What happens when a family attorney and a doctor compare notes?
In September 2019, I joined Mark Astor, an attorney who helps families get help for a loved one with a substance use problem, on his own show. We treated it as a shared episode. He asked about my work, and near the end I asked about his.
Mark said the people who come to him are usually parents, and sometimes a spouse or a sibling, and that he speaks to a lot of crying mothers. He wanted his listeners to hear a physician explain medication for opioid use disorder, because, as he put it, many of them would not know what it is.
This is an archive episode, recorded when the show covered addiction and recovery broadly.
How did a family doctor come to focus on opioid dependence?
At 2:11, I explained that I started in family practice and that, over the years, my work shifted toward treating opioid dependence with medication. By the time we spoke, it was close to all of what I did. Part of the reason is how quickly people can improve.
From 4:27, I told the story of how it began. I showed up, almost by accident, to a one-day course that allowed doctors to become credentialed in this field. Years later, a long conversation with another doctor at a convention showed me what a practice built around this work could look like.
The writing grew out of patients’ questions, answered in general terms so the answer could help more people. Interestingly, at 6:51 I described how that writing brought calls from families as well as patients.
What medications are used for opioid use disorder?
At 9:22, I explained medication-assisted treatment, which Mark had asked about. There are three medications: methadone, buprenorphine, and naltrexone. Methadone has to be given through a specially licensed facility, so I did not prescribe it, although I sometimes referred people there when it suited them better.
Buprenorphine is the active ingredient in Suboxone and several other brands. Naltrexone works differently. It only blocks the opioid receptor, it is not a controlled drug, and any doctor can prescribe it. I said that all three give people a far better chance than trying to stop without medication.
Mark asked at 10:38 how trauma and mental illness fit in. At 11:10, I said that medication is only part of it. Conditions such as depression and bipolar disorder may be caused by the drugs, may have come first, or may simply exist alongside them, and therapy has to address them.
Why is naltrexone harder to start than buprenorphine?
At 17:38, I explained the catch with naltrexone. A person has to be off opioids for about a week, sometimes two, before starting it, and starting too early makes withdrawal worse. Unfortunately, that waiting period falls right where withdrawal and cravings are at their hardest, so few people choose it.
Buprenorphine works on a shorter timeline. From 25:07, I described how most people stop a short-acting opioid for about a day, go into moderate withdrawal, and then feel relief when the first dose takes effect. So it can suit someone who cannot or will not go away for inpatient care, such as a person who is still working.
At 20:46, Mark asked how buprenorphine is taken. Most people dissolve a tablet or film under the tongue. I also described a monthly injection and an implant that lasts six months, and the question the implant raises: how do you keep someone coming to visits when the medication is already in their arm?
What could protect someone after a month off opioids?
At 23:16, I said that if nothing else came out of our conversation, I hoped this would. When a person has been off opioids for a month or more, I strongly recommended that they go on naltrexone long term, maybe even indefinitely, as ongoing protection against relapse. The generic tablet is inexpensive, and any doctor can prescribe it.
Yet, most people know naltrexone only as Vivitrol, the monthly injection. I said the injection is expensive and hard to keep covered, and that the maker’s lobbying for it has left the oral form overlooked.
How has fentanyl changed the picture?
From 25:07, I described what drug testing in my office was showing. Nearly every person who believed they were using heroin tested positive for fentanyl, and some tested positive for fentanyl and not heroin at all.
Some of it is fentanyl analogs rather than the fentanyl used in hospitals, and some forms last longer in the body. That can make the switch to buprenorphine harder. In fact, methadone may be the better choice for some people, because it is the one medication of the three that can be started the same day a person stops.
Do courts ever order someone to take these medications?
At 28:55, Mark asked whether anyone is court ordered to take them. I doubted it, apart from possibly the monthly naltrexone injection, whose maker had lobbied judges and law enforcement. At 29:10, I said that few judges would order someone to take an opioid to treat opioid dependence, even though it had become the standard of care.
At 30:02, Mark admitted that when he first heard about this medication, he thought it made no sense to give someone a legal opioid to get them off an illegal one. Then a mother at one of his talks told him that medication was keeping her son alive. He decided to take another look.
What is the Marchman Act, and does it work outside Florida?
At 31:22, I asked Mark my own question. He explained that the Marchman Act is a Florida law, so it applies only when the person is in Florida, even though many of the families who call him live in other states.
Every state has a guardianship law, he said, and his office also does guardianship work when more control is needed for a longer period. When a family takes their loved one home, they can often ask a court in their own state to recognize what was done in Florida. However, he stressed that this depends on each state.
Who is Mark Astor?
