Effective Harm Reduction and Opioid Addiction Treatment, by David Poses

Dr. Mark Leeds [00:00] David Poses, welcome to the podcast. David, you’re a writer, a speaker, an activist, and you’ve published a book called The Weight of Air. Now, you speak and write about depression, addiction, specifically opioid addiction. Tell me about The Weight of Air. How did that come about?

David Poses [00:21] Yeah I hit for a very long time I started using heroin when I was 16 and I’d heard about it from in a dare assembly in school when I was fifth grade in fifth grade a cop came to my school and he said you can’t drive a car if you drink alcohol pot makes you stupid cocaine makes you angry he told this very scary story about a kid who from our local high school who took LSD, thought he was an orange, and peeled his skin off. And so, you know, at that point in my life, depression wasn’t part of my vernacular. I just, I thought I was broken. I knew that I had no business doing anything that was going to make me angrier. And I felt stupid, so potting is out of the question. My lifelong ambition at that point was to drive headlong into a tree as fast as possible. So alcohol was easy to cross up too. And then the cop said the worst drug is heroin. And he described it as it was originally a painkiller, but it was so strong that it killed your feelings. It kills your feelings also. And he said that like as if it was, you know, undesirable. But that was really it was the first time that I felt like, you know, this is going to help my problems. So I, you know, I was 10 years old and heroin was, harder to find than, you know, weapons grade plutonium. But, six years later, I mean, by then, you know, I had tried every conceivable antidepressant, and nothing worked. And so, I mean, I was basically at a point in my life where, you know, it was either heroin was going to do everything I thought it was going to do or I was going to jump off a roof. And so it did. And it worked. I mean, you know, it definitely made me feel normal. I mean, it was the first time that I felt like this is what normal feels like for most people. So, I mean, I was definitely committed to using it, but I hated the lifestyle. All of the deception and getting beat up and not going to bad neighborhoods all the time and getting ripped off. It was awful. My fear of needles was quickly rendered practical by an increase in tolerance. And so a little before my 19th birthday, I decided I was going to stop. I mean I tried a few times but I put myself into this kind of no egg cold kick while my mom was in florida and that’s where the book begins so you know instead of the usual you know let me tell you how you know bad things were and you know I didn’t want to kind of glamorize, you know, those early days. But, so from there, I went to rehab, like this is when the first, you know, 10 pages, I went to Hazelden, which at the time was like the Harvard of rehabs. And, I just, I couldn’t relate to, there it’s an, it was an AA based, you know, faith and abstinence program. And I just, I couldn’t reconcile my experience with the program. Just none of it made sense. I mean, the idea that, you know, these are medical experts without medical credentials, and they’re pushing this magical thinking cure of, you know, you can’t achieve remission from this disease without placing your life and will in God’s hands, but you’re powerless, but somehow God’s going to help you. And, you know, my mom had had cancer. So the idea that like God is going to he wants to solve my problems and the problems of anyone who uses drugs, but he doesn’t help anybody with cancer. Like it was just, it didn’t make any sense. And so from there, you know, I told my counselor that, you know, addiction, depression was my problem and my addiction is a symptom of depression. I would have no use for drugs if I wasn’t so depressed and, you know, everybody in the facility was saying that, you know, depression is an excuse. Heroin has absolutely no medicinal value. You know, I’m rationalizing. That’s addict mentality. AA works and, you know, I’m out of my mind. So they told my mom that, you know, I was going to throw out all the alcohol in the house because I’m going to drink hand sanitizer if I get desperate enough. And, you know, I got drunk once when I was 15 and that’s the only time I’ve ever been drunk. I spoke about a few times, you know, but I knew who I was and what I was about. And so just that kind of invalidation, you know, I didn’t know what to do from there because sobriety was clearly not the answer. I mean, I was I just I wanted to feel safe in my own skin. And so long story short, I relapsed not long after and spent the next 16 years going from one relapse to the next. But I was so ashamed. And nobody knew. So when I was, I guess, like around 42, you know, when everyone in my life believed that I was 24 years sober, the opioid crisis was starting to occupy so many more newspaper headlines. And there was so much misinformation out there. And, you know, I was on I’d been on buprenorphine for 10 years at that point. Nobody knew about that. And I was just so overwhelmed with them. With guilt and shame from, you know, deceiving, my family and friends and knowing that, you know, I didn’t, I’ve always known that I’m not the exception, you know, I’ve never met a stereotypical junkie, but I know a lot of people like me, who are, you know, killing emotional pain with a painkiller. So I started writing, I mean, the book didn’t really feel like a choice. It was, you know, this is how I’m going to explain this. I mean, it was really, the idea was, I basically wrote it for my wife, I mean, as a way to, you know, explain everything. And so, you know, at that point, as far as everyone was concerned, the last time I used drugs was what you see on the first page of the book. So

Dr. Mark Leeds [07:23] Yeah you said you were 42 when you that was when you started writing the book and you had been on buprenorphine for 10 years at that point yes yeah what year was that

David Poses [07:33] It was 2018

Dr. Mark Leeds [07:39] Okay so buprenorphine had been in use for something like 16 years at that point I think it was approved maybe the program the whole thing with the data waiver thing with the dea was yeah around 2000 and then 2002 I think suboxone came out or subutex and one of the and I mean so there was like a huge lost lost opportunity to help you like when you’re 19 years old you wanted help and

David Poses [08:12] Yeah I mean it’s funny you should say that I’m sorry what

Dr. Mark Leeds [08:15] Yeah even if they even if somebody he had offered you medical heroin, you know, or something, you know, anything other than just attacking you know, with a program that had, you know, nothing to offer you really. I mean, it’s just a huge lost opportunity. And you went back for another 16 years, you know, just imagine what you could have accomplished and, you know, enjoy life, you know, just what I mean, that’s like a, you know, horrible experience, you know, to just basically put you in something that had no hope of working. I mean, it’s, yeah, I mean, that must be difficult to deal with looking back, thinking like, wow, if they had just given me this stuff the first day, I wouldn’t have had to do all that.

