Lloyd Sederer, M.D.: A Leader In Public Health Discusses The Future Of Addiction Treatment

Announcer [00:00] Welcome to the Rehab Podcast on the Mental Health News Radio Network. Here is your host, Dr. Mark Leeds.

Lloyd Sederer, MD [00:08] Welcome to the Rehab Podcast. It’s great to be here, Dr. Leeds. An honor to speak with you.

Dr. Mark Leeds [00:16] Thank you. So, Dr. Lloyd Sederer, you’ve been working in public health for about two decades now. In New York, at the state level, you’ve worked at the city level, and previously you worked at McLean Hospital, which is a psychiatric teaching hospital for Harvard Medical School. And I believe that was that 1989 to 2000? You were the psychiatrist in charge, rehabilitated the whole program, got them up to date for managed care. I just read your new book, Ink Stained for Life, which is a memoir of your life going back to, I think, is it the ages of eight to 17 years old?

Lloyd Sederer, MD [00:50] Yes, it is. But each story, I tell 14 stories, but I match or pair each story with an essay. On the theme of the story. The story might be about family. It might be about family business. It might be about running away from home. It might be about gambling, rich people, Jewish people. So I write an essay developing the theme and relating it to 2020.

Dr. Mark Leeds [01:19] That’s one thing I liked about it. When I first picked it up and read, oh, this is going to be about your childhood, I wasn’t sure if it was going to be a book I was going to enjoy reading. But as soon as I got into it, I really enjoyed it. And you do bring things back to the present. You talk about addiction. You talk about, like you said, rich people and Judaism. And I think there’s a lot in there for a lot of people. I would recommend this book to anyone, anyone in the medical field, anyone who’s a doctor, a resident, medical student, thinking about going to medicine. I would recommend it to people who are addicted or have family members who are addicted, or people interested in what it’s like to grow up in New York in the 50s. There’s so much in there for a lot of people. I think pretty much anybody could get a lot out of the book. It’s almost like sitting with you and you being a mentor or a friend and getting your life story and history and your opinions on things and your philosophies. I love the story about the chicken farm. It was just, you know, just really so much great stuff in there. You know, people interested in public health and why we really need public health and good people running it. I mean, it’s just so much good information in there.

Lloyd Sederer, MD [02:19] That’s very kind of you. I also hope it will demonstrate, if people read it, how improbable my future was. At eight years old, I was this skinny, nervous, shy Jewish kid in the Bronx. And as you described at the beginning, I’ve had a lot of jobs, really great jobs. So it’s an improbable leap from eight years old to recent decades.

Dr. Mark Leeds [02:48] And you’ve had a lot of really interesting life experiences. And I definitely want to talk about addiction and your experience in treating addiction, helping people with addiction. One interesting topic, you do talk a little bit about the use of psychedelic drugs in the treatment of addiction, maybe for other mental health disorders. People have asked me about it. Now we have legal marijuana everywhere. And marijuana feels like a, you know, when they say that you have one tool, if you have a hammer, everything looks like a nail. And, you know, they say it’s good for everything, but there’s definitely dangers and maybe it’s not as good as they say. But we have these psychedelic drugs that they tried them in the 60s and there were Harvard professors and psychologists studying them and some good things being done. And then suddenly it just got out of control.

Lloyd Sederer, MD [03:32] First, let me make a comment. I am not an advocate for widespread access to cannabis, to marijuana because of its effects on the brain of young people, teenagers, young adults, their brains under construction. It’s a really potent drug. It’s 60 times more potent than the stuff I smoked in college. So I think we have a lot more to learn about the cannabis and about quality control and limiting access, particularly to young people. But I am an advocate for one particular psychedelic drug, psilocybin. I am because psilocybin has been studied very rigorously at Imperial College of London, Stanford, NYU, and others. And it was used first with patients who were facing their death. They were terminally ill with cancer, and they were also in enormous emotional distress facing the end. And the first cohort was 500 people treated with it, and 80% improved, namely that fear of facing the end went away, and it was replaced by a sense of life is continuous. We are part of a larger universe, a much more comforting way of thinking about our moment on earth and subsequently. The other thing about it is that it is safe when administered properly, which is namely synthetic psilocybin, therefore no contaminants, in a safe place with an experience guide, and one or two trips do the job. So it’s not just the trip, which is maybe six hours. It is in perpetuity, months and months and months, a year later, that the effects of altering a person’s view of their life and therefore what distress they feel, it persists.

Dr. Mark Leeds [05:39] And that makes sense. There’s a lot of spiritual philosophies, you know, where they talk about having a connection with the universe or the universal mind and how thought is the problem. You know, all of our problems come from our thoughts. And it’s easy for someone to sit down with a patient and say all these things. But if someone is in active addiction or just coming out of it may not be easy to focus on these concepts and really understand what they mean.

Lloyd Sederer, MD [06:05] This is one treatment, sometimes two, and it works immediately. And we’re all disposed to treatments that are quick, safe, and effective. And that’s what psilocybin is. And it’s been around for a long time. Thousands of people have been given it. And I think it may well be a big step forward for addictions and for other terrible states, refractory depression, OCD.