Mark Astor is an attorney whose office, Drug and Alcohol Attorneys, works with families seeking help for a loved one with a substance use problem. His work includes Florida’s Marchman Act and guardianship cases. He also hosts his own podcast about addiction and recovery.
What can listeners take away from this conversation?
Mark admitted he once doubted medication for opioid use disorder and said he needed to educate himself more (24:05, 30:02). Yet, an attorney and a doctor found real common ground here. Both want the person alive, protected from relapse, and supported for long enough to rebuild a life.
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.
Call 911 or go to an emergency department if there is a seizure, confusion or hallucinations, or thoughts of self-harm. For thoughts of suicide or any mental health crisis, you can also call or text the 988 Suicide and Crisis Lifeline.
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 (36 minutes)
Mark Astor [00:00] All right, everybody, welcome to another edition of The Journey. I have a very different guest today, and I’m very excited to have an opportunity to chat with him, Dr. Mark Leeds. Thank you, Dr. Leeds, for joining us. And what’s really cool about Dr. Leeds is that he is a doctor that, and correct me if I’m wrong, is specialized in helping people who have opioid and opiate addiction and, I guess, issues of that nature. Is that right? So I want to interview him today because to be honest with you I think dr lee I think you may be the first physician I’ve sort of come across who does this kind of work I mean we’re sort of not used to dealing with you know doctors who do this kind of work so I was I’m flattered that you agreed to come on the show and just talk about what you do
Dr. Mark Leeds [00:51] Oh thank you thank you oh can you can you give me I’m sorry. Can you give me one second? Yeah, I’m waiting here. I’m sorry. I had a video conference. Yeah, 100%. […] Are you there? Security wanted to check me out.
Mark Astor [01:12] Yeah, that’s okay. […]
Dr. Mark Leeds [01:22] Yeah […]
Mark Astor [01:24] And also so I know that you have your own podcast what’s the name of it where where can people view it
Dr. Mark Leeds [01:30] Yeah my podcast is audio only and it’s the rehab podcast on the mental health news radio network and people can find it at the rehab podcast.com the official website is therehab.com or you can just search for it on itunes or whatever podcast app that people use
Mark Astor [01:48] All right so I guess the way this is going to work is I know that normally in my podcast, I get to ask all the questions about seeing as how we’re sort of treating this like as a dual podcast. You’re going to get to ask me a bunch of questions too, which I think actually might be beneficial to the folks that are going to watch this. So in any event, so tell us about what you do, because it’s so unusual to find a doctor that does this kind of work.
Dr. Mark Leeds [02:11] Yeah. So I’m a family practice doctor and I’ve been doing family practice since 1999. So about 20 years now. And in the last few years gradually my practice became more dedicated towards the treatment of opioid addiction using medication assisted treatment and I became certified to do that in 2006 and for years I wanted to do more and more of it and just at some point about four years ago three or four years ago I decided this is what I want to do mostly you know kind of push everything else aside, you know, I still do family practice, but less and less of it as, you know, I do more writing. And that’s the other thing. I started doing a lot of online writing, you know, blogging, some YouTube videos, you know, I started the podcast and everything kind of went in that direction because it’s such a rewarding field to be able to help people. Yeah. So, and you know how that is, you know, when you help someone get better and you see someone get better after struggling with active addiction, it’s incredibly rewarding. And with, in the field of medication assisted treatment, you can see results very quickly. You can see someone going from, you know, being hopeless to the next week that their life has turned around. And within a month, they’re a whole different person. You almost don’t recognize them sometimes when they come back in the office, they look so much better. So, yeah, I’ve just, at this point, it’s become, you know, close to 100% of what I do, you know, treating mainly opioid addiction, some alcohol, you know, some other people come in and I do the best that I can to help them, you know, as far as directing them to the right kind of program. If they come in for something like cocaine addiction or amphetamine addiction, where there’s no medication-assisted treatment specifically for those conditions, but at least I can talk to them about what’s available in recovery and treatment. And hopefully now that I know you, maybe even point them in that direction.
