their emotions are wired to respond in a way to psychoactive chemicals that's kind of outside the normal response. They want it more. They think about it more. It relieves inner pain so they're more driven to seek it, which eventually leads to addiction. But you mentioned something really interesting. You know, it's the behavior of people with substance use disorder or opioid use disorder in particular that, you know, seeking the drug, obtaining the drug, injecting the drug, maybe in fact, acquiring money to purchase the drug in ways that they wouldn't normally do. Can you talk a little bit about how does a person who may be brought up, you know, with a really, you know, a sterling value system under the influence of addiction, behave in ways that are outside their value system? What is that? How does the brain operate where it enables that kind of behavior? How do people do that? So, as I think about it, it's rare for me to ever meet anybody that says, I've always wanted to be a heroin user. Right? When I was 10 years old, I didn't wake up one day and say, by golly, that's what I want to do. And so, people I think are constantly upset at themselves for how they got there. And let's not be mistaken. A lot of people who are using opiates started legitimately. They were prescribed. And for whatever reason, it filled a void, as you say, and they couldn't stop. So, part of what we have to recognize is that in the wiring of the brain, we have a pleasure system. And that pleasure system responds to some kind of thing that makes us feel like we've been rewarded. For some people, it's doing well on an exam. For some people, it's winning a race. For some people, it's jumping out of an airplane. And for some people, it's some kind of substance that they have to take because for whatever reason, their reward system has either been hijacked or maybe had some abnormalities to begin with. Maybe there's a genetic component because that does exist in some cases. And so, when you have that kind of situation where your normal thinking gets hijacked, because we're talking about chemicals in the brain, it's pretty potent. So, in the case of opioids, we have many places in the brain where a chemical called an endorphin, which is an opioid peptide, go. And that purpose is to relieve pain and stress. And it's tied in to our sympathetic nervous system. So, for instance, if you have something traumatic happen, let's say you drop something on your foot, and it really hurts, you're most likely going to release some dopamine to help you through that so that you can at least deal with it for a short period of time, and then you get better. But if it was more significant for that or you had a difficulty in the way that you released endorphins, you may continuously release that adrenaline as a stress response. And if your way of dealing with that stress response is not as functional as it could be, you may seek out substances which reduce the amount of adrenaline that you make so you don't feel so anxious. And so when you talk about people with any kind of substance use disorder, we like to use the word trauma-informed. And when you look at data, you look at people that come in so much of what is at the basis of how people choose to use substances. If something happened, something traumatic, in many cases, 60%, 70%, 80% of the time, that caused the front part of the brain, the sensing part called the amygdala, these memories are stored, to be activated in a way that has a negative connotation for the person where they're trying to avoid something. And so by taking opioids, you down-regulate that adrenaline, you don't make as much adrenaline, and you feel calmer. Cocaine will do the same thing. Alcohol will do the same thing. So if you're not able to, on your own, release the chemicals that you need, you may discover that by taking a substance, you can feel better. And so you kind of hijack your normal way of coping. And so people find themselves in distress. Someone dies, they get divorced, they lose a job, and someone says, oh, here, try this, snort this, and they like it, and they keep doing it, because at that moment they were vulnerable. Even well-meaning folks who were whatever, they're vulnerable, and they start to use it. And because of the nature of receptors in the brain, when you start taking some of these drugs as a receptor, you can become physically dependent. And so by being physically dependent, you take it all the time, and then when you don't take it, what happens? You go into a drawer. What happens when you're in withdrawal? You release all this adrenaline. So what happens when you release adrenaline? Then you're motivated to seek the drug. You sweat, you're anxious, you're uptight, your belly hurts exactly. You take the drug and the problem goes away. So I think research will say that most people keep using drugs that are really sick, and when they finally recognize they're having difficulty, there's shame and there's guilt and there's resentment and all the things that you wouldn't expect a person to feel, they say, how the heck did I end up here? And there's that self-loathing that occurs. So there's that part then. There's the person with addiction being driven to seek the drug because of withdrawal or stress. So there's that part of the person that's still there, their value system that says no, you know, you're in therapy or you've promised your loved one you're not going to do that anymore or you're about to get fired from your job or that's behavior that you just never wanted to engage in. So while the person is driven toward a behavior, they're also resisting the same behavior. What is it about people with substance use disorder where that ability to resist fails them and they may want with every cell in their body to not engage in taking that drug, but yet they go ahead and do it anyway. That's a great question. And what I