Episode 30

all right welcome back to another exciting episode of finding peaks i i was actually thinking about this before this started and i always say exciting episodes of peaks yeah like is that people are just yeah like just can’t just can’t wait more brandon more in the background so i hope it’s as exciting for you as it is for me uh at the end of the day so exciting episode we talked about it a few weeks ago or at least have promoted it uh joined today with uh medical uh team members uh here at peaks recovery centers uh dr ryan johnson uh md and he is our medical director and director of nursing cali thank you kelly i am spacing on your last name thank you i was going to say kind so i’m glad we got that i dressed i’m new to this everybody is watching first day chief operating officer clint nicholson everybody hello everybody so very excited to be joined by the medical team i think they’ve got a lot of great things to um help educate on in regards to medication assisted treatment or mat as sometimes you’ll see the acronym out there in the world of the addiction treatment space and so in good fashion let’s kick this off with what is medication assisted treatment our friend matt our friend matt who is matt we’ll find out um so matt is medication assisted treatment and it’s a program that we’ve implemented recently here at peaks to kind of target the cravings of an individual that comes into our program specifically for alcohol and opioid use disorder so swift and to the point wow way to deliver that so i guess in in this way let’s let’s complicate it a little bit let’s nerd out a little bit for with you doc you know uh dr johnson um how does that work within the brain what are we looking at here so the point of it is to cut cravings people crave less they use less and so the first question people had to figure out is what is a craving and what’s going on with it so when we have something pleasurable in our body a pleasurable experience like we climb a fourteener we win a marathon we have a spike of a chemical called dopamine in our body and it’s basically the pleasure chemical addiction hijacks that chemical so it usually hovers let’s say a range between 5 and 25 25 is when you win the marathon when you have sex when you win the lottery five is kind of what you need to get out of bed all not all but almost all chemicals that drugs of abuse cause that to spike irrationally high it goes up to 100 something you can never get in real life and that’s why people love it that’s why they why they go after it


the medications that we use cut that craving that cram craving is a memory of that initial event of of that drug use and when we when we have that memory in our brain we actually have a spike of dopamine again just a little spike but it’s just enough for our body to completely remember exactly what it felt like and we crave and then we go back and we relapse and then so the medications are supposed to stop that and so there’s two two different ways they can do that um one is what suboxone does which is it replicates it binds to that dopamine receptor in a way that keeps it from going up higher it kind of gives you a little bit of that satisfaction all the time and so you don’t get the big burst and the second way is just by preventing that dopamine spike and that’s what the medication naltrexone does and they just work work very effectively in in different ways wonderful beautiful that’s great yeah i liked it box it up that’s a you’re wrap


anything you want to sprinkle on top of that no i think that that’s great that explanation of the craving state is fantastic and i think from um when you’re looking at it from a behavioral standpoint when you’re you’re getting these spikes in the brain it is really motivating you and act really activating you to go seek that hundred level again and so from a behavioral standpoint mat helps to sort of um by mitigating those cravings helps to reduce those like drug seeking behaviors reduce risky behaviors as far as going out and seeking um uh an illicit way to achieve that high so yeah so you know for peaks recovery in particular you know going back two years ago or prior to uh two years ago so the first five years of our company we uh we operated very similarly to the way that this uh industry operates that those things are in a way stigmatized because they were adding to the problem or seemingly adding to the problem right if we gave someone suboxone it’s like well they’re craving and now it’s another drug and you know they’re using it so the cycle you know perpetuates in that regard so we have pretty hardened philosophy about this but i think that you know from uh you know really the implementation of our detox and you guys coming on board in early 2020 and moving away from that model i think we’ve seen a lot of extraordinary things you know namely you know lowered ama rates and we’ve been given a lot of insights to this but one of the things that i think that we’ve done uh a little bit differently maybe than some other centers out there who are you know um who are you know bringing matt into their program and we’re not just treating it as an ambulatory thing we’re treating it in-house as an inpatient program and so um you know maybe for the sake of time just highlighting maybe you know alcohol use and opioid use you know where are we seeing the benefits of starting that and continuing without dropping them off at sort of a cliff edge um in regards to the effectiveness of matte within residential and stabilization model of care


