Can listening to patients change how we understand stimulant use?
In July 2021, I spoke with Dr. Michael Miller, a physician who had spent more than two years working with people who use methamphetamine, cocaine, and spice. He believed that most of them were living with an underlying condition that had been missed or misdiagnosed. Of course, he called his observations anecdotal while that data was still being analyzed.
This is an archive episode, recorded when the show covered addiction and recovery broadly. The medications Dr. Miller described for each group are in the transcript as his own clinical choices, and they are not a recommendation.
Why would anyone want a drug that revs them up?
At 5:59, Dr. Miller described the question that started his work. Opioids were easy to understand, he said, because they treat pain of every kind. Yet, he could not see why anyone would want to rev themselves up and burn themselves out.
So, he and his team started asking patients and listening to the answers. They kept hearing the same presentations, and patients told them the symptoms were there whether they were using or not. In his view, the literature that blamed those symptoms on the drug had the cause and effect backward.
At 8:27, I pointed out that he had done something almost unheard of. He listened to people.
What is a low internal state of arousal?
From 10:05, Dr. Miller described the first of the two groups he identified, which he named LISA, for low internal state of arousal. These are people with no energy. He described them as lovely, wonderful, and personable, and also as the friend who promises to pick you up at eleven and is still in bed at half past one.
To tell this group apart, he uses a deliberately stressful scenario built around the person’s own work. He pressed a man who repaired transmissions, rapid fire, to take on four times his usual workload. Interestingly, he listened for the direction of the answer, whether the person reached for a way to try or shut the idea down.
At 17:51, I checked my understanding. These sounded to me like tired people, and I offered my own version of his test: a doctor told that no one else showed up and the whole clinic is theirs today. He agreed, and added that the receptionist would be out too.
Could an interview like that ever be automated?
At 18:32, I asked whether a questionnaire or an artificial intelligence system could do the same job. Dr. Miller said he had only his own experience to go on, and that he was training colleagues to do it. He never says never.
As soon as the questioning ends, he explains what he did and thanks the person. Still, one or two patients told him it felt like an attack, and he apologized to them and saw room to improve.
How do you know whether cravings have really stopped?
At 22:07, Dr. Miller described the two measures he tracks. The first is subjective: does the person still crave? The second is objective: urine testing, backed up by laboratory analysis to catch anything a screening cup would miss. In fact, in his experience, a person who says they are craving does not stay clear for long.
At 23:39, I mentioned that some stimulants are not tested for by drug testing companies at all. He agreed.
At 24:38, I made a comparison with buprenorphine (Suboxone). A person who takes a medication but is not craving, not causing problems for themselves or others, and not caught up in illegal activity is not showing addictive behavior. As I put it then, that is not addiction.
What did the second group have in common?
From 26:49, Dr. Miller described the larger group, which showed three features: intense emotion, with anger that flares over small things and vanishes minutes later, a locked-in focus that shuts out everyone nearby, and a sudden loss of the thread of a conversation.
When he looked those three features up, he found they matched attention deficit disorder (ADD). In his view, many of these people had been diagnosed with other conditions over the years. Interestingly, when he meets someone with the same features who has never used a stimulant, he tells them, only half joking, that they would probably have loved it.
At 32:35, he told the story of a man who had lost three marriages. Dr. Miller offered him a scenario: his wife makes a small, kind suggestion about loading the dishwasher, and what he hears is an insult. Once Dr. Miller explained the difference, the man broke down and recognized his whole history in it.
Is this the same as borderline personality disorder?
At 36:45, I asked about it, because the outbursts reminded me of borderline personality disorder. Dr. Miller did not think so. He said these patients show all three features together, and that once they start talking about them, it all comes out.
Unfortunately, he said, many of them carry deep self-loathing because they know something is wrong and cannot fix it. He tells them their family and friends will notice the change even more than they do.
What is the point of a few days without cravings?
For Dr. Miller, the goal was a window. If cravings stop within about three days, he said at 37:00, there is time to bring in a psychiatrist, counseling, and group support, and to look for anxiety, depression, or other conditions underneath.
At 39:39, I agreed that it is hard to focus on recovery when the obsession and the cravings never stop. He added, at 39:48, that most of the people he sees have never had a stretch like that.
He was also modest about it. At 3:45, he reminded listeners that many people stop using stimulants without any medication at all. However a person gets there, he said, it is not how you get there that matters, but whether you get there.
Are people born with these patterns?
At 40:10, I asked whether one group does better than the other. He did not know yet and was waiting for the data. At 40:24, he also said that someone who uses both a stimulant and opioids can be treated for both, because mental health, pain, and substance use are one tangled ball.
At 42:59, I asked whether these patterns come from birth, from childhood trauma, or both. Dr. Miller suspected a strong link with attention deficit hyperactivity disorder (ADHD) in childhood. Many of his patients told him they had been diagnosed as children, or believed they had the condition, although he had not tracked that formally.
Who is Dr. Michael Miller?
Dr. Michael Miller is a physician based in Indiana who leads Miller Care Group, which he described as independent and not hospital affiliated. At the time of this conversation, he was working with people who use stimulants and opioids, teaching medical students, and seeing patients across the United States by telemedicine.
What can listeners take away from this conversation?
Dr. Miller’s central point was that a careful diagnosis begins with listening, and that the people in front of us often know what is wrong long before anyone asks them. Whether or not his categories hold up, the idea that a period free of cravings gives a person room to work on everything else is worth hearing.