would say is let's take heroin for instance. The unique thing about heroin as opposed to say taking pills is that heroin is a substance, the way it's manufactured, the chemical structure that it gets into your brain when you inject it in about 10 seconds. It crosses the blood-brain barrier which sort of protects our brains from different drugs. We have a barrier and it gets in there in 10 seconds. And what it does is it flicks that part of the brain on where those receptors are very quickly on but it doesn't stay there very long and then it turns off. So when you use heroin long enough, you begin to change the way that that cell is actually coded to operate. So that instead of being a cell that can tolerate some stress, without the opiate being present, you feel edgy, irritable, anxious weeks or months after you stop using heroin. And we believe based on human models, animal models, genetic studies that the cells change fundamentally in some cases permanently. So there's a big recognition that heroin use can become a chronic brain condition that despite your best intentions, your promises, everything you've done, your brain has changed in such a way that you just can't live without it because you're on edge, you're irritable and then you take the drug and you feel well again. And so that in many ways informs our belief that this is methadone, which is an opioid replacement or buprenorphine, could be for some people a lifelong treatment. But we don't argue that about thyroid replacement or insulin replacement. We're like, yeah, but it's the same thing operating and I think part of my work has been to try to normalize this as a process that's treatable, but it may be long-term treatment despite the persons. And so what happens is that people who come on to methadone or come on to buprenorphine, and let's face it, not everybody does well in any kind of medical treatment, but people who do well, they stop having the cravings. They stop having that and they begin to function in a way that they restore themselves to their previous state of being and they feel like they're in recovery and they do activities and they become normalized in a way. And then if they want to wean off because they think they've been good for 20 years, maybe they are. Maybe they sprain an ankle in a basketball game and some ER doc gives them a pill or two and they're off and running again because their brain's been recharged. So I think the point is that it's long-term changes that often occur that's very frustrating for people because if I'm your partner and I'm like, listen, you've been da-da-da-da and you're like, oh, I don't want to use, I don't want to use and you do, I don't want to be around the being angry and blaming the person for something that may be a biologic change. And that's really the point, that it's not a choice, given the choice nobody chooses, I'm going to grow up and be an addict. That it's a brain disease. It's a powerful brain disease and it's a chronic disease. It can last a lifetime, but also it responds really very favorably to the correct treatment. Sometimes medication, all the time psychotherapeutic supports and all the time adequate recovery services. I mean, I know many, many people who have been in recovery for many, many years and I've known people who have relapsed and gotten back into recovery. So when we have this kind of approach, then our response as a public is compassion, inclusion, vote for the people and put money into the programs to provide adequate services to help these people. If we don't have adequate information, then the normal response is, as you say, punitive, anger. I'm going to modify your behavior. I'm going to punish you until you stop, which we know doesn't work. Every now and then it does. Some people sit behind bars like, okay, I'm never going to do this again or do it again, but maybe they were lucky to have that kind of a brain that allowed them to do it again. For the most part it doesn't work. There's exceptions to everything. But the other thing I just wanted to say in response to that is I think what happens, and we talked about this earlier, is that it's really hard for people to feel self-compassion. You know, I often feel as though you have to give yourself credit for what you're going through, because every time you think about what you even use, we try to get away from pejorative language. We try to get away from saying, I'm clean, I'm dirty. It's like I used and I have a positive result, I had a craving, I acted on it, but not to... Because sometimes people who have the disease can be their worst critics. The language that's used and the way that they feel about themselves doesn't lend to recovery, because they're like beating themselves up. How can you really do well every time I drop a cup of tea? I don't think I'm like the worst person. I just sweep it up and move on to the next cup of tea. Isn't that really the point of consciousness-raising and positive messaging speaking about addiction, about substance use disorder in medical terms rather than punitive terms? Because people with this order, they will internalize the stigma that's placed on them by the general public. So if the general public is saying, we care about you. We care about you enough to have adequate services for you. Okay, you've relapsed. Let's try again. Let's use it as a learning experience. That person will begin to internalize that. That's the wonderful thing about everything that you and other leaders in this field are doing. It's like a cultural shift that has to happen now. And we owe it to the people who have been taken by the disease. They're the ones who shed the light on the gravity of this and have motivated us all to finally do something about it. And I know how deeply you care about the population. So I wanted to ask you. You've been a leader. You've been an innovator in medication-assisted