Dr. Mark Leeds [06:33] And another one you’ve talked about is ketamine, which is a different kind of drug, a disassociative anesthetic used as an anesthetic for humans, for children, in fact, in the ER, and has been proven effective in treating depression.

Lloyd Sederer, MD [06:47] Yes. And now ketamine is available as an inhalant, not just as an infusion. And so it’s become quite popularized. And there are many clinics, I imagine, in Florida, certainly in New York, where a person can go and receive it under the care of a physician. But it’s not without its side effects or ill effects, like you’re saying. Some people become quite dissociated during and after it, and it can be habit-forming because it is that kind of drug. People have this extraordinary experience of energy and engagement with the world. And the first experience blows people away and it’s hardly ever obtained again.

Dr. Mark Leeds [07:36] From there, I wanted to ask you about, and I know you’ve talked about this in your books also, about MAT, medication-assisted treatment, which mainly applies to opioid addiction, can also refer to alcohol addiction treatment, alcohol use disorder. And MAT includes mainly three drugs. There’s methadone, buprenorphine, buprenorphine being suboxone, and naltrexone, which is available in tablets and also Vivitrol, the monthly injection. Especially buprenorphine is, you know, since 2002, I think when they approved it and suboxone became available and subutex, the widespread use has not been what we would have hoped for. You know, there’s a lot of fear, I think, of suboxone being used and misunderstanding about it, but it definitely works. In my experience, people who take it for usually at least a year do very well, even when they decide to come off of it. And not everybody should come off of it, but people that do, they tend not to have drug cravings when they come off. They do have significant opioid withdrawal symptoms that they have to deal with, but not the drug craving. So it does seem that there’s an actual healing occurring in the brain over that period of that they’re taking it.

Lloyd Sederer, MD [08:42] Yes. Those are the three FDA approved medications. And the first two are opiate agonists. They fill the opioid receptors and in some ways block it as well with buprenorphine. And the third is Vivitrol, which actually acts differently in that it prevents somebody from experiencing pleasure. So you can shoot up and you’re just not going to get the hit from it. And that’s also not been very widespread. It is a monthly injection. It’s expensive. Not all insurers cover it, including Medicaid in many states, but it is effective. And its effectiveness was proven, as you suggested, with alcohol as an addiction. It’s a good drug. But the one drug I want to add, I think maybe the most important of all, and that’s naloxone. Because people recover from addictions as long as they don’t die from them first. And what naloxone is, it’s a reversal drug that when somebody’s going into respiratory arrest, it works immediately. It saves lives. And it should be available like on the counters free in every pharmacy. And New York City has tried to make it very accessible. And what’s also important is that it used to be an injection and even first responders like firefighters didn’t like sticking a needle into somebody. But now it’s a nasal spray and it works just as well. So naloxone keeps people from dying while they’re trying to get into recovery and stay in recovery.

Dr. Mark Leeds [10:35] Yeah, naloxone is very important. And it’s the rescue drug. A couple of years ago, we were talking about that it should be everywhere on the walls where they have the automated defibrillators. Why not have naloxone there? And now we’ve even talked about that it could be as common as hand sanitizer. Or everyone could have it in their pocket or their handbag. The more of us that have it, the more chance we might save someone.

Lloyd Sederer, MD [11:01] Carry it in my backpack. Yeah, a two-pack of nasal spray.

Dr. Mark Leeds [11:07] That’s great. I actually had a patient a while back that I had prescribed it, and I asked on a visit, the parents were there, and I said, do you have the naloxone available? And the mother said, well, we have it in the house, but I locked it up because I’m afraid he might get to that and do something with it.

Lloyd Sederer, MD [11:24] Yeah, she doesn’t understand the drug. She batches it with others that are more addicting.

Dr. Mark Leeds [11:32] Yeah, and luckily she understood after our conversation that, of all things, he’s not going to abuse the naloxone. Luckily, it came out of the lockbox because it wasn’t, you know, within the year after that, they ended up using it successfully. And that patient is back on track and doing very well now.

Lloyd Sederer, MD [11:48] Yeah, I’ve not had a chance, thankfully, to use it, you know, in a shop or something. Somewhere public. But a friend of mine was in a Starbucks, also a doc, and the bathroom door was locked and people were lining up and they were pounding on the door and no response, no response. So they got the owner, opened it, and there was a man lying on the floor with a needle in his arm. And this friend squirted some naloxone in his nasal passages and he was revived.

Dr. Mark Leeds [12:20] If someone is carrying naloxone and you happen to come across a scene like that, you’re not going to hurt a person giving them naloxone. So even if you’re not sure why they’re there unresponsive, you can still try it. And yeah, it’s really definitely important. I actually heard a story from an ER doctor about a patient that came in that had actually overdosed in the middle of an NA meeting. And so, yeah, even in NA, those kind of meetings, they’re not going to be responsible for having it, but members can bring it with them.

Lloyd Sederer, MD [12:50] And in fact, many people shoot up, use with other people. So it’s a good idea if you’re part of that world for everyone to carry it, because you’re not going to be able to administer it to yourself, but your buddy might, or one of the people in the room of an NA meeting.