How do I approach this today?
My thinking has kept developing since this conversation was recorded. Today my practice is built on one idea that runs through all of it: when the body has adapted to a substance, the safest way off is usually gradual, with the smallest steps the person’s nervous system can tolerate. Physical dependence is not addiction.
For opioid dependence I prescribe buprenorphine, which steadies the body so a person can rebuild their life without the cycle of withdrawal. Visits are monthly, or weekly when needed. Some people stay on it for a long time, and that is a legitimate choice. Others later taper slowly, using the same gradual approach I use for every other medication.
I believe medication for opioid dependence should be available wherever people need it. I prescribe in Florida only.
This page is educational. It is not medical advice, and listening to the episode or reading this page does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.
Full transcript
A note from Dr. Leeds: my guests speak from their own experience and expertise, and the terminology they use is their own. Whatever the topic, this show holds to one distinction: physical dependence on a prescribed medication is not addiction. This transcript is educational content, not medical advice, and nothing here creates a doctor-patient relationship.
Read the full transcript (45 minutes)
Dr. Mark Leeds [00:00] Dr. Michael Miller, welcome to the podcast. You have been treating stimulant addiction for at least several years now. And successfully, you’ve been getting incredible results. And I think you told me you’re almost ready to publish some study results.
Dr. Michael Miller [00:20] That’s correct. After over two years of doing this, treating methamphetamine and ultimately cocaine and spice addiction, Yeah, our data right now are being crunched by the local PhDs at the local medical school. Preliminarily, the data looks good. Of course, anecdotally, we can talk all day. The only statistic that we have right now that we can confirm is that we have an 85% rate of mitigation of cravings for methamphetamine 72 hours after establishing the diagnosis, of course, which is the key, and then initiating the appropriate treatment, which I was blown away when I heard that.
Dr. Mark Leeds [01:02] That’s incredible. I know people that go to like 12-step meetings and do nothing else other than going for that kind of peer support can have cravings six months out, even a year out, maybe even several years out. They’re suffering with cravings and fighting those addiction cravings, those amphetamine or cocaine addiction type cravings. Yeah, I mean, And it’s like an ongoing struggle. And it’s mental torture for these people to have to suffer through that, to just constantly be fighting it off.
Dr. Michael Miller [01:30] True. And that’s the issue. As physicians, we are trained. I jokingly call the alternative ready, fire, aim, where it’s OK. We start a treatment and then let’s see what happens. And the problem is physicians, that’s not how we’re trained. Everything is why. And so for my purposes, when we first started to look at this and I was seeing a lot of methamphetamine patients and I kept scratching my head and saying, why would anyone want to use methamphetamine? Why would anybody want to rev themselves up and burn themselves out? I mean, opioids are easy. Everybody can understand opioids. You know, if you have pain, opioids treat pain. It can be physical pain. It can be emotional pain, anxiety, depression. Opioids are easy. You know, my practice, we talk about three major categories of substance abusers. The category one we talk about is the adolescent who peer pressure, you know, drink this, smoke this, swallow this, whatever, and then they get addicted. And we found that’s maybe five percent are in that category. Very small. Of course, second category are the ones that not to accuse you and I of anything indiscreet pain pills. We treat them pain pill, pain pill, oxy, whatever. And then ultimately, once they are unsuccessfully or successfully, depending on how you look at it, addicted, then realizing the horror of what we did, we cut them loose. Now they have to go to the streets to get something. And our experience is in, that’s only about 20%. Mental illness, unquestionably the highest category. Dual diagnosis is the more common term, 75 to 80%. And that brings the issue of if you’re an MAT clinic and not treating dual diagnosis, that means you are guaranteed to have a 75 to 80 percent failure rate. And then you add the pain on top, even with overlap. You’re probably not able to help 90 percent of those people other than giving them opioids, which in the form of buprenorphine or God forbid methadone.
Dr. Mark Leeds [03:34] Buprenorphine does work. I mean, it has a fairly high success rate. I mean, even if you do nothing but give a person buprenorphine, at least for the time that they’re on it, they function very well.
Dr. Michael Miller [03:45] We’re amazed that one of the things that I have to keep reminding myself, and again, that statistic I gave you is, you know, I know, and most of us in the addiction field know a huge number of people that were meth addicts, were opioid, heroin, fentanyl, what have you, and they are no longer using. And they did it either through 12 step or something, but that, and again, to stick to the meth topic, lots of people are former meth addicts that are no longer using meth that never were diagnosed, you know, with our protocol, never had the meds and yet they’re not doing meth. So I’m not looking at this as the ultimate panacea that everyone needs to be on. It’s more the realism that, and again, that 72 hour statistic to me is the most important Because if I can stop cravings for a stimulant, that means that I now have 72 hours to get them into mental health counseling, get their psychiatric issues dealt with, let them get away from the drug, get some confidence, and then hopefully expand that interval of window. I mean, if I can get it going longer, and my longest patient right now is about nine months that we’ve been able to track, it’s fantastic. But you lose patients. You know, when I hear of entities, addiction centers, whatever, that talk about their long term success, I have to laugh because I don’t know about you, doctor. But despite my hardest attempts, we lose these people to follow up. They move. They change their phone. So anyone who’s purporting to have long term statistics, I have a real hard time dealing with it. The best we can do is kind of look at those that are out there and surviving and TikTok, Facebook, LinkedIn, whatever it is they’re on saying, I am now successful. And then we give them a hearty round of applause and say, you know, however you got there, that was the way that was the answer. It’s not how you get there. It’s whether you get there. And if what we’re doing contributes even a little bit to getting there. Hey, I’m happy. I’m delighted. Makes it worthwhile.