you want to do that sure well i’m thinking back to two years ago when i came on board and we opened the detox facility in early 2020 and our model of care was very abstinent based at the time you have a client that comes in maybe with an opioid use disorder they do their seven days of detox on suboxone and our thinking at the time was like okay they’re done with their taper so now let’s start on other different medications like antidepressants and start diving in with therapy and whatnot and what we were seeing um over time is just more post-acute withdrawal syndrome symptoms and um when they discharge out of our care maybe the rates of relapse you know because those cravings were so high throughout the treatment stay and so really integrating mat were able to control those cravings and follow them through their their mat treatment and we’re able to adjust those doses based on cravings too that the client has the opportunity to meet with a provider and talk about you know where they’re at in their treatment and we can adjust as necessary and then furthermore with opening our iop program this year we’re able to continue that mat treatment through iop and that gives us the ability to more time to case manage them out and find them good resources in the community so that they can continue on this mit treatment program for as long as they need so i just think it’s such a turnaround that we went from absentee space to more of a harm reduction model just because we did research within our own facility i think we really saw the benefit of early suboxone in our open and in our opiate users because after getting on their last day of their taper they would they wouldn’t say i want to use they’d say i just want to leave i don’t want to be here absolutely yeah absolutely and they would just they would bolt and they didn’t even recognize themselves that it it was craving and so we found just doing a low dose of the suboxone two milligrams four milligrams um was enough to keep them engaged in treatment throughout the absolutely and it helps to change that narrative that used to be well they’re just not ready right i think that that’s what we would always go to and the industry would go to back in the day is uh you know you get somebody on day seven of their taper and their those craving states are so intense particularly with opioid users um that they’re just they’re gonna go they’re gonna leave because the brain is literally telling them to go use it’s almost to a certain degree demanding that that happen and so they would leave they would pack up go and you know i think in the industry up until that point in the abstinence-based world there’s this sort of mentality of oh they’re not ready they haven’t hit rock bottom you know and and so we kind of kind of throw our hands up in the air and say well hopefully they don’t die when they relapse and we get to see him again and now we see him a week after that after we started it and they have hope for the first time ever it’s awesome and i also think with with the mit program you know we just talked about after seven days i’m out of here um the prevalence of fentanyl in our society is so huge um somebody could do seven days of detox those cravings are high they go out and they use and we don’t know what’s in the substance that they’re using absolutely and it could be fentanyl lace to the point where um they could overdose coma and possibly die so keeping them on this mat program to control that risk of ama and possibly using unknown substances is huge as well and a lot of people don’t know that the mat medications themselves actually help to prevent overdose you know the way that they’re designed particularly suboxone which has an opioid component and then it has a actually um basically a naltrexone or a narcan component to it so it’s it does help to decrease the the risk of overdose if somebody does use in addition to mitigating withdrawal symptoms in addition to mitigating cravings so it um it really is a really powerful medication that allows people to again because of you you don’t have those behaviors that go along with cravings people start to live normal lives you know they get to actually go and start to build a life within society that allows them to um be successful and and be productive and it gets it gets them out of their their habits they’re using habits they develop a healthy lifestyle absolutely so this box is not a forever tool but it’s a great tool for the first three years of sobriety absolutely great stepping stone so what do you think is essential in running you know a sophisticated medication assisted treatment platform right because at the same time too even though the ideal maybe you know dosages for residential care is four milligrams two milligrams you know at the same time we’re going to run into patients who are going to say no no i’m better at eight you know 16 i don’t know what the full doses in between are but you know what is it what does it take to really nurture that from a programming standpoint you got anything to say for that i mean i personally think it’s it’s our wonderful providers um they spend a lot of time with the clients they meet with the clients multiple times a week and they really check in and ask those difficult questions and really allow the client to open up and say because sometimes people may downplay how they’re feeling right whether it’s they’re embarrassed or they don’t feel like talking about it and i just think the providers that we have at peaks really have that gift and talent to to ask those difficult questions and pull those answers and so and just having them work together provider and client figure out what is an appropriate um dose and then also following up after that so i do think you guys are a huge component of why it’s successful i mean i think there is truth to that because i think that the clients feel cared for they feel someone wants to help me actually get off of this off this drug i’m using and and so listening to them and trying to tailor it individually for their needs i think makes a difference i’m sorry no that tailoring component is huge and and the sort of recognition that when somebody is in a residential facility that dose may actually be lower and they may be sustained on a lower dose because there are a lack of stressors right they’re in a sort of bubble that allows them to really those the very early stages of healing and stabilization once you leave that bubble those stressors increase and so those cravings will and triggers will naturally increase with it so being able to meet with providers who will listen to the client and will be able to adjust those doses appropriately given the fact that you know life happens right yeah and so and as life happens triggers cravings all of those things do increase and so i think being realistic about that and being able to have these sort of ongoing conversations in which there is a real um it’s interesting that a sophisticated mat program is really a relational mat program if you when you get it gets down to it yeah absolutely and um you know kind of in the the host seat operating here thinking of like where do i want this to go you know in a way because i’m i’m advocating for how not only um addiction treatment