David Poses [08:59] Yeah, I mean, the part that’s really so tragic, and I think I misspoke before, I was struggling with heroin for 16 years in total from 16 to 32. Too. I guess after rehab, it went on for 13 years. But anyway, so my friend, Rob, who you meet on the first page of book, I still know him today. He was my friend who turned out to be on heroin. So he was how I got my first hit. He was part of the buprenorphine clinical trials in New York City in the early 90s. So I actually was aware of buprenorphine before I tried heroin, except I didn’t know. I thought it was just to help you through withdrawal. I didn’t realize it was a maintenance drug. And over the years that I was trying to figure out what to do and stay alive, I thought about methadone a lot. I mean, that would have been a great solution, but because nobody, I couldn’t tell anyone about this. Like there was no way I could go to a methadone clinic every day. And with the buprenorphine, you know, not knowing that it was a maintenance drug, that didn’t feel like an option either. And so, you know, ultimately, I, you know, it was a kind of a very serendipitous, you know, way to arrive at the buprenorphine. But, you know, the other thing that’s so tragic about it is I had to, I mean, you know, this is 2008 when I started buprenorphine and in my, within like, it was either like a hundred or 200, you know, some ridiculous radius of miles. There were six doctors that were, that, you know, had the special license, the X waiver to prescribe. And I called all six of them. And at the time system was totally clean. I had, And there were no drugs in my system for months. So one by one, I said, look, we’re sorry, we can’t help you. Unless you’re going to fail a urine test, basically, we can’t treat you. And I explained the obvious paradox of if I have to go out and score in order for you to treat me, I’m not going to come to the appointment and I could die. You know, and the last the last doctor agreed to, you know, to see me. But there’s so much I just I feel like we have this very irrational fear of drugs in general and even the treatment. I mean, the way that we, you know, you can get like illicit fentanyl analogs can be delivered to any address in America in under 24 hours. You can’t get buprenorphine that fast from, you know, calling a doctor and making all that. And you can’t get methadone that fast either. So, I mean, you know, at some point we’re going to have to make the antidote more accessible than, you know, the toxic drugs that are killing people.

Dr. Mark Leeds [12:06] Oh, yeah. Yeah, definitely. I mean, there’s definitely an issue with accessibility and yeah, I mean, you know, they’re controlled drugs. And I don’t totally understand some of the stuff going on with that. Like, you know, marijuana is a Schedule I drug, but there’s also marijuana clinics everywhere. But then when you talk about buprenorphine, Schedule III and methadone, Schedule II drug, things that should be available, well, we have to highly control them. I read an article once, and I wish I could track it down because I don’t remember. You know it wasn’t it wasn’t a u.s doctor or scientist who wrote it but in the article he suggested that maybe buprenorphine should be freely available you know not prescription yeah you know just you can walk into a store and get if you need it and it’s something that not a lot of people want to talk about I brought it up with another guest and I said what do you think about buprenorphine being available over the counter and she said well that would be great and then quickly she backtracked and said oh I thought you were talking about naltrexone or something else. You know, it’s almost something, you know, that people are afraid to even talk about the possibility of the lives that could be saved. You know, if we had supervised consumption sites, you know, where people could use heroin, fentanyl under supervision and be kept safe, and then they could be offered buprenorphine, you know, freely without having any difficulty getting it. And I mean, it would just, I mean, some of these things are being done elsewhere in the world. I mean, there’s medical heroin in a couple of countries, there’s supervised consumption sites. Even in Canada, they have some dilaudid dispensing machines on the streets. Yeah. I mean, it’s really not…

David Poses [13:45] Oh, sorry, what? Oh, no, go ahead. Sorry. I just, I feel like our, we see, you know, we know what we need to, we know how to save lives, Right. So like nobody’s going to argue with the idea that like our toxic illicit drugs that are involved in, you know, 90 whatever percent of overdose fatalities are those drugs safer than legally regulated pharmaceutical drugs. You know, of course, they’re not. Everybody knows that. Nobody argues with that. So safe supply is a solution to the overdose crisis. It will save lives. Drugs will be safer. And whether you call it a safe supply or legalize and regulate drugs, like whatever you want to call it, whatever configuration, however it happens, most people will say, well, we can’t do that because then more people will use drugs. And so I feel like we have to stop looking at this as a fear of, but reject every solution because of our rational fear of increased drug use and people are dying as a result. And like, if you look at the questions kind of in order of this, you know, chicken and egg, it’s like, you know, I meet people who say, I mean, they think I’m out of my mind for wanting to legalize and regulate drugs. I mean, I have two kids, you know, I think I seem like a reasonably intelligent person. But so, you know, they say these things like everybody is going to start using drugs if we legalize drugs. Like, how could you say that? Blah, blah, blah. Right. So you say, OK, are legal regulated drugs safer than the toxic drugs? They say, yes, of course they are. OK, so less people dying isn’t more important than a fear of more people using. Well, everybody’s going to get drugs, whatever. So then you say, like, all right, how psyched are you if would you be if meth and heroin were legal? Oh, my God, I’m talking about I would never do that stuff. OK, well, surely, you know, a lot of people who would. No, I don’t. All right. Well, I mean, you know, then who are we talking about here? Like everybody is so afraid of more people using drugs if they’re more accessible and safer. But nobody knows that. Like nobody can name a single person who might start using. And at the end of the day, it’s like, if you don’t want people to use drugs for whatever your reason, is it not better to have some safety and protection in that? Like, why are the options, you know, just say no or you take your life in your hands and we’re not going to do anything to make you safe? Like, anything else, when something’s dangerous, we find ways to make it safer. It’s like, you know, our attitudes and laws toward drugs are like saying, you know, guns are dangerous, so we’re not going to give anybody a gun lock because, you know, something bad might happen. Like, we just – it’s so counterintuitive. And it’s really unfathomable to me that, like, you know, laws exist to protect us. Lawmakers’ job is to make the laws that keep us safe. The fact that these guys, that any of them can support the drug war or not recognize, this crisis is not going to end until there is a safe supply of legal regulated drugs, period. There’s no solution. There just isn’t. People are dying from toxic drugs. Restricting prescription opioids, that reduces prescription opioid use. It doesn’t reduce demand for opioids. It doesn’t reduce pain that people have that make them use opioids, whether legally or illegally. So what are we trying to accomplish here? You can’t stop people from using drugs, but we can stop people from dying from drugs.