Dr. Mark Leeds [05:44] Wow. So, yeah, I was I was curious, you know, when you got started with this, you know, a few years back, first of all, what made you interested in treating stimulant addiction like methamphetamine addiction? And how did you first get started? What was it like in the beginning?
Dr. Michael Miller [05:59] Well, because, as I said, I kept scratching my head saying, why, you know, opioids are easy, marijuana, you want to get high. Why would anybody want to rev themselves up? As I said earlier, it made no sense. And so we started to talk to these people and started to listen to these people and ask them what kind of things. And we discovered that there was this amazing reproducibility of symptoms, of presentations. And we kept hearing the same things over and over again. And so we started to listen and say, well, gosh, you know, we’ve had 10 people this week, you know, the last week, this week, whatever. And it’s interesting that all of them seem to be talking about the same issues that they are having. But when you go to the literature, it’s interesting because a lot of the literature, which is mostly mental health, not medical based literature. It says that, oh, these things are the result of methamphetamine or the result of cocaine. And I kept saying, no, that’s not what we’re finding. When we’re talking to these people, there is clearly no association between methamphetamine and causality of these presentations. These people will tell you they’ve had this for a long time, whether they’re on meth or not. They got off the meth for six months. They still had these presentations. And we started to cone down and hearing the same thing time after time. Ultimately, and again, I’m almost embarrassed to say that it was easy. If you listen to these patients, they divide into two major categories like Moses parting the Red Sea at Sinai. It’s laughable. And I train medical students and we have nurses that come and my new colleagues and they come in on these evaluations with us. And of course I pre-educate them and I say, look, your job is to poke holes in what we’re doing. I want you to find fault. I want you to find why, you know, are we confusing things? Are we looking at too much? And I will tell you that overwhelmingly they’re saying, oh my gosh, this is almost too easy. It’s almost too easy making it. And maybe that’s the problem is the fact that we’re so busy looking for a complicated solution that the fact that it’s right in front of our faces is almost disingenuous. It’s almost embarrassing how easy this has been. And it’s not that I’m intelligent. It’s that I basically did what physicians are supposed to do is I made a diagnosis and we’ve been treating the diagnosis and it’s worked and it’s worked well.
Dr. Mark Leeds [08:27] And you also did one other thing that’s almost unheard of is that you listen to people.
Dr. Michael Miller [08:32] Correct. They’ll tell you. So to kind of cut to the chase, we basically have identified two major categories of stimulant users. Initially, when I started to look at what our workup was, how to get these people to differentiate. And of course, after two and a half years, we’ve really refined the system. The workup is a lot of fun. These people know that they have an issue. They know they have some deep seated psychological, emotional, inter-societal issues. The problem is they don’t know how to deal with it. And the worst problem is that their presentations are confused. We have them being treated for bipolar. We have them being treated for schizophrenia, for anxiety and depression. And when you talk to these people, it’s as though they couldn’t come up with the real diagnosis. Well, it sounds bipolar. I mean, they have highs and lows. Let’s put them on Seroquel. Let’s put them on Latuda. Let’s put them on whatever. And once you get these people coned down, these medicines disappear. They say, well, it hasn’t been working. I don’t know why I’m still on it. Well, in fact, we have entities that treat stimulant addiction with Suboxone, which blew me away because I said, wait a minute, that’s not an opioid. That’s, well, that’s what they said. They said the only thing they knew was to treat it with Suboxone.
Dr. Mark Leeds [09:48] I mean, I’ve never done that. I wouldn’t think of doing that. But the only justification I can think of is that there’s some similarity with buprenorphine and naltrexone where naltrexone has been used. And there’s, you know, people think that might have been something successful in treating stimulant addiction.