Dr. Mark Leeds [13:10] Naloxone brings us to harm reduction, which I know you’re in favor of, you’ve mentioned it in your books. Harm reduction, including naloxone, but also possibly including clean needle and syringe exchanges, supervised injection or supervised consumption sites where a person can go safely use drugs under supervision. If they have an overdose, they can be revived with a variety of methods, including naloxone. Another important thing, I actually interviewed someone on a supervised consumption site in Canada, and they talked about how not only do they provide all these services, but they form relationships with the people that come in. And that seems to be the most important part of it.

Lloyd Sederer, MD [13:47] Help somebody get into recovery, get into treatment, stay with the 12 steps. It’s always relationships.

Dr. Mark Leeds [13:57] What do you think about that as far as the lack in the U.S. In Philadelphia, there was a case where someone was trying to open up a supervised injection site and the government was blocking it, the federal government was blocking the opening of this site. Do you think that there’s any hope that we’re going to be like in British Columbia where they have all these different forms of harm reduction? Do you think that’ll come to the U.S.?

Lloyd Sederer, MD [14:19] I don’t think it’s imminent. This country has certain fixed views, convictions about certain things like opening a site for people to shoot up down the block. Moreover, the elected officials are really scared because, in a way, it’s condoning the purchase of an illegal substance. Because at these sites, a person has to bring their own stuff, their own drug, their own needles, which are illegal. So the DAs and others oppose it vigorously because they don’t want to be at risk for a federal suit.

Dr. Mark Leeds [15:01] And even in canada and apparently switzerland they actually have medical heroin prescription heroin yes and I had brought up to this on this other interview we talked about it and I said well that’s probably would that probably would help us a lot here in getting people on suboxone because now there are these contaminants in the heroin on the streets whether it’s fentanyl or some analog to fentanyl or even some other kind of drug that’s opioid like that stays in the system for a long time I’ve heard that maybe it’s sequestered in the fat cells. But for whatever reason, they go 24 hours, like you would normally expect. They take their first suboxone and they go into precipitated withdrawal and sometimes even wait two, three, four or five days and they still can’t start the suboxone. And it would be really helpful if we could put them on something known, like a known opioid with a short half-life and transition them. But we really can’t do that. We can’t use oxycodone. We can’t use anything but those three MAT drugs.

Lloyd Sederer, MD [15:55] This thing is methadone. But also, it’s a method in the U.S. Put so many people off that a daily observed treatment, you have to go, wait in a line, drink while somebody observes from a little plastic cup. And every day, go every day. It takes a year or two before you’re given a few days supply. And especially with someone who may be working or trying to work, That whole, all those barriers, all those demands put people off.

Dr. Mark Leeds [16:27] There’s a program, I think it started in 2015 at Yale, ER initiated buprenorphine treatment. And it was very successful. And there’s actually, I think, two programs within a short distance from where I am. But I don’t think there’s a lot of these programs around the country. And I don’t think they’re advertised in any way that there’s not any easy way for people to find them. Where someone goes to the ER and the ER doctor gives the patient their first dose of suboxone or buprenorphine, and then they’re referred to a local clinic and they’re able to continue treatment. In most cases, I think these programs are usually funded. So if a person can’t afford it, all the treatment is covered from therapy to doctor’s visits to medication. And it seems like a really successful model.

Lloyd Sederer, MD [17:07] It’s a great model, but that transition from receiving it right away in the ED and the time to appointment at one of those clinics and the very limited access of prescribers, doctors and advanced practice nurses who have the DEA approval to prescribe it is very low. We did a study about that in New York in terms of trying to not only understand the presence of those prescribers or those who are permitted to prescribe because they have the waiver, and those permitted to prescribe who actually prescribe. And only a small portion of those who are allowed to prescribe prescribe. And one of the things I did a little over a year and a half ago before I left being the chief medical officer for this mental health in the state of New York is I set as a standard requirement, licensing requirement, for mental health clinics to dispense naloxone or to show somebody where they could get it for free and to prescribe buprenorphine, which was never done. And the reason we did it, I did it, was we actually looked at Medicaid recipients who or predominance of public health patients, and what percentage of them in their entire medical records, which we have as a state agency, either were diagnosed with an opioid use disorder or had taken opioids, been prescribed, because it’s a registry, in the past year. And about a little over 30%, one in three, were in need of buprenorphine. And so we made it a stand. And now we’re trying to make it happen, scale it up. And it’s very slowed down by COVID, as you can imagine.

Dr. Mark Leeds [19:07] There was a program in Bangor, Maine. There was an article from two years ago that they had spent a lot of time working on this program, getting it up and running. And it was very difficult, where they were determined to make one-day access available for buprenorphine, that if a patient showed up for help, that they were almost guaranteed that they could start treatment that same day if needed.