Dr. Mark Leeds [17:49] Yeah yeah that’s a good point what do you what do you think of now it seems like they always want to blame doctors one way or the other doctors and drug companies and pharmacies well it always feels like it’s mainly doctors but what do you think of this whole thing with purdue you know they are kind of trying to blame purdue for like the entire modern opioid crisis I mean I know in history we’ve been through this before even going back centuries but I guess current the current crisis, say from like maybe the somewhere in the 90s to the present, that they want to blame Purdue and OxyContin for the whole thing. What do you think of that?

David Poses [18:26] I mean, you know, I feel like it’s a very sticky wicket. I feel like when I talk about this with anybody, I’m very, very careful to say, and I believe, that these guys deserve the most medieval of punishments, no question. I mean, what they did was completely reprehensible. On the other side of the coin, how did we not think that a company wants to, a for-profit company wouldn’t be looking for ways to increase the profitability? That shouldn’t have surprised us. And the fact that we are an instant gratification society. We know that 49% of people are unresponsive to antidepressants. We know that something like 70% of depressed people aren’t getting, you know, don’t have the resources or aren’t, you know, being properly treated. We know that, you know, there’s this massive crisis of untreated pain. You know, there’s like an epidemic of chronic pain. And so if Purdue Pharma made shit sandwiches, I’m quite certain that this wouldn’t be a shit sandwich epidemic, you know? So it’s, while they certainly did everything they could to be the biggest fucking scumbags in the history of the world, you know, no question. I mean, El Chapo is in jail for the rest of his life and he loses all of his money and these guys are walking the streets. I mean, you know, it’s crazy. But it seems like, you know, there was this article in an op-ed in the Washington Post maybe a couple of years ago. And it was, the headline was, I’m not a junkie, give me my pain pills. And so this, I feel like she had knee surgery or something. And so, you know, she was prescribed whatever opioids she had. And she’s basically saying that, you know, people like me made, you know, are responsible for these restrictions that make, that basically limit her prescription painkillers. And she doesn’t really need them so much for her knee anymore, but she feels kind of depressed when she doesn’t have them. And so, you know, she’s not a junkie, so why can’t she have her pain medicine? It’s like, that’s why everybody uses painkillers. I mean, the idea of, you know, nobody’s abusing opioids. I understand how, like, you know, drinking Purell is not the intended purpose of soap, right? But opiate receptors regulate our physical pain and emotional well-being. Opioids work by, you know, flooding your brain with dopamine and serotonin. So we’re so hung up on this idea that like bad people use drugs and anybody who’s using painkillers is making excuses and all the things that I was told in rehab. But like, if you take a step back, doesn’t it make more sense that people who are in pain are using painkillers? You know, opioids don’t know if you have a prescription. They don’t care if you have a prescription. It doesn’t matter what kind of pain you’re feeling. They’re going to do the same thing, whether you’re, you know, terribly depressed or dealing with some kind of emotional trauma, or if you had hip replacement surgery. And, you know, I mean, if we’re not going to provide the resources to, you know, keep people from, to feel like you have more options than turning to drugs, then, I mean, is it too much to ask to, you know, make drugs safer so that people don’t die when they’re using them? I guess that’s a little bit of a tangent, but, you know, so as far as Purdue Pharma goes, I feel like it’s a very, I feel like important, there are a bunch of important points that get missed in that conversation because, you know, I don’t know if you’re, if you’re prescribed, you know, you have knee surgery, you get a, whatever, you know, Percocet, Oxycontin, whatever it is. And the, at some point the physical pain is gone, right? Like the wound heals and you feel better. If you’re still taking, whatever the medication is after that point, you’re doing it for a reason. It feels good. You know, something else is, it’s making your, you know, it’s making you less depressed, you know, whatever it is. And so it makes it like when we focus on, Oh, those Purdue pharma scumbags and the doctors and the whatever, like there’s no question that’s all true, but it makes it kind of like obfuscates the reason that you are using, you know, the Oxycontin longer than, you know, need beer or whatever. And I feel like that makes it harder for anyone to heal those emotional wounds that led to taking the OxyContin longer. I don’t know. Does that make sense?

Dr. Mark Leeds [23:16] Oh, yeah. Yeah. And maybe their I guess their biggest crime was promoting OxyContin as being a non-addicting, safe treatment for all kinds of pain. And they really infiltrated the system as far as we had doctors at conventions lecturing to us saying it’s fine to give an OxyContin prescription if someone, for example, hurts their shoulder. I remember that lecture very clearly. An older doctor who was very respected in the community got up and gave us a lecture and told us about how he injured his shoulder, went to the orthopedic surgeon, and got a short-term prescription for OxyContin 20 milligrams. And it worked great. And then he finished it. And you know that kind of thing and the drug groups coming in and they were they were backing I think some different pain societies you know we would get all these you know paperwork to put in the chart like pain contracts to have with patients and pain assessment forms and so you know maybe their biggest crime was making it so people that never would have touched opiates know the kind of people that like you’re talking about that would never go out and go looking for heroin, you know, maybe they were in that percentage of people that were susceptible to addiction to opioids and they were given it for the wrong reasons, you know, where maybe something else should then try. Yeah, absolutely. Yeah, yeah. But imagine if Purdue was the safe heroin company and maybe they, suppose they came out and said, well, here’s oxycodone, very highly addicting for many people. And it does need to be prescribed, you know, under this new law. Anybody can go to the pharmacy and pick up their oxycodone you can snort it inject it wherever you want to do with it much safer than fentanyl analogs you know probably you know like those people that were had shoulder pain or back pain you know they’re not going to do that you know if you said yeah legal heroin I mean but so I mean that’s kind of what we’re talking about like being you know maybe having that kind of a thing but being very open about it this is not something for you, for the person who has chronic pain or acute pain, you have your thing that you can go to your doctor for. But this is, you know, legal, safe opioids for people that use opioids as an alternative to, you know, to these dangerous fentanyl analogs that are coming from who knows where somewhere in China. And they’re designed to be, they’re very highly potent, hard to quit. But, yeah,