Mark Astor [04:01] Yeah, so I’m going to ask you the same question that I always get asked is, how on earth did I end up doing this kind of work? Because there’s this bit like you I’m few with this few I don’t think anybody doesn’t doesn’t specialize in this stuff anywhere in the country but I know the practitioners like you and me are few and far between you gotta have a real passion for this stuff because it’s stressful so maybe give us a little bit you know of your background and what made you decide to sort of move into this arena
Dr. Mark Leeds [04:27] It kind of just happened I actually I showed up at the class you know there’s a one-day class an eight-hour class where you get certified. And I almost showed up accidentally. You know, I saw the course was being offered. I wasn’t sure what it was exactly. I showed up to it. And, you know, they said, by the end of this course, we’re going to allow you to become credentialed in this field. And I didn’t know much about it. So I, you know, I saw some people I know. I took the course, went through it. A few years went by. I didn’t do much with it. And I met a doctor, I think 2011 at a convention. And he, you know, we had a conversation outside for probably a couple hours and he told me all about what he does. And I was in practice for myself at that point, you know, didn’t really know what direction we’re going in. And what he laid out for me, what he does as far as exactly what I’m doing now, it really kind of struck me as like, that’s what I want to do. You know, we talked about MAT, we talked about suboxone treatment, you know, and how he had done the same thing. He went from family medicine to dedicating his practice to it. And, you know, just kind of, you know, I got to a point where, you know, we just had to kind of pick a direction for what we’re going to do. And it was also with the writing, you know, I started writing and the way that I did my writing was I didn’t know exactly what to write about or how to write about addiction. So what I would do is when people would come in and ask me questions, I would write about, you know, how I would answer them, you know, how I would put it in general terms to not only help them, but maybe help, you know, as many people as possible to answer that question for everybody. And it just kind of took off that way. I did more research, more reading, you know, attending meetings, attending lectures. And I think it really was kind of the synergy between seeing patients and doing the writing and doing the research and kind of wanting to do more of it. So
Mark Astor [06:17] So I’ll ask you when you when you had your your before you were doing this and you had your family practice did did you get families coming in or individuals coming in saying look this is what’s going on with us you know we’re having an issue with you know our son or daughter our spouse sibling whatever it was what can we do you know to get help did you notice a lot of that because it just seems like if you know I know it’s a general rule right I mean I go to unless it’s as a general when I feel like I have a condition I generally go to my sort of family practitioner or my GP and say, okay, what do I do with this? And if it’s not something you can handle, they refer me to a specialist.
Dr. Mark Leeds [06:51] And that’s also, I think, a function of the writing, the blogging, is that there’s something called SEO, search engine optimization, that when you write on a certain topic, people start finding you on Google. And somehow whatever I was writing just got out there. And I started getting phone calls and emails exactly like what you’re saying, not only from patients and people looking for help and people from far away that weren’t able to come in to see me in person, but also family members you know people who want to know can can you help me with this or help me with that and I would go and write about other topics and get people you know just for example and I did want to ask you about this in the field of treating alcoholism I learned about someone told me about something called the Sinclair Method and I’d never heard of it so I went online and researched it watched a youtube video about it read a book about it and you know I did a little bit of writing about it
Mark Astor [07:39] What is the Sinclair Method I have to I’m not familiar with it
Dr. Mark Leeds [07:42] It’s something it’s a little bit concerning because it’s an alternative to treating alcoholism where a patient is given naltrexone, daily naltrexone, usually 50 milligrams orally daily. And then rather than being told to quit alcohol altogether, they’re told now you can reduce to one or two drinks a day. And because the naltrexone will suppress your cravings for alcohol and your enjoyment of alcohol. And supposedly it’s an alternative way to overcome alcoholism. And I don’t know that I agree with that, but the benefit is maybe that it brings people in to have that conversation where you can, you know, they come in to ask about the Sinclair method and now you can tell them, well, I really strongly recommend that you just plan on going completely without alcohol and, you know, get detoxed off the alcohol first. And naltrexone is still helpful. It’s still something that can help people stay sober long term and suppress cravings. But you know the idea of having a drink or two every night for an alcoholic might not be a great idea
Mark Astor [08:42] Yeah probably not so let’s go back a little bit and let’s maybe explain sorry about this all right you know but just so you know before before we went online we had the fire alarm going off in my building so oh I said jay who does my production I said I said I wonder if this is going to work if the fire alarm’s going off because people were coming into the office and they were saying hey there’s a fire the fire alarm’s going off I said look I’m doing a podcast I got work to do. Bill will have to burn down around me. That’s all there is to it. Oh, well. It’s okay with the chiming bells or pleasurable compared to the screeching noise we have with the fire alarm. So maybe for the folks who are watching the show, explain to us what MAT is, medically assisted treatment is, because a lot of people probably won’t even know what that is.
Dr. Mark Leeds [09:22] Oh, yeah. Yeah. So typically call it MAT or medication assisted treatment. And it is the use of one of three medications to treat opioid addiction or opioid dependence. The first is methadone and I don’t get involved in methadone treatment because that has as you know it has to be done in a special government licensed facility so methadone is one then the next one is buprenorphine buprenorphine is the active ingredient in medications like suboxone there’s other brands like Zubsolv there’s a monthly injectable Sublocade so there’s a variety of brands that have buprenorphine so that’s the second one the third one is naltrexone And so we have three medications, methadone, buprenorphine, and naltrexone that can treat opioid addiction. Methadone is known to have about a 75% success rate, which is excellent. Buprenorphine and naltrexone both have about a 50% success rate. And not using medication, just abstinence-based treatment, I’ve heard numbers anywhere from 1% to 10% to 15% success rate. So yeah, it works very well. I mostly deal with buprenorphine and some naltrexone, and I do sometimes refer people to the methadone screen, and I feel that would be better for them.