Dr. Michael Miller [10:05] Well, there’s one study out. And again, not to be disparaging, because as I said, we know people are getting better without any treatment. And in my mind, any treatment that helps anybody is good. But the most recent study is a combination of naltrexone and Wellbutrin. And it was a very, very, and I will happily, you know, discuss it with you, get your opinion. Of course, it was a bad study. The results were very, very inconsistent. You know, the way they said it was almost kind of pandering like a gee whiz kind of thing. You know, well, some of these people said they didn’t crave and occasionally the urines were clear and you know so this is what we think might work is Vivitrol and Wellbutrin and I read the study I said you know for the one or two people that it helped how fantastic but uniform general applicability gosh I don’t know is that better than random chance no I don’t think so and the other study is of course the one on contingency management and the problem I have with that study is one, I’m not sure bribery is ethical. Two, it’s a homogeneous study. You know, when as physicians, we hate to use the word normal because normal is a bad term, you know, if we accept it as a range. But this study looked like they were saying, well, we’re going to give everybody contingency management, you know, bribery. You do a good thing. You give me a clear urine. You get to stick your hand in the prize bag. And the problem is that assumes that everybody has the identical issue and that one size fits all. And I had a huge problem with that study, recognizing that 14% success, I think is what they reported, maybe 15. And that means 15% got helped. That’s good. But what’s the general, you know, we talked about meth users who got better without treatment, that has to exceed 15% in the general population anyhow, or the meth using cocaine using population. So better than nothing, I don’t know. What about crack? Is that kind of following the same group? We’re taking on any stimulant addiction because what we find is it has to do with these people’s exposure. Certain areas of the country, well, in Europe, I’ve had a conversation with my European colleagues. They have essentially no methamphetamine issue in Europe. None. Minimal. What they do have is cocaine. Lots and lots and lots and lots of cocaine over there. Very little meth. Here in the United States, we have enclaves where meth is just rampant. I’m in Indiana right now, and Southern Indiana, meth is just rampant. But, you know, to go back to our early discussion, the question was, what were we hearing when we started to talk to these patients? And again, like I said, Moses Parting the Sea, we identified two categories. The first category I’ve entitled LISA, L-I-S-A, low internal state of arousal. And I want to digress for a moment. One of the most common misdiagnoses that we see in a lot of our patients, adult patients, is this concept of ADHD. My experience and my belief is that’s not correct. There’s no such thing as ADHD in adults. Kids, absolutely uncontrolled. The brain has a million things going on. And the brain says to the kid, you know what? I’m still bored. I need more stimulation. Run, jump, kick, go yell at that kid, kick out the chair. And that stimulation is what the brain craves. Because when you put them on an amphetamine, Concerta, Adderall, what have you, their behavior calms down. It’s paradoxical. And it makes sense because you are adding additional arousal is the word I use to the brain. That makes sense. But adults, we’re adults. You can’t run around the room and kick out chairs and scream, different hormones, different brain structure, societal mores, not happening. And so when I hear someone treated with ADHD as an adult, it’s very bothersome. It’s not correct. However, ADD does exist. Now I’m going to digress back to my initial point because I don’t want to kill the second, but what we found is that a lot of these patients and not a huge percentage, but the first category, LISA, they have no energy. When I talk to my meth users, basically, they know. And I say, I want you to imagine all the meth users you know. What they’ll tell me is they themselves on occasion or someone they know has no energy. They’re get up and go, got up and went, as they used to say on the TV show, hee-haw. They have no energy. These are people that say, I’ll pick you up at 11 o’clock and you call them at 1.30 and say, where are you? And well, I just got out of bed or something came up. They are the most lovely, wonderful, personable, unreliable people that anyone would ever meet. And when we do their workup, these people tell us and demonstrate to us, they have no energy. Their state of arousal is not existent and they use meth or cocaine or some stimulant because their brain is saying, do something. Now, there is our experience, a high correlation with ADHD in them as a child. But there’s no way, heck, I’m giving an adult an amphetamine. That’s not happening in my universe. Yeah. But what we found, and again, the workup with them is interesting. What I do is I find out what their occupation is, just in general conversation. So one of the scenarios we had was a gentleman that did transmissions. And he was able to do five transmission repairs a day. It’s pretty good. The scenario I presented with him with to see what his brain arousal was, is I created a scenario where he suddenly had to do 20 transmissions in a day because of a big account. You know, you embellish, it’s fun to play, but I said, you need to do 20. Now, what I do as part of the scenario is I actually get very, I don’t want to say in their face, but confrontational. I don’t want to give them time to think about their response. Because if I do, then they say, well, I wonder what Dr. Miller’s trying to get at. Is he accusing me of being lazy? So I’m going to say, yeah, I could do 20 transmissions. Instead, I am in staccato fashion. Bang, bang, bang. You told me five. I need 20. If you don’t do 20, we’re going to close the factory. All these guys are going to be out of work. I need 20 done. Can you do 20? Why can’t you do 20? And I’m bang, bang, bang. And my hope is that their brain is going to say something along the lines of, would you please shut that little stir up? And out comes a response. It’s amazing. And we listen for a response that either demonstrates positivity or negativity. A positivity response would be 20, I don’t know if I can do 20, but I sure would try, or that’s a positive response. Or can I get some help if I needed to get the, you know, their brain is trying to think of a way to accomplish the impossible. That’s a brain that doesn’t lack arousal or energy. Negativity is, no, there’s no way. No, five, I can do five. I’m not even sure I can do five. You want 20, there’s no way. Or some other response that is absolutely not positive. And you don’t need to be a physician to differentiate between a negativity and a positivity. Right now, my own anecdotal, and again, the statistics are coming, probably 10% to 15% of stimulant users are Category 1. And when you talk to the meth user in the room that we’re talking to, they all know somebody that’s a Category 1. They all know them.
Dr. Mark Leeds [17:51] So Category 1, just to go see if I understand it, Category 1 is the LISA people, which to me just sounds like tired people, you know just tired no energy and so you push them with this line of questioning maybe if you were questioning a doctor you might say none of the other doctors showed up to the clinic I need you to see 150 patients today
Dr. Michael Miller [18:12] Correct exactly 150 patients and the bad news is your receptionist isn’t there you get to see them all by yourself do your medical records do your blood draws and order all the labs so I really really create the non-winnable scenario I want their brain to be pushed, but I want their brain. I don’t want to talk to them. I want to talk to their brain.
Dr. Mark Leeds [18:32] Yeah. Now it sounds like the way that you’re doing the questioning, it has to be done in a very specific way to push them to that point. Can you imagine any way that this could possibly be automated, like with some kind of an online questionnaire or artificial intelligence driven thing or something like that, like some way to make a system for that?