David Poses [25:41] I mean, the fentanyl analogs are so dangerous also for stopping because, you know, the half-life, I mean, like I know somebody with a mass spectrometer that has been, you know, studying these analogs. And, you know, most people, like, have no idea what this stuff is. And that’s really the biggest danger of drugs. I mean, if you look at like alcohol, you know, you’re not going to drink a beer and find out it was methanol after the fact, you know, and that’s what’s that’s what’s killing people. Like if you buy a bag of heroin and you’re shooting a bag of heroin every time and that’s pretty much your tolerance and the potency is inconsistent. And then you buy a bag that’s 20 times more powerful than the one before and you don’t know that you’re dead. Like you don’t get another chance. So we look at these things like a gram of whatever and a bag of this, and our units of measure are completely skewed because potency is made by volume. I mean overdose is an overly potent dose, right? The dose is too potent. If you don’t know the potency and purity of the substance you’re using, you can’t prevent it. Accidental overdose is the leading cause of death in America right now, right, for Americans under 50. So, you know, if accidents can be prevented and overdose is an overly potent dose, how are you supposed to prevent overdose when there’s no way to prevent overdose? You know, and it’s like the people who refuse to get behind legalization and regulation are the very same people who don’t want a safe injection site in their neighborhood and don’t want a methadone clinic. And, you know, the safe injection sites in the history of the world, 100% safe injection sites that have ever existed anywhere on the planet since the dawn of time, there have been zero overdose fatalities in total among all of those places. So they work, right? But people don’t want them. And the fact is, any idiot can serve a shot of tequila at a bar because it’s 80 proof or whatever it is. You know exactly what you’re pouring. We need safe injection sites that are stacked with medical qualifications because you have no idea what you’re putting in your body. And that’s really the danger. I mean, you know, 80 milligrams of oxycontin. Are people going to die from drugs if drugs are legal? Of course they are. People die of alcohol overdose all the time also. Alcohol, I mean, heroin withdrawal was one of the most brutal things I’ve ever experienced, if not the most brutal. And I certainly wish for death any number of times, but it’s not going to kill you in withdrawal. Alcohol is so addictive that it will kill you in withdrawal. I mean, people die in alcohol all the time. Alcohol can shut down every organ in your body. Like all other drugs combined can. So it is, we think alcohol is legal because it’s safer. Alcohol is safer because it’s legal. And you say that to people And like, they’re just like, that can’t possibly be true. You know, I mean, I have this conversation with my mother all the time and it’s impossible, you know, but that’s, that’s really what it is. Like if you, if you pour, I mean, I said to my mom recently, you know, she drinks a glass of wine with dinner around again. So, all right. So you open a bottle of wine, you pour a glass and you drink it. You know, if you had two glasses of wine, would you be throwing up? And she’s like, you know, I don’t know, but I definitely wouldn’t feel good. Okay. Right. So what if you what if you had the equivalent of 35 glasses of wine and one glass of wine? You’d be dead, right? Absolutely. So whose fault is that? Is that your fault because you knew that wine could kill you or that something fucked up happened with your wine? You know, she’s like, that would never happens to my wine. Why? Because I buy it in a liquor store and the bottle is sealed. OK, why? Because that’s it. You know, that’s how they make it. And she goes, the whole thing basically makes my argument for me. And then you say well what do you think I mean do you think anybody’s going out and saying like yes hello Mr. Drug Dealer please sell me the most deadly fentanyl I mean drug dealers you don’t have to be a genius to know that a dead customer is not good for repeat business right so we have this idea that drug dealers are predatory you know bloodthirsty monsters and drug addicts you know we’re just careless you know and if it’s if we I then you know it’s our fault I mean And people have said to me, look, you know drugs are dangerous. You know they can kill you’re choosing to do them. So you deserve what you get. I mean, my mom said something like that to me. And I mean, not just about people in general. So if I were to have died, you would have just been like, well, he knew drugs were dangerous, so too bad for him. No, I would be devastated. How could you even say that? Okay, so who do you think is dying out there? People who don’t have parents? I mean, it’s somebody else’s kid, you know?

Dr. Mark Leeds [30:46] Yeah. Yeah, definitely. So, now, you’ve probably researched this. I’ve heard, I’ve read some places that these fentanyl analogs, and they make it very difficult for people to even start buprenorphine. And this is something I’ve experienced with, you know, when a patient, sometimes even three, four, or five days out after their last use of street fentanyl, you know, you give them buprenorphine. And they still can’t get started with it puts them in precipitated withdrawal. Normally, usually when a person starts Suboxone or Subutex buprenorphine type medications, they can usually start like 18 to 24 hours after their last use of opioids. Like pure heroin or pure oxycodone, you just have to wait about a day and you can get started. And these analogs, like you’re saying, they’re very long half-lives and they just can stay in your system for days. And so, but I’ve read that these things are coming out of the same place where the coronavirus came from, Wuhan. Apparently, Wuhan was known at one point as the fentanyl capital of the world or something like that.

David Poses [31:55] Yeah, I mean, it’s the precipitated, like, I feel like there’s so much misinformation about buprenorphine. Buprenorphine. And I mean, I can’t tell you how many parents I’ve heard from who their kid was on buprenorphine at some point, whether it was legal or diverted buprenorphine, which there’s a billion studies that show that nobody’s drug of choice is Suboxone or Subutex. If you’re using it, you’re not dying from fentanyl and you’re trying to avoid, you know, using the drugs that are going to kill you. So with heroin or any kind of, you know, other full agonist that isn’t stored in your fat cells, yeah, you can, you know, start to take eight milligrams of buprenorphine, however long, you know, 18, 24 hours into withdrawal, your COWS score is high enough and, you know, no problem, you’re going to feel much better. So with the fentanyl, I mean, when I first started hearing of people who, you know, were getting sick 36 hours, 48 hours, 72, I heard a few 110 hours, you know, people are getting precipitated withdrawal. It’s like, that makes it so hard. So there are a few clinics in Canada that are giving you know, 10 days of slow release oral morphine or, you know, whatever else it is, some kind of pharmaceutical full agonist, because they know what they’re dealing with. And so their induction rate is 100%, you know, And it’s like, what are we-

Dr. Mark Leeds [33:28] Our hands are tied here. We’re not allowed to do that. In the US, our hands are tied that way.