Mark Astor [10:38] Right. So, you know, one of the things that we try to do in our office is we probably because both my partner and I have doctors in the families, we try to do what we call triage in the case and find out what’s really going on. And in a lot of our cases, we’re dealing with folks who are using, but they have trauma. It could be physical, sexual, things of that nature. So I get it you know in terms of dealing with the substance use disorder but if there’s underlying issues of trauma or mental illness you know whatever it happens to be how does that all fit in together to work with the mat
Dr. Mark Leeds [11:10] Oh yeah therapy is part of it also so it’s not just medication psychotherapy which I recommend you know that a patient see a phd in psychology you know someone who has experience and credentialing in the treatment of addiction there’s an excellent excellent one near our office in the area of fort lauderdale that we refer people to all the time okay you know so that yeah that’s important because things like bipolar disorder depression I mean there’s things that are caused by the drugs but then there’s also underlying conditions that maybe the patient was self-treating or they just happened to coexist and that definitely needs to be addressed
Mark Astor [11:46] Yeah and I’m so glad that you said that because for us sometimes it’s a chicken egg thing right what comes first the substance use disorder or the mental illness and maybe we’ll digress just for a second, but we’ve been getting calls lately from younger and younger, the parents of younger and younger children. And I use the word child loosely because I’m 52 and my mother still thinks I’m a little boy, but that’s maybe a different conversation. But for instance, yesterday I had a call from a crying mother. I speak to a lot of crying moms. A young man is 16 years of age and he’s using a ton of marijuana. So the question is he suffering from some type of mental illness, anxiety, depression, whatever it happens to be? So he’s smoking marijuana because it makes him feel better or is he smoking marijuana and that’s causing you know the other effects because from what I’ve read and seen and I’ve been told marijuana today is probably not what it was I know when I was growing up and can cause brain damage you know an iq perspective so tell me how this all sort of fits together with the mat program
Dr. Mark Leeds [12:47] Sorry there’s the bell again
Mark Astor [12:48] As far as in london with all the charming bells oh
Dr. Mark Leeds [12:53] Yeah oh
Mark Astor [12:54] Are you from london originally originally many years ago
Dr. Mark Leeds [12:57] Oh well I yeah I went to I went to europe for the first time last year and we visited ireland and london it was fun we just went to london for a day and that it was a lot of fun yeah it’s a great place yeah definitely so yeah as far as marijuana that’s kind of a difficult situation because you know, obviously it’s legal now in a lot of places. And, you know, they’re in Florida, you know, it went from there’s a short list. Well, you know, there’s a short list of conditions that medical marijuana was going to be used to treat. And now it seems like they open it up to everything. You know, anything that somebody has, if they go to a marijuana doctor or dispensary, I guess it treats everything. But so what I tell patients when they come in, if they insist that they need marijuana therapeutically for one thing or another. Of course, they’re still referred to the psychologist. But what I tell people is that anything that you take should be from a doctor. Nothing should be from the streets because we don’t, like you said, we don’t know what’s in anything that’s out on the streets. We don’t know if there’s fentanyl in it. We don’t know if there’s cocaine or PCP or whatever they add to marijuana, pesticides. So if someone has to take it, you know, and, you know, go see a doctor that specializes in that, preferably one that deals with also their particular condition. I don’t know if there’s psychiatrists out there that recommend or prescribe medical marijuana, but either way, it should not be any of this stuff on the streets, which could be very potent. And as you’re probably aware, fentanyl, fentanyl being a synthetic opioid, which is 80 to 100 times more potent than morphine, is being found in every kind of street drug. So everybody’s at risk for fentanyl toxicity and overdose, even if they just use marijuana, off the streets and so you just don’t know what you’re getting so if it has to be used you know it should be from a doctor yeah
Mark Astor [14:43] You know this past was it friday through through yesterday we’re up in massachusetts we went up there for there was a big conference up there on addiction disorders and I guess in massachusetts you know recreational marijuana is legal and we drove past the dispensary I mean they had a line around the corner and they had that they had security there because there’s so many people I’m like wow I don’t know if it’s putting the black market out of business, but there’s apparently a big demand for this stuff. Yeah. I’m talking recreation, not medicinally.