Dr. Michael Miller [18:51] You know, it’s a great question. You know, the only experience I have is my own. You know, I’ve been training my colleagues how to do it. I’ve sat in on one. And I’m sure that someone will say, you know, I have another way that I do this and it works just the same. So I never say never. But my own thought about the process, at least to identify or get rid of category one, is to literally and pleasantly and respectfully pound the hell out of their brain. As soon as they’re done, you can bet that I’m quick to say, you know what, you did absolutely wonderful. I appreciate it. I know that may have been stressful. And I will explain to you what we did when we’re done. You did fantastic. I’m very pleased. You obviously know yourself very, very well. Despite that, I’ve had one or two patients who said, you know, that really, really upset me greatly. You know, it felt like you were attacking me. And I say, you know, I apologize. Not my intention. And again, at the end, we explain the whole scenario and why the overwhelming majority of the time they appreciate it and they understand why that method was used. Not 100%. So there’s always room for improvement. And I recognize that, you know, that’s part of the getting this out there for people to develop different ways of getting to the same endpoint.
Dr. Mark Leeds [20:08] Yeah, yeah. And so that’s category one. I feel and that’s 10 to 15, or sorry, 15 to 20%.
Dr. Michael Miller [20:16] Roughly, yeah, I don’t have the numbers, but gestalt, you know, anecdotally, yeah. Now the treatment for that, interestingly, is because they require stimulation, what I did is I’ve spoken to some dear colleagues, psychiatrists, a friend of mine who’s actually a board-certified sleep medicine doc, and another psychiatrist. And then I looked at the literature and said, all right, how do I increase brain arousal? How do I increase internal? And so we’ve been using arguably three different medicines in combination. One, we put them on modafinil, Provigil. Provigil is indicated for shift worker syndrome, for narcolepsy, and in multiple sclerosis. It increases the arousal of the brain. And so we’ve been putting them on 100 of Provigil twice a day. And initially, we were using Wellbutrin 100 twice a day, which worked well and okay. But as a physician, I try and reduce the number of pills they take. And so I went back to the literature and looked at what medications also have a similar effect. And now the protocol pretty much is Remeron. So they get modafinil, Provigil, 100 twice a day, and Remeron, 15 milligrams at bedtime. If there’s an issue with the Remeron, we will go back to the Wellbutrin. But for my category one LISAs, that’s the protocol. The beauty of this is these people sleep you put normal people on Remeron they’re popped up and awake these people they fall unconscious they’re sleeping eight to 12 hours a night on the Remeron it’s outrageous yeah
Dr. Mark Leeds [21:50] Now the thing with Remeron from what I remember from when you know it was a brand new thing and the drug reps were trying to sell it to us was it’s an antidepressant that has some kind of a side chain that acts like an antihistamine and there was something about how if you gave less, it would make people more sleepy? Yeah.
Dr. Michael Miller [22:07] I mean, in terms of their arousal, these people suddenly, and again, how do we gauge it? And this is what the research will show. Well, you know, subjective is great, but how about objective? And so in the research, what we’ve been tracking is two things. One, are you craving? Because if I treat the underlying cause for craving, you should not crave. Same thing we do with Suboxone. You know, The goal is to stop the cravings for the opioids. In our opioid practice, I give you the appropriate dose of Suboxone twice a day. We key our weaning on craving. Same with meth. And I say to them, are you craving methamphetamine or cocaine or spice? No. Second component is the objective. What does their urine show? And we’re looking at that. And that’s another important correlation. And it’s funny. I guess the correlation of, no, I’m not craving and the urine is clear. That’s good. Saying, no, I’m not craving, but the urine is dirty. Okay, then we got to figure out what happened. I’m not sure the final combination of, yes, I’m craving, but my urine is still clear. You know, what? Wait a minute. If you’re craving, why haven’t you used? It has not happened to us yet. So it’s just worthy of a note in the conversation, but not a reality. You know, if they’re craving, they’re going to use. So cravings is our subjective results of the urine. And we also do liquid chromatography, by the way. So we not only track the screening cup, but liquid chromatography analysis to make sure that a molecule didn’t sneak in there we didn’t know about.
Dr. Mark Leeds [23:39] Oh, you mean like other kinds of stimulants that aren’t normally tested for? Okay, yeah, because there’s a lot of them out there. And there’s some that none of the drug companies are really, none of the drug testing companies are testing for at all.
Dr. Michael Miller [23:53] Correct. Yeah. Yeah. So, you know, based on our common knowledge and that’s kind of how we look at it works well. And that’s pretty much our category one LISAs, as I said, maybe 15 percent or so, because everybody in the universe complains of not having enough energy. I mean, you and I are physicians, you know, the end of a busy day. So how are you doing? Oh, my God, I’m tired. I wish I had more energy. When I first did this. And again, I mentioned that this wasn’t created in a vacuum as I went to several very, very good, very high quality physicians that I knew. And, you know, I was warned, you know, the question is Provigil, quote unquote, addictive? And I said, you know, it’s a great question. However, in the grand scheme of things, I’m not concerned about an addiction to Provigil compared to an addiction to methamphetamine.
Dr. Mark Leeds [24:38] Yeah. If someone were to ask that, yeah, you might think of it the same as suboxone. If someone is someone on suboxone addicted to suboxone, well, no, they’re not exhibiting addictive behavior. They’re not craving. They’re not running around doing illegal activities and causing problems for themselves. There’s no self-harm going on. If a person’s on your regimen, they’re not craving and they’re not harming themselves and others. You know, it’s not addicting.