David Poses [33:32] Yeah. I mean, we just, it’s like, I think at some point we have to ask ourselves, like, what are we actually trying to accomplish here? Because if we’re wanting to help people and, you know, save lives and not have so much death, I mean, we couldn’t have possibly designed a better system to kill as many people, you know, in every conceivable way.

Dr. Mark Leeds [33:54] Yeah. Yeah. Now, one thing that we can do, they have a thing which is discussed in a lot of Canadian journals, the Bernese method, which is microdosing. We can start someone on a very low dose of buprenorphine and gradually increase it. Probably not as good of a method as what you’re describing, but at least it’s something that doctors here are allowed to do. They can say, you know, we’re going to start with give you some medications for withdrawal, things like clonidine or Lucemyra. And there’s some other things that can help with withdrawal symptoms. But in addition, they can start very low, like maybe half a milligram or something of buprenorphine and gradually increase it.

David Poses [34:37] I’m happy you brought that up because I feel like, I don’t know this for sure, But I just think that most doctors, most buprenorphine prescribers, I can’t imagine that they’re all aware of the Bernese method. Right. And it’s clearly a much better way to go in the fentanyl era. But the problem with it is there’s the misinformation that’s out there. I mean, I probably hear from, you know, like over the last few weeks, I’ve heard from at least a dozen people, you know, who are struggling to get on buprenorphine or have all of these questions. And, you know, I’m not a doctor, so I am definitely not qualified to be dispensing medical advice whatsoever. But, you know, I have lived experience and I know the facts. And so if I’m going to say something, I’m going to be able to back it up with credible citations. But I know that buprenorphine works from my own experience with buprenorphine. If I didn’t and I was in the worst kind of withdrawal and then I took a tiny little piece of suboxone and I went into precipitated withdrawal, there is no fucking way I would ever go near it again. I mean, I would fentanyl for the rest of my life before I wanted to experience that. So I understand why that’s happening. And a lot of people seem to think that because Subutex doesn’t have Narcan in it will spare you from precipitated withdrawal. And they find out the hard way that it doesn’t. I mean, the Narcan in Suboxone is only activated when it hits your bloodstream. So if you dissolve it in your mouth, you snort it in your ass, whatever you want to do, that’s not going to hurt you. But most people don’t know that. And it just seems like there’s this, you know, we just like a vortex of well-intentioned, extremely dangerous ignorance out there. And, you know, doctors know what they know, you know, based on what they’re taught and what, you know, their patients say. But, you know, the attitude of you can’t trust addicts because we’re all a bunch of liars and all that kind of stuff. Like, you know, it’s not unreasonable to think, or it is unreasonable, but it’s, you know, it’s easy to imagine a situation where somebody goes into a doctor and they say, I did what you said with the buprenorphine, except I got crazy sick. And I mean, I hear these stories all the time of some young kid who, 18, 19, 20, whatever years old, they’re on buprenorphine. The doctor says, wait 18 to 24, whatever it is, and then you can take it and you’re going to feel much better. The kid gets sick and the parents go, the doctor said that, you’re lying to us. You have definitely not abstained for 24 hours because look at yourself, right? And the doctor’s going, yes, of course, clearly, this is why we can’t trust these guys. So the kid gets his ass kicked by the doctor, the parents. He’s got no tolerance. He needs to get well. I mean, that’s a miserable state to be in. He goes out and scores. No tolerance is the highest risk for overdose. Add the illicit drugs that are the highest risk of overdose. And, you know, like these kids are dying. I mean, this is happening every day. And it’s really it’s it is just tragic beyond words because this is a perfectly good solution. I mean, people for everybody, methadone, there’s nothing wrong with methadone. I mean, look, these medications, medically assisted treatment, cut the risk of overdose, death and relapse by 79 percent. Going to rehab, a 30-day stay in a traditional faith and abstinence rehab, increases those odds as dramatic a fashion, but doing nothing. Like if you find out your kid is on drugs and you get a bunch of Narcan and you say, please don’t use by yourself. We have Narcan. Circulate all the Narcan around, you know, whatever it is. You have a better chance of being alive in six months from that than you have of being alive three days after you leave rehab on the faith and abstinence program. I mean, like that’s pretty. And I say that to parents. And, you know, they know that I have kids and they’re just going like, I don’t want my kid to use drugs. Like, how could you even say that? It’s the stupidest thing I’ve ever heard in my life. It’s not about do you want your kid to use drugs. It’s do you want your kid to not die from drugs? Like we have to just look at this differently because we’re looking at it all wrong. You know? I don’t know.

Dr. Mark Leeds [39:37] Yeah. No, that’s – yeah, yeah. So, I mean, the misunderstanding, misinformation, the stigma. And that’s something I wanted to definitely talk to you about because one thing, I’ve not had the opportunity to interview any of my patients on the podcast because I wouldn’t do that because of obviously confidentiality. So, you know, even though I’ve interviewed top experts in the field and on medication assisted treatment and, you know, experts in the field of addiction, I’ve actually not interviewed anybody in the podcast who was on buprenorphine and having success with it. Although I can say I’ve seen unbelievable success. I’ve seen women have had children, no problem with the babies. None of the babies ever born addicted to buprenorphine or draw. I’ve had patients who have gotten better jobs. They’ve, they’ve started companies. They’ve written books. They’ve, I mean, accomplished unbelievable things, you know, all, all the while, you know, hearing in the news and hearing from people in the rehab industry saying, oh, that Suboxone is bad. You know, it doesn’t, you can’t function on it’s, it’s like trading one drug for another. And it’s not, I mean, they can say that all they want. And I have my small group of patients that are just endlessly having unbelievable successes. And so now here I am talking to you on the podcast, you’ve been on buprenorphine for a long time. You’re a writer, you’re a speaker, you have a family, you’re married. I think you said you had three children. Did you, were all the children born during the time that you were in treatment on buprenorphine?