Lloyd Sederer, MD [19:26] Right. When I was in New York City in 2002, I was a mental health commissioner in the Bloomberg administration. And I worked, one of my main campaigns was to introduce buprenorphine to people with opioid disorders in New York City. And it was extremely hard to get people to do it. And one of the things that happened as an unintended consequence is that the black market started to sell it on the street. At first, when buprenorphine came out, I asked the police chief, you know, is this stuff being peddled on the streets? And he said, no, we haven’t seen any instances. But a year or two later, it was sold on the street by drug peddlers, and people bought it as a type of insurance policy that if they couldn’t get access to the deal or a dealer didn’t have drugs or the price was too excessive, or even if they wanted to reduce their dose to spend less money, they buy buprenorphine on the street. And in some ways, that’s pretty smart. If you know you’re addicted and you know you may be cut off and how horrible it will be, I think it should be accessible to people who are addicted and not all of these conditions and difficulties to get it. Buprenorphine is a lifesaver. And the point that you made earlier about at least a year treatment is really important. Because some people think, well, a few months of this, six months of this, but it’s a year, year and a half that enables people to get off of it and stay off of opioids. So there’s something about the longer term treatment that’s different.

Dr. Mark Leeds [21:18] The coming off of it is a difficulty. I think a lot of people are afraid of that, sometimes even afraid of getting started. I’ve had patients that have come off of buprenorphine and had a lot of difficulty and issues with long-term effects of feeling some depression, some opioid withdrawal symptoms of, you know, chills and aches. Some people have come off of it with very little problem, you know, in a week or two or a month and a half. And that’s an issue. One patient recently, and I’m wondering what to make of this patient, you know, the family was concerned about a history of bipolar disorder. And I know you talk a lot about that, of comorbidities or coexisting conditions. The patient was started on a combination of an antidepressant and also Abilify, which is for bipolar, and then came off buprenorphine and was very successful, had very little withdrawal, like in a week or two, was doing well and very happy. And she felt good as far as not having the blocking the opioid receptors. I guess for long-term use, that’s one issue is you block the natural endorphin system to some degree. And people don’t get the runner’s high and those kind of feelings. But in this case, you know, I was thinking like, well, is Abilify some kind of a, maybe a wonder drug as far as helping people transition off? Or is it just that she did better because the bipolar was treated a little bit? And it’s hard to say it’s just one case, it’s anecdotal, but it would be nice if there was some more research done in that area of helping people transition off of buprenorphine.

Lloyd Sederer, MD [22:43] Indeed. And your point about the fact that when someone has a drug dependence, frequently they have a mental health disorder as well. And you, to succeed, for that person to succeed, both disorders have to be detected and treated in order for somebody to stand a chance. And in this case, this patient was treated for depression. And Abilify seems to be a sort of add-on drug for many conditions, you know, not a good enough response with depression, people with a very troublesome impulsivity and self-destructiveness, even some kids with ADHD. It sort of seems to quiet the nervous system, but it is an anti-psychotic and it has a lot of side effects. And that’s a concern, particularly with kids.

Dr. Mark Leeds [23:40] Yeah, definitely not something that’s going to be right for everybody. But as far as psychiatry, In my experience, I took a month of a psychiatry rotation, and I was really excited to learn about psychoanalysis and what psychiatrists do. And to be honest, in the area that I did in Miami, a psychiatrist, in my experience, in a lot of cases, would see a patient for a few minutes, figure out what medications to give them. There wasn’t a lot of talking. I don’t think any psychoanalysis. But I know that does occur. I know there’s an organization. Is it BPSI? PSI, there’s an organization that teaches, I think, psychiatrists and other practitioners how to do psychoanalysis. And also, as far as McLean, I had actually met someone that was a 12-step liaison at one of the signature programs there. And they mentioned that at that program, the residents of the rehab, if they’re there for 30 days, every single day they see a psychiatrist. And my thought was, well, if a psychiatrist is only handling medications, what do they need to see them for every day? But maybe they’re, do they actually get psychoanalysis and therapy, CBT? Does a psychiatrist do those sort of things?

Lloyd Sederer, MD [24:48] Yes. You know, but not that many psychiatrists provide any type of therapy, cognitive therapy, analytically oriented therapy. And in some ways, it’s, we’ve, as a field, been driven to do that. One, the supply of doctors who can prescribe is very limited. But second, it’s an economic issue. So if you’re a doctor who spends 45 or 50 minutes talking with the patient prescribing medication, maybe if you work hard, you may see 10 patients a day and you’ll make, you know, $1,000 or $1,200 that day. It’s not bad. But if you have four patients an hour whom you prescribe medications to, and each one of those visits is close to the what’s paid for a 45-minute session, essentially you’re quadrupling your income. And many young doctors, as you know, leave training with enormous debt, often they are at $200,000 or more. And many of them are living in cities that are very hard to afford living in. And so, you know, there’s the rent, they want a car, they have kids, they have to pay tuition. So these doctors essentially can’t afford to do what many people in our field like to do, which is to talk to people. They’re driven to this by the economics.

Dr. Mark Leeds [26:23] I can say in my experience that having the opportunity to spend an hour with a patient is definitely rewarding. It’s definitely helpful for the patient. You know, I feel like I’ve done more than just rushing into a room and out again. And you don’t make as much money doing it, but you definitely feel better about helping your patients, having more time to spend with them.