Dr. Michael Miller [25:00] Right. We’ve been asked, and it’s funny, we’ve been asked, you know, how long are they on this? And my answer is always yes. And the reason is because I don’t know. I mean, when I talk to my patients about it and we’re doing a lot of telemedicine, we have clients now all over the United States that we’re working with. And my answer to them is, look, at some point, it’s worth it to try and not keep you on meds. You’re learning valuable tools to deal with this issue. You know, things change. You’ve moved away from your using environment. Can we do things? Maybe we take the modafinil and we go to 50 milligrams twice a day. The sky is the limit. Nobody realistically wants to be on any more pills than they have to. I respect that. If we reduce and you start to feel that you’re trending back toward, it’s nothing to go back to where you were. It’s not that you’re on a bad, potentially detrimental treatment, which is worse, being on it or being off of it. So at least for the category ones, and I will tell you, we’ve not had anybody coming down or requesting it. And the ones that we are tracking long-term, and there’s not many, as I said, are doing fantastic. Their lives are radically changed. The functioning members of society working full-time, talking to their spouses and significant others. It’s fabulous to hear these people saying, you changed our life. I no longer have to worry about him going into the garage and using methamphetamine. I don’t have to worry about money is better. Our relationship is better. That’s what makes this all worthwhile. You know, there’s plenty of ways to make a living, but helping these people and seeing the help, you know, fabulous. It’s just a way to go.
Dr. Mark Leeds [26:40] Yeah, and these medications are safe for long-term use. I mean, there’s no reason that a person couldn’t take them indefinitely if they had to.
Dr. Michael Miller [26:49] That’s correct. And that’s category one. Category two is one that I kept hearing the same things over and over and over and over. And I kept saying, well, this doesn’t sound bipolar. This doesn’t sound depression. And to kind of cut to the chase, the characteristics that we keep hearing, and there’s three major characteristics to this, and they don’t have to have all three, but invariably they do, you know, to a greater or lesser extent. The first presentation we hear about is a hyper emotionality. What does that mean? Anger management. You know, I think back to that movie, you know, goose, frava and whatever. What we hear from these patients is I’m going to use a vulgarism. So I will apologize in advance. What I say to them is you have a significant other, a wife, a husband, a girlfriend, whatever. If I were to ask them whether or not you could continue to be the world’s biggest bitch, what would they say? And my category twos will laugh and say, oh yeah, my wife, my husband, my girlfriend will tell you that there are times where I am just more than anyone else they know. And these people will laugh and kind of say, yeah, yeah. And I’ll say, how often during the day do you apologize for your behavior, for something you said or in action? And the answer is, oh, five or six or seven times a day, because they have hyper emotionality, anger issues where it takes next to nothing to set them off. It can be someone saying something insignificant and if it rubs them the wrong way, and this can be an internal hyper emotionality or God forbid the external. So part one is the hyper emotionality, either internal, external. It lasts seconds to minutes, disappears and worse. They don’t remember it’s like me saying to you, doctor, let’s go out for lunch. And you say, you just yelled at me, called me bad names for five minutes. Why would I go out for lunch with you? And I say, well, I didn’t mean that. I was just joking or whatever. Yeah, but you’ve been doing this with me for years. You know, what’s going on with you? Why can’t you control your temper? And then five minutes later, they’re pussycats. So that’s part one. Part two is this what I call hyper focus, where it’s someone that is doing something. And normally I call you and say, hey, doc, got a second for me. And you pop up and say, sure. These are people that lock in. And they’re going, you can’t distract them. And the wife will say, honey, I need to talk to you. And honey, I need to talk to you. And then they get mad and say, damn it, why aren’t you listening to me? And these people will tell you that their spouse, significant other, social circles, scream at them constantly because they don’t pay attention. They say I need your attention and they say well I heard what you said oh yeah what did I say well it doesn’t matter it wasn’t important anyhow and I know what you’re saying and you know what quit bothering me because having been caught in the act of not paying attention now they’re angry and so number two loss you know this hyper focus the third and most important and everyone knows someone that does this it’s almost laughable loss of continuity or thought where you and I are talking and all of a sudden I’m like, oh, crap. What were we talking about? And they suddenly go blank and they can be leading the conversation. We had a lady that we were evaluating and she starts giving me her history and I’m just sitting there listening. And 15 seconds into her discussion, she suddenly goes pale and says, oh, my God, I just forgot what we were talking about. And I looked at my senior medical student and said, well, I’m satisfied. You want to continue the workup or do we have our diagnosis? And he laughed and said, no, no, no, let’s continue it. But I agree. They suddenly and completely lose their train of thought. They’re gone and they can’t get it back. And people call them an airhead or a space cadet or a ditz. And these people will tell you, I hate it. People pick on me because I don’t. So loss of train of thought. Those three things. Now, the funniest part is when you look those three things up, guess what they’re called? ADD. Those are the stigmata for ADD. I, before I made the connection, called it CAP, chronic, agitated, aggressive, or absent presentation. Now it’s ADD it’s classic ADD when you look up ADD and again I’d mentioned earlier the problem was that those characteristics the non-physicians the mental health are saying oh no that’s due to meth no absolutely not and no way in heck you’re missing the point these people have this and their brains are saying do something and I’m not a physiologist I don’t know but they choose meth and the funniest part is when I get someone that I see that is not a meth user that demonstrate these characteristics the first question I ask them is have you ever tried meth did you ever try cocaine did you ever try spice and in the overwhelming majority of the time they never have and then kind of tongue-in-cheek I say oh thank god because if you’d have tried meth you’d have loved it
Dr. Mark Leeds [32:09] Yeah I know I know people that fit the exact description of what you just said and, you know, they don’t use meth, but each of those criteria, they meet each one of them. You know, the person who’s angry and goes off on just angry tirades and then apologizes later, focused, he can’t interrupt them. You know, maybe they’re looking at their phone, you know, shopping or doing whatever on their phone. You talk and they just never even look up.