Dr. Mark Leeds [15:14] Yeah. And I’m sure another issue is harm reduction. Harm reduction for opioid use disorder and heroin use on the streets as far as, apparently we don’t have any safe injection sites in the United States. People were places where a person could go under medical supervision and use heroin and be given education on how they might get clean when they’re ready to get clean and test the heroin to make sure there’s no fentanyl in it. Make sure they’re using clean syringes and needles. If they overdose, you have Narcan, you have medical personnel that can reverse an overdose and call for emergency help. So we don’t have any of those. And there was an article the other day about that, about, I guess, somebody wanted to open a safe injection site and partner with a clean needle exchange place. And, you know, somebody in the administration, I guess, like, you know, I don’t know if it was the attorney general or whoever it was, went and fought it in court and said, you know, they’re not allowed to do this because this is, for whatever reason, it’s an illegal schedule, one class, one drug. And the first thing I thought when I saw that, well, so was marijuana. So we’re going to ignore all these marijuana dispensaries and say, well, let’s let the states decide, but let’s go after the one safe injection site and not let that open, which could actually save lives.
Mark Astor [16:31] Yeah. I mean, I think it’s one of the countries in Europe, I’m not sure if it’s Holland or Norway, one of those countries that actually has done that. And they’ve had tremendous success with it’s basically eliminated a lot of the street crime. And I guess they also provide recovery services for the folks that are coming in to use use the drugs. So it seems like it’s a win-win. But I hate to say it, but sometimes in this country, it’s all about the Benjamins, as it were. Yeah. Marijuana is supposed to be illegal, and we can certainly have to debate about it until the cows come home. And I’ve got my own personal views on it. But it seems like we’re going to let the states do it, even though it’s illegal under federal law for a number of reasons. But in any event, so let me ask you a question. Give us an idea of, like, so a typical patient walks in, they get referred to you. So I’m looking at your website, and it’s got a, It’s really a great website, by the way. It’s got a ton of information on there. Some of the words, I always joke with my brother because my brother’s a Dr. Anabaptist. Some of the medications, I almost can’t pronounce the name. You do a better job than me. So how do you figure out what’s an appropriate type of medication for someone’s substance use disorder?
Dr. Mark Leeds [17:38] Yeah with opioid use disorder buprenorphine is in the case of our practice usually the best choice naltrexone the problem with naltrexone even though it has about the same success rate is it a person has to be opioid free for about a week and in some cases up to two weeks which seems yeah it seems like it wouldn’t be a big deal you know for people that aren’t familiar with the condition, but the worst of the, you know, when a person stops taking opioid like heroin or oxycodone, they go through a severe physical withdrawal and psychological withdrawal. So the wind’s blowing the air. Yeah. So, you know, they have, and at about 72 hours, along with these excruciating withdrawal symptoms, which have been described as, you know, like flu symptoms, but times a hundred or times a thousand. I mean, it’s intolerable, You know, muscle cramping, nausea, vomiting, upset stomach, chills, aching. So it’s pretty severe. And then along with that are severe cravings for opioids. You know, so for a person to tell a person, OK, you have to stick it out for a week or two, you know, then come in and we’ll get we’ll see if we can start naltrexone. And if you start too early, it’s going to throw the person into even worse withdrawal. So you can imagine that’s not a popular option. And I kind of question a little bit if it really has the same success rate, although studies have shown that it does. So, you know, so maybe it does. I think the ideal place to start naltrexone would be after a person has been in an inpatient program. Naltrexone is the only one of the three. Sorry, I don’t know if the wind is getting a little windy here. Okay. Yeah. So naltrexone of the three drugs of methadone, buprenorphine, and naltrexone is the only one which is not a controlled drug. It’s not an opioid. The other two are forms of opioids. So methadone is an opioid. Buprenorphine is an interesting drug because it’s a mixed opioid agonist and antagonist. It blocks the receptor very strongly and partially activates the receptor. And then you have naltrexone, which is a strong opioid blocker. All it does is block the receptor. It’s not controlled at all. Any doctor can prescribe it. Even a doctor who’s not registered with the DEA can prescribe naltrexone. I think the ideal place for naltrexone is after a person has been admitted to treatment, they’ve been detoxed off of the opioid, they’ve been cleaned, they’re in there for a month or maybe more than a month, and now they’re going to leave and you want to give them the best possible chance for success. Giving them naltrexone to take indefinitely would be a great idea. Now, one problem with that is that the most commonly known form of naltrexone is a monthly injectable called Vivitrol, which you’re probably familiar with. Yeah, Vivitrol is expensive. It’s hard to get it paid for. It’s hard to have it continued long term. And it’s a big issue where parents get upset because their kid didn’t get their Vivitrol or it gets discontinued. It’s not covered anymore. It’s, I think, a $1,500 injection if insurance isn’t paying for it. And because the company that makes it has lobbied so hard for it, people are not familiar with the oral form of it, of naltrexone, which costs a book.