treatment. You've succeeded in Vermont. The first methadone treatment program, the first buprenorphine treatment program, your model is there are people all over the United States looking at your model wanting to replicate that. The hub and spoke model. All over America. What do you see as being next? Is it injectable buprenorphine? Is it safe injection facilities? What's the... We're obviously trying our best, but the fatalities are still rising. So, what is next? What do we do next? So, if you think about let's talk about the worst-case scenario, overdose and fatalities. I'm a medical doctor. I have patients who, despite my best efforts, continue to have heart attacks and die. People who, despite my best efforts, don't take their diabetes medicines and lose a leg. I said, just because treatment's available doesn't mean everybody wants to do it because getting up every day, getting dressed, going to the clinic, going to the doctor's office, for some people it's work, and for some people it's easier on some level to just get the drug delivered to their home and use. So, how do you motivate individuals to say, treatment, how low can the barrier be so that there's no barrier there? Okay. So, if we start there, you could say, all right, we have 1.6% of Vermonters over the age of 18 on medication-assisted treatment, which is the greatest number in the United States per capita. What's the actual number in Vermont? We have about 8,000 people right now on either Method owner, Bupenorf, and I have about 500,000 people over the age of 18. When you think about that and you say, okay, let's say that there are maybe 20... 30, 40% of people using. Who have opiate use disorder on some level and it can be as low as 10 years old to 90 years old. We shouldn't kid ourselves that there's a certain segment of society that uses because there's a lot of older people who are maintained by opioids that are probably having difficulty with it, but let's just say we need to make sure we have enough capacity. So, from my perspective, we've got enough structures in place. We've got enough doctors prescribing Bupenorf and we've got enough doctors wavered. We've got enough hubs, but we don't have necessarily the workforce. We don't have enough people who can be licensed alcohol and drug counselors, masses and social work, RNs to sort of fill the roles of what we call the MAT teams that help the docs in the team-based approach. So that's an issue and I think Governor Scott has talked a little bit about the workforce. We're training all docs, all family medicine doctors, and I think almost all internal medicine doctors who go through UVM residency programs are being wavered in how to prescribe. So you're building the next wave of people who can take this on. I think that the criminal justice system is an area we really need to focus on because if we could eliminate the thought that you are a drug user and you are committing a crime, we perhaps can redirect more people into treatment. Now anybody who's incarcerated who's on MAT continues for up to 90 days while incarcerated which is a big change. And I think the concept of a safe injecting site and looking at the risk factors that exist for people getting infections of their heart and their bones and their brains from injecting and the cost associated with being hospitalized and obviously first case scenario, the cost of death we need to kind of be smart about how do we help people not necessarily put themselves at risk because even though our overdose rate is going up the amount of people the rate of increase is still very very small compared to most other states and I can only say that if we didn't have this many people in treatment, we would probably mirror the state of New Hampshire right next to us or Massachusetts with very large overdose. So even though we have people who are not doing well we still are doing very well in terms of access to treatment and so how do we just again get more people to come into treatment and accept the fact that MAT is often very beneficial. Okay, so the goal would be to have 100% of people who need it receiving it. Also along those lines of naloxone the easy availability of naloxone in Vermont I think the fatality rate would be much higher without naloxone. I completely agree with you it's a pretty low barrier to getting naloxone in fact if you come into treatment at the Chittenden Clinic we have a pretty much 100% access to naloxone so if you don't have a kit we give you one safe recovery which is down on Clark Street does a lot of naloxone kits and so we really feel like if you're not in treatment or even if you're in treatment and you're not using you should have a kit so if you have a family like Grace Keller I have two naloxone kits now I carry one in my backpack I mean you just don't know you go into the bathroom and all of a sudden you see somebody down So you know in closing I want to thank you You're welcome I want to thank you for your leadership for your perseverance over time for your single-minded focus and your innovative mind and I want I'd like you to close the show today I'd like you to tell the general public you know directly tell people out there with substance use disorder just in closing whatever you want to tell them John So I think what we have to recognize and I think most people know it's our sons and daughters our mothers and fathers I mean this is a disease that can touch anybody but for the grace of God we've never encountered that and so if we can move to a place where we're not maligning someone for having developed a substance use disorder of some type and treat that person with try to help them, control them somehow find their way to recovery I think that's really where we ought to be going and not being so angry and upset even though we're going to have that reaction and I think it'll make for a better society overall Thank you John Alright