Dr. Michael Miller [32:35] It destroys lives in our addiction center. And again, you know, everybody’s got anecdotes. The saddest story I heard was a guy who came in methamphetamine and we were talking and we did the full workup. I did the category one with them and then we went to category two. And he has he had been divorced three times, destroyed three marriages. And I said, how’s your current wife doing? He said, we’re having the same issues. And I said, do you love your wife? And he said, I love my wife more than anything else in the universe. And I said, does your wife love you? And he said, my wife loves me. There’s no question. But sometimes she pushes my buttons and I said, time out, time out, time out. I said, wait a minute, wait a minute. You just told me your wife loves you more than anything else in the universe. You believe that. Let me ask you a question. If your wife loves you that much, why would she want to piss you off purposely? I’m not talking about love play where they poke you or tease you, whatever. However, you’re saying that your wife will on occasion maliciously and purposely try and hurt your feelings. I said, let me give you a scenario. You loaded the dishwasher and some of the dishes were dirty. And your wife said, honey, next time you put the bowls in, face them forward because they don’t get clean. We’re in the other way. I said, that’s what your wife said. What you heard was you are the stupidest man I know. You don’t even know how to load a dishwasher. Every time you touch something, it turns to crap. And now I have to waste my time loading a dishwasher because you’re an idiot. And you know what this 47 year old gentleman did? Cried, blubbered like a baby and said, oh, my God, that’s so true. And I didn’t realize it. He said, that’s what happens. My wife constantly says you don’t listen to me you don’t listen to me and the three wives that I divorced all of them said if you would only listen to me and we’re not talking major discussions even the simplest discussion these people fade out and it’s tragic and so you can imagine when we start the treatment within 72 hours these guys are telling me this is absolutely outrageous And the treatment for category two ADD is just what it says in the literature. We put them on atomoxetine, Strattera, and we put them on guanfacine, Tenex. And in 72 hours, these people come in and they are like, this is outrageous. Outrageous. I have no cravings for meth. And not only that, but my conversations, I’m not losing track. And of course it progresses. So it’s not perfect. But the hyper emotionality blows me away because we had a patient come in at three weeks in the detox who’d been on at three weeks. And he said, I don’t think it’s working. And I said, why not? Let’s let’s figure it out. You’re taking it. The scenario he gave me is he had been at the detox and had been screwing around and did something that irritated one of his fellow inmates or one of his fellow addicts. This guy got in his face and said, I don’t want you to do that again or I’m going to beat the hell out of you. And this guy turned and walked away and the guy grabbed him and said, did you hear me? I don’t want this done again. And our guy turned around and the guy, this occurred four times on the fifth time. Our guy punched him in the face and our patient said to me, well, it couldn’t have worked. I punched him in the face after the fifth time. And I said, let me ask you a real question. You know, in me three weeks, I’m a doctor. If the situation had been reversed and I had told this guy, I apologize. And on the fifth time, he still jacked me. What do you think Dr. Miller would have done? And he said, you’d have punched him in the face. I said, bingo, gave him a big hug. I said, I got to tell you, buddy boy, if it took five times for this guy to get in your face before you popped him, I think the treatment’s working fantastic. You are an A plus because there’s no human being or no drug that’s going to mitigate anger when someone’s pounding on you five times. That’s the stuff that we’re seeing.
Dr. Mark Leeds [36:45] Now, one thing I was thinking about when you talk about outbursts of anger, it kind of reminded me of borderline personality disorder. Is it related or are they different?
Dr. Michael Miller [37:00] I don’t think so. I think it’s different because we’re not seeing this occurring in an isolated situation. When these people are coming in on meth, on spice, on cocaine, they have all three. And again, I’m specifically saying, explain what that means. And it’s funny because like any any diagnosis, they’re kind of reluctant to give it to you until you get the door moving in that direction. It opens and then invariably it gushes out. Yeah, you’re right. You know, like invariably. No, I don’t think I’m any angrier than anybody else. You know, I know people that get angry and I say, I understand. I said, but, you know, does it take little things? Yes. Sometimes the little things bother me. And, you know, sometimes when they bother me, I really lash out. And, you know, more often than not lately, it’s all of a sudden, bang, bang, bang, bang, bang, bang. And now the floodgates are open and they’re talking. And the loss of continuity is almost funny because they’re almost embarrassed to admit it. Yeah, sometimes I said more often than not. Yeah, sometimes I said and I say, what do you do about it? Nothing. I hate myself because they have self-loathing because they know something is wrong. They can’t fix it. They don’t know why. And as you said, diagnosis, borderline personality. Well, no, I didn’t describe borderline personality. That’s ADD. Bipolar. Again, the bipolar. Well, he’s bipolar. No, no, no, no. They may be bipolar, but this presentation is absolutely ADD. And as I said earlier, this anger outburst stuff, you know, road rage and all that crap, that’s ADD. And again, what we find is with the Strattera and the guanfacine, I say, how are you doing? It’s unbelievable. I said, are you having any of this? You know, and early on, it’s almost none. And then farther down the road, no, no, no, no. You know, because I tell them, you might notice a difference, but everybody around you, your wife will notice the difference, your family, your friends, they’re the ones. And so as time progresses, it’s good for you to say, how am I doing? You know, my doctor put me on a medication. How am I doing? And the overwhelming majority of time, the feedback they get is good because that’s important. They self-loathe, they hate themselves, their self-respect is in the toilet. So finally getting some control over those issues. And again, what’s the ultimate goal? I get 72 hours where they’re not craving meth, more hopefully. So I can then get them into a group session, get a psychiatrist to look at them to make sure there is an anxiety, depression, bipolar, schizophrenia. I can get them in counseling. I can get them on their 12 steps. I can get them in group sessions. We can actually start treating.