Mark Astor [20:46] The buprenorphine, how is that administered? Is that an injection?
Dr. Mark Leeds [20:49] Oh, yeah, buprenorphine is sublingual. So it’s either a tablet or a film. It’s either a small rectangular film or a tablet, and it goes under the tongue, and it dissolves under the tongue. There’s a couple other ways. That’s the most common way, like overwhelmingly probably 98%. I mean, I would assume like nearly 100% of people take it that way. There’s also a monthly injectable, which is Sublocade, came out last March. It works really well, but not as popular because you have to get it covered by insurance. And, you know, there’s a little bit of a process and it just hasn’t really caught on. It would be nice if more people were interested and would go through the little bit of effort it takes to get it because it’s not really that hard. There’s a few pages of paperwork to fill out and most insurances will cover it. And it’s very effective. And a person doesn’t have to worry about taking a daily medication. They just come in for their monthly doctor’s visit and get their monthly shot, and they get the same effect. Then there’s also an implant form of buprenorphine, which is Probuphine. Probuphine, that was, I think, approved two or three years ago. Also not very popular because it’s an implant. It’s four rods of buprenorphine that get implanted on the inner part of the arm, and that lasts for six months. That can be changed every six months. Just the idea of a surgical procedure doesn’t get people excited. But, you know, and then it’s also recommended that they still come in for at least monthly visits, if not more often. So that’s a little bit of an issue is how do you motivate somebody to continue with their doctor visits when they have six months of medication implanted in their arm?
Mark Astor [22:23] I got a question. How long can someone continue to take either the naltrexone or the buprenorphine?
Dr. Mark Leeds [22:28] Any of the three medications, whether it’s methadone, buprenorphine or naltrexone, can be taken indefinitely. It’s generally recommended these days that a person plan on a year, year and a half, two years. Less than that may not be enough time to get the appropriate therapy and make lifestyle changes to be ready to come off of it. Initially, people for a long time thought that two weeks was enough or a week was enough, and then three months and then six months. Now the thinking is generally that it should be an average of a year and a half.
Mark Astor [23:01] Okay so tell me how this might fit in say with some type of abstinence-based treatment because obviously the work that we do is you know even through the Marchman Act or guardianship and even some of the criminal if you do is the idea is to get somebody into a program
Dr. Mark Leeds [23:16] Yeah I would yeah I would say you know if nothing else comes out of our conversation that if you get someone into treatment for opioid use disorder and they’re there for a month and they’re in the program for a month or more and they’re clean, that when they come out, I would strongly recommend that they go on naltrexone long-term, maybe even indefinitely, maybe even for life as an ongoing protection. Naltrexone is not an opioid. Any doctor can prescribe it. A month’s supply of the generic tablet is, it’s an oral tablet. You swallow it’s about $30 a month for the generic. And that would give the person a much higher success rate long-term to protect them against relapse in the future. So it’s something that for whatever reason, it’s not being done. And I think it should at least be brought up.
Mark Astor [24:05] All right. So, you know, you and I are going to have to sit down and have a chat about that after we’re done with this podcast, because I’m intrigued because, you know, for us, you know, our goal is always trying is just to try and keep somebody in recovery. I say just, our goal is to get somebody in recovery for at least one year, because we know just from our experience and statistically speaking, if we can keep them, if we can get them for that one year, they’re more likely to stay in recovery. If it’s less than a year it’s more like they’re going to relapse and so obviously you know we’re in terms of treatment providers we’re really careful because we want to make sure that you know as long as you know for the time we’re on the journey with our families that there’s an aftercare program in place and I’m you know I’m not gonna as a non-doctoral non-physician I’m not gonna sit here and preach about you know the work you do but it certainly sounds like it might be really really helpful and I need to educate myself more so this is this is really great stuff. I mean, if we can keep somebody in recovery for life, because we can take away whatever is sort of driving their needs, I think it’s huge.