David Poses [41:09] No, my daughter was born, she was three when I started, or two when I started on the buprenorphine. My son, I’ve been on buprenorphine his entire life. I mean, when people say it is trading one substance for another, I think I’m better off on buprenorphine than heroin. I don’t think anybody would disagree. I have plenty of relatives who wish that I wasn’t on buprenorphine. Look, I wish I didn’t have to take something every day, but I know I need it. I mean, I need glasses too. What am I going to do? Say, like, deny that? How’s that going to go over? When somebody says, you know, buprenorphine is just as bad as heroin or whatever, look, it’s a partial agonist for one thing. But if you don’t believe me, go out and, you know, next time you get hip replacement surgery, ask for buprenorphine instead of morphine and let us know how that works out for you know, like, it’s very simple. I feel like all of these, we believe these totally bullshit myths that would make absolutely no sense to us, or we would know our complete nonsense, if we would just apply it to anything else. I mean, the AA approach, you know, the medical experts that don’t have medical qualifications that are, you know, pushing you, pushing magical thinking cures. That’s the definition of quack medicine. Look, if you cross out addiction and swap it with any medical condition, you know that’s completely fucking preposterous. You know, oh, you have cancer? You don’t need the chemotherapy and the surgery. All you have to do is go to the anonymous support group and pray. Like would anybody think that makes sense no yeah no it’s

Dr. Mark Leeds [43:05] Okay no one would ever tell a cancer patient or someone with asthma or diabetes or high blood pressure go work the steps you know you’re not working the steps well enough you’re not talking to your sponsor often enough yeah that’s not medical

David Poses [43:19] It’s not it’s totally it’s completely insane I mean you know I was I didn’t tell anybody about the buprenorphine for so long because I was ashamed of that too. Last, I guess like November, I was on that show, CBS on CBS, the doctors, you know, that show with a bunch of doctors. So, you know, we went over a bunch of questions before they started taping. And what that, you know, it was like the third question or whatever they said. So, you know, you’ve been on buprenorphine for however long. When are you going to stop taking that stuff? Your addiction is clearly in check. And I said, I mean, if I was diabetic and this was insulin, would you ask me when I’m going to stop taking this insulin and saving my life because my diabetes is in check? My diabetes is in check because of fucking insulin. You know? How do we miss that? And that’s what it is because we have such an aversion to anybody using drugs. I mean, it’s such an alarmist reaction. You know, you find out your kid is on drugs. You don’t even ask them why they’re using the drugs. It’s just, you got to stop this. The shit is bad. You know, this is dangerous and it’s embarrassing and, you know, all that kind of business. I mean, my mom, to me, at some point, fairly recently, you know, she had no idea that I was on drugs the whole time I was on drugs. So, you know, And she obviously knows the whole story now, and she knows that depression was most definitely my gateway. So she said to me, I really wish that at some point you could have found an antidepressant at first. And I’m like, yeah, I do too. And I actually found one. And she said, well, I don’t understand. What happened? Did you forget? Did you not remember to take it? Every day, because I would have called you every day to make sure that you took it. And I said, no, I totally took it every day. Well, I mean, I don’t understand why you’re not on it now. Like you’d have to be out of your mind not to be taking this stuff. There’s no shame in it. Get back on it right now. Call your doctor or whatever. And, you know, so I told her what the antidepressant was. Heroin. It hadn’t already guessed. And, you know, her face just like all the color drains from her face. And she’s, you know, aghast about it. You know, why would you even say that? It’s not funny. You know, whatever. And I’m like, you know, look, you can’t think of a single bad thing that happened. Like, you know, when I was on, this is not any kind of endorsement for heroin at all. But for me personally, you know, I was, I couldn’t get out of bed if I wasn’t on heroin. Like I was, I couldn’t function without it. And I don’t just mean the withdrawal. Like I was so depressed. And so I said to my mom, like, you don’t have a problem with heroin. You have a problem with the way that it’s spelled and pronounced, because if it looked and sounded like Prozac, your reaction would have been very, very different. You like what heroin does. You don’t like saying it. You don’t like a word. Yeah. And I feel like, you know, I mean, I was too ashamed of the heroin to tell my parents why I started using. They were too outraged to ask. And I feel like that’s a fundamental part of the conversation because for all the years that I went around, you know, hiding, I would say things like, oh, heroin is pure evil, it steals your soul and, you know, all kinds of stuff like that. And the fact is, like, by doing that, I’m invalidating my own reason for using it. If it’s pure crime, it steals your soul. Like, what am I, a moron? Why am I doing that? Yeah we know I mean millions of people all over the world like we think that nobody can function on heroin it makes you into this you know terrible zombie kind of person like we’re totally convinced of that and yet we know that there are much more powerful opioids that are prescribed by doctors every day to people who not only function on them but need them specifically to function we know that And we don’t think that your grandmother is going to steal your car because she’s on a oxycontin, you know, or she’s going to get violent or whatever it is. Like we like these myths. We can debunk them ourselves. Like we don’t need science to, you know, to figure stuff out. But it’s so baked into our collective conscious that it’s really it’s insane. I mean, it’s truly insane.

Dr. Mark Leeds [47:51] Yeah. Yeah, when you were telling the story about your mother, I actually thought that you were going to finish it with when she asked, what’s the name of the antidepressant? I was imagining you might say buprenorphine or Suboxone. And I wonder how would she have responded to that if you were already in treatment? Would she have changed her opinion then? Because buprenorphine does help with depression on the Kappa opioid receptor. Has some effect as far as blocking that receptor of being somewhat an antidepressant and anti-anxiety medication.