Dr. Mark Leeds [39:39] Yeah. And that’s important for someone to be able to focus on the recovery by, by not having the obsession and the cravings constantly going on.
Dr. Michael Miller [39:48] That’s correct. And that’s the goal. And that’s, that’s all that we’ve talked about, you know, whatever the statistics show, and I’m confident they’ll be great. It’s I can mitigate cravings for methamphetamine almost all the time at 72 hours. That means you get a chance to work on your abstinence and your sobriety and yourself. That’s a good thing because these people have never had a period like that, most of them.
Dr. Mark Leeds [40:10] Yeah, I want to ask you about the type 1 and type 2. You know, you have the type 1, the really tired people, and type 2, the angry ADD people. Does one group respond better than the other to treatment, like between those two groups?
Dr. Michael Miller [40:24] I will tell you that’s what we’re looking at the statistics right now. That’s what I want to know. I mean, I can talk anecdotally all day. It seems like they both respond well, and we’re giving them the treatment based on that diagnosis. And arguably, that’s the thing I’m most proud of with all this, is that we have a high level of confidence in the fact that there is definitive predisposing diagnosis. There’s no question. And once you’ve got your diagnosis, now you can make treatment. The answer to your question, the statistics are going to come out and we’ll find out. Certainly, it makes sense. Now, sidebar, I just had the most fantastic experience today. My organization, Miller Care Group, is rapidly expanding because of the work we’re doing. And I mean rapidly. I had the great honor of meeting a psychiatric nurse practitioner today. And we’re talking about what we’re doing. And she said, oh, I’m treating meth too. And of course, forgive me with a little jaundice in my tone. I said to her, what are you doing? Oh, she says, well, I’m using Strattera and my jaw dropped. How did you come up with that? Well, I’m a behavioralist. This lady’s a pharmacophysiology man. She said, well, based on what I’m seeing, they seem to have an ADD complex and I’m giving them that. She also uses Tenex guanfacine, which is our second drug for the category twos. So I was blown away. I mean, here’s someone also operating in a vacuum because I’m independent. I’m not hospital affiliated because I kept saying to myself, I can’t be the only one in the world that arrived at this. So I was just thrilled that here’s somebody coming up and saying, yeah, yeah, we’re seeing this too. And I’m using it too. So I’m confident statistics are going to be good. Certainly they’re going to be a heck of a lot better than 15%. Can this be used with suboxone for someone who’s using both? Yes. This is for someone who I say, if I lined every illicit drug up on the table and only said you could pick one, what would you pick? If they say meth or coke, bang, you’re a primary meth user. That’s it. If they also are on heroin or whatever, adjunctively, absolutely, we treat both. And again, dual diagnosis, the mental health, the psychiatry, this is a giant ball. You cannot tease this apart. It’s all interrelated. And I think that’s what’s missed. They’re hoping that giving someone Suboxone will shut off the cravings. If they have pain and you don’t treat it, they’re going to continue to use. Even if you get them on Vivitrol, that’s great, but they’re still having pain. So what have you done for their pain?
Dr. Mark Leeds [42:59] Do you think that these Category 1 and Category 2 people, are they born with these conditions, or is this something that comes from childhood trauma or is it a combination?
Dr. Michael Miller [43:09] Well, again, having told you, I don’t believe in ADHD in adults. I would tell you we’re finding, and again, I don’t think this is part of our statistics and I wish now that I’m looking back, we had kind of tracked it that we can look back. I think there’s a high correlation with ADHD. We certainly ask it. And I ask them either A, were you A, diagnosed with ADHD, be treated for ADHD or see as an adult who has read the newspaper, seen the news stories and whatever, do you think you might have had ADHD as a child? And what we’re hearing in a fairly significant anecdotal percentage, yeah, I think I had it. Or yes, I did have it. They put me on Adderall till I was 15 and then it stopped. And that’s why this protocol for the meth, category two is so important to me because I tell them, look, it’s one pill in the morning and one capsule in the morning. That’s it. All I need you to do, one small pill and one capsule. And if you are willing to do that, all of this disappears. And it has been hugely rewarding to see these people not suffer and more see them not crave meth. It’s just fabulous. It’s fabulous.
Dr. Mark Leeds [44:27] Dr. Michael Miller, thank you for being on the podcast today. Thank you.
Dr. Michael Miller [44:29] Dr. Leeds, thank you very much for inviting me. I’ve been following your work. You are an amazing source of information. And I hope that in some small way, I was able to contribute to all the great stuff that you’re putting out there. Thank you.