Dr. Mark Leeds [25:07] Yeah. And there’s no, of course, there’s no guarantee with anything, but to go from a success rate long-term of 10% or less up to 50% is a huge jump. And that’s for a medication that they can get from their family doctor. It’s not controlled. It shouldn’t concern anybody. I know that there’s doctors out there that are not comfortable with because they’re not familiar with it, but naltrexone is a very safe medication, and it’s something that should be considered. Now, what I mostly deal with is mostly buprenorphine, which is people think of as suboxone. That’s kind of like the common, like the Kleenex brand, you know, everybody knows the suboxone, and the benefit is that you don’t have to wait a week or two. So, for people that can’t or won’t go to inpatient treatment, you know, say, for example, someone is a professional and they haven’t lost their job, you know, they’re still working or whatever, or they haven’t lost their family, but they want to quit using opioids. The person has to come off the opioids for usually between 18 and 24 hours, depending on the nature of the opioid they’re using. But for most short-acting opioids, the transitional period is about 18 to 24 hours. They go into moderate withdrawal. And when they start the buprenorphine, it immediately relieves the withdrawal symptoms and they feel better. And then going forward, they can continue taking it as a safe medication. It also helps with some other conditions. Additionally, it helps a little bit with things like anxiety and depression, although it’s not officially an anxiety and depression medication. It can, as an additional side effect, may help with those things. For people that have chronic pain issues, it may help a little bit with the chronic pain. And it’s something that a person can transition to quickly and easily, if they’re willing and able to go that short period. Now, recently, there’s the issue with fentanyl contaminating the heroin supply in the streets. Pretty much everybody we’re testing now, when they’re a heroin user, even when they think that they’re only using heroin, they have the one dealer that has the good heroin. We test them, and it comes up positive for fentanyl. In some cases, it comes up only for fentanyl and not even for heroin when we do the drug test. So there’s everybody, as long as we’ve been testing for fentanyl, I don’t think I’ve seen for a long time someone who tested only positive for heroin and not fentanyl. So it’s a big problem. And apparently some of the fentanyl is out there. It’s not the same fentanyl that they’re using in hospitals and for cancer patients. It’s fentanyl analogs, which is imported through the U.S. Mail from China. And it’s synthetic. It’s different. In some cases, it’s very long lasting. And for some patients, that transition can be longer and more difficult of going from quitting that drug to starting Suboxone. And for some people, methadone may be the best option for them. And also, there’s people that just can’t make it through even that 18 to 24 hours. One patient called me. He had quit his heroin, and his heroin dealer was showing up to his house, just texting me, shows up at the door. I’ve even heard of heroin being delivered by Uber. So it’s crazy how accessible and easy it is for people to get it. A guy called me, you know, it was about 11 or 12 hours in. He said, I feel a little bit sick. Do you think I’m ready yet? And I said, I don’t think you’re ready yet. When do you come back in tomorrow? And he said, well, do you think I should just call the heroin dealer? And so, of course not. He said, go to the hospital, go to the ER. Whatever you do, don’t call the heroin dealer. He said, you know, I think I’m just going to start this tomorrow. I think I’m just going to call him. And, you know, I’m on the phone with him and I can beg and plead with him. There wasn’t much I could do about it at that point. In those cases, maybe methadone is the best option because methadone is one of the three drugs for MAT that you can start the same day that you quit heroin or quit whatever opioid you’re using. So there’s no downtime or transitional time of going through withdrawal.
Mark Astor [28:55] Really scary stuff, but it sounds like you’re doing a lot of great work. I’d like to start a chat with you. We can work together. Do you have anybody that gets court ordered to you to take these medications?
Dr. Mark Leeds [29:10] I don’t know if anybody is court ordered to take medications like methadone, buprenorphine, or naltrexone maybe, because, you know, like I said, the company that makes Vivitrol, apparently they lobbied heavily with judges and law enforcement and prisons. So a person may as possible they’ve been court ordered to use Vivitrol but yeah I think I think the abstinence-based treatment is so ingrained in the addiction treatment industry and in society that I think a person you know it’s not very likely to be court ordered to take one of these to take an opioid to treat opioid addiction even though it’s the standard of care now and the best possible chance a lot of people have I think you know court orders that would be from a judge and I don’t think a lot of judges want to say, okay, I want you to go take this opioid to treat your opioid addiction.
Mark Astor [30:02] Doctor, I really love what you’re doing. I really do. You know, it’s interesting. There was a period of time when I first started doing this, I’d heard about MAT and I was like, are you kidding me? You know, because a lot of it was getting funded. You know, we had all this money coming to fund. I said, they’re going to give money to the drug companies. We’re giving more to the drug companies. And I’ll be candid with you. This was a while I was really like, this is ridiculous. How can we give people a legal opioid to get them off an illegal opioid? And then one day I was giving a talk to some folks, and her mother said, he interrupted me, and she said, you know, my son’s taking me, and I covered them with medication. She’s like, you know, it’s keeping them alive. And if someone is buying drugs on the street, I was like, you know, she’s got a point. She’s got a real point. And I said, wow, you know, maybe I’ve got to take another look at this because if we’re talking about keeping somebody alive who’s not using drugs, street drugs, and putting themselves just in danger for many reasons, then maybe there’s something to this. So I really appreciate you coming on and educating us. I think this is going to open some eyes for sure. So before I let you go, because I want you to give out all your content information, seeing as we’re sharing this on our respective channels, I don’t know if you have any questions for me.