Lloyd Sederer, MD [26:43] Yes, absolutely. You know, and some people even change their field. There might have been a GI doctor or a pulmonologist, and they go back into training for psych residency because they want the opportunity to spend time with patients, talk to patients, not have eight patients in eight waiting rooms. And they want that experience of being able to form a therapeutic relationship and help somebody change the course of their life.

Dr. Mark Leeds [27:15] I was wondering, are you familiar with the Sinclair method for treating alcoholism? It’s using naltrexone, but it’s using naltrexone, but the person continues to drink a small amount with the medication.

Lloyd Sederer, MD [27:28] I heard of it, but I don’t know beans about it. Well, tell us more.

Dr. Mark Leeds [27:32] They take the naltrexone, the 50 milligram tablet, one hour before they’re planning to have a drink. And then they restrict their drinking to half a drink or one drink, or maybe at most two drinks, for example, a glass of wine. And then they stop, and apparently the naltrexone by blocking cravings would help them to not drink anymore. And also they call it pharmacological extinction of the craving. Over time, you’re kind of doing the end part of Pavlov’s experiment where the dogs aren’t getting the reward anymore by blocking the opioid system. But the key part of it is that they have to continue drinking a small amount, but they don’t do it every day. They’re not supposed to take the naltrexone every day, only on the day they’re going to have a drink. And then they’re instructed for the rest of their lives. If they ever plan to have a drink, always take your naltrexone one hour before.

Lloyd Sederer, MD [28:22] Yes. It’s a way of diminishing a person’s response. So it takes away the reward of the drink because their pleasure centers are blocked. So they may have, you know, in the past, the more they drank, the more their pleasure centers were activated. Whereas here, they have a minimal response and it doesn’t get better because the drug puts a cap on that. And that is a type of extinction as well.

Dr. Mark Leeds [28:56] You’ve published, I think, 13 books total. And you wrote a book two years ago, which is really great. I think also any doctor who treats addiction or any patient or family member should read this book.

Lloyd Sederer, MD [29:08] Can I show a picture of it?

Dr. Mark Leeds [29:10] Oh, yeah, that would be great. Yeah, if you could show the book.

Lloyd Sederer, MD [29:12] Yeah. Okay, so here’s the book. It’s easy to recognize. It has a great cover with all pills. The Addiction Solution. Addiction Solution, yes.

Dr. Mark Leeds [29:22] And I actually, I originally ordered the audio book, which is excellent. And it’s like I listened to it in the car driving. And I liked it so much. I’m like, I want to be able to take notes and highlight things. So then I got the Kindle version. And I think that’s important. You want to be able to look at it and be able to reference back to things. But both versions are excellent.

Lloyd Sederer, MD [29:41] Well, thank you. Thank you very much. The premise of that book, what got me to write that book, is my view fundamentally about substances, about drugs that change how we feel and think. And that is that people use drugs because they serve them. They are useful to them. I’ve come to believe that’s where we as clinicians need to meet people, understand that they’re doing this for a purpose. We’re given to exhort people, don’t you know this stuff is going to kill you? It’s ruining your family. You lost your job. That doesn’t work at all. Because they’re having the experience of either pleasure from it, dramatic and immediate reduction in pain, physical pain, mental pain, and also drugs transport us, many of them, out of the everyday grind. So there’s a purpose being served, and that’s what needs to be appreciated. That’s where the connection, I think, starts with the patient, that I understand you’re doing this because it serves you. And you’re going to keep doing it until you find other ways that serve you in the same ways.

Dr. Mark Leeds [31:00] And that’s where harm reduction comes in, that you talk about the stages of a person being ready. And when they’re in that first stage where they’re not ready at all, and you want to meet them where they are, at least you can put them in a safe place of, you know, here’s something that can save your life. You know, we’re going to keep that on hand in the naloxone. And if possible, here’s a safe place where you can go use the drugs that we know you’re not going to quit yet and form relationships with people that may help you when you’re ready to quit.

Lloyd Sederer, MD [31:25] Right. That’s so important that relationships, family, friends who care about you, not friends and family who tear you down, make you feel bad about yourself, but those that you care about and they care about you, AA meetings, these are support systems and fundamental to a person tolerating the kind of demands that getting off drugs require.

Dr. Mark Leeds [31:56] People should know that you don’t have to be drug free to go to a meeting, that you’re definitely welcome to go to an AA meeting, NA meeting, sit in the room and listen. And you could have used drugs that day. You might not even be planning to quit yet, but you are definitely welcome to go and sit there quietly and hear what they have to say and talk to people afterwards.

Lloyd Sederer, MD [32:16] Yes, that’s, I think, a really good policy. I spent some time with a leadership group in AA a couple years ago, and what I discovered is that their numbers of attendees, It’s pretty hard to collect because they’re essentially independent entities with important privacy protections. But the number of people using 12-step programs has not increased in two decades. Whereas we know that just the population growth alone, no less this storm of addictions that we’re going through now, The numbers are greater, but they’re not drawing more people.