centers can behave more responsibly but in better engage with care and provide quality of care not just access to care but the word that’s coming up for me certainly here is access to care having providers on site dedicated medical staff members allows for that continuous access in a way that promotes quality over time and i think that’s just resonating for me and certainly something that i want to say you know um because it’s again what i want families to hear out there who are listening to me as the host within you know the finding peaks episodes is to be curious how these treatment centers are working again because at the end of the day you can call any one of us and our admission teams are awesome and they’re going to tell you we have everything available to this but it’s just not always true and to the point and if you have a loved one who is suffering from an opioid use disorder for example 96 000 people last year died of overdoses related to opioids in that regard this is a serious thing that’s taking place an epidemic you know overshadowed by a pandemic at times but it’s a significant amount of people that are dying um you know all the time now as a result of this and so accessing care where there’s quality being provided supports and mitigates those risks um you know post treatment in that regard so i’m off my type tyrant here my tyrannical tear here uh moving back into the into the episode here so so what does some of the you know we use matt or i think i think we think about it a lot in terms of alcoholism or opioid you know use in that regard so what are some of the medications that are used you know maybe we’ll start with alcohol and move into opioids and then you know what makes them uh effective in that regard yeah so um inpatient we use naltrexone which is actually like an opioid antagonist so it just blocks the effects which also works for alcohol to reduce those cravings and a lot of our clients do start on naltrexone and as they move to the end of their treatment stay we also offer a long-term injectable form of naltrexone called vivitrol and so that just is more convenient when you’re out you know discharge and you’re back to normal life and getting going it’s sometimes it’s frustrating to have to remember to take an oral tablet every single day so vivitrol is a program that we implement to inject once a month and so dr ryan is our providers our vivitrol providers so what we do is we get them set up we educate them hey if you’re interested if you don’t want to take this maltrexon you can get these monthly injections so we get them started on that we give them their first injection if they continue through the iop program we continue the injections for them but ultimately set them up with another vivitrol provider that they can continue to get those monthly injections and a lot of patients just find that really convenient and the great thing in alcohol for that medication is it actually does two things it helps with the cravings but it also helps if if you do drink if you do relapse it doesn’t feel as good it blocks some of that pleasure so your relapse lasts less long and you return to sobriety quicker absolutely so in regards to you know opioids as well too you know we have buprenorphine and uh you know suboxone and i think those are common subutex common you know language that’s used to of course to describe the medications but um within that i think we have sublicate as well too as an injection right and some what are sort of the trade-offs that we see benefiting not benefiting in regards to vivitrol and sublicate from a provider’s standpoint not following you that’s fair


you know um i guess if there’s insights that can be added to the the notion that right that you know we see hesitancy around sublicate right because it’s an injection lasts what two to four weeks depending on body size vivitrol works in a very similar way three to four weeks depending on just a disadvantage to injectables is what you’re asking yeah or tension maybe that you’re seeing when you’re sitting with patients and the tension that arises versus you know suboxone subutex taken you know daily whatever the case might be versus those sort of long-term regimens you know i think part of it is if there’s any part of them that still wants to use if they’re only 99.5 percent sure that 0.5 percent fights it yeah because they want to be able to get off and use again and so it’s kind of an early early sign that they might not be fully in yet but additionally that there’s a huge cost difference if your insurance doesn’t cost doesn’t cover it it’s absolutely not affordable by private pay i mean i think it’s like a thousand dollars a month for those those shots and the pill version is is reasonable so sometimes it’s just a cost reason why we have to continue the pills sometimes the shots are too uncomfortable for people to want i mean it creates puts a little lump under your skin it’s a depo so the medication is there for a month and then just slowly dissolves but i think in in all cases they work they work better the other last thing is there’s sometimes a provider issue if you’re going back to washington we can’t always find a provider we know is going to provide it where where you are yeah the access to naltrexone and suboxone we feel is a lot more prevalent when we when we’re discharging in case managing somebody out versus injectables um so there’s an advantage versus a disadvantage to both yeah absolutely and there’s and there’s a i think also like a a behavioral component that’s there as well as far as what if suboxone is better for you or if no or vivitrol and attraction is going to be the better option for you i think that different at different times in your treatment and at different places you are as far as the commitment to sobriety either one of those can be a better option and i’ve seen them used really well together as well where somebody does a suboxone regimen which the regimen is the recommendation is a minimum of two years actually so three years has a tremendous amount of efficacy um a year would be the minimum that we would ever really recommend but typically it’s a two year regiment and then after that time on suboxone then going to vivitrol as another sort of weight as almost like as a step down um in in the level of care and sort of managing uh cravings and symptoms and almost giving another safety net