Dr. Mark Leeds [31:15] Oh, yeah. Yeah. Let me take a look at my questions. You made those, didn’t you?
Mark Astor [31:19] Yeah. Let me see if we covered everything here.
Dr. Mark Leeds [31:22] Oh, yeah. I wanted to ask you, the Marchman Act, is that Florida only or is that nationwide? I mean, where can you use that?
Mark Astor [31:30] Yeah. So it’s a Florida-specific statute. I would tell you that most of our clients who are typically moms and dads, but not always, sometimes it could be a spouse or a sibling, they’re out of state. We take tons of calls from out of state. As long as the person is either is in florida regardless of where the residency is we can we can initiate a Marchman Act and we do stuff all over the state just to happen is believe it or not florida which is just so switched on down here so it’s a florida specific statute now even though that there’s very few states that have anything like the Marchman Act every state has a guardianship statute so we do a lot of guardianship work too because sometimes we need a longer we need more control for a longer period of time, which sort of takes them out of the game. But every state has a guardianship statute. So what we tell clients is that when you take your loved one back to your home state, you can typically ask a court under the auspices of a guardianship to domesticate what we have down here. So it’s not really a transfer. It’s just asking the court in another state to recognize it. And a lot of time that can be done. But it’s very state-specific. But as far as the Marchman Act is concerned, yeah, it’s Florida. And I mean, I always tell people, you know, now that we’ve done a great job cleaning up the industry, you know, I think coming to Florida is a great idea. We have a great selection of treatment centers and now I’m hearing about what you do, that might be an even better reason, but also the Marchman Act, which gives families who send their kids thousands of miles for treatment, gives them some type of safety net, you know, and it gives them like me or you on the journey with them.
Dr. Mark Leeds [33:07] Yeah that’s that’s great because I mean up until now I mean florida has developed kind of a bad reputation for addiction treatment and maybe by accident you know people end up here you know looking for the beach and the cable tv and the gym membership and whatever these treatment programs are offering them and they end up in maybe the best possible place because now you have a way to really give them some help yeah yeah
Mark Astor [33:30] So listen before I let you go how do folks get a hold of you I know I’ve got your website which is dr leeds l-e-e-d-s.com dr leeds.com but what’s the best phone number folks to reach out to you in any other way
Dr. Mark Leeds [33:42] Okay yeah my phone number is 954-776-6226 and the web page the website is actually a great way to get in touch with me there’s a contact form there’s an email newsletter which I definitely would would love for people to sign up for my email newsletter that’s that’s kind of a new thing where we send out up-to-date information and updates and new articles that I’ve come out with, new podcast information, up-and-coming podcast guests, and some exclusive stuff that you won’t get anywhere else. So yeah, I love when people sign up for the newsletter, and it’s also a great way to keep in touch with me.
Mark Astor [34:16] I’m doing it as we speak.
Dr. Mark Leeds [34:17] Oh, thank you. Thank you.
Mark Astor [34:20] I would encourage everyone else to do that.
Dr. Mark Leeds [34:23] And of course, when someone gets the newsletter, they can respond to that, and now they have my email address. They can email me. So, you know, which is just info at drleeds.com. So yeah, people can contact me directly through the website through a few different ways. They can email me, they can call me. And definitely people are welcome to contact me, even if they’re not coming in to see me as a patient. One thing I’d like to start doing, I’ve had some guest bloggers, you know, blogging for, you know, I have three websites that I’m maintaining now. And, you know, we put up different stories and things like that. So people, even if they want to do it anonymously, that would be great to have stories of recovery, of hope, of tools that people can use. You know, I’ve had like, just for example, you know, some patients have contacted me where, you know, I’ve lost touch over time and they contact me and they say, you know, I’m doing really well. I got off of the Suboxone and now I’m clean and I’m, you know, I just want to let people know that it can be done. You can go from treatment to being completely abstinent and staying clean. And I ask them like well could you share that with us I mean it can be anonymous you know maybe write a blog post but you know let people know how you did it let them know what worked for you know so that would be great if you know we can get more of this information out there and make it more accessible
Mark Astor [35:36] I love it listen I’m going to sign up but don’t go anywhere just yet okay I want to talk to you
Dr. Mark Leeds [35:39] Okay thank you thank you
Mark Astor [35:41] All right folks thanks for tuning in to another edition of the journey from addiction to recovery you can check us out on the web drug and alcohol attorneys […] We’re also on Facebook, LinkedIn, Instagram, iHeartRadio now. And if that doesn’t work, just Google us. You’ll find us. And until next week, thanks for tuning in.