Dr. Mark Leeds [33:06] And that’s another interesting thing that you go into in your book, which I think is really interesting and critical for people to understand, is that there’s a lot of different kinds of therapy. And you even diagram the brain and talk about what kinds of therapy will work on different parts of the brain. And, for example, the meetings, the spiritual support that works on the prefrontal cortex, the newer part of the brain that we have and other animals don’t have so well developed. And the part of our brain that makes us different maybe from a rat that keeps running back from more cocaine that we can actually think things through and maybe stop ourselves. And then you also talk about the reward center and different parts of the reward center and different kinds of therapy that will work on those areas. It’s really important that people know that there’s a lot of different things they can do, not just meetings, not just MAT medications.

Lloyd Sederer, MD [33:54] Yeah, I try to emphasize by that tour of the brain that graphic, maybe you can put that up or your producers can put that up because there are four key areas, as you were mentioning, that allow us to intervene. And addiction dependence is really a tough thing to quit. And so if you enable these four different areas to quiet down or to act more strongly, you’ve given the person comprehensive treatment. You’ve touched on their motivation. You’ve touched on their pleasure center. You’ve touched on their judgment, reasoning, and judgment, and also their hippocampus and amygdala, the memory centers, which are really important and responsive to CBT, cognitive behavioral therapy. And this is the example that you mentioned before, Pavlov’s dogs. He taught the dogs to salivate to the bell rather than the food and essentially demonstrated that we can change what people respond to. And one of the biggest problems with recovery or remaining drug-free are cues, which are bound in the hippocampus and very salient, very powerful. So someone may see a drug deal going down. A friend may call them and who’s high and Prince dies. And those cues are what trigger relapse. Someone may be, you know, not using for 10 years. And then there’s this convergence of events and maybe, you know, they’re fighting with their partner and a cue comes along and boom, the next day they’re using as if those 10 years didn’t mean anything.

Dr. Mark Leeds [35:49] Have you heard of prescription digital therapeutics? You know, using an app on your phone to provide CBT and other forms of therapy?

Lloyd Sederer, MD [35:57] Yeah. For those people who can stay with it works. But the retention rate is actually very low. You know, even if you get a prompt on your phone, you know, it’s time for your session or whatnot, doesn’t seem to hold people. Maybe for a few sessions, but retention is important. And this is a chronic disease, a chronic relapsing disease. So care needs to be ongoing, not all the time, but regularly. And someone needs to have the kind of care that they go to.

Dr. Mark Leeds [36:30] And one interesting thing about one of the apps I looked at, it provides another kind of reinforcement, which I don’t think is CBT. And you do mention in the book, on certain parts of the app, when you get to certain points, they have you spin a wheel on the screen and it’s kind of like gambling you spin the wheel and you might win a like an amazon gift card right and you know and I although I don’t know if that’s different there’s that we spin the wheel like you’re gambling and you get the gift card and they say that kind of lights up parts of the brain you know where you’re getting that thrill of gambling but then you also mentioned the treatment of actually paying somebody for being abstinent

Lloyd Sederer, MD [37:03] Yeah this is called contingency management. And it works. The problem is that a lot of regulators are kind of, I think, myopic about this because they are morally opposed to paying someone to do what he or she should be doing. And New York City, when I was there, the mayor wanted to have a program where mothers were paid to take their kids, poor mothers, single mothers, paid to take their kids to the pediatrician. And the program was going to cost $50 million. And the city council said, we’re not going to pay mothers to do what they’re supposed to do. So he tossed in $50 million. But it still never got off the ground because people were still being stigmatized because they were being paid to do the right thing. But it works. Yeah.

Dr. Mark Leeds [38:01] Yeah, I mean, I think we need to look more closely at things at work, even if we don’t agree with them. Like back to in British Columbia, Canada, there’s areas where they have a lot of dispensing machines on the streets, biometric machines where you can get Dilaudid, which is intended to be crushed up and injected. And it sounds crazy, and I’m sure that will never happen in the U.S., but things like that are saving lives and keeping people from getting HIV, hepatitis, and maybe preventing them from getting endocarditis, you know, heart valve infections. So, yeah, I mean, there’s just things that we might not agree with. Even MAT, a lot of people are against it. In fact, even naloxone, there’s the stories of sheriff departments where the sheriff says, we’re only going to give one or two doses of naloxone and stop if that person keeps relapsing. And they really need to get it as many times as they need it, even if it’s 10, 20, 30 times or more.

Lloyd Sederer, MD [38:54] Yes. And what’s also under that reluctance is the cost, because those sheriff’s departments, police departments have to pay for the naloxone. And now with fentanyl, a single dose often doesn’t do it. Two doses and two more doses four hours later. So the cost of administering in some ways bankrupt these first responders. And that’s why it needs to be essentially covered, made possible free, particularly to first responders. So that’s not a factor, but it is a factor and needs to be fixed.