David Poses [48:23] Yeah. I mean, you know, that’s interesting too, because it seems like, you know, we’re so convinced that bad people use drugs. Like nobody, I mean, nobody, buprenorphine is effective for depression, you know, because of the Kappa receptor, you know, certainly, but also just by virtue of even if it’s a partial agonist, it’s still, you know, opioid. And so, of course, you know, look, every dose, no matter whether you’re, you know, an illicit opioid user or it’s legal or you have a prescription, like it doesn’t matter what it is or what you’re using it for. Every dose multiplies your opiate receptors. And, you know, there’s so many studies on, what happens to your neurotransmitters and all the significant dysfunctional activity. It’s been observed many, many, many years after withdrawal. Abstinence is hard because however many receptors I had before I started using heroin, I’ve got a trillion billion more now. And so if that was as happy as I could possibly be naturally, because depression is a degenerative biological illness, you know, I, my receptors need to be saturated. And why? I mean, you know, I know that my life isn’t so terrible, but if I can, if I had a choice between suffering and not suffering, I’m going to pick not suffering 100% of the time. And I can’t think of a reason why I wouldn’t, but we have such an aversion to that stuff. I mean, And, you know, originally my family was not all that psyched about the buprenorphine either when I told them about that. I mean, I think, you know, I said heroin instead of buprenorphine in the conversation with mom because I was trying to make a, you know, a more oomph of a point. But, you know, yeah, it’s the same thing. I mean, buprenorphine is, you know, heroin was like a Lamborghini on a golf course. Like I didn’t need that much, you know, saturation. In you know I mean in the beginning like if I had had you know coding or not coding but you know like a kind of a thing would have been probably fine if not for the you know high acetaminophen count but anyway yeah

Dr. Mark Leeds [50:46] But I mean what one big difference is you know a person who uses heroin at least from people I’ve talked to is that there’s constantly that obsession of like you know when am I going to take my next one where am I going to get my next one from but I don’t hear that from anybody taking buprenorphine. You know, there’s no addictive thoughts whatsoever. You know, it’s just no obsessions, no compulsions. They just take the medication on time. And typically it’s, you know, with every other opioid, the problem is people develop tolerance and need more and more and more. With buprenorphine, they typically over time need a bit less or at least they stay constant at the same level.

David Poses [51:28] Yeah. I mean, yeah, it’s really, you know, I mean, I think, certainly the longer half-life helps, you know, for sure. But like somebody, somebody asked me recently, you know, would I go back to heroin if it was legal? And you know, it’s certainly something that I’ve been asked before and I, you know, certainly thought about it, but the fact is like buprenorphine is doing a perfectly fine job of what I needed to do. And the idea that I would Like, you know, I would have to, in order for heroin to rip the buprenorphine off of my receptors, like, I’d have to, like, be in withdrawal for a week before I would even feel the heroin. So, like, the idea of switching is stupid. But even if it wasn’t, like, even if I really wanted to do it, like, if heroin lasts for four hours, I mean, I don’t want to be out there in the world having to, you know, redose myself with heroin every 15 minutes. Buprenorphine is great. You take it in the morning. Sometimes I take more at night. Sometimes I don’t. That’s it. Like, it’s very, very simple. And it does its job. And it should be. It should be. I’m curious which article you referenced before, because I had an article. I wrote a couple of articles on that subject. I mean, it should be available. When you hear about these clinics that make you, that are like treating you like methadone clinic, where you have to go in every day for your dose. I mean, people are buying diverted buprenorphine because they don’t want to go to, like there’s nothing normal about going to a clinic every day. And, you know, it’s certainly, I mean, nobody is in counterfeit buprenorphine strips and sealing them into, you know, the individual, you know, whatever you call them, that they come in. I mean, like it’s ludicrous to think that anybody would do that. And also, anybody who’s going to a drug dealer and asking for buprenorphine instead of, you know, any full agonist, like, they’re, it’s not like they don’t have a choice. Like, they’re choosing the buprenorphine for a reason. And I think, you know, we’d really be smart to pay attention to that. I mean, you know, my drugstore, I live in, it’s right in town. It’s a small town. They know who I am. They know my family. Like, I’m not, you know, some anonymous, you know, unsavory looking person off the street. They fuck with me every month. I mean, if I, you know, if my doctor, like, usually our appointments are, you know, eight days apart. Sometimes they’re more, sometimes they’re less. If I go in on the 29th day to refill the buprenorphine, they won’t fill it. I mean, I’ve had situations where I was going on a business trip the next day. It was the 29th day, and they refused to fill it. And they understand why I’m taking buprenorphine. They understand that it’s much, much better than taking anything illegal. They totally get all that stuff. And when I say to them, so you realize that if you don’t fill this prescription, which you can because pharmacists have discretion, what am I going to do? You know, you would be basically killing me. And why would you do that?

Dr. Mark Leeds [54:41] Oh, wow. Have you ever considered moving? It doesn’t sound like a great place to treat you that way.

David Poses [54:47] I know. I actually, I mean, I went to, I’ve probably been to like several dozen pharmacies over the years. And I had one that I really liked. It was an hour away from my house, but I don’t work in, I used to be in private equity. And I stopped doing that like three years ago. So it’s no longer, you know, convenient. I just kind of have a fundamental problem paying for, you know, shipping. But, you know, and they’d be, they’d be happy to do it. But I mean, I’m kind of like in a in a weird spot with these guys because I never I mean, I’ve talked about this publicly, but I never named I haven’t named the drugstore publicly until a couple of months ago in town. I was at this small event for my book and they had like that morning they had they had done something, you know, fucked up with my prescription. And I felt like it was time to fire a warning shot. There were a bunch of local politicians there. And I feel like this, you know, it’s not because, you know, it’s a nuisance for me. Like, I’ve got plenty of buprenorphine in my house because my doctor understands that it would be dangerous for me to run out. So like, you know, he over prescribed a couple of times. So I would have extras, which is responsible, you know, given that we’re the do no harm thing and all that. But, you know, so I feel like I really want to do something about this situation that I don’t want to hurt them. But it’s important that they understand the impact of what they’re doing, because I’m definitely not the only person that they do this to. And if your average person is new to buprenorphine, there’s a lot of, among the misinformation, the idea that nobody needs more than eight milligrams, even though a lot of people need 32 coming off of fentanyl. So you’re 18, you got eight milligrams a day, it’s not enough. Maybe you took some extra because it’s not enough and you’re filling your prescription and they won’t give it to you and now you run out, right? Like you ran out three days earlier, whatever it is, you’ve got none left, and they refuse to fill it. Your options are Drug World can fill it for you, or you go out and score. Like, which is the better of those two options? Clearly, it’s the drugstore. The drugstore can save your life. They’re actively choosing not to.