there so the enrollment period or the the time that’s needed there is i mean i guess it’s independent per individual right but at the same time too maybe what i’m hearing there as well too is just the concept of neuroplasticity and new neural pathways that support the healthier side of the brain with that supporting cast being you know suboxone naltrexone or otherwise um so it you know so those are those are big time frames but are there any like identifiers to for which like you can look at you know year one you two three or what not to say yeah this is this is a good point to kind of step off this and move into a different direction so the the only problem with the naltrexone the vivitrol is it doesn’t protect against overdose right um so so anybody who’s using medications off the street with as much fentanyl as there is around we i i’m not comfortable using the pushing the the naltrexone vivitrol in them you want the protection that the suboxone provides which is the naloxone yeah that blocks right and you really i mean for those you really actually want a sick some level of stability when you’re starting to engage in those medications because again the risk is there there are added risks actually even though it may be more convenient and it may um in the sense that it’s a 30 you know once a month kind of thing but there are risks that um definitely start to present if somebody is still actively using yeah and so opioids and alcohol are in their use um can be very deadly of course long-term use even one-time use with fentanyl lace within it you know meth and marijuana thc present i think uh different types of problems they’re not as high risk for you know death um in long-term abuse short-term abuse but at the same time it’s still a patient demographic that’s suffering in a variety of ways but it doesn’t seem like that we have a lot to kind of throw at them differently than those prior you know two substances uh in that regard and so kind of you know when somebody when we pull the pot out of them for the first time right and they can’t and they can’t use it they seem extremely irritable you know by comparison and you know maybe meth user has to sleep it off but they wake up irritable in a similar sense of things and so uh you know in that regard it’s not a harm reduction approach there’s nothing significant in the way as far as you know death being imminent maybe on the other side but you know what are things that we’re utilizing you know today that can support those individuals in a way in which they’re vividly suffering in those early moments so i mean that’s kind of two separate questions the the marijuana there isn’t any fda mat medication for it we control their anxiety through medications through therapy and that helps because usually anxiety is a trigger for the marijuana use gabapentin is commonly used as an mat for marijuana it’s been shown to have a little efficacy and actually n-acetyl cysteine which is just a a supplement has been shown in young kids to help with marijuana but as far as methamphetamine cocaine that those are the medications are those the drugs that bump dopamine directly and there’s one medication that’s not fda approved but makes sense that we use and that’s bupropion or wellbutrin which just it releases dopamine and so after people been using those medications a lot instead of sitting at the at the 25 which is normal they’re they’re down near zero and all the wellbutrin does kind of get them feeling normal again so it doesn’t block the craving state but it um helps them normalize a little faster is the thought at least the kind of innovative thing we’re looking at is tms that’s transcranial magnetic transcranial magnetic simulation which was new to me two years ago when i when i started here but it’s basically this big machine that has magnetic coils that creates magnetic pulses you put a helmet on people and those magnetic pulses are aimed at the prefrontal cortex where depression occurs and basically stimulate it so you end up with stronger cells and those stronger cells secrete more dopamine they create more serotonin you just end up with people that normalize again a lot a lot faster than they would have otherwise and we’re seeing see indefinite improvement in people with that so one potential avenue then for innovation in regards to um you know the methamphetamine users and marijuana users even potentially or just stimulate more stimulants okay but yeah absolutely as an mit yeah absolutely tms is definitely a it it’s going to help a lot of our population because depression is a huge huge trigger and that’s what the predominant it was designed for us to treat the depression and so uh even though it’s not um mainstream in the addiction world i think we are seeing just market improvement a lot of patients with it i think it’s a fascinating future yeah absolutely yeah absolutely well in that regard i think we touched on a little bit of innovation there and we were able to see extraordinary things happening certainly your wife dr ashley johnson is doing wonderful things in the tms world and um ketamine infusion and those sorts of practices and would love to continue forward with that innovation and and what that looks like you know maybe contrasting with you know pharmacology approaches in the future um as well too so for a future episode we’ll we’ll invite you back in bring the docs the medical team back and hopefully have a a wonderful conversation about potential uh innovating features of this industry on behalf of addiction and mental health disorders as well too in that regard so we’ll come back next time medical team thank you so much for being here thank you absolutely good to have you guys most exciting episode very exciting most exciting yes and so yeah uh as uh as we normally do in exiting here thanks again for joining us i look forward to having you guys on future episodes chris burns jason friesman myself as host um for all the kids out there check us out on the instagram i think we’re we’re doing tick tock now yeah pretty much the coolest people ever uh facebook spotify um instagram if i didn’t say it um finding peeks at peaksrecovery.com uh send your questions thoughts ideas um all of that so that we can speak to you guys directly and speak to what’s important to you guys in regards to how this industry operates and so forth so thanks again for joining us and until next time