Dr. Mark Leeds [39:35] And when it comes to drug costs, that was an issue with buprenorphine for a long time until I think it was last year, The Indian company, Dr. Reddy, fought Indivior, the maker of Suboxone, in court, and they finally were able to sell the generic Suboxone films, the buprenorphine naloxone films. And now Indivior is being disciplined for restricting access to buprenorphine. And I think part of that might have been that there was talk in the company about getting people hooked, which was a terrible thing to talk about because people don’t really get addicted to buprenorphine. And they become physically dependent on it. But yeah, a lot of issues with drug costs. There’s actually a quote, and I don’t remember where I saw it. I actually think it might have been Timothy Leary talking about LSD, where he made a comment saying, the drug is cheaper than water. And I think that’s probably true of every drug. I think every drug is cheaper than water when it’s made to scale. And it’s not that the drug costs too much, it’s just that they’re charging too much.

Lloyd Sederer, MD [40:34] That’s right, the profit margins.

Dr. Mark Leeds [40:37] Yeah, so naloxone costs, I think, $150 for two doses at most pharmacies. And it probably only costs pennies to make a nasal spray.

Lloyd Sederer, MD [40:46] That’s right. Especially when it’s made in huge volume like you were suggesting.

Dr. Mark Leeds [40:50] Yeah. So, I mean, there’s no reason why we can’t all have access to it for free, you know, maybe paid for by the government or very low cost, you know, maybe walk into a pharmacy and buy it for $2 to $5 for a package or something.

Lloyd Sederer, MD [41:03] Yeah, it’s not just a profit motive, but also many people think that this is bad behavior, taking drugs. They don’t see it as a psychological, sociological, neurological disorder. They see it as somebody being bad or weak and damaging their family, exploiting, stealing. And so these are not people that they want to help. These are people that they want to be mad at, which of course doesn’t work. It just drives people away.

Dr. Mark Leeds [41:44] Yeah. Speaking of that, you know, with people who are addicted, at least the patients that I’ve seen tend to be people that have huge potential. They’re not like your average person. The person who is susceptible to addiction is often very intelligent, very creative, because I think addiction uses those abilities against them, and it’s harder for them to break free of it. For example, I had a patient, which was a funny story. He was a very intelligent, high-functioning guy that was taking heroin, and his father came in with him, and I was telling him that. I said, you know, usually people who are addicted are very intelligent, creative, high-functioning people. They get caught in addiction. And he said to his father, he said, you hear that, Dad? That’s what I was trying to tell you. And the father just looked at me and said, I never had a problem with addiction. And I’m like, there, we just made our point. You clearly are not in that category because it never affected you. But yeah, and I’ve also compared it to like that, you know, if you remember the old Superman movie with Christopher Reeve where they put the chain with kryptonite around his neck, that imagine if Superman wasn’t wearing a Superman costume and he was laying there helpless with a kryptonite, if you saw him in a dark alley, you’d say, oh, look, it’s a junkie. You know, he’s probably high or something. Not realizing he’s Superman. And I kind of see my patients that way. If you can take away this kryptonite, take away the active addiction, that these people are really capable of incredible things. And they deserve to get naloxone if they need it a million times or get their MAT drugs.

Lloyd Sederer, MD [43:11] That’s a lovely analogy. While some guy lying in an alley being wiped out by kryptonite and who can be helped to stand up and contribute to society again, just like Superman.

Dr. Mark Leeds [43:27] Doctors who get hooked, and they have an incredible potential to help a lot of people if they can overcome their addiction. And, you know, not just doctors, there’s politicians, there’s artists. I mean, people that have a huge potential to not only help themselves, but help a lot of other people if we can just help them get past this act of addiction. You just never know who that is lying on the side of the road who needs our help or what they’re capable of if we can help them get past this.

Lloyd Sederer, MD [43:52] Yes, yes. I mean, this is, naloxone is a little bit like the CPR that people learned if someone passed out on the street, especially when it didn’t require mouth-to-mouth. It just had to pound on. And a lot of people were saved by that, by random passerbys, not by doctors who were there or nurses. And in a way, that’s where naloxone needs to be in terms of its standing in our country, other countries that. This is the way to revive somebody, keep them alive.

Dr. Mark Leeds [44:30] Have you ever thought about, would you accept a position in national public health of helping in the country as far as, you know, if you were asked, you know, say by the new president coming in, is there a place for that, for what you did for the state of New York and the city of New York City at the level, national level in the U.S.?

Lloyd Sederer, MD [44:45] Yeah, well, of course, it depends on who the president is, but I think I’m done with government service. It’s been a really good run for New York City and New York State. And the other thing that even during those years that gave me pause about working for the federal government was that there’s a different horizon for change in cities, in states, and across the country. So in cities, you can do things and you can realize gains, make changes that appear within a year to two. At the state, it’s three to five. And nationally, it’s five to 10. And that’s, I’m too impatient, I think, for that kind of work.

Dr. Mark Leeds [45:34] There was a law passed in 2018, just two years ago, the federal law, I think it was the Opioid Emergency Response Act of 2018 or something like that. And I actually interviewed somebody on the podcast about that he was recommending that doctors or the heads of medical facilities start applying for grants, you know, for funding, that this is going to be like a great program to make a lot of changes. And I don’t know how much effect that law has had, but at least I haven’t seen myself, you know, a lot of programs coming up. Maybe they’re out there, maybe they’re hard for people to find, but have you seen that law has made any positive changes?

Lloyd Sederer, MD [46:13] Yeah, I don’t know about other states, but those grants are rendered state by state and New York State received first $30 million and then I think another 15, I’m not sure. And it was through the state agency for substance abuse called OASAS in New York. And they distributed that money to increase access to enable clinics to hire more doctors to pay for naloxone so that it would be free and accessible. And that’s visible. Whether it’s going to make a population level change remains to be seen, but that’s where it has to start. The money needs to go and be spent responsibly by some regulatory body that will ensure that the right things are purchased for the money.

Dr. Mark Leeds [47:14] Dr. Sederer, I definitely want to highly recommend listeners get Ink Stained Life, your new book.

Lloyd Sederer, MD [47:20] I have a picture of that.

Dr. Mark Leeds [47:22] Oh, great. Oh, yeah. So there’s a hardcover book. I would definitely recommend people get that. It’s paperback, too. Oh, okay. Oh, okay. Yeah, so you can get the book as a coffee table book. The Kindle, I highly recommend the Kindle because you can click on a word and get the definition right away because you introduce a lot of great vocabulary. There’s haberdasher. There’s quotidian. Just some really great words. I really enjoy just clicking on the words to see what they mean.

Lloyd Sederer, MD [47:50] I didn’t mean to be hired. I love those words because the haberdasher was my grandfather. And that’s a men’s, someone who sells or makes men’s clothing. And that’s what he was a salesman in a Lower East Side men’s store. And they were known, these men were known as haberdasher. So it’s not like it’s a fancy word for me it’s a word that I heard when I was three years old and five years old and quotidian I love because it’s a nice way of saying every day without saying every day

Dr. Mark Leeds [48:33] There’s a lot of great stories in there and for me you know being Jewish but not observant really my religion but you know wondering where do I stand in the world of being Jewish there was a great connection there of reading your experience just a lot of great stories about living in new york and kind of you know […] there’s just so many great stories about things that have contributed to you know working on the farm and you know how that led to in the future your public health career and learning how to work together with other people and you know the your experience with the fireworks, that was interesting.

Lloyd Sederer, MD [49:14] I had a business selling illegal fireworks as a kid. But what I’m also trying to show there is the arc of our lives, how this thing or that thing heralds who we become. The experience of cleaning chicken coops, the experience of working in a family business. These are all etched into us, and they do shape our decisions, including going to medical school or being an attorney or being an artist. It doesn’t matter. They’re etched in during those early years, and you can see an arc develop.

Dr. Mark Leeds [49:57] Did you also talk about the experience of being a smart person, but then meeting an actual genius and how that feels or being well off, but then meeting people who are actually rich. And, you know, I know that can sometimes make a person feel bad or even inhibit them from going further in something. And, you know, for example, with me, I used to love playing piano, […] And when I actually met real musical geniuses, it kind of made me feel like what’s the point of going any further?

Lloyd Sederer, MD [50:24] Yeah, yeah, that can be discouraging. You know, I went to a really good exam school in New York City called Bronx High School of Science. And that’s when I met some classmates who were truly geniuses. They were operating at a totally different level. And I would never get there. You know, we would get a calculus problem and I’d labor on it. And, you know, this guy next to me, he would figure it out in 25 seconds and it might take me an hour. And you knew that there are people who really are operating in that zone. Robert Strom, people never remember him, was one of the kids in my class. And he was on the $64,000 question, which many of your viewers may not recall, never saw. But it was a quiz show where a contestant could win up to $64,000 in a progression of getting the correct answers to questions. And Robert Strom was on that show, and he won $64,000. He was like 15 years old. It’s a little daunting, but each of us, I think, needs to strive to be as good as we can with our own native abilities complemented by hard work. And not to try to be somebody else, but to be as much of ourselves as we can, contribute as much as we can.

Dr. Mark Leeds [51:59] That was another lesson you brought up as far as hard work, that if you find what you love doing, it doesn’t feel like work. Which I related to with my blogging. At first I was afraid to write. I don’t want people to read what I write and tear it apart and point out what I wrote, what was wrong. But, yeah, once you find that one thing or those things that you really enjoy, it doesn’t feel like work anymore.

Lloyd Sederer, MD [52:21] Right. And as you’re describing, many people discover that they love to write because they’re not trying to be scholarly. They’re not submitting this for a grade. But they’re talking like we’re talking to one another in everyday English about something they know a lot about. And then the words flow. And that’s a beautiful thing.

Dr. Mark Leeds [52:46] Yeah. And if someone is sensitive about grammar, they’ve got some great grammar checkers now. There’s a really…

Lloyd Sederer, MD [52:51] Right.

Dr. Mark Leeds [52:54] Sorry to keep you for so long. And I really appreciate you coming on the podcast with me.

Lloyd Sederer, MD [52:58] Oh, I’m very grateful to join you and recognize the kind of work that you’re doing. This country needs a lot more Mark Leeds.