Dr. Mark Leeds [57:30] Oh, yeah. That’s really gross. And I mean one you know as far as like the you know and it to me it seems like the pharmacies that they give people the most trouble and I don’t know if this is true across the board but it seems like it’s the ones that got in the most trouble during the peak of the opioid crisis you know like maybe 10 years ago 2007 to 2011 around that time period you know there was a major farm a major pharmacy that at least here in florida and Orlando, they got in big trouble. And then that same company is now very tough on doctors, you know, blacklisting doctors and not filling their prescriptions. Another company did that more recently. I mean, one that I think consistently has been good through the entire thing, Walgreens, as you know, maybe not every store and every pharmacist that works for Walgreens, but as a corporation, as far as like the larger ones, they seem to be one of the better ones as far as, making things relatively easy for patients. Although I know that’s not true in every state, in every store, with every pharmacist. But some of the small ones are, even with the small pharmacies, the ones that seem to have gotten the most trouble during the opioid crisis are the ones that are most tough on patients now. Yeah.

David Poses [58:46] Yeah. I mean, it’s really, I mean, it’s amazing how in the 90s, every lawmaker was, I mean, look, like Purdue Pharma had pain turned into the only subjective vital sign. I mean, the power of that. And so many politicians and these lawmakers, nobody should have to be in pain. Pain is the enemy. We’ve got to kill pain. I mean, that’s what they wanted to do. And now that they’ve changed their tune on opioids, that carries over to buprenorphine and methadone. And the prescription opioids as well. Like pain doesn’t go away when you, restrictions aren’t going to reduce your pain. Restrictions aren’t going to make, not need buprenorphine. Like restrictions, you know, we’re like doing everything we can to kill people in the most possible ways. And it’s really, it’s so tragic. I mean, every one of these deaths can be prevented. Nobody should have to suffer. Like when did pain get to be so pop, so, you know, popular that killing it is such a travesty now.

Dr. Mark Leeds [59:50] Oh yeah. Yeah. Yeah, it’s unbelievable just the change, you know, how they’ve gone, the media, the message in the media has gone from one extreme to the other. And you can still search. There’s an article that I sometimes search for it, a CNN article from 2001, where they talk about how doctors are going to be disciplined for under-treating pain. And then, of course, 10, 20 years later on CNN and all the other news outlets, it’s completely the opposite. That doctors, rogue doctors are over-prescribing, doctors are going to be disciplined for prescribing pain medication. So they just go from one extreme to another, and we’re supposed to forget. It’s like they’re gaslighting all of us. We’re supposed to forget that they were at the other extreme, you know, 50, 20 years ago.

David Poses [1:00:36] Yeah, exactly. I mean, it’s really, you know, I mean, look, we’re throwing drug users in jail and letting them die because the DEA can’t keep the toxic drugs out of here. And they won’t let you know, they can’t stop that stuff, but they can stop you from getting, you know, from accessing the drugs that won’t kill you know, and we’re going to jail?

Dr. Mark Leeds [1:01:05] Yeah, it’s what they call the low-hanging fruit. You know, it’s easier to arrest a doctor who isn’t armed, you know, and probably a little bit overweight and older, can’t run very fast, you know, than to go after some armed drug dealers with guns, you know, in the jungle.

David Poses [1:01:20] Right. Yeah, exactly. It’s really, it’s so crazy. Oh, it’s, I have another call in a few minutes.

Dr. Mark Leeds [1:01:27] Oh, yeah. Sorry. Let me, let’s finish up. But what do you, what do you think of, they either pronounce it kratom or kratom, the herbal thing that I’m promoting?

David Poses [1:01:36] Yeah, you know, I’ve never tried it before. I know a bunch of people who have and swear by it. From everything that I’ve read, it seems like, and I don’t know if all of this is true, but it sounds like it feels opiate-ish, but it’s definitely not poppy flower or opium or anything like that, like totally different species. I’ve heard that it’s hard to stop using it and there’s some you know discrepancies between I feel like it’s like green and red kinds of like there’s two different colors and how much I need to use like I can’t remember exactly what this guy said but I want to say he said like seven grams a day was what he needed just it seems like I don’t get it personally because you could get on people with morphine or methadone? Like, I don’t understand the appeal of it.

Dr. Mark Leeds [1:02:40] I think it’s kind of like that thing of like, you know, avoiding the medical community of like treating yourself and staying away from doctors, you know, for people that don’t have trust in doctors. And you can understand why people wouldn’t trust doctors. But yeah, I mean, but it is kind of, it seems like a dirty drug, you know, people develop tolerance quickly. And even though it’s technically not an opioid, I know that I gave a patient naltrexone who said he was opioid-free for three months, and he wasn’t including the kratom that he had been using every day. And he did go into precipitated withdrawal. So I don’t think it was as bad as it would have been if he had been taking a real opioid. He got better pretty quickly. But yeah, it does work like an opioid. But yeah, I think that’s the thing is people are looking for things to turn to for treatment because, you know, rightfully, you know, they’re afraid of going to the doctor because they don’t want to go to that one doctor who’s going to say like, oh, I, you know, I don’t really believe in this. I’ll give you a small amount of buprenorphine. We’re going to taper you really quickly and do it the wrong way. So, you know, they just want to avoid that whole mess and just do it on their own, where it would be much better if they could go to a doctor that’s understanding and, or maybe even not have to go to a doctor, maybe, you know, maybe to a facility where this is how it’s done. We can give you up to 24, 32 milligrams if needed, taper it down gradually as tolerated, and keep you on it as long as necessary. Yeah. Yeah.

David Poses [1:04:12] I mean, yeah. I don’t get it. Anyway.

Dr. Mark Leeds [1:04:18] Yeah. Anyway. Yeah. Sorry. I don’t keep you so long. I know you have another call. So David Poses, author of The Weight of Air. Thank you for joining me today on the podcast.

David Poses [1:04:28] Oh my god, thank you so much. It’s so great to be here and so nice to meet you